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Clinical guidelines do not clearly define hospitalization time after primary angioplasty in ST-segment elevation myocardial infarction (STEMI). The hospitalization time should be tailored according to risk stratification., Aim: Evaluation of a local early discharge protocol to identify low-risk patients after primary angioplasty., Methods: A local protocol was applied to all patients admitted to Las Higueras Hospital after primary angioplasty in the context of STEMI from the Health Service of Talcahuano (Those belonging to other Health Services were excluded). Those who met the established criteria were discharged < 48 hours. Clinical variables, comorbidities, angiographic characteristics, and the procedure, as well as intraoperative complications, mortality, and hospital readmission up to 6 months, were analyzed., Results: A total of 51 patients were identified, with a mean age of 59.5 years and 25% female. The mean ischemia time was 5.5 hours with a risk profile that showed a mean GRACE score of 106 and a Zwolle risk score of 1.7. The mean length of stay was 1.7 days (40.8 h). There was only 1 readmission and no mortality events were registered up to 6 months of follow-up., Conclusion: The application of a protocol for early discharge after primary angioplasty allowed for shorter hospital stays without compromising patient safety in the medium term.

The indication for percutaneous aortic valve implantation (TAVI) has increased considerably in recent years, preferably using transfemoral access (TF); however, it is not clear which should be the preferred access in the event of contraindications to the latter. We present an 81-year-old patient with high surgical risk in whom a 50% obstruction of the descending aortic lumen was identified and so, a left transcarotid access was chosen. Numerous alternative approaches to the TF approach have been described in recent years. The transcarotid approach has been the one with the best results in different clinical reviews and the one that has been presented as the second alternative to TF in established algorithms. We report the first transcarotid TAVI implantation in Las Higueras Hospital, Talcahuano, Chile.

Background: In those patients who do not have timely access to primary angioplasty, the pharmaco-invasive approach, that is, the use of thrombolysis as a bridging measure prior to the coronary angiography, is a safe alternative., Aim: To describe the features of patients with an acute ST-elevation myocardial infarction (STEMI) treated with a pharmaco-invasive strategy., Material and Methods: Descriptive observational study of 144 patients with mean age of 46 years with STEMI who received a dose of thrombolytic prior to their referral for primary angioplasty at a public hospital between 2018 and 2021., Results: There were no differences the clinical presentation according to the Killip score at admission between thrombolyzed and non-thrombolyzed patients (p = ns). Fifty-three percent of non-thrombolyzed patients were admitted with an occluded vessel (TIMI 0) compared with 27% of thrombolyzed patients (p < 0.001). The thrombolyzed group required significantly less use of thromboaspiration (3.5 and 8.4% respectively; p = 0.014). Despite this, 91 and 92% of non-thrombolyzed and thrombolyzed patients achieved a post-angioplasty TIMI 3 flow. Long-term survival was 91 and 86% in thrombolyzed and non-thrombolyzed patients, respectively (p = ns)., Conclusions: The pharmaco-invasive strategy is a safe alternative when compared to primary angioplasty in centers that don't have timely access to Interventional Cardiology.

Background: Transfemoral transcatheter aortic valve implantation (TAVI) is the standard of treatment for patients with symptomatic severe aortic stenosis (AE) and intermediate or high surgical risk. The use of conscious sedation (CS) could reduce complications and allow an early discharge of these patients., Aim: To report our experience with TAVI under conscious sedation., Material and Methods: Review of medical records of 15 patients aged 79 ± 6 years (53% women) undergoing a transfemoral TAVI implant under conscious sedation., Results: The indications for the procedure were severe AE in 13 patients and biological prosthetic dysfunction in two. The mean Thoracic Surgeons predicted risk of mortality score was 7.3. The valves used were Edwards Sapien 3 in three patients, Medtronic Evolut in five, Boston Acurate Neo in four and Meril Myval in three. A successful implant was achieved in all cases and there were no hospital mortality or pacemaker requirements. One patient had a stroke, and one patient had a vascular access complication. Early discharge (< 72 h) was achieved in 80% of patients., Conclusions: TAVI under conscious sedation was a safe procedure and associated with a complication rate similar to previous reports, allowing for an early hospital discharge in most patients.

Background: Mitral balloon valvuloplasty (MBV) is the therapy of choice for the treatment of symptomatic mitral stenosis with suitable anatomy. Although its short and mid-term results are favorable, there is a paucity of information about long-term follow-up., Aim: To assess the late results of MBV., Material and Methods: A cohort of 225 patients aged 8 to 20 years who were subjected to a MBV from 1989 to 2001, was studied. All variables at the time of the procedure, short and long-term results and major events during follow-up (new mitral intervention and mortality) were recorded. Uni and multivariate analysis were used to assess prognosis., Results: The mean follow-up lapse was 13.5 years (range 8 to 20 years). During this period, 88 patients (39.1%) remained event-free and in acceptable functional capacity. Eight percent died, 8% required a second MBV and 43.5% required a surgical mitral valve replacement. A post-procedural area equal or greater to 1.9 cm² was associated with a greater likelihood of free-event survival (log rank test: p = 0.02/Cox proportional regression model: coefficient 0.54, p = 0.04)., Conclusions: MBV is effective, although there is a high chance of new interventions in the long-term follow-up. A larger post-procedure mitral area is associated with a better prognosis.

We report a 56 years-old man presenting with chest pain with exercise, seven years after an orthotopic heart transplant. A coronary angiography showed an atherosclerotic lesion in the common left main coronary artery with more than 90% obstruction. The lesion was successfully treated with a transluminal angioplasty with stenting. A 131-1 metaiodobenylguanidine (MIBG) scan demonstrated sympathetic reinnervation. Sixteen months later, due to progression of allograft vasculopathy, coronary artery bypass was required.

Background: In large series, nearly 60% of admissions for suspected acute coronary syndrome (ACS) had a non-coronary etiology of the pain. However, short term mortality of non recognized ACS patients, mistakenly discharged from the emergency room is at least twice greater than the expected if they would had been admitted. The concept of a chest pain unit (CPU) is a methodological approach developed to address these issues., Aim: To evaluate the efficacy of a CPU in the emergency room of a general hospital for evaluation of acute chest pain., Material and Methods: Prospective study of patients with chest pain admitted in the CPU. After a clinical, electrocardiographic and laboratory evaluation with cardiac injury serum markers, patients were stratified in three risk groups, based on the likelihood of ACS of the American Heart Association. High probability patients were admitted to the Coronary Unit (CU) for treatment. Moderate probability patients remained in the CPU for further evaluation and low probability patients were discharged with telephonic follow-up., Results: Of 407 patients, 35, 30 and 35% were stratified as high, intermediate and low probability ACS, respectively. Among patients admitted with high probability, 73% had a confirmed ACS diagnosis. Among intermediate probability patients, 86% were discharged after an evaluation in the CPU without adverse events in the follow-up., Conclusion: Structured risk evaluation approach in a CPU improves the management of acute chest pain, identifying high probability patients for fast admission and start of treatment in a CU and allowing safe discharge of low probability ones.

Background: The mechanism involved in dyspnea in patients with mitral valve stenosis (MS) is not completely understood., Aim: To evaluate in patients with MS, changes in hemodynamic parameters during the assessment of inspiratory muscle endurance (IME) and the relationship between IME, hemodynamics and dyspnea., Subjects and Methods: We studied 13 patients (9 in NYHA class II and 4 in class III). Endurance was evaluated using a two minute incremental threshold loading test, to obtain the maximal sustainable inspiratory pressure (SIP), and maximal inspiratory load (MIL). During the test, cardiac output (CO), mean pulmonary and capillary pressures (PAP and PCP, respectively), were evaluated., Results: Compared to six normal subjects, MS patients had reduced SIP and MIL (p <0.01), which correlated with baseline index of dyspnea (r= 0.57 and r=0.52, respectively, p <0.05). At the end of the test period, basal CO, cardiac index (CI), PAP and PCP increased from 3.4 to 4.0 l/min-1; 2.1 to 2.5 l/min-1/m-2; 15 to 25 and 11 to 18 mmHg, respectively (p <0.01). No relationship between IME and hemodynamic parameters was found., Conclusions: IME is reduced and is closely related to dyspnea in these patients with MS. The observed low CI, suggests that muscle underperfusion could contribute to this dysfunction during the inspiratory.

Background: Continuous infusion of short life vasodilators are employed to test reversibility of pulmonary hypertension in cardiac transplant candidates. Sublingual isosorbide administration has not been described in the literature and it might be a simpler alternative., Aim: To evaluate sublingual isosorbide administration as a test of reversibility of pulmonary hypertension in heart failure., Patients and Methods: Prospective evaluation of patients referred for cardiac transplant evaluation. Patients underwent right catheterization for hemodynamic measurements at baseline and after repeated doses of 5 mg sublingual isosorbide every 5 minutes until observing a decrease in pulmonary vascular resistance decrease or symptomatic hypotension., Results: Twenty one patients, 18 men, age 49+/-15 years, were studied. Fourteen (66%) were transplanted. The mean sublingual isosorbide dose was 15+/-5 mg. After isosorbide administration, there was a significant decrease in mean arterial pressure (80+/-8.5 to 71+/-6.6 mmHg, p <0.0001), mean pulmonary artery pressure (38+/-11 to 26+/-7.8 mmHg, p <0.0001), systemic vascular resistance (1540+/-376 to 1277+/-332 dyn*s/cm5 p <0.001), pulmonary vascular resistance (3.5+/-2.2 to 2,5+/-1.6 Wood Units, p <0.05) and transpulmonary gradient (13+/-7 a 10+/-4 mmHg, p <0.004). The cardiac output increased from 3.96+/-0.7 to 4.38+/-0.9 L/min, p=0.05. The relation between pulmonary and systemic vascular resistance before and after isosorbide was 0.17 and 0.15, respectively (p=0.04). One transplanted patient with partial reversibility of pulmonary hypertension developed acute right heart failure., Conclusions: Sublingual isosorbide administration is useful and well tolerated to evaluate the reversibility of pulmonary hypertension prior cardiac transplant.

Background: Hyperuricemia has been proposed as a risk marker in chronic heart failure, but its value as an independent prognostic is not well established., Aim: To determine the prognostic value of hyperuricemia, in patients with chronic stable heart failure., Patients and Methods: Forty six male patients with chronic heart failure, aged 62 +/- 13 years, were studied. Their election fraction was less than 40% and their serum creatinine was less than 2 mg/dl. Serum uric acid and catecholamines, maximal oxygen consumption (VO2 max) and left ventricular ejection fraction were measured. Mortality and the need for cardiac transplant were recorded as endpoints during a mean follow up of 39 +/- 18 months. The relationship between basal measures and the occurrence of events was analyzed using univariate and multivariate methods., Results: Basal VO2 max and left ventricular ejection fraction were 16 +/- 4.6 ml/kg/min and 22 +/- 7% respectively. Eighteen patients died and three required transplantation during the follow up. Patients reaching these endpoints had a lower VO2 max and left ventricular ejection fraction and higher uric acid levels. Multivariate analysis accepted left ventricular ejection fraction (relative risk 0.89, 95% CI 0.82-0.97) and serum uric acid (relative risk 1.335 95% CI 1.02-1.74) as significant predictors of events. The relative risk for cardiac transplantation was 7.07 times higher among those with a serum uric acid over 7 mg/dl., Conclusions: A high serum uric acid is an independent predictor of bad prognosis in patients with stable chronic heart failure.

A 33 years old woman was admitted to the hospital after four days with cough, dyspnea, orthopnea and hemoptysis. Blood pressure was 170/90 mmHg, pulse was 112 and temperature was normal. She had cyanosis and a left ventricular gallop, without heart murmurs. A chest radiograph revealed pulmonary edema and echocardiogram showed a global left ventricular systolic disfunction. Oxygen and furosemide were started, but cardiopulmonary collapse ensued. The patient was supported with mechanical ventilation and treated with inotropic drugs. A right sided cardiac catheterization showed pulmonary wedge pressure of 18 mmHg and a cardiac index of 3 l/min/m2. The levels of creatinine and urea nitrogen were elevated and a urine protein was 97 mg/dl. Coagulation tests were normal except by a positive lupic anticoagulant. Markers of connective tissue diseases or vasculitis were negatives. The clinical evolution suggested that a catastrophic antiphospholipid syndrome was ongoing. Intravenous corticoids, gammaglobulin and cyclophosphamide were administered with transient improvement. On her fourth day of treatment, the patient presented sudden pulmonary bleeding and embolism. A plasmapheresis was performed with improvement of renal, cardiac and pulmonary function. After this episode, the patient has been treated with prednisone and oral anticoagulants treatment for the last two years, without further clinical events.

Background: Heart transplantation currently provides the most effective treatment for advanced heart failure. However, medical therapy for this condition has also improved, heart donors are scarce and the cost of the procedure is high. Therefore the indications and management of these patients need reevaluation., Aim: To analyze the results of 24 patients submitted to heart transplantation for end-stage heart failure needing repeated hospitalizations and i.v. inotropes for compensation., Patients and Methods: The group was comprised by 21 men and 3 women with a mean age of 36.8 years, mean left ventricular ejection fraction 19 +/- 4.5%, mean systolic pulmonary artery pressure 48 +/- 13 mmHg (24-70) and mean pulmonary vascular resistance 2.6 Wood Units (1-5). Fourteen patients (58%) had a previous median sternotomy. Immunosuppression did not include induction therapy and steroids were discontinued early., Results: Operative mortality was 4% at 30 days. Actuarial survival at one year was 90% and at 5 years 72%. Freedom from rejection at one year was 76% and at 5 years 50%. Freedom from infection was 70% at one year and 56.5% at five years. All patients with more than 3 months of follow-up were in functional class I., Conclusions: These results justify the proposed modifications for transplantation protocols.

Background: It has been proved that there is an inspiratory muscle dysfunction in mitral stenosis; Although its causes still remain unknown., Aim: To evaluate the effect of percutaneous balloon mitral valvuloplasty (PMV) on inspiratory muscle performance (IMP) in patients with mitral stenosis (mitral area < 1.5 cm2)., Patients and Methods: We studied IMP in 8 patients (35 +/- 10 years) before and 3 months after successful PMV. Inspiratory muscle strength was studied by measuring maximal statistical inspiratory mouth pressure (MIP). Endurance was evaluated using a two minute incremental threshold loading test in order to obtain the maximal sustainable inspiratory pressure (SIP), with the maximal sustainable load (MSL) the patients could sustain for 2 minutes., Results: Mitral valvuloplasty increased mean cardiac index from 3.1 +/- 0.3 to 4.15 +/- 0.3 l/min/m2 (p < 0.01), and significantly decreased mean pulmonary and capillary pressures. The MIP value(118 +/- 6 cmH2O), similar to that of normal group, increased to 137 +/- 7 cmH2O (p < 0.01). SIP and maximal sustainable load were 52 +/- 3 cmH2O and 294 +/- 29 g respectively, lower than normal subjects (p < 0.05). They increased after PMV to 80 +/- 3 cmH2O and 463 +/- 26 g respectively (p < 0.001)., Conclusions: PMV improved inspiratory muscle function in patients with severe mitral stenosis, probably secondary to a decrease work of breath and improvement of ventricular function.

The strength and endurance of the inspiratory muscles was assessed in 14 patients with severe mitral valve stenosis uncomplicated by other diseases. Strength was evaluated measuring the maximal static inspiratory pressure (MIP). Endurance was measured using a two minute weight incremental test, to obtain the maximal sustainable pressure (SIP), which is the highest pressure that a subject can generate to mobilize air with incremental weight during inspiration. MIP was similar to that of 8 normal subjects (110 +/- 21 and 128 +/- 27 cm H2O respectively p = NS). SIP, maximal sustainable weight and SIP as percentage of MIP were 47 +/- 10 cm H2O, 261 +/- 81 g and 43 +/- 6% respectively, all lower than in normal subjects (89 +/- 25 cm H2O, 525 +/- 167 g and 71 +/- 15% respectively) We conclude that patients with severe mitral valve stenosis have decreased inspiratory muscle endurance compared to normal subjects and this feature may be related to their decreased exercise tolerance.

We characterized the acute manifestations of gastroesophageal reflux in 46 patients attending an emergency ward. 43 were females and the mean age was 41 +/- 14. The diagnosis of G-E reflux was confirmed in all by the acid reflux test; esophagitis was present in 55% of patients submitted to endoscopy; the Bernstein test was positive in 43%. The population represents 3% of all emergency consults and 8% of gastroenterological consults. Severe epigastric pain, usually burning or constrictive and radiating to the dorsum, left hypochondrium and sternal region was the presenting form in 55% of patients. Pain was refractory to antispasmodic agents but was relieved by antacids. Dyspnea or bronchial obstruction was the main symptom in 16% of cases, heartburn in 13%, hematemesis in 6%. Among these patients a prolonged history of chronic G-E reflux was common. Surgical correction was undertaken in 6%, with some symptoms persisting in 17%.