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Resumen Introduccion La endocarditis infecciosa (EI) sobre transcatheter aortic valve implantation (TAVI) es una complicacion emergente. Existen datos incompletos y dispares sobre su incidencia. Se aporta la experiencia en nuestro centro sobre incidencia, mortalidad y factores asociados de la EI post-TAVI y se compara con datos de la literatura. Metodos Estudio retrospectivo observacional de los casos de EI diagnosticados en pacientes que habian recibido TAVI, entre el 1 de junio de 2009 y el 1 de noviembre de 2017, en un centro universitario tras una mediana de seguimiento de 15,3 meses (rango intercuartil [RIC] 9,1-36,2). Se analizaron la incidencia, los datos clinicos, microbiologicos y pronosticos, y los factores asociados a EI post-TAVI. Resultados Se detectaron 11 pacientes con EI de 200 TAVI. Incidencia global: 5,5% (2,77 casos por 100 anos-paciente). La mediana de tiempo hasta la EI post-TAVI fue de 112 dias (RIC 36-578), la tasa de mortalidad intrahospitalaria fue del 36,4% y la mortalidad al ano, del 54,5%. Todos los microorganismos identificados fueron grampositivos (4 Enterococcus faecalis, 3 Staphylococcus coagulasa negativo). Los pacientes con EI post-TAVI eran significativamente mas jovenes (mediana 78, RIC 73-80, frente a 82, RIC 79-84, p = 0,002), tenian un EuroSCORE mayor (5,1 ± 2,4 frente a 3,2 ± 1,2, p Conclusiones En nuestro medio, la incidencia de EI post-TAVI es mayor que la descrita en series multicentricas, lo que concuerda con la tendencia publicada en la literatura. Conlleva una elevada mortalidad y se asocia con una peor situacion clinica basal.

Background When permanent pacemaker implantation is not possible or advisable via superior venous access (i.e., axillary or subclavian veins), safe and feasible surgical alternatives are required. The femoral approach is relatively unknown and seldom studied. This single-center study analyzed 10-year outcomes of a femoral implantation approach. Methods Data about the implantation procedure (indication, approach, lead and pacemaker models, complications), patient characteristics (age, sex, medications, comorbidities), and follow-up were analyzed for all permanent pacemaker implantations using the femoral approach between June 2001 and June 2011. Results A permanent pacemaker was implanted with the femoral approach in 50 patients (mean age, 76 years [range: 45-96], 31 [61%] men). The most frequent indication was atrioventricular block, associated with sinus rhythm in 30 patients and with atrial fibrillation in eight patients. Overall, 20 patients (40%) were treated with oral anticoagulants postimplantation. Mean implantation time was 64 minutes (range: 20-210) and mean fluoroscopy time was 6.7 minutes (range: 0.2-50). Minimum follow-up window was 1 year (June 2012), with a mean of 50 months [range: 1-113]). No deaths, septic episodes, or severe complications were associated with the procedure, acute or long-term. Follow-up data were available for 46 patients, of who 21 (46%) died during follow-up (mean age, 87 years [range: 73-101]). No cause of death was associated with the femoral technique. Conclusion Permanent pacemaker implantation through femoral access is not difficult for an experienced implant surgeon. Outcomes were comparable to systems implanted by superior venous approach, and no severe complications were observed at 10-year follow-up.

BACKGROUND A left ventricular (LV) endocardial lead implant to achieve cardiac resynchronization therapy (CRT) is feasible when a conventional implant failed due to anatomical or technical issues or when the venous implant was performed but the patient did not respond to the therapy. METHODS Data about the implantation procedure (age, sex, clinical characteristics, anticoagulant use, and previous devices), patient characteristics (indication, technique used, lead model, complications), and follow-up (clinical and echocardiographic outcome, LV lead electrical measurements) were analyzed for all CRT systems implanted using LV endocardial lead, due to failed conventional implant or nonresponse, between April 2011 and November 2016. RESULTS Thirty-five patients were implanted with an active fixation LV endocardial lead during the study period, without significant complications. There were no dislodgements or severe complications related to the implant procedure in the follow-up period (36 ± 20 months) and a high percentage of patients responded to therapy, as assessed by several indicators. CONCLUSIONS An LV endocardial lead implant was feasible when the conventional technique had previously failed or was not effective. A high rate of response was achieved without any significant complications.

Resumen Fundamentos y objetivo El sindrome de Tako-tsubo (SmT) es una miocardiopatia aguda reversible que simula un infarto. Analizamos los 60 pacientes ingresados con SmT en nuestro centro. Pacientes y metodo El 73,3% eran mujeres (edad media [DE] de 70,6 [8,11] anos). El 83,3% tenia algun factor de riesgo cardiovascular, el 25% tenia trastorno ansiosodepresivo y en el 58,3% se identifico algun desencadenante, siendo el estres emocional el mas frecuente. El 15,3% mostro bloqueo completo de rama izquierda (BCRI). En el 23,3% las alteraciones de la contractilidad respetaban el apex (formas medioventriculares o diafragmaticas). Resultados La arteria descendente anterior mostro lesiones no significativas en el 35% de los pacientes, y en el 68,3% tenia trayecto diafragmatico. El 40% desarrollo insuficiencia cardiaca (ICC) y el 18,3% shock cardiogenico (SC). La mortalidad hospitalaria global fue del 3,3%, siendo del 8,3% entre aquellos que desarrollaron ICC. La incidencia de SC fue mayor entre los pacientes con BCRI (44,4 frente a 13,7%; p = 0,05) y los varones (43,8 frente a 9,1%; p = 0,005). Conclusiones Aunque la mortalidad hospitalaria del SmT es baja, un porcentaje importante de pacientes desarrollan ICC, siendo la mortalidad de este subgrupo elevada. Los pacientes varones y aquellos con BCRI presentaron mayor morbilidad hospitalaria.

Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients.A total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter2.5 mm or length28 mm in vessels3mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients).Baseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P.0001).The everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis.

Introduccion y objetivos Hasta un 25% de los pacientes sometidos a intervencionismo coronario percutaneo presentan alguna limitacion para la utilizacion de los stents farmacoactivos. Nuestro objetivo es evaluar si el stent bioactivo de titanio y oxido nitrico podia ser una buena alternativa al stent de everolimus para pacientes diabeticos. Metodos Se aleatorizo a 173 pacientes diabeticos con lesiones de riesgo de reestenosis intermedio (criterios de exclusion: diametro 28 mm en vasos < 3 mm, oclusion cronica): 83 pacientes en el grupo con titanio y 90 en el grupo con everolimus. Resultados Las variables basales estaban bien equilibradas, el 28,3% eran insulinodependientes. Al ano, las incidencias de eventos adversos cardiacos mayores (muerte, infarto de miocardio no fatal, ictus o nueva revascularizacion del vaso tratado) eran significativamente mas frecuente en el grupo con titanio que en el grupo con everolimus (total, el 14,5 frente al 4,4%; p = 0,02; subgrupo no insulinodependiente, el 9,7 frente al 3,2%; p = 0,14; insulinodependiente, el 28,6 frente al 7,1%; p = 0,04) y de muerte, infarto de miocardio no fatal, ictus o cualquier revascularizacion, del 16,9% en el grupo con titanio y el 7,8% en el grupo con everolimus (p = 0,06). La revascularizacion de la lesion diana se produjo en el 8,4 frente al 3,3% (p = 0,15), y la del vaso tratado, el 13,3 frente al 3,3% (p = 0,01). El seguimiento angiografico a 9 meses mostro una perdida luminal tardia significativamente menor en el grupo con everolimus (en el segmento, 0,52 ± 0,58 frente a �0,05 ± 0,32 mm; en el stent, 0,76 ± 0,54 frente a 0,13 ± 0,31 mm; p < 0,0001). Conclusiones El stent de everolimus fue superior al titanio en pacientes diabeticos incluso con lesiones de riesgo de eventos clinicos y angiograficos intermedio.

Resumen Introduccion y objetivos El cierre del apendice auricular izquierdo puede ser una opcion terapeutica atractiva para pacientes con fibrilacion auricular no valvular y contraindicacion para tomar anticoagulantes orales, siempre que se obtengan buenos resultados durante la implantacion y en el seguimiento. Metodos Se analizo a 35 pacientes consecutivos y no elegibles para los estudios aleatorizados con anticoagulantes orales a los que se implanto el dispositivo oclusor Amplatzer. Tras los primeros 5 casos, se incorporo una tecnica de imagen 3D. Se analizaron los resultados de la implantacion y de seguimiento durante 1 ano. Resultados La media de edad era 74,65 ± 7,61 anos, con un CHADS2 de 2,41 ± 1,53 y un CHA2DS2-VASc de 3,17 ± 1,60. No se pudo implantar el dispositivo en 1 caso y en 5 fue necesario cambiar la medida seleccionada. No hubo ninguna complicacion cardiaca durante la implantacion ni durante la estancia hospitalaria. Hubo una complicacion vascular (fistula arteriovenosa). Se realizo seguimiento con ecocardiografia transesofagica a las 24 h y tras 1, 3, 6 y 12 meses; se documentaron 5 trombos, que se resolvieron con heparina. En el seguimiento de 21,14 ± 10,09 meses, hubo 3 muertes de pacientes mayores de 80 anos, ninguna de ellas cardiologica, y un accidente isquemico transitorio sin secuelas. Conclusiones El cierre del apendice auricular izquierdo por un operador con cierta experiencia puede ser una opcion terapeutica con pocas complicaciones y con resultados a mas de 1 ano eficaces en la reduccion de complicaciones tromboembolicas y hemorragicas, incluso en poblaciones de muy alto riesgo.

Introduction and objectives Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. Methods Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. Results The mean age was 74.65 (7.61) years, with a CHADS2 score of 2.41 (1.53) and a CHA2DS2-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24 h, 1, 3, 6, and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. Conclusions Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups.

We present a case of a 52 year old female who suffered from a sudden syncope. A coronariography was performed and spontaneous coronary dissection was diagnosed in the posterior descending artery after an optical coherence tomography (OCT) was performed. A conservative management was decided. During hospitalization the patient presented with an episode of chest pain with an anterior ST elevation on ECG. Coronariography showed total occlusion of the left descending artery and again a dissection was diagnosed by OCT. This time, 2 stents were implanted in the affected artery. The hypothesis that the coronary adventitial volume of vasa vasorum is higher in patients with spontaneous coronary artery dissection has been demonstrated in a recent small study and it was observed in this patient. Conservative management is preferred in most cases, proceeding to revascularization for patients with ongoing chest pain, hemodynamic instability and ST elevation, mostly if it affects major arteries.

When permanent pacemaker implantation is not possible or advisable via superior venous access (i.e., axillary or subclavian veins), safe and feasible surgical alternatives are required. The femoral approach is relatively unknown and seldom studied. This single-center study analyzed 10-year outcomes of a femoral implantation approach.Data about the implantation procedure (indication, approach, lead and pacemaker models, complications), patient characteristics (age, sex, medications, comorbidities), and follow-up were analyzed for all permanent pacemaker implantations using the femoral approach between June 2001 and June 2011.A permanent pacemaker was implanted with the femoral approach in 50 patients (mean age, 76 years [range: 45-96], 31 [61%] men). The most frequent indication was atrioventricular block, associated with sinus rhythm in 30 patients and with atrial fibrillation in eight patients. Overall, 20 patients (40%) were treated with oral anticoagulants postimplantation. Mean implantation time was 64 minutes (range: 20-210) and mean fluoroscopy time was 6.7 minutes (range: 0.2-50). Minimum follow-up window was 1 year (June 2012), with a mean of 50 months [range: 1-113]). No deaths, septic episodes, or severe complications were associated with the procedure, acute or long-term. Follow-up data were available for 46 patients, of who 21 (46%) died during follow-up (mean age, 87 years [range: 73-101]). No cause of death was associated with the femoral technique.Permanent pacemaker implantation through femoral access is not difficult for an experienced implant surgeon. Outcomes were comparable to systems implanted by superior venous approach, and no severe complications were observed at 10-year follow-up.

Transcatheter aortic valve replacement (TAVR) is an increasingly common procedure for the treatment of aortic stenosis in elderly patients with comorbidities that prevent the use of standard surgery. It has been shown that implantation without aortic regurgitation is related to lower mortality. Mild paravalvular regurgitation is inevitable in some cases due to calcification of the aortic annulus and its usually somewhat elliptical shape. Central regurgitation is less common, but has been associated with valve overdilatation in cases in which reduction of paravalvular regurgitation was attempted after the initial inflation. However, there are no reported cases of central prosthetic aortic regurgitation due to acute LV dysfunction. We report a case in which central aortic regurgitation occurred due to transient ventricular dysfunction secondary to occlusion of the right coronary artery by an embolus. The regurgitation disappeared after thrombus aspiration and normal ventricular function was immediately recovered. Resumo: A substituição percutânea de válvula aórtica (transcatheter aortic valve replacement – TAVR) tem-se tornado cada vez mais frequente para o tratamento da estenose aórtica em pacientes idosos com doenças associadas, para evitar a cirurgia convencional. Sabe-se que, não havendo refluxo aórtico após o implante, a mortalidade será mais baixa. Em alguns casos, contudo, um refluxo paravalvular moderado é inevitável, devido à calcificação do ânulo-aórtico e à sua configuração geralmente elíptica. O refluxo central é mais raro, tendo sido associado à excessiva dilatação da válvula em casos em que se tentou redução do refluxo paravalvular, após a inflação inicial. Entretanto, não foram referidos casos de refluxo aórtico central por disfunção ventricular esquerda aguda. Referimos um caso em que ocorreu refluxo aórtico central por disfunção ventricular transitória, secundária à oclusão da artéria coronária direita por êmbolo. O refluxo desapareceu após aspiração do trombo, sendo recuperada imediatamente a função ventricular normal. Keywords: Aortic regurgitation, Transcatheter aortic valve replacement, Coronary occlusion, Palavras-chave: Insuficiência aórtica, Substituição percutânea de válvula aórtica, Oclusâo coronária

Fundamento y objetivo El dolor toracico agudo (DTA) es un sintoma inespecifico que puede ser expresion de cardiopatia isquemica (CI). La arteriosclerosis frecuentemente esta presente en mas de un territorio vascular. El indice tobillo-brazo (ITB) es una herramienta util en el diagnostico de enfermedad arterial periferica (EAP). Nuestro objetivo fue evaluar la utilidad del ITB en pacientes con DTA en los que se sospecha CI. Pacientes y metodo Estudio transversal de 94 pacientes consecutivos, con una edad media (DE) de 57,4 (12,2) anos, ingresados por DTA con sospecha de CI, en los que se determino el ITB y se investigo la presencia de CI. Resultados La CI estuvo presente en 22 pacientes (23,4%) y estuvo ausente en 72 pacientes (76,6%). La EAP asintomatica (ITB=0,9) estuvo presente en 6 pacientes (27,2%) en el grupo con CI y en 7 pacientes (9,7%) en el grupo sin CI. Encontramos diferencias significativas en el ITB segun la presencia o no de CI (0,9 [0,23] frente a 1,17 [0,15]; p

Introduction: When venous access via the upper venous tree is not possible, the usual approach is to proceed to epicardial lead placement. Material and Methods: This report presents a consecutive series of 12 permanent pacemaker systems utilizing the right femoral vein for venous access implanted between May 2001 and October 2004. Results: A modification of the previously reported surgical technique was used with a mean implant time of 52 minutes. Five were dual-chamber systems and seven were VVIR. All the leads implanted were active fixation. There was a 0% dislodgment rate and a mean follow-up of 18 months. During this time, three patients required revision or treatment of a pocket complication. All systems remained in the pacing mode as originally programmed with stable low sensing and pacing thresholds. There was no clinical evidence for acute or chronic venous thrombosis and no evidence of asymptomatic venous obstruction in eight patients who underwent echo-duplex studies. Conclusion: We believe that the permanent femoral implant utilizing the technical modifications described in this article, offers an alternative to epicardial lead placement when the usual upper venous tree access is not available.

Aims: Paclitaxel drug-eluting balloons (pDEB) could be an attractive option to minimise side branch (SB) restenosis in bifurcated coronary lesions. We compared angiographic and clinical outcomes with pDEB plus bare metal stent (BMS) versus drug-eluting stents (DES) in de novo bifurcated lesions. Methods and results: This multicentre randomised trial included 108 patients. Sequential main branch (MB)/SB dilatation with pDEB, with provisional T-stenting with BMS in the MB was performed in the pDEB group, and with everolimus DES in the DES group. The primary endpoint was late lumen loss (LLL) at nine months. The secondary endpoint was the incidence of major adverse cardiac events (MACE: death, myocardial infarction, or target lesion revascularisation). In-segment MB LLL was 0.31±0.48 mm in the pDEB group, and 0.16±0.38 mm in the DES group (p=0.15); mean difference was 0.15 mm (upper limit one-sided 95% CI: 0.27 mm; p=0.001; non-inferiority test). LLL in SB was –0.04±0.76 mm in the pDEB group and –0.03±0.51 mm in the DES group (p=0.983). MACE and TLR were higher in the pDEB group (17.3% vs. 7.1%; p=0.105, and 15.4% vs. 3.6%; p=0.045), due to higher MB restenosis (13.5% vs. 1.8%; p=0.027). Conclusions: pDEB bifurcation pretreatment with BMS implantation in MB showed greater LLL (ns) and increased incidence of MACE compared to everolimus DES. Both strategies showed similar results in the SB.

Durante las reacciones anafilacticas (o anafilactoides) pueden ocurrir reacciones cardiovasculares graves, incluido el infarto agudo de miocardio. Esta etiologia de infarto de miocardio, aunque conocida, es sin embargo infrecuente, y solo esporadicamente comunicada en la literatura. Presentamos un caso de infarto agudo de miocardio secundario a reaccion anafilactica tras ingesta de marisco, tratada con adrenalina subcutanea, en el que fue necesaria una angioplastia de rescate. Se discute el mecanismo de la oclusion coronaria en este tipo de reacciones y como podria influir en la eficacia del tratamiento.

Tuberous sclerosis is an autosomal-dominant disease with involvement of several organs, the heart included. The cardiac anomaly most frequently found is the rhabdomyoma association. However, WPW association has also been encountered more common than usual. In the majority of the published related-series, infant or adolescent patients are described. We report the case of a 68-year-old patient with tuberous sclerosis whose first cardiac manifestation was a pre-excited atrial fibrillation. This association is reviewed and the consideration of accessory pathways is highlighted as the first mechanism to take into account when arrhythmias are present in these patients even in adult age.

Introduccion y objetivo La inversion precoz de las ondas T en pacientes con infarto agudo de miocardio ha sido recientemente relacionada con una mejor funcion ventricular y una evolucion mas favorable, al contrario de lo que sucede en la angina inestable. No se conoce en cambio el significado de las ondas T negativas profundas que aparecen en ocasiones en la fase aguda de algunos infartos agudos de miocardio. El objetivo de este estudio es valorar su relacion con el dano miocardico existente y la extension de la enfermedad coronaria subyacente en los infartos agudos de miocardio anteriores con onda Q. Metodos Se analizaron a 48 pacientes con un primer infarto agudo de miocardio anterior con onda Q, con o sin trombolisis, ingresados con una evolucion menor de 24 h y que tenian realizada una coronariografia. Se definio como onda T negativa gigante aquella que tenia 8 mm o mas desde la linea base. Resultados De los 48 pacientes, 17 presentaban ondas T negativas gigantes (grupo T ) y 31 no (grupo N). En el grupo T, el tamano de la onda T negativa era de 11,29 ± 2,86 mm y el numero de derivaciones precordiales con ondas T negativas era de 4,35 ± 1,57. No hubo diferencias entre ambos grupos en variables como el sexo, factores de riesgo y otras caracteristicas basales. Los pacientes del grupo T eran mas jovenes, tenian menores niveles maximos de enzimas cardiacas y presentaron, asimismo, mayor recuperacion de ondas R durante el seguimiento, con diferencias significativas respecto al grupo N. La fraccion de eyeccion era mayor (56,3 ± 13,4 frente a 42 ± 12%; p I mientras que esta situacion ocurrio en el 38,7% de los pacientes del grupo N. Conclusiones La aparicion de ondas T negativas gigantes en la fase aguda o precoz de un infarto agudo de miocardio anterior con onda Q se asocia a un menor tamano del infarto, un menor deterioro funcional y una menor extension de la enfermedad coronaria subyacente.

Flecainide is an antiarrhythmic considered safe in patients who have no structural cardiopathy, and frequently used in the prevention of atrial fibrillation. However, in patients with a history of infarction and/or severe conduction disorders, its proarrhythmicity may be lethal. Torsade-de-pointes type tachycardia is not included as one of these proarrhythmic effects, since the drug's scant action on ventricular repolarization makes this adverse effect very unlikely. We present the case of a patient who, shortly after beginning treatment with flecainide, was admitted because of syncope related to bradyarrhythmias, long QT, and torsade-de-pointes. There have been very few published cases in which one finds such an association between flecainide and this infrequent arrhythmia.

The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumour (with myxoma being the most frequent), invasion of an extracardiac tumour, vegetations on the tricuspid valve, and an atrial thrombus. We describe the case of a patient who was admitted to our service with a diagnosis of suspected myxoma based on the chance transthoracic echocardiographic discovery of a right atrial mass. A transesophageal echocardiogram showed the process to be extracardiac, and magnetic resonance imaging showed it to originate at the renal level extending via the inferior vena cava to the right atrium. Tumour extension with thrombosis of the vena cava is a relatively frequent complication of renal carcinoma, but only exceptionally does it reach the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient.

Se presenta el caso de un paciente de 77 anosque ingresa por un cuadro de taquicardia ventricularsostenida y que es diagnosticado de miocardiopatiahipertrofica medioventricular con aneurismaapical. Puesto en tratamiento con amiodarona a bajasdosis, el paciente esta asintomatico y sin presentarrecurrencia de sus arritmias al ano. Se revisala asociacion de miocardiopatia hipertroficamedioventricular con aneurisma apical y de esteconjunto con las taquicardias ventriculares sostenidas,asi como su tratamiento.

El seudoaneurisma ventricular izquierdo se asocia principalmente con infarto de miocardio y rotura de la pared libre del ventriculo izquierdo, aunque puede asociarse a otras afecciones. La rotura del seudoaneurisma causa el colapso y la defuncion si no se interviene de forma temprana. Presentamos un caso poco frecuente del aneurisma ventricular izquierdo en un paciente con lesiones coronarias que desencadenan un infarto de miocardio silente con rotura de la pared libre, creacion de un gran seudoaneurisma posterolateral y rotura de la primera bolsa seudoaneurismatica con creacion de una segunda, lo cual provoco shock y el fallecimiento del paciente.

The Tako-tsubo syndrome (TS) is a reversible acute cardiomyopathy simulating an infarction. We analyzed 60 patients admitted with TS in our center.A percentage of 73.3 were women (mean age: 70.6 ± 11.8 years); 83.3% had some cardiovascular risk factor, 25% had an anxiety-depressive disorder and in 58.3% a precipitating factor was identified, emotional stress being the most frequent. A percentage of 15.3 showed complete left bundle branch block (LBBB). In 23.3% of patients, contractile abnormalities respected the apex (mid ventricular or diaphragmatic types).The anterior descending artery showed no significant lesions in 35% of patients and in 68.3% it had a diaphragmatic segment. Forty percent of patients developed heart failure (HF) and 18.3% cardiogenic shock (CS). The overall in-hospital mortality was 3.3%, while it was 8.3% among those patients who developed HF. The incidence of CS was higher among patients with LBBB (44.4 vs. 13.7%, P=.05) and males (43.8 vs. 9.1%, P=.005).Although in-hospital mortality in patients admitted due to TS is low, a significant percentage of these patients develop HF with a high mortality in this subgroup. Males and patients with LBBB had higher in-hospital morbidity.

Left ventricular pseudoaneurysm is usually associated with myocardial infarction and ventricular wall rupture, although it can also be associated with other pathological conditions. Rupture causes shock, and death if not repaired urgently. We report the very rare case of a man with coronary lesions that resulted in a silent myocardial infarction with rupture of the myocardial wall and the subsequent development of a large, posterolateral, left ventricular pseudoaneurysm. This was followed by rupture of the primary pseudoaneurysm and the consequent creation of a second pseudoaneurysm, which finally resulted in shock and death.