Javier Lacunza - Academia.edu (original) (raw)

Papers by Javier Lacunza

Annals of Internal Medicine, Mar 21, 2017

Acute Myocardial Infarction Masked by Brugada Syndrome: A Case Report Background: Brugada syndrom... more Acute Myocardial Infarction Masked by Brugada Syndrome: A Case Report Background: Brugada syndrome is characterized by abnormal findings on electrocardiography and an increased risk for sudden cardiac death (1). The distinctive electrocardiographic finding is a coved ST-segment elevation in V1 to V3 that is more than 2 mm high followed by a negative T wave, although other findings have been reported. Ventricular tachycardia and fibrillation are the mechanisms for sudden cardiac death, which occurs more frequently in men (especially those in their early 40s) and perhaps in persons from Asia. Brugada syndrome is believed to be a genetic disorder because it also occurs more frequently in some families and because some patients have genetic mutations that affect the cardiac sodium channel or other ion channels. However, the yield of genetic testing is limited. This condition was first described in 1992 and is being recognized more frequently for uncertain reasons. Purpose: To alert clinicians to the difficulty of diagnosing acute myocardial infarction in some patients with Brugada syndrome. Case Report: We provided care for a 60-year-old white woman with Brugada syndrome. Her electrocardiogram showed changes in the anterior leads consistent with type 1 Brugada syndrome (Figure, panel A) (2). The patient has never had syncope and has no family history of sudden death. Two years ago, she developed new-onset central chest pain. Positive results on an exercise test prompted coronary angiography, which showed a severe lesion in the proximal left anterior descending artery. This lesion was treated with angioplasty and a drug-eluting stent. She recovered completely, and her electrocardiogram was unchanged after the episode. The patient was admitted recently with new chest pain and new electrocardiographic findings (Figure, panel B). We suspected an acute anterior infarction, but interpretation of her electrocardiogram was complicated by persistent changes on it from Brugada syndrome. Urgent angiography revealed a subocclusive thrombosis of the stent with unobstructed left main stem, circumflex, and right coronary arteries (Figure, panel C). Another angioplasty was done (Figure, panel D), and she has since returned to her usual clinical status. Discussion: Diagnosing an acute myocardial infarction with ST-segment elevation is complicated in some patients with other medical conditions that affect the electrocardiogram, such as cardiomyopathy, pericarditis, electrolyte disturbances, and early repolarization pattern, and in some AfricanCaribbean patients (3). We believe that this case report adds Brugada syndrome to the list. A detailed medical history and comparison of the patient's current electrocardiogram with previous ones is crucial to make the correct diagnosis and avoid delays in urgent cardiac catheterization. If the patient has Brugada syndrome, looking for new horizontal ST elevations and mirror ST depressions is especially important.

Revista española de cardiología, Aug 1, 2013

International Journal of Cardiology, Jul 1, 2012

Restrictive cardiomyopathy due to myocardial deposition of amyloid protein usually presents as ri... more Restrictive cardiomyopathy due to myocardial deposition of amyloid protein usually presents as right-sided heart failure. Prognosis in such cases is poor, but patients who receive specific treatment for the underlying condition causing amyloidosis seem to have a slightly better outcome [1]. Early diagnosis of restrictive ventricular physiology and it ultimate cause may be important for patient prompt useful management. In deposition cardiomyopathies, ventricular ejection fraction is usually preserved and end-diastolic ventricular volumes are normal or reduced. Raised filling pressure is the main compensatory mechanism to maintain cardiac output in such cases [2]. Distinguishing between constriction and restriction is a common challenge in healthcare practice [3], since clinical presentation is usually similar, and even typical causes of myocardial restriction may provoke true pericardial constriction [4]. Pulmonary regurgitation Doppler flow morphology depends on the pressure gradient between pulmonary artery and right ventricle. Echocardiography is able to record pulmonary regurgitation signal in more than 80% of studies [5]. High right ventricular end-diastolic pressure due to restrictive physiology has been shown to produce a distinctive morphology in continuous-wave Doppler tracings of pulmonary regurgitation, with prognostic value in the setting of right ventricular infarction [5]. Gilman et al. pointed out the respiratory

European Heart Journal, Mar 1, 2003

Revista española de cardiología, Mar 1, 2010

Cardiology Journal, Feb 27, 2018

Revista española de cardiología, Apr 1, 2023

Transradial access (TRA) has been shown to lower morbidity and bleeding complications compared to... more Transradial access (TRA) has been shown to lower morbidity and bleeding complications compared to transfemoral access (TFA) in percutaneous coronary interventions. Transfemoral crossover has been used to describe instances where interventions are initiated via the radial artery but require a secondary access site for completion. In this study, we evaluate the incidence and outcomes of transfemoral crossover in peripheral vascular interventions. Material and Methods: A retrospective review was performed for all peripheral interventions for which the initial attempt at vascular access was the radial artery and either ipsilateral or contralateral femoral artery access was obtained prior to completion. A Barbeau test was first performed in all cases. Following this, access to the left radial artery was attempted under ultrasound guidance using a micropuncture with placement of a hydrophilic-coated sheath (5, 6 Fr). Following sheath placement, a standard solution of heparin (3000 units), verapamil (2.5 mg), and nitroglycerin (200 mcg) was administered intra-arterially. Upon completion, a TR-band (Terumo, Somerset, New Jersey) was used for hemostasis. Incidence of femoral crossover, reason for femoral crossover, secondary access site used, and major and minor adverse events were recorded. Results: From April 2012 to July 2014, a total of 960 procedures were performed in 633 patients for which the radial artery was intended as the primary access site. Of these, there were 18 procedures in 18 patients (66 Ϯ 13 years, 10 female, 8 male) completed with femoral access yielding an overall femoral crossover rate of 1.9%. Procedures performed were peripheral embolization (n ¼ 7), radioembolization (n ¼ 5), chemoembolization (n ¼ 3), and peripheral vascular stent placement (n ¼ 3). Causes of femoral crossover included vessel spasm/small vessel diameter (n¼7; 38%), radial loops (n¼5; 28%), proximal occlusion (n¼3; 17%), and catheter length limitations (n¼3; 17%). There were no complications in 14 of the 18 procedures. Other outcomes in transfemoral crossover cases that occurred in 1 patient each included Grade 2 hematoma in an endoleak repair performed at the contralateral site due to vessel spasm, bruising in a radioembolization performed at the ipsilateral site due to radial loop and bruising in another patient in a renal stent performed at the contralateral site due to vessel spasm, and radial spasm in a radioembolization performed at the ipsilateral site due to vessel spasm. Conclusions: In our experience, incidence of transfemoral crossover in peripheral vascular interventions initiated via a transradial approach is extremely low. Recognizing anatomical and experience-related factors contributing to femoral crossover may be helpful in lowering access site complications while analysis of technical limitations may contribute to future product development.

Revista española de cardiología, Mar 1, 2018

International Journal of Cardiology, Sep 1, 2011

A 36 year-old male with palpitations was referred to our cardiac outpatient clinic for evaluation... more A 36 year-old male with palpitations was referred to our cardiac outpatient clinic for evaluation in 1998. ECG demonstrated sinus bradycardia, normal QRS complex and repolarization abnormalities consistent with an early repolarization pattern, together with unusual peaked T waves up to 20 mV high in the precordial leads. The patient had similar ECGs at annual follow-up visits (QTc range: 342–385 ms) (Fig. 1). No arrhythmias were found using Holter ECG monitoring. Based on the peculiar repolarization appearance, a procainamide drug challenge test was then performed with no ECG changes suggestive of Brugada syndrome. During the drug challenge test QTc went from 342 ms to 405 ms. An echocardiogram demonstrated a normal heart. Repeated 24 h and 7 days ambulatory Holters failed to demonstrate any arrhythmia. An ECG from a previous cholesteatoma surgery performed 10 years earlier (1988) had shown similar findings. The patient was admitted to hospital with acute myocardial infarction in 2005 (when hewas 43 years old). The ECG showed up to 3 mm ST elevation in II, III and aVF, together with a mild ST segment depression in V1–V2. The T waves seemed to have normalized (a maximum of 6 mV in V3 was measured) while the QTc interval remained short (380 ms) (Fig. 2C). After primary angioplasty of an occluded right coronary artery, the clinical coursewas unremarkable. Despite a rise in cardiacmarkers (max CK 2219 IU/L), ECGwas normal at hospital discharge. The echocardiogram revealed limited basal inferior wall akinesis. Smoking cessation, betablockers and statins were recommended. An exercise test performed 6 months after myocardial infarction demonstrated no signs of ischaemia or arrhythmia. QTc atmaximal exercise test was365 ms(Fig. 2E). Thepatient remainedasymptomatic onhis last visit in 2010 (46 years old). He enjoys regular exercise 3 days a week, with good tolerance. The patient complained of occasional atypical chest pain and palpitations but, notably, he did not report any syncopal or presyncopal episodes. Familial and genetic testings were performed. His father, aged 75, was diagnosed with dilated cardiomyopathy. The father's echocardiogram showed a left ventricular ejection fraction of 45% (LVEF), a left ventricular end diastolic diameter of 65 mm (LVEDD) and left ventricular hypertrophy of 13 mm (LVH). He had a history of paroxysmal atrial fibrillation, smoking, and no other cardiovascular risk factors. ECG showed RBBB with relatively short QTc (QTc 390 ms for a QRS complex duration of 150 ms). A 41 year-old sister had a history of paroxysmal supraventricular tachycardia which was successfully ablated and paroxysmal atrial fibrillation. She had mild dilatation (LVEDD of 56 mm) with normal LVEF in the echocardiogram. QTc measured from the sister's ECG was 365 ms. There were no peaked T waves seen in either the father's or the sister's ECGs. A younger brother, aged 39, had QTc 350 ms with borderline LV diameters and ventricular function. A 48 year-old brother had both a normal ECG and echocardiogram. The eldest brother, aged 50, had dilated LV with regional wall motion abnormalities (LVEF 45%, LVEDD 61 mm) secondary to a prior inferoposterior myocardial infarction. There was no family history of sudden cardiac death. The sequencing of genes encoding ion channels related to QT syndromes and conduction disease was performed. Only two known polymorphism in KCNH2 (K897T) and KCNE1 (S38G) were identified, with normal SCN5A, KCNJ2 and KCNE2. Short QT syndrome has been related to a high risk of ventricular arrhythmia and sudden cardiac death [1,2]. This association is based on a few series with small populations and case reports [2]. Atrial fibrillation has also been described as part of the syndrome [2]. Mutations in potassium channels have been identified as cause of short QT syndrome [3–5]. Although an isolated case of dilated cardiomyopathy with short QT has already been published [6], this is the first reported case of a familial short QT syndrome with dilated cardiomyopathy. In keeping with a Finnish epidemiological study, a short QT interval is consistent with a long life expectancy [7]. In contrast, a recent review reported this syndrome accounted for 19/61 (41%) cases of sudden death mortality/cardiac arrest [2]. Despite most cases with severe events having a very short QT interval, patients with QTc of around 350 ms were not free from fatal complications. This case illustrates QTc interval behavior in a patient followed up for over 20 years, including measurements of changes in ischaemia, exercise and procainamide. ECG variations in short QT patients in different settings are mostly unknown [2]. Multiple Holter studies in our patient have failed to demonstrate any malignant arrhythmia. Severe forms are often described in early descriptions of similar diseases such as long QT, Brugada syndrome, hypertrophic cardiomyopathy and left ventricular non-compaction, etc. Later publications on these conditions have…

Europace, Nov 12, 2019

Reflex vasovagal syncope (VVS) is the most common cause of syncope and patients with recurrent ep... more Reflex vasovagal syncope (VVS) is the most common cause of syncope and patients with recurrent episodes may severely impair quality of life (QoL). This pre-specified analysis evaluated whether the clinically significant reduction in syncope burden demonstrated by dual-chamber pacing with closed loop stimulation (DDD-CLS) reported in the SPAIN trial translates into improved QoL.

Revista Espanola De Cardiologia, 2002

Head-up Tilt Test Potentiated with Nitroglycerin. What is the Optimal Duration of the Test after ... more Head-up Tilt Test Potentiated with Nitroglycerin. What is the Optimal Duration of the Test after Administration of the Drug? Introduction and objectives. Numerous variations of the head-up tilt-table test potentiated with nitrates have been reported. After the administration of nitroglycerin, between 10 and 25 min of continued tilting have been recommended. The aim of this study was to assess the optimal duration of the pharmacological phase of the headup tilt-table test potentiated with sublingual administration of nitroglycerin spray (NTG-TT). Method. The records of 498 consecutive NTG-TT were reviewed. Our protocol consisted of a 20-min drug-free phase at a 60 o angle. If syncope does not develop, 400 µg of sublingual nitroglycerin spray is administered and the patient continues to be tilted for a further 25 min. The test results and time to a positive response were analyzed. Results. The result of NTG-TT was positive in 288 procedures, most of them after nitroglycerin administration (255, 88.5%). The mean time to a positive response was 10.7 ± 6.7 and 5.0 ± 2.4 min during the control and pharmacological phases respectively. Most positive responses were concentrated in the 3 to 5 min after drug administration. The time to syncope after nitroglycerin administration was over 10 min in 9 patients and 15 min in only 2 patients. Conclusions. The duration of the pharmacological phase of NTG-TT using the described protocol can be reduced to 15 min without loss of sensitivity. A further reduction to 10 min would decrease the rate of positive responses by a small amount and might be considered clinically acceptable.

Circulation journal, 2013

Background: The implantable loop recorder (ILR) is a useful tool for diagnosing paroxysmal condit... more Background: The implantable loop recorder (ILR) is a useful tool for diagnosing paroxysmal conditions potentially related to arrhythmias. Most investigations have focused on selected clinical studies or high-volume centers. The aim of this study was to evaluate the indications and outcomes of the ILR in real clinical practice. Methods and Results: This was a prospective, multicenter registry of patients undergoing ILR implantation for clinical indications (April 2006-December 2008). Clinical characteristics (symptoms, arrhythmias, treatments) were recorded in a database. Follow-up data at 1 year or after the occurrence of the first episode were also recorded. Total enrollment: 743 patients (male, 413, 55.6%; 64.9±16 years); 228 (30.7%) had structural heart disease (SHD), and 183 (24.6%), bundle branch block (BBB). Recurrent syncope (76.4%) was the most common indication for implantation. Complete follow-up was obtained for 680 patients (91.5%). Three hundred and twenty-five patients (48%) presented 414 events, with a final diagnosis in 230 patients (70.8% of patients with events; 33.1% of patients with follow-up). Syncope secondary to bradyarrhythmia was the most frequent diagnosis. Similar rates of final diagnoses were noted in subgroups of SHD, BBB and normal heart. Regarding the cause of implantation, higher event rates were registered among patients with recurrent syncope. Conclusions: One-third of patients obtained a final diagnosis with the ILR, independent of the baseline characteristics. Only the cause of implantation provided different rates of final diagnosis.

International Journal of Cardiology

Revista Española de Cardiología

European Heart Journal, 2019

Background Risk stratification for sudden cardiac death (SCD) in Brugada syndrome (BrS) is a sign... more Background Risk stratification for sudden cardiac death (SCD) in Brugada syndrome (BrS) is a significant challenge. Purpose To evaluate the importance of clinical and ECG factors in the likelihood of developing significant ventricular arrhythmias (VAs)/SCD in BrS patients. Methods VA occurrence during follow-up were assessed and the role of 16 proposed clinical or ECG risk markers evaluated in a multicenter international study of BrS patients and no history of cardiac arrest. Markers with predictive power were identified and incorporated into a risk score model. Results Across 15 international centers, 1084 patients were included. During a follow-up of 5.3 years (IQR 2.7–9.0 years)- 110 patients had VA occurrence (10.1%) with an annual event rate of 1.7% (95% CI 1.4–2.0). Of the 16 proposed risk factors, diagnosis by family screening of sudden cardiac death (HR 4.65; p<0.001), probable arrhythmia related syncope (HR 3.88, p<0.001), type 1 spontaneous ECG (HR 3.56; p<0.001),...

Contraception, 2019

This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

REC: interventional cardiology, 2019

Imagen en cardiología Rotura de guía intracoronaria evaluada por tomografía de coherencia óptica ... more Imagen en cardiología Rotura de guía intracoronaria evaluada por tomografía de coherencia óptica Optical coherence tomography assessment of intracoronary guidewire fractures

Journal of the American College of Cardiology, 2018

European Geriatric Medicine, 2018

Background/objectives Syncope in octogenarians represents an important problem in terms of comorb... more Background/objectives Syncope in octogenarians represents an important problem in terms of comorbidity, quality of life and substantial medical costs, resulting from studies and treatments. An implantable loop ecorder (ILR) may improve diagnostic performance. The objective of the study was to evaluate the results of the ILR in a population of octogenarians. Design Prospective registry of patients receiving an implantable loop recorder in 40 Spanish centers. Participants 128 octogenarians implanted with a device for clinical evaluation of syncope. Methods Prospective registry recording the incidence of new symptoms or device activations within the first year after the implant, the incidence of new diagnosis and treatments, and an evaluation of the safety of this strategy in this population. Dedicated database for the registry. Results Forty-two patients (33% of the population) obtained a final etiological diagnosis of the syncope, which led to a specific treatment in 39 (31%) patients. No differences regarding the presence of conduction disturbances or structural heart disease were found in this population. A mortality of 4% was recorded during follow-up. Conclusion The implantable loop recorder seems to be an effective and safe tool in the management of syncope in the octogenarian population. Keywords Octogenarians • Implantable loop recorder • Syncope The members of Spanish Reveal Registry are listed in Acknowledgements.