Cardiovascular surgery and cardiology, current status of two sister specialties in Spain: the CARDIOXCARDIO study.

In recent years, there has been a notable shift in cardiovascular clinical practice within cardiology and surgery. The CARDIOXCARDIO study aimed to identify professionals' opinions on working practices and relations between specialties. A survey was simultaneously sent to the 4442 members of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) and the Spanish Society of Cardiology (SEC), yielding 385 valid responses. More than half (59%) of respondents were men, mostly specialists (7.3% residents), and 74.8% worked in the field of cardiology, predominantly in public centers (88.3%). Using a Likert scale ranging from 1 to 5 (worst to best), respondents rated relations between surgery and cardiology with an average of 3.57±0.9 points. Cardiologists rated surgeons with a mean score of 3.83±0.8, while surgeons gave cardiologists a mean score of 3,92±0.72. In addition, respondents provided numerous suggestions for improvement, which are discussed in detail, highlighting certain discrepancies in criteria between specialties. Implementing strategies based on the suggestions of professionals, together with a proactive approach to continuous improvement, could substantially enhance the quality of cardiovascular care in Spain.

Factors associated with vasoplegic shock in the postoperative period of cardiac surgery and influence on morbidity and mortality of the use of arginine vasopressin as rescue therapy.

OBJECTIVES: Analyzing associated factors with vasoplegic shock in the postoperative period of Cardiac Surgery. Analyzing the influence of vasopressin as rescue therapy to first-line treatment with norepinephrine. DESIGN: Cohort, prospective and observational study. SETTING: Main hospital Postoperative Cardiac ICU. PATIENTS: Patients undergoing cardiac surgery with subsequent ICU admission from January 2021 to December 2022. INTERVENTIONS: Record of presurgical, perioperative and ICU discharge clinical variables. MAIN VARIABLES OF INTEREST: chronic treatment, presence of vasoplegic shock, need for vasopressin, cardiopulmonary bypass time, mortality. RESULTS: 773 patients met the inclusion criteria. The average age was 67.3, with predominance of males (65.7%). Post-CPB vasoplegia was documented in 94 patients (12.2%). In multivariate analysis, vasoplegia was associated with age, female sex, presurgical creatinine levels, cardiopulmonary bypass time, lactate level upon admission to the ICU, and need for prothrombin complex transfusion. Of the patients who developed vasoplegia, 18 (19%) required rescue vasopressin, associated with pre-surgical intake of ACEIs/ARBs, worse Euroscore score and longer cardiopulmonary bypass time. Refractory vasoplegia with vasopressin requirement was associated with increased morbidity and mortality. CONCLUSIONS: Postcardiopulmonary bypass vasoplegia is associated with increased mortality and morbidity. Shortening cardiopulmonary bypass times and minimizing products blood transfusion could reduce its development. Removing ACEIs and ARBs prior to surgery could reduce the incidence of refractory vasoplegia requiring rescue with vasopressin. The first-line treatment is norepinephrine and rescue treatment with VSP is a good choice in refractory situations. The first-line treatment of this syndrome is norepinephrine, although rescue with vasopressin is a good complement in refractory situations.

Uric acid and acute kidney injury in high-risk patients for developing acute kidney injury undergoing cardiac surgery: A prospective multicenter study.

PURPOSE: It is unclear whether preoperative serum uric acid (SUA) elevation may play a role in the development of acute kidney injury (AKI) associated with cardiac surgery (CSA-AKI). We conducted a cohort study to evaluate the influence of preoperative hyperuricemia on AKI in patients at high risk for developing SC-AKI. DESIGN: Multicenter prospective international cohort study. SETTING: Fourteen university hospitals in Spain and the United Kingdom. PARTICIPANTS: We studied 261 consecutive patients at high risk of developing CSA-AKI, according to a Cleveland score ≥ 4 points, from July to December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: AKIN criteria were used for the definition of AKI. Multivariable logistic regression models and propensity score-matched pairwise analysis were used to determine the adjusted association between preoperative hyperuricemia (≥7 mg/dL) and AKI. Elevated preoperative AUS (≥7 mg/dL) was present in 190 patients (72.8%), whereas CSA-AKI occurred in 145 patients (55.5%). In multivariable logistic regression models, hyperuricemia was not associated with a significantly increased risk of AKI (adjusted Odds Ratio [OR]: 1.58; 95% confidence interval [CI]: 0.81-3; P = .17). In propensity score-matched analysis of 140 patients, the hyperuricemia group experienced similar adjusted odds of AKI (OR 1.05, 95%CI 0.93-1.19, P = .37). CONCLUSIONS: Hyperuricemia was not associated with an increased risk of AKI in this cohort of patients undergoing cardiac surgery at high risk of developing CSA-AKI.

Seguimiento a 5 años de pacientes octogenarios post cirugía cardíaca / A five year follow up of octogenarians following cardiac surgery

Introducción: El aumento significativo de la esperanza de vida en el grupo de octogenarios en Chile ha generado preocupación sobre la eficacia y la necesidad de cirugías cardíacas mayores en esta población incluso cuando el 85 % de ellos llega a dicha edad en condiciones de salud favorables. Objetivos: Este estudio se propuso evaluar la mortalidad hospitalaria y a mediano plazo, así como identificar complicaciones postoperatorias en pacientes octogenarios sometidos a cirugía cardíaca en Chile. Métodos: Se llevó a cabo un estudio observacional retrospectivo en el Hospital Las Higueras de Talcahuano entre enero de 2014 y diciembre de 2022, con una muestra de 79 pacientes. Resultados: Se encontró que el 86% de los procedimientos utilizaron circulación extracorpórea, y el 84% fueron electivos, principalmente cirugías coronarias (54%). La mortalidad intrahospitalaria fue 9%, con el uso preoperatorio de Balón Contrapulsación Intraaórtico identificado como un factor de mal pronóstico. Complicaciones postoperatorias como la Fibrilación Auricular afectaron al 17%, mientras que solo Neumonía y Falla Renal influyeron significativamente en la mortalidad. La supervivencia a 1, 3 y 5 años fue 81%, 76% y 73%, respectivamente. Conclusión: La cirugía cardíaca en octogenarios en Chile presenta resultados comparables a nivel mundial, destacando la importancia del análisis individual por un equipo multidisciplinario al considerar cirugías mayores en pacientes frágiles. El uso de técnicas mínimamente invasivas podría mejorar la calidad de vida, aunque se requieren estudios adicionales con más pacientes para confirmar esta hipótesis.

Background: Background: The significant increase in life expectancy among octogenarians in Chile has raised concerns about the efficacy and need of major cardiac surger in this population, even as 85% of them reach this age in favorable health conditions. Objectives: This study aimed to evaluate in-hospital and medium-term mortality and identify postoperative complications in octogenarian patients undergoing cardiac surgery in Chile. Methods: An observational retrospective study was conducted at Hospital Las Higueras de Talcahuano between January 2014 and December 2022, involving a sample of 79 patients. Results: 86% of procedures utilized extracorporeal circulation, and 84% were elective, predominantly coronary artery surgeries (54%). In-hospital mortality was 9%. Preoperative Intra-Aortic Balloon Pump use identified as a poor prognostic factor. Postoperative complications such as Atrial Fibrillation affected 17%, while only Pneumonia and Renal Failure significantly influenced mortality. Survival at 1, 3, and 5 years was 81%, 76%, and 73%, respectively. Conclusion: Cardiac surgery in octogenarians in Chile yields comparable outcomes to those worldwide, emphasizing the importance of individual assessment by a multidisciplinary team when considering major surgeries in frail patients. The use of minimally invasive techniques may enhance quality of life, although further studies with larger patient cohorts are needed to confirm this hypothesis.

Regional differences in infective endocarditis epidemiology and outcomes in Spain. A contemporary population-based study.

INTRODUCTION AND OBJECTIVES: Our aim was to describe the contemporary epidemiological profile of infective endocarditis (IE) in Spain, and to evaluate variations in IE incidence, characteristics, and outcomes among the different Spanish regions (autonomous communities [AC]). METHODS: We conducted a retrospective, population-based study, using data obtained from national in-patient hospital activity of all patients discharged with a diagnosis of IE from hospitals included in the Spanish National Health System, from January 2016 to December 2019. Differences in the IE profile between the 17 Spanish AC were analyzed. RESULTS: A total of 9008 hospitalization episodes were identified during the study period. Standardized incidence of IE was 5.77 (95%CI, 5.12-6.41) cases per 100 000 population. Regarding predisposing conditions, 26.8% of episodes occurred in prosthetic valve carriers, 36.8% had some kind of valve heart disease, and 10.6% had a cardiac implantable electronic device. Significant differences were found between AC in terms of incidence, predisposing conditions, and microbiological profile. Cardiac surgery was performed in 19.3% of episodes in the total cohort, and in 33.4% of the episodes treated in high-volume referral centers, with wide variations among AC. Overall in-hospital mortality was 27.2%. Risk-adjusted mortality rates also varied significantly among regions. CONCLUSIONS: We found wide heterogeneity among Spanish AC in terms of incidence rates and the clinical and microbiological characteristics of IE episodes. The proportion of patients undergoing surgery was low and in-hospital mortality rates were high, with wide differences among regions. The development of regional networks with referral centers for IE could facilitate early surgery and improve outcomes.

Factors associated with increased lactate levels in cardiac surgeries: scoping review / Factores relacionados a la elevación del nivel de lactato en cirugías cardíacas: revisión de ámbito / Fatores associados à elevação do nível de lactato em cirurgias cardíacas: revisão de escopo

ABSTRACT Objectives: to map the factors associated with increased lactate levels in the postoperative period of cardiac surgery using extracorporeal circulation. Methods: this is a scoping review carried out in December 2022, across ten data sources. It was prepared in accordance with the recommendations of the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews checklist. Results: the most recurrent findings in studies regarding the factors responsible for the increase in lactate were: tissue hypoperfusion, cardiopulmonary bypass time and use of vasoactive drugs. In 95% of studies, increased lactate was related to increased patient mortality. Conclusions: discussing the causes of possible complications in cardiac surgery patients is important for preparing the team and preventing complications, in addition to ensuring quality recovery.

RESUMEN Objetivos: mapear los factores relacionados a la elevación del nivel de lactato en el posoperatorio de cirugía cardíaca con uso de circulación extracorporea. Métodos: se trata de una revisión de ámbito realizada en diciembre de 2022, en diez fuentes de datos. Fue elaborada conforme las recomendaciones del Instituto Joanna Briggs y del checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Resultados: los hallados más recurrentes en los estudios sobre los factores responsables por el aumento del lactato fueron: hipoperfusión tisular, tiempo de circulación extracorporea y uso de fármacos vasoactivos. En 95% de los estudios, el aumento del lactato se relacionó al aumento de la mortalidad de los pacientes. Conclusiones: discutir sobre las causas de posibles complicaciones en pacientes de cirugía cardíaca se hace importante para el preparo del equipo y prevención de intercurrencias, además garantizar recuperación de calidad.

RESUMO Objetivos: mapear os fatores associados à elevação do nível de lactato no pós-operatório de cirurgia cardíaca com uso de circulação extracorpórea. Métodos: trata-se de uma revisão de escopo realizada em dezembro de 2022, em dez fontes de dados. Foi elaborada conforme as recomendações do Instituto Joanna Briggs e do checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Resultados: os achados mais recorrentes nos estudos a respeito dos fatores responsáveis pelo aumento do lactato foram: hipoperfusão tecidual, tempo de circulação extracorpórea e uso de fármacos vasoativos. Em 95% dos estudos, o aumento do lactato relacionou-se ao aumento da mortalidade dos pacientes. Conclusões: discutir sobre as causas de possíveis complicações em pacientes de cirurgia cardíaca faz-se importante para o preparo da equipe e prevenção de intercorrências, além de garantir recuperação de qualidade.

Falla del ventrículo derecho en el posoperatorio de cirugía cardíaca valvular: prevalencia, características clínicas y ecocardiográficas y pronóstico / Right ventricular failure in the postoperative period of heart valve surgery: prevalence, clinical and echocardiographic characteristics, and prognosis / Insuficiência ventricular direita no pós-operatório de cirurgia cardíaca valvar: prevalência, características clínicas e ecocardiográficas e prognóstico

Introducción: la falla aguda del ventrículo derecho (VD) en el posoperatorio de cirugía cardíaca (POCC) constituye un desafío clínico por su importante morbimortalidad. El reconocimiento de la importancia de la función del VD en el POCC es un hecho reciente, lo que puede evidenciarse por la ausencia de parámetros de función ventricular derecha en los scores de estratificación del riesgo quirúrgico. Su definición varía según diferentes autores; es difícil conocer su prevalencia y los factores asociados a su desarrollo. Objetivo: analizar la prevalencia, las características clínicas, ecocardiográficas y el pronóstico de los pacientes con falla del VD en el POCC valvular intervenidos en el Instituto Nacional de Cirugía Cardíaca (INCC) en el año 2021 y establecer una comparación con los pacientes intervenidos en el mismo período que no desarrollaron dicha complicación. Método: estudio observacional retrospectivo, analítico. Se incluyeron los pacientes sometidos a cirugía cardíaca valvular en el INCC durante el 2021 que no presentaban ciertos criterios de exclusión preestablecidos. Se consideró la falla aguda del VD en el POCC como la evidencia ecocardiográfica de disfunción ventricular derecha definida cualitativamente en el ecocardiograma posoperatorio. El análisis estadístico se realizó con el software SPSS versión 26.0. Resultados: se incluyeron en el estudio 45 pacientes, de los cuales 7 (15,6%) desarrollaron falla del VD en el POCC. No hubo diferencias entre las características basales. El grupo que desarrolló falla del VD en el POCC presentó una fracción de eyección del ventrículo izquierdo (FEVI) significativamente menor en el ecocardiograma preoperatorio (p = 0,010). No se objetivaron diferencias en las variables intraoperatorias. Respecto al pronóstico, falleció un paciente de cada grupo en el POCC inmediato. Conclusiones: la FEVI preoperatoria podría cumplir un rol predictor de falla aguda del VD en el POCC valvular, hallazgo para comprobar en estudios prospectivos. El impacto de la falla del VD en la mortalidad no pudo definirse, dado el limitado número de pacientes.

Introduction. acute right ventricle (RV) failure in the postoperative period of cardiac surgery (POCC) constitutes a clinical challenge due to its significant morbidity and mortality. Recognition of the RV function importance in POCC is a recent fact, which can be evidenced by the absence of right ventricular function parameters in surgical risk stratification scores. Its definition varies according to different authors, it is difficult to know its prevalence and the factors associated with its development. Objective: to analyze the prevalence, clinical and echocardiographic characteristics, and prognosis of patients with RV failure in valvular POCC operated at the National Institute of Cardiac Surgery (INCC) in 2021 and to establish a comparison with patients operated on in the same period who did not develop this complication. Method: retrospective analytical observational study. Patients undergoing heart valve surgery in the INCC during 2021 were included. Acute RV failure in the POCC was considered as echocardiographic evidence of qualitatively defined right ventricular dysfunction in the postoperative echocardiogram. Statistical analysis was performed using SPSS version 26.0 software. Results: forty-five patients were included in the study, of which 7 (15.6%) developed RV failure in the POCC. There were no differences between baseline characteristics. The group that developed RV failure in POCC had a significantly lower left ventricular ejection fraction (LVEF) on preoperative echocardiography (p = 0.010). No differences were observed in the intraoperative variables. Regarding the prognosis, one patient from each group died in the immediate POCC. Conclusions: preoperative LVEF could play a role in predicting acute RV failure in valvular POCC, a finding to be verified in prospective studies. The impact of RV failure on mortality could not be defined given the limited number of patients.

Introdução: a insuficiência aguda do ventrículo direito (VD) no pós-operatório de cirurgia cardíaca (CCPO) constitui um desafio clínico devido à sua significativa morbidade e mortalidade. O reconhecimento da importância da função do VD no CCPO é fato recente, o que pode ser evidenciado pela ausência de parâmetros de função ventricular direita nos escores de estratificação de risco cirúrgico. Sua definição varia de acordo com diferentes autores, é difícil conhecer sua prevalência e os fatores associados ao seu desenvolvimento. Meta: analisar a prevalência, as características clínicas e ecocardiográficas e o prognóstico dos pacientes com insuficiência de VD em POCC valvular operados no Instituto Nacional de Cirurgia Cardíaca (INCC) em 2021 e estabelecer uma comparação com pacientes operados no mesmo período que não desenvolveram essa complicação. Método: estudo observacional analítico retrospectivo. Foram incluídos pacientes submetidos à cirurgia valvar no INCC durante o ano de 2021. Insuficiência aguda do VD no POCC foi considerada como evidência ecocardiográfica de disfunção ventricular direita qualitativamente definida no ecocardiograma pós-operatório. A análise estatística foi realizada com o software SPSS versão 26.0. Resultados: quarenta e cinco pacientes foram incluídos no estudo, dos quais 7 (15,6%) desenvolveram falência do VD no POCC. Não houve diferenças entre as características basais. O grupo que evoluiu com falência do VD no POCC apresentou fração de ejeção do ventrículo esquerdo (FEVE) significativamente menor no ecocardiograma pré-operatório (p = 0,010). Não foram observadas diferenças nas variáveis intraoperatórias. Quanto ao prognóstico, um paciente de cada grupo faleceu no POCC imediato. Conclusões: a FEVE pré-operatória poderia desempenhar um papel na predição de insuficiência aguda do VD no CCPO valvular, achado para ser verificado em estudos prospectivos. O impacto da falência do VD na mortalidade não pôde ser definido devido ao número limitado de pacientes.

Sarcoma sinovial primario de pericardio / Primary pericardial synovial sarcoma

Resumen El sarcoma sinovial primario del pericardio es un tumor muy raro y de mal pronóstico y se sabe poco en cuanto al manejo terapéutico. Presentamos el caso de una paciente de 51 años a quien se le realizó resección quirúrgica incompleta, quimioterapia y radioterapia. Hasta donde sabemos, este es el primer caso de un sarcoma sinovial primario de pericardio que luego de operado se mantuvo asintomático durante 5 años hasta que en una TAC de control se le detectaron metástasis cardiacas que comprometían las cavidades derechas y con quimioterapia, la ecocardiografía demostró la reso lución completa de las mismas.

Abstract Primary pericardial synovial sarcoma is an extraor dinarily very rare tumor with a poor prognosis, and little is known about its therapeutic management. We describe the case of a 51-year-old woman patient who underwent incomplete surgical resection, chemotherapy, and radiotherapy. To the best of our knowledge, no pri mary pericardial synovial sarcoma has been described which, after surgery, remains asymptomatic for 5 years, and until a control CT scan detects cardiac metastases that compromised the lumen of the right cavities and with chemotherapy, echocardiography demonstrated complete resolution of cardiac metastases.

Capacidad predictiva de diferentes puntajes de riesgo quirúrgico en la endocarditis infecciosa / Predictive Capacity of Different Surgical Risk Scores in Infective Endocarditis

RESUMEN Introducción. La endocarditis infecciosa (EI) es una enfermedad potencialmente mortal que puede requerir tratamiento quirúrgico. A pesar de ser fundamentales en la toma de decisiones, los puntajes de riesgo quirúrgico no fueron generados específicamente para estratificar el riesgo de esta enfermedad. Objetivos. Evaluar la capacidad predictiva de los puntajes de riesgo quirúrgico ajustados a la EI. Material y métodos. Estudio unicéntrico observacional y retrospectivo de 270 pacientes mayores de 18 años que cursaron internación por EI en actividad desde 06/2008 hasta 02/2023, de los cuales 70 (26 %) fueron sometidos a cirugía cardíaca central. Se excluyeron las endocarditis asociadas a dispositivos, y los pacientes que no se sometieron a cirugía cardíaca. Los puntajes de riesgo quirúrgico analizados fueron: EuroSCORE II, EURO-IE, STS-IE y PALSUSE (Prótesis, Edad >70, (Large) gran destrucción, Staphylococcus, Urgencia, Sexo femenino, EuroSCORE >10). La capacidad predictiva de cada puntaje se evaluó por medio del estadístico C, calculando el área bajo la curva de la relación sensibilidad/1-especificidad, con sus respectivos intervalos de confianza (IC) 95%, y su significación estadística. Resultados. La mediana (rango intercuartílico, RIC) de edad fue de 60 años (48-67) y la de los días de internación fue de 23 (17-39). Cuarenta y un pacientes (58,57 %) tenían una válvula protésica. Respecto a los gérmenes causales, el Staphylococcus fue responsable del 30 % de las infecciones. Las principales indicaciones de tratamiento quirúrgico fueron la insuficiencia cardíaca (44 %), el absceso (19%) y la disfunción protésica (12 %). Se objetivó absceso anular en el 28,57 % de los pacientes. La necesidad de cirugía de urgencia fue del 45,71 % y de emergencia del 7,14 %. La mortalidad hospitalaria fue del 21,42 %. La capacidad predictiva de todos los puntajes fue estadísticamente significativa, excepto el STS- IE . El STS-IE presentó un área bajo la curva (ABC) de 0,586 (IC 95% 0,429-0,743). El EuroSCORE II, un ABC de 0,685 (IC 95 % 0,541-0,830); el EURO-IE presentó un ABC de 0,695 (IC 95 % 0,556-0,834) y el PALSUSE un ABC de 0,819 (IC 95% 0,697-0,941). Conclusión. Los resultados de este estudio sugieren que el score PALSUSE fue mejor predictor de riesgo quirúrgico en pacientes con EI activa, en comparación con los puntajes Euroscore II, EURO-IE y STS-IE.

ABSTRACT Background. Infective endocarditis (IE) is a life-threatening disease that may require surgical treatment. Despite being fundamental in decision making, surgical scores were not generated specifically to stratify the risk of this disease. Objectives. The objective of this study was to: To evaluate the predictive capacity of surgical risk scores adjusted for IE. Methods. Single-center observational and retrospective study of 270 patients > 18 years, hospitalized for active IE from 06/2008 to 02/2023, of which 70 (26 %) underwent central cardiac surgery. Device-associated endocarditis and patients who did not undergo cardiac surgery were excluded. The surgical risk scores analyzed were: EuroSCORE II, EURO-IE, STS-IE and PALSUSE (Prosthesis, Age >70, large cardiac destruction, Staphylococcus, Urgency, Female gender, EuroScore >10). The predictive capacity of each score was evaluated using the C statistic, calculating the area under the curve of the sensitivity/1- specificity relationship with their respective 95 % confidence intervals (CI), and statistical significance. Results. The median age (interquartile range, IQR) was 60 years (48-67) and the number of days of hospitalization were 23 (17-39). Forty-one patients (58.57 %) had a prosthetic valve. Regarding the causative germs, Staphylococcus was responsible for 30 % of the infections. The main indications for surgical treatment were heart failure (44%), abscess (19 %) and prosthetic dysfunction (12%). Annular abscess was observed in 28.57 % of patients. Urgent surgery was performed in 45.71 % and emergency surgery was performed in 7.14 %. Hospital mortality was 21.42 %. The predictive capacity of all scores was statistically significant, except for the STS-IE. The STS-IE score presented an area under the curve (AUC) of 0.586 (95 % CI 0.429-0.743). The EuroSCORE II, an AUC of 0.685 (95 % CI 0.541-0.830); the EURO-IE presented an AUC of 0.695 (95 % CI 0.556-0.834) and the PALSUSE an AUC of 0.819 (95 % CI 0.697-0.941). Conclusion. The results of this study suggest that the PALSUSE score was a better predictor of surgical risk in patients with active IE, compared to the Euroscore II, EURO-IE and STS-IE scores.

Comparison of ultrasound guidance and palpation technique for femoral artery catheterization in children undergoing cardiac surgery.

OBJECTIVE: The aim of this study was compare the palpation technique and ultrasound-guidance for femoral artery catheterization in pediatric patients undergoing surgery for congenital heart disease. MATERIALS AND METHODS: This prospective and randomized controlled study included American Society of Anesthesiologists III-IV 40 children who underwent congenital heart surgery. The patients were divided into two groups; ultrasound-guided catheterization group and palpation-guided catheterization group. Demographic and clinical characteristics of the patients, access time, success rate, number of attempts, first-attempt success, number of trials, and failed cannulations were recorded. RESULTS: The diameter of the femoral artery was significantly shorter, access time and numbers of trials were significantly lower, and first-attempt success rate was significantly higher in the US group. The complication rate was significantly higher in the P group. The number of failed catheterization was higher in the P group. Total cost required for the procedure was significantly lower in the US group. CONCLUSION: We found that ultrasound-guided arterial catheterization increases the success rate and the number of successful catheterizations, while reducing the overall procedure time, incidence of complications, and cost. Therefore, we believe that the use of ultrasound guidance in arterial catheterization in pediatric cardiac surgery would be a better choice.

OBJETIVO: El objetivo de este estudio fue comparar la técnica de palpación y ecoguiado para el cateterismo de la arteria femoral en pacientes pediátricos operados de cardiopatías congénitas. MATERIALES Y MÉTODOS: Este estudio prospectivo, aleatorizado y controlado incluyó a 40 niños ASA III-IV que se sometieron a cirugía cardíaca congénita. Los pacientes se dividieron en 2 grupos; Grupo de cateterismo guiado por ecografía y grupo de cateterismo guiado por palpación. RESULTADOS: El diámetro de la arteria femoral fue significativamente más corto, el tiempo de acceso y el número de intentos fueron significativamente menores y la tasa de éxito del primer intento fue significativamente mayor en grupo estadounidense. La tasa de complicaciones fue significativamente mayor en el grupo P. El número de cateterismos fallidos fue mayor en el grupo P. El costo total requerido para el procedimiento fue significativamente menor en el grupo de EE. CONCLUSIONES: Encontramos que el cateterismo arterial guiado por ultrasonido aumenta la tasa de éxito y el número de cateterismos exitosos, al tiempo que reduce el tiempo total del procedimiento, la incidencia de complicaciones y el costo. Por tanto, creemos que el uso de guía ecográfica en cateterismo arterial en cirugía cardiaca pediátrica sería una mejor opción.

Perioperative stress and anxiety in parents of children operated on for congenital heart disease.

INTRODUCTION: Levels of stress and anxiety suffered by parents of children with congenital heart disease (PCUCS) during their children's admission for cardiac surgery may be higher than those suffered by other parents who go through the same experience. OBJECTIVE: General objective of this study was to measure the stress and anxiety suffered by PCUCS and parents of children undergoing renal surgery (PCURS) in relation to the intervention of their children. The specific objective of the quantitative study was to compare global stress and anxiety according to sex, time of the perioperative period, and cohort. The general objective of the qualitative section is to explore the experience that PCUCS and PCURS have during their hospital stay and to identify the specific factors that influence the genesis of stress and anxiety. METHOD: A cohort study was carried out in which PCURS and PCUCS were included. The quantitative part was performed by comparing the scores of three questionnaires that measure stress levels (PSS-14), state anxiety (STAIE) and trait anxiety (STAIR) throughout three perioperative moments. At the same time, a qualitative study was carried out with semi-structured interviews and collection of diaries on which a descriptive phenomenological analysis was carried out, according to Munhall. The analysis of the text was carried out according to Colaizzi. RESULTS: Stress and anxiety levels were significantly higher in PCUCS compared to PCURS. Mothers in the cardiac cohort were those with the highest scores on all scales. In the qualitative study, four themes emerged: "stress and anxiety from the moment of diagnosis", "surgical intervention as a critical moment", "harshness of the postoperative period in the Intensive Care Unit" and "joy and gratitude versus dependence and fear for the future". CONCLUSIONS: PCUCS suffer higher levels of stress and anxiety than PCURS, being the mothers of the cardiac cohort those who suffer these disorders with greater intensity. This study can constitute a starting point to develop strategies that cover these parental needs.

Abordaje terapéutico de cardiopatías congénitas en el síndrome de Down / Congenital heart disease in Down's syndrome

Resumen Antecedentes: El síndrome de Down es la anomalía cromosómica más frecuente y se asocia con defectos cardiacos congénitos, elementos clínicos de una alta morbilidad y mortalidad infantil. Objetivo: Describir los desenlaces clínicos de los pacientes con síndrome de Down sometidos a cirugía e intervencionismo como tratamiento de las cardiopatías congénitas en esta institución. Material y métodos: Estudio retrospectivo que incluyó pacientes menores de 18 años con síndrome de Down y patología cardiaca asociada durante los últimos 10 años. Las variables estudiadas fueron: peso, talla, sexo, edad, tipo de cardiopatía, procedimiento correctivo, tiempo de estancia intrahospitalaria y en unidad de terapia intensiva, morbilidad y mortalidad. Resultados: 368 pacientes pediátricos fueron llevados a corrección quirúrgica o intervencionista, de los cuales 197 (54%) pertenecían al sexo femenino, la mediana de edad fue de 24 meses (rango intercuartílico [RIQ]: 14-48) en el grupo quirúrgico y de 36 meses (RIQ: 17-85) en el intervencionista. Las cardiopatías congénitas más frecuentes fueron: persistencia del conducto arterioso (31%), comunicación interventricular (28%), canal atrioventricular (CAV) (20%), comunicación interauricular (16%) y tetralogía de Fallot con el 4% respectivamente. La estancia hospitalaria fue de 9 días (RIQ: 7-15) en el grupo quirúrgico y de 3 días (RIQ: 2-5) en el hemodinámico. Las morbilidades fueron infección postoperatoria en 30 pacientes (14%) y en 19 pacientes (9%) bloqueo atrioventricular completo. La mortalidad global incluyendo tanto el quirúrgico como el intervencionista fue del 2%. Conclusiones: Los resultados terapéuticos, quirúrgicos e intervencionistas, en los niños con síndrome de Down y cardiopatías congénitas han mejorado en forma muy satisfactoria. Es de destacar la menor prevalencia del CAV en la población mexicana. Es indispensable realizar evaluación cardiológica a los niños con síndrome de Down y aquellos con cardiopatías congénitas llevarlos a corrección de manera oportuna para favorecer la sobrevida y calidad de vida.

Abstract Background: Down syndrome is the most common chromosomal abnormality, it is associated with a wide variety of congenital heart defects, being considered as clinical elements of high infant morbidity and mortality. Objective: To describe the clinical outcomes of patients with Down syndrome undergoing surgery and interventionism as treatment for congenital heart disease at this Institution. Material and methods: 368 patients with Down syndrome and associated congenital heart disease were diagnosed. The variables studied were weight, stature, sex, age, type of heart disease, corrective procedure, length of stay in the hospital and intensive care unit, morbidity and mortality. Results: 368 pediatric patients underwent surgical or interventional correction. Of which 197 (54%) were female, the median age was 24 months (interquartile range [IQR]: 14-48) in the surgical group and 36 months (IQR: 17-85) in the interventional group. The most frequent congenital heart diseases were: PCA (31%), IVC (28%), CAV (20%), ASD (16%) and tetralogy of Fallot with 4% respectively. Hospital stay was 9 days (IQR: 7-15) in the surgical group and 3 days (IQR: 2-5) in the hemodynamic group. Morbidities were postoperative infection in 30 patients (14%) and complete atrioventricular block in 19 patients (9%). Overall mortality including both surgical and interventional was 2%. Conclusions: The therapeutic, surgical and interventional results in children with Down syndrome and congenital heart disease have improved very satisfactorily. The lower prevalence of the atrioventricular canal in the Mexican population is noteworthy. It is essential to carry out a cardiological evaluation of children with Down syndrome and those with congenital heart disease to correct them in a timely manner to promote survival and quality of life.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery.

INTRODUCTION: Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AIM: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. METHODS: We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. RESULTS: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. CONCLUSIONS: Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Ultra-fast track extubation protocol following cardiovascular surgery: Predictors of failure and outcomes.

OBJECTIVES: Identifying independent predictor factors of failure of ultra-fast track (UFT) extubation and to compare in-hospital outcomes with UFT extubation versus fast track (FT) extubation after cardiovascular surgery in adults. MATERIAL AND METHODS: Retrospective analysis of 1498 consecutive patients aged over 18 years-old undergoing cardiovascular surgery at a single institution. Between December 2014 and December 2016, FT extubation was used (N = 713) while, between December 2016 and December 2018, all patients were preoperatively considered suitable for UFT extubation (N = 785). In this instance, a standardized anaesthetic protocol was applied in all cases. The decision to not extubate in the operating room (OR) was based on intraoperative haemodynamic and ventilation. RESULTS: Extubation in the OR was possible in 699 (89%) patients. Significant independent predictors factors of UFT extubation failure were: preoperative NYHA class III-IV, myocardial infarction within two days prior to surgery, preoperative intra-aortic balloon counterpulsation, urgent/emergent surgery, intraoperative transfusion of platelets and intraoperative inotropic and vasopressor support. UFT extubation was associated with lower rates of cardiovascular complications such as congestive cardiac insufficiency (OR: 1,57; 95% CI: 1,13-2,19; p = 0,008) and new-onset postoperatory atrial fibrillation (OR: 1,40; 95% CI: 1,06-1,86; p = 0,020). Patient extubated in the OR presented lower risk of overall complications, shorter intensive care unit stay and higher short-term survival, although, no statistically significance was found when performing the multivariate adjustment. CONCLUSIONS: A routine immediate extubation in the OR following adult cardiovascular surgery is a feasible and safe practice, associated with low cardiovascular morbidity.

Early tracheostomy after cardiac surgery improves intermediate- and long-term survival.

OBJECTIVE: Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study's second aim was to assess the incidence of both superficial and deep sternal wound infections. DESIGN: Retrospective study of prospectively collected data. SETTING: Tertiary hospital. PATIENTS: Patients were divided into 3 groups, according to the timing of tracheostomy; early (4-10 days); intermediate (11-20 days) and late (≥21 days). INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection. RESULTS: During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014-1.036)] and timing of tracheostomy [0.315 (0.159-0.757)] had significant impacts on mortality. CONCLUSIONS: This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4-10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.

Microorganisms isolated in patients with post-cardiac surgery mediastinitis at a cardiology hospital of Mexico City.

INTRODUCTION: Mediastinitis after cardiovascular surgery gives rise to prolonged hospital stay and increased medical care costs, and is associated with high in-hospital mortality. OBJECTIVE: To describe the clinical characteristics of patients with post-surgical mediastinitis, including the isolated microorganisms, resistance profile, and in-hospital survival. METHODS: Cross-sectional study of patients with bacteriologically-confirmed post-surgical mediastinitis cared for at a cardiology hospital in Mexico City between January 2017 and March 2019. RESULTS: Fifty-eight cases of mediastinitis were included. Median age was 67 years. Most subjects were males who underwent myocardial revascularization. During in-hospital follow-up, all-cause and mediastinitis-related mortality were 27.6% and 20.7%, respectively. Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli were the most commonly isolated microorganisms. High resistance to methicillin was found in coagulase-negative staphylococci, as well as high expression of extended-spectrum beta-lactamases in Escherichia coli and Klebsiella pneumoniae strains. CONCLUSIONS: High mortality and significant antimicrobial resistance were found in patients with post-cardiac surgery mediastinitis.

INTRODUCCIÓN: La mediastinitis posterior a cirugía cardiovascular deriva en estancia hospitalaria prolongada e incremento de los costos de la atención médica, y se asocia a elevada letalidad hospitalaria. OBJETIVO: Describir las características clínicas de los pacientes con mediastinitis posquirúrgica, incluyendo los microorganismos aislados, perfil de resistencia y supervivencia hospitalaria. MÉTODOS: Estudio transversal de pacientes con mediastinitis posquirúrgica bacteriológicamente confirmada, atendidos en un hospital de cardiología de la Ciudad de México entre enero de 2017 y marzo de 2019. RESULTADOS: Se incluyeron 58 casos de mediastinitis. La mediana de edad fue de 67 años. La mayoría de los sujetos fueron varones sometidos a revascularización miocárdica. Durante el seguimiento hospitalario, la letalidad por todas las causas y la secundaria a la mediastinitis fueron de 27.6 y 20.7 %, respectivamente. Los microorganismos más frecuentemente aislados fueron Staphylococcus aureus, Staphylococcus epidermidis y Escherichia coli. Se encontró alta resistencia a meticilina en los estafilococos coagulasa negativos y alta expresión de betalactamasas de espectro extendido en cepas de Escherichia coli y Klebsiella pneumoniae. CONCLUSIONES: En los pacientes con mediastinitis posquirúrgica analizados se observó alta letalidad e importante resistencia antimicrobiana.

Dinamometría como predictor de morbimortalidad en pacientes geriátricos con moderado riesgo quirúrgico sometidos a cirugía cardíaca / Dynamometry as a predictor of morbidity and mortality in geriatric patients with moderate surgical risk undergoing cardiac surgery

Resumen: Introducción: con los cambios demográficos el término «fragilidad¼ trasciende cada vez más en el ámbito quirúrgico. La relación entre fragilidad medida por dinamometría y la morbimortalidad en cirugía cardíaca no ha sido del todo estudiada. Objetivo: establecer la utilidad de la fragilidad determinada mediante dinamometría como predictor de morbimortalidad en pacientes geriátricos con bajo riesgo quirúrgico sometidos a cirugía cardíaca. Material y métodos: se realizó un estudio de cohortes prospectivo que incluyó 65 pacientes geriátricos de moderado riesgo quirúrgico sometidos a cirugía cardíaca electiva con derivación cardiopulmonar. A los pacientes se les realizó dinamometría preoperatoria para determinar fragilidad y se estimó su relación con la morbimortalidad postoperatoria. Se calculó sensibilidad, especificidad, valores predictivos y coeficientes de probabilidad positivos y negativos, coeficiente alfa de Cronbach y área bajo la curva ROC. Los datos se procesaron con SPSS v-24.0. Resultados: la evaluación del componente de calibración mostró que se ajusta a nuestra muestra (coeficiente alfa de Cronbach 0.79). La evaluación del componente de discriminación mostró que puede distinguir la población con riesgo de morbilidad (0.625) y mortalidad (0.597). Conclusión: la fragilidad determinada mediante dinamometría es útil como predictor de morbimortalidad en pacientes ancianos con bajo riesgo quirúrgico sometidos a cirugía cardíaca.

Abstract: Introduction: recent demographic changes have meant that more and more frail patients undergo surgery. The relationship between frailty, measured by dynamometry, and morbidity and mortality in cardiac surgery has not been fully studied. Objective: determine the usefulness of frailty, as measured by dynamometry, as a predictor of morbidity and mortality in geriatric patients with low surgical risk undergoing cardiac surgery. Material and methods: a prospective cohort study including 65 geriatric patients with moderate surgical risk undergoing elective cardiac surgery with cardiopulmonary bypass. The patients underwent preoperative dynamometry to determine their frailty, whose relationship with postoperative morbidity and mortality was evaluated. Sensitivity, specificity, predictive values, positive and negative probability coefficients, Cronbach's alpha coefficient and area under the ROC curve were calculated. The data were processed with SPSS v-24.0. Results: the evaluation of the calibration component showed that it fitted our sample (Cronbach's alpha coefficient 0.79). The evaluation of the discrimination component showed that it was able to distinguish between risk of morbidity (0.625) and risk of mortality (0.597). Conclusion: frailty, measured by dynamometry, is a useful predictor of morbidity and mortality in elderly patients with low surgical risk undergoing cardiac surgery.

Feasibility and effects of prehabilitation in cardiac surgery. Preliminary study.

Prehabilitation programs that combine exercise training, nutritional support, and emotional reinforcement have demonstrated efficacy as a strategy for preoperative optimization in abdominal surgery. The experience in cardiac surgery, one of those associated with greater morbidity and mortality, is anecdotal. OBJECTIVE: evaluation of the feasibility of a multimodal prehabilitation program and its effect on functional capacity in patients candidates for elective cardiac surgery. METHODS: Pilot study conducted from July 2017 to June 2018 in patients candidates to myocardial revascularization and/or valve replacement. The program consisted of: 1) supervised exercise training program, 2) breathing incentive exercises, 3) nutritional support, and 4) mindfulness training. An evaluation was carried out prior to the start of the program and at the end of it (preoperatively). RESULTS: All patients except one who refused surgery, completed the program, which lasted an average of 45 days. No patients presented complications related to the program. The program induced a significantly increase in functional capacity measured by the six-minute walking test (510.7 + 62 m vs 534.3 + 71 m, p = 0.007) and the chair test (13.2 + 4, 7 vs 16.4 + 7 repetitions, p = 0.02), as well as an increase in the level of physical activity measured by the Yale physical activity questionnaire (37.6 + 20 vs 54.2 + 27; p = 00029). CONCLUSIONS: Multimodal prehabilitation in patients candidates for elective cardiac surgery is feasible and it increases functional capacity preoperatively without being associated with complications. The presumed beneficial impact of this improvement on the incidence of postoperative complications and hospital stay, requires further investigation.

Microorganismos aislados en pacientes con mediastinitis poscirugía cardiaca en un hospital de cardiología de la Ciudad de México / Microorganisms isolated in patients with post-cardiac surgery mediastinitis at a cardiology hospital of Mexico City

Resumen Introducción: La mediastinitis posterior a cirugía cardiovascular deriva en estancia hospitalaria prolongada e incremento de los costos de la atención médica, y se asocia a elevada letalidad hospitalaria. Objetivo: Describir las características clínicas de los pacientes con mediastinitis posquirúrgica, incluyendo los microorganismos aislados, perfil de resistencia y supervivencia hospitalaria. Métodos: Estudio transversal de pacientes con mediastinitis posquirúrgica bacteriológicamente confirmada, atendidos en un hospital de cardiología de la Ciudad de México entre enero de 2017 y marzo de 2019. Resultados: Se incluyeron 58 casos de mediastinitis. La mediana de edad fue de 67 años. La mayoría de los sujetos fueron varones sometidos a revascularización miocárdica. Durante el seguimiento hospitalario, la letalidad por todas las causas y la secundaria a la mediastinitis fueron de 27.6 y 20.7 %, respectivamente. Los microorganismos más frecuentemente aislados fueron Staphylococcus aureus, Staphylococcus epidermidis y Escherichia coli. Se encontró alta resistencia a meticilina en los estafilococos coagulasa negativos y alta expresión de betalactamasas de espectro extendido en cepas de Escherichia coli y Klebsiella pneumoniae. Conclusiones: En los pacientes con mediastinitis posquirúrgica analizados se observó alta letalidad e importante resistencia antimicrobiana.

Abstract Introduction: Mediastinitis after cardiovascular surgery gives rise to prolonged hospital stay and increased medical care costs, and is associated with high in-hospital mortality. Objective: To describe the clinical characteristics of patients with post-surgical mediastinitis, including the isolated microorganisms, resistance profile, and in-hospital survival. Methods: Cross-sectional study of patients with bacteriologically-confirmed post-surgical mediastinitis cared for at a cardiology hospital in Mexico City between January 2017 and March 2019. Results: Fifty-eight cases of mediastinitis were included. Median age was 67 years. Most subjects were males who underwent myocardial revascularization. During in-hospital follow-up, all-cause and mediastinitis-related mortality were 27.6% and 20.7%, respectively. Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli were the most commonly isolated microorganisms. High resistance to methicillin was found in coagulase-negative staphylococci, as well as high expression of extended-spectrum beta-lactamases in Escherichia coli and Klebsiella pneumoniae strains. Conclusions: High mortality and significant antimicrobial resistance were found in patients with post-cardiac surgery mediastinitis.

Delay of surgical treatment of severe tricuspid regurgitation and outcomes in patients with left-sided heart valve disease.

INTRODUCTION AND OBJECTIVES: The influence of the delay between diagnosis and surgery in severe tricuspid regurgitation (TR) remains controversial. We aimed to analyze the association between delay to surgery and operative and mid-term mortality in patients with severe TR concomitant to left-valve surgery. METHODS: We conducted an observational retrospective study analyzing risk factors in patients undergoing left-valve surgery concomitant with severe TR. The clinical and demographic variables were prospectively collected. The time of first diagnosis of TR was retrospectively collected. RESULTS: A total of 253 patients were analyzed. TR was functional in 82.6%. The median latency between diagnosis and surgery was 24 months. Operative mortality was 12.2%. On multivariate analysis, higher operative mortality was associated with older age, worse preoperative NYHA functional class, triple valve surgery, hyponatremia, and anemia. The median follow-up was 35 months. Survival at 1 and 5 years was 85.2% and 73.7%, respectively. Mortality during follow-up was associated with male sex, preoperative massive TR, and longer latency between diagnosis and surgery. CONCLUSIONS: The variables related to worse preoperative functional class were associated with increased operative mortality. Lower mid-term survival was associated with longer latency between diagnosis of severe TR and surgery, massive preoperative TR, and older age.