[Surgical treatment of the aortic root dilatation]. / Tratamiento quirúrgico de la raíz de aorta.

The aorta is considered as pathologically dilatated when the diameter of the aortic root and of the ascending aorta is exceeding 50% of its standard diameter for a determined body masc. The aortic root dilatation is frequently associated with valve's pathology, rupture and dissection are two serious events that might occur; are linked with high mortality and are closely connected to aortic diameter and to wall's pathology, so that the elective indication is essential and it basically depends on those two factors. There are different technical alternatives, anatomical and functional, of the aortic root, the procedure's election is most specially based on patient's age, on pathological substract, on anticoagulation risk, and on possible infection, etc. We wish to report our experience performed from 1990 onto 2004 with 364 cases of aortic root surgery, of which 312 were elective interventions and 52 were emergencies, with a mortality of 4.8% and 19.2% respectively, and a global mortality of 6.8% using the different procedures. The choice of procedure is a multifactorial decision and it is necessary try offering the patient, the most idoneus individualized solution, according to personal characteristics. The different surgical techniques (valved conduits, remodelling procedures, biological grafts, etc.) can be carried out with low figures of morbid-mortality and excellent long term outcomes.

[Severe mitral regurgitation in Libman-Sacks endocarditis. Conservative surgery]. / Regurgitación mitral severa en endocarditis de Libman-Sacks. Cirugía reparadora.

Libman-Sacks endocarditis is a classic but rarely symptomatic manifestation of systemic lupus erythematosus, and valvular surgery is needed in a few cases. We present a patient with systemic lupus erythematosus and Libman-Sacks endocarditis that progressed rapidly to severe mitral regurgitation that needed surgery; surgical valve repair was decided upon. The literature on this topic is reviewed.

[Replacement of the aortic valve with pulmonary autograft (the Ross procedure)]. / Reemplazamiento valvular aórtico con autotrasplante de válvula pulmonar (procedimiento de Ross).

UNLABELLED: The search for the ideal substitute for the aortic valve led Donald Ross to develop the pulmonary autograft concept in 1967. A historical, technical, an scientific review of this surgical option is presented together with our clinical experience. MATERIALS AND METHODS: The literature is reviewed to identify the advantages and pitfalls of the Ross procedure over the last decades. We also present our clinical experience with 100 patients operated between 1997 and December 2003. RESULTS: Of the total, 70% (n = 70) were males, mean age was 29.32 +/- 11.9 years, with 20 patients under 16 and 6 patients under 10 years. Twenty-five patients (25%) had 31 previous interventions. There were 41 associated procedures in 34 patients. Perioperative mortality was 2% (two patients). Eight patients required reexploration for bleeding, one required an aortocoronary bypass, an one a permanent pacemaker. Follow-up was 97% with 2.71 patients/year (average 32.55 +/- 19.01 months). Two patients required Autograft replacement, one suffered a 44-mm dilatation of the Autograft, and one 13-year-old girl developed Autograft endocarditis. Six patients suffered severe Homograft stenosis (> 50 mm/Hg), two were treated percutaneously, and one required replacement. Combined freedom from reintervention is 93.56 +/- 2.81% at 5 years. CONCLUSIONS: The Ross procedure is a mature concept with thousands of patients operated worldwide and a cumulative experience of over 30 years. Although we believe that it is the procedure of choice in the pediatric population, women in child-bearing age, and substantial subgroups of adult patients, efforts must continue to minimize the incidence of auto- and Homograft failure in the long-term.

[Incidence and clinical impact of pulmonary homograft dysfunction after the Ross procedure]. / Incidencia e impacto clínico de la estenosis del homoinjerto pulmonar tras el procedimiento de Ross.

INTRODUCTION AND OBJECTIVES: We analyzed the incidence, risk factors and clinical impact of pulmonary homograft dysfunction after the Ross procedure in our patients. PATIENTS AND METHOD: All patients were evaluated at 3, 6 and 12 months, and annually thereafter. Patients with a transhomograft pressure gradient greater than 30 mmHg were referred for cardiac magnetic resonance imaging. RESULTS: At the end of the study, 9 patients (11.8%) showed a transhomograft pressure gradient >30 mmHg after a mean period of 15.3 months post-surgery. Mean transhomograft pressure gradient was 19.8 (16.2%) (range, 2-100 mmHg). All patients were in functional class I, except 2 who were in New York Heart Association class II with severe stenosis. These 2 patients were treated percutaneously with stent placement and no reoperation. No association was found between clinical outcome and sex, age or homograft diameter. We found a trend toward greater perioperative use of plasma, platelets and red cells in the group of patients in comparison to controls, although the difference was significant only for postoperative use of plasma (1.7 [3] vs 5.5 [5.3] units; P<0.05). Cardiac magnetic resonance imaging showed stenosis predominantly in the body of the homograft, whereas the valvular component itself remained competent. Right ventricular hypertrophy was mild or very mild in 7 patients and moderate in 2. CONCLUSIONS: The incidence of some degree of pulmonary homograft dysfunction after the Ross procedure was non-negligible, but its clinical impact seems to be slight. Patients with severe stenosis were treated successfully via a percutaneous approach. The use of blood products might be a risk factor for the development of this complication.

Embolia en cavidades cardiacas derechas: Aspectos diagnósticos y terapéuticos / Right heart chambers embolism. Diagnostic and therapeutic aspects

La trombosis venosa profunda puede causar embolias pulmonares. En raras ocasiones, la embolización se produce, no directamente en el árbol arterial pulmonar, sino en las cavidades cardiacas derechas. Aunque el valor de la ecocardiografía en el diagnóstico es bien reconocido, actualmente no existe consenso en cuanto al tratamiento apropiado. Presentamos seis casos de trombo flotante en aurícula derecha, diagnosticado por ecocardiografía, en pacientes con embolias pulmonares o con shock o síncope sin causa evidente. Se realizó embolectomía quirúrgica en 4 pacientes, y tratamiento fibrinolítico en 2, sin mortalidad hospitalaria. La elevada mortalidad asociada con esta patología puede reducirse con un diagnóstico ecocardiográfico rápido y un tratamiento emergente con fibrinolisis o cirugía. Nuestros datos sugieren la posible utilización de la fibrinolisis como tratamiento de primera elección en casos seleccionados