Attention to acute cerebrovascular disease in Guipúzcoa: description of the results of a reference hospital in a centralized care model.

INTRODUCTION: In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model. MATERIAL AND METHODS: We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients' baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year. RESULTS AND DISCUSSION: We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in < 6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2. CONCLUSIONS: After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.

Attention to acute cerebrovascular disease in Guipúzcoa: Description of the results of a reference hospital in a centralized care model. / Atención a la enfermedad cerebrovascular aguda en Guipúzcoa: descripción de los resultados de un hospital de referencia en un modelo de atención centralizado.

INTRODUCTION: In the last 15 years, considerable improvements have been made in acute stroke care in Guipuzkoa, including the implementation of a centralised care model at Hospital Universitario Donostia (HUD), improved coordination between professionals, early detection campaigns, new treatments, a stroke unit, and specific rehabilitation. The aim of this work is to describe the results of a reference hospital (HUD) in a centralised care model. MATERIAL AND METHODS: We performed a retrospective observational study of a sample of patients discharged between August and December 2015 from the HUD with a diagnosis of acute stroke (ICD-9-CM codes 430-436, except 433.10). We review patients' baseline characteristics, acute-phase care, and functional outcomes and mortality at discharge and at one year. RESULTS AND DISCUSSION: We identified 536 patients, with a mean age of 73.6 years and a high comorbidity rate. Ischaemic stroke accounted for 64.8% of patients, followed by haemorrhagic stroke (20%) and transient ischaemic attack (14.8%). A total of 53% of patients were attended in <6 hours, with code stroke being activated in 37.1%; 52.2% of patients were admitted to the stroke unit. Intravenous therapy was administered to 8.3% of patients with ischaemic stroke, and 9.5% underwent mechanical thrombectomy. Surgery was performed in 12.1% patients with haemorrhagic stroke. Rehabilitation was started at hospital in 56% of patients, and 39.6% continued with this treatment at discharge. Mortality was 13.8% at discharge and 25.9% at one year (ischaemic stroke, 25.3%; haemorrhagic stroke, 47.5%); these figures are lower than those previously reported in Guipuzkoa. At one year, 62.5% of patients had a Barthel Index score of 95-100, and 50% a modified Rankin Scale score of 0-2. CONCLUSIONS: After the strategic changes implemented in acute stroke care in Guipuzkoa, including the centralisation of the acute stroke care model, mortality rates at discharge and at one year are lower in 2015 than the previously reported rates, with similar rates of independence. These results are consistent with those published by other Spanish and European centres.

[Treatment of an infection from an intravenous cardiac stimulation lead with extracorporeal circulation]. / Tratamiento de la infección del cable de estimulación cardíaca intravenoso mediante circulación extracorpórea.

The infection of a transvenous lead implanted for cardiac stimulation is a rare but serious complication, because it can lead to the development of septicemia, tricuspid endocarditis, recurrent pulmonary emboli or thrombus formation in right cardiac chambers. The most efficient treatment is the removal of the entire pacing system (generator and lead). We describe our experience with the removal of infected leads with the aid of cardiopulmonary bypass. Indications of this technique and its advantages and disadvantages over the percutaneous extraction methods are discussed. A review of the literature is also presented.

[Valve repair in tricuspid endocarditis in the drug addict. Apropos a case]. / Reparación valvular en la endocarditis tricúspide del drogadicto. A propósito de un caso.

Valve replacement, valvulectomy and valve repair are the alternatives for the surgical treatment of intractable tricuspid valve endocarditis. We present the case of a 24-year-old, HIV-positive Caucasian female, intravenous drug addict, with intractable tricuspid valve endocarditis, that was successfully treated with tricuspid valve repair. Advantages and major drawbacks of the different techniques are discussed and the appropriate literature is reviewed.

[Surgical treatment of hypertrophic myocardiopathy using a video-assisted technique. Apropos of a case]. / Tratamiento quirúrgico de la miocardiopatía hipertrófica mediante técnica vídeo-asistida. A propósito de un caso.

The use of endoscopic technology is gaining more and more popularity within cardiac surgery. We present a case employing endoscopic instruments in the resection of the interventricular septum in a patient with hypertrophic cardiomyopathy unresponsive to medical treatment. Advantages of this technique are discussed.

[Maze technique for the treatment of auricular fibrillation: initial experience]. / Técnica de MAZE para el tratamiento de la fibrilacion auricular: experiencia inicial.

INTRODUCTION AND OBJECTIVES: The MAZE procedure was developed as a surgical approach to the management of patients with atrial fibrillation refractory to medical treatment. This study seeks to identify the risk and benefits of adding the MAZE procedure in patients with atrial fibrillation undergoing surgery for underlying organic cardiac disorders. MATERIAL AND METHODS: Since november 1993, we have performed 10 interventions with the MAZE procedure, for the treatment of refractory atrial fibrillation. The indication to perform the technique was systemic embolism in 5 patients, contraindication for the anticoagulant treatment in two cases and no response to antiarrhythmic treatment in 5 cases. Two patients had more than one indication. In all the cases another surgical procedure was performed, 5 replacements of mitral valve, a mitral repair, one tricuspid repair and tree repairs of an atrial septal defect. RESULTS: Soon after surgery 9 patients were in sinus rhythm, and one in atrial fibrillation. Four patients needed atrial pacing during the first days. One patient required a pacemaker due to symptomatic sinus bradycardia. During the first 3 months, 4 patients had episodes of paroxysmal atrial fibrillation and flutter. One patient died suddenly one month after surgery. Seven patients have completed two years of follow-up, and are in stable sinus rhythm, in functional class I and free of antiarrhythmic drugs. All of them have echocardiographic evidence of mechanical activity in both atria. Left atrium had been reduced from 5.3 +/- 0.7 cm to 4.5 +/- 0.7 cm (p < 0.05). No patient has presented new embolic events. CONCLUSIONS: The MAZE procedure is a good choice in selected patients with atrial fibrillation refractory to medical treatment, or a precedent of systemic embolism. However, several problems can complicate the patient's course.

[Surgical treatment of atrial fibrillation]. / Tratamiento quirúrgico de la fibrilación auricular.

Atrial fibrillation is the most frequently found sustained arrhythmia. It increases the risk of thromboembolism and adversely affects cardiac performance because of loss of atrial kick. New surgical treatments of atrial fibrillation have been developed to ablate the origin of abnormal impulses on the atrium. The left atrial isolation and the corridor operation restores the regular rhythm, but do not reduce the risk of thromboembolism because the left atrium may continue to fibrillate. The maze operation has proven to be effective in both converting to sinus rhythm and regaining atrial contractility. However, this method is meticulous and time-consuming and takes more cardiac ischemic time, especially when other cardiac procedures are performed simultaneously.

[Biphasic graft preservation for lung transplantation]. / Preservación bifásica del injerto en el trasplante pulmonar.

The standard, most widely applied way of preserving a lung for transplantation is infusion through the pulmonary artery (PA) of a pulmonaryplegic solution. In this prospective study, we analyzed the initial function of the pulmonary and cardiac graft after biphasic infusion of a solution introduced retrograde through the left auricle and antegrade through the PA. Twenty-six heart and lung grafts (9 unilateral and 17 bilateral) were preserved by cardioplegia and pulmonaryplegia (biphasic) between January 1996 and March 1997. Indicators of graft viability recorded were the ratio of arterial oxygen pressure (PaO2) to inspired fraction (FiO2), mean systemic pressure (MSP), mean pulmonary artery pressure (MPAP) cardiac output, pulmonary vascular resistance (PVR) and systemic vascular resistance (SVR). The variables were recorded upon arrival of the grafts in the intensive care unit and in the first 24 h. Morbidity and mortality after heart transplants were recorded throughout a follow-up period of one month. After transplantation, most patients had a oxygenation coefficient (PaO2/FiO2) greater than 252 mmHg in the first 48 h. Hemodynamic parameters were also kept within normal ranges immediately after surgery and 24 h later. Mean ischemic time was 245 min for unilateral transplants, 215 for the first lung in double lung transplants, and 300 min for the second lung. In the early postoperative period, 3 patients suffered lung graft dysfunction, which was treated satisfactorily with nitric oxide (NO). No heart transplant patient suffered primary heart failure or left ventricular dilatation. We conclude that biphasic pulmonary preservation achieves satisfactory initial functional viability of the graft. Heart grafts removed simultaneously functioned successfully in the transplanted patient without additional pharmacological or mechanical support.