Effect of preoperative oral pravastatin reload in systemic inflammatory response and myocardial damage after coronary artery bypass grafting. A pilot double-blind placebo-controlled study.

AIM: Statins exert pleiotropic effects that result in cardioprotective and antiinflammatory properties. There is a lack of information about the effect of preoperative reloading statin administration in surgical coronary patients regarding myocardial protection, systemic inflammatory response (SIR) attenuation and nitric oxide (NO) metabolism. METHODS: Thirty consecutive dyslipidemic patients under chronic treatment with statins were randomized to orally receive pravastatin 80 mg (N.=10), 40 mg (N.=10) or placebo (N.=10) two hours before anesthetic induction for non-emergent on-pump coronary artery bypass grafting (CABG) procedures. Perioperative peripheral venous and intraoperative CS blood samples were collected for determination of drug-related adverse effects, NO metabolism and both myocardial damage and SIR biomarkers. RESULTS: Pravastatin reloading resulted in a significant and dose-related intense attenuation of SIR, but no differences in cardiac damage biomarker levels were demonstrated. NO release and inducible nitric oxide synthase expression was significantly reduced in both treatment groups. Highest pravastatin doses significantly increased systemic creatine phosphokinase (CPK) concentration compared with intermediate doses but no other adverse effects were observed. CONCLUSION: Oral pravastatin reloading before non-emergent CABG significantly attenuates postoperative SIR and systemic NO/iNOS concentrations with no effect in perioperative myocardial damage. Highest pravastatin doses increase CPK levels and must be avoided in susceptible patients.

Thoracic aneurysm as a cause of chyluria: resolution by surgical treatment.

A 37-year-old man who had suffered a thoracic trauma presented night release of whitish urine 2 years later. Thoracic computed tomography and aortography demonstrated an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. After surgical repair the patient has remained asymptomatic.

Massive calcification of the left atrium: surgical implications.

BACKGROUND: Massive calcification of the atrial walls ("porcelain atrium") is a rare condition that usually has been reported as an incidental radiologic findings. METHODS: Between January 1988 and June 1993, 971 patients underwent valvular operation at our institution; 21 patients showed extensive calcification of the left atrium. In 8 patients the calcification was massive, involving almost all the atrial surface. The diagnoses were established by radiology and were confirmed at operation. The mean age of these patients (4 men, 4 women) was 55 +/- 9.6 years. All had rheumatic valve disease, were on atrial fibrillation, and had undergone at least one operation previously. Pulmonary artery pressure was severely increased, even up to systemic levels, in all patients except 1. Total endoatriectomy of the left atrium and mitral valve replacement were performed. No patient was lost during the follow-up. RESULTS: Hospital mortality rate was 12.5% (1 patient) and 2 patients died in the late postoperative period. None of these deaths are attributable to the surgical procedure. CONCLUSIONS: In toto endoatriectomy of a massively calcified atrium is an easy to perform technique that helps to replace the mitral valve and close the atrial wall.

Flow capacity of the human retrograde internal mammary artery: surgical considerations.

The diastolic flow of the retrograde internal mammary artery (IMA) was calculated in 30 patients and compared with the expected coronary flow of the left ventricle and that of specific branches. Arterial pressure and free flow were measured in the proximal and distal IMA as well as in the superior epigastric and musculophrenic arteries. Systolic and mean arterial pressure were significantly higher in the proximal IMA than in any other site, but diastolic pressure was comparable. Overall and diastolic antegrade IMA flows (77 +/- 6 and 44 +/- 3 mL/min) were significantly greater than the retrograde flows through the distal IMA (18.5 +/- 2 and 11.5 +/- 1 mL/min), musculophrenic artery (13.3 +/- 1 and 7.9 +/- 1 mL/min), and superior epigastric artery (5.3 +/- 0.4 and 3.1 +/- 0.2 mL/min). Only patient-size-related variables correlated significantly with retrograde IMA flow. Diastolic retrograde IMA flow represented 8.5% +/- 0.6% of the expected left ventricle coronary flow and in 12 patients (40%) was greater than the expected flow of at least one posteroinferior coronary artery. Based on these data, the retrograde IMA may adequately perfuse the posterior descending or other posterolateral coronary branches in select patients. Previous measuring of the retrograde flow is mandatory.

Eight years' experience with the Medtronic-Hall valve prosthesis.

During the period January 1981 to September 1986, 444 Medtronic-Hall heart valve prostheses were implanted in 351 patients (mean age, 45 +/- 10 years) mainly for rheumatic valve disease (63.2%). Most of the patients were in New York Heart Association functional class III. Concomitant surgical procedures, mainly conservative tricuspid or mitral procedures or coronary artery bypass grafting, were performed in 101 patients (28.7%). Single-valve replacement was performed in 262 patients (74.6%) (aortic in 117 patients, mitral in 143, and tricuspid in 2), double-valve replacement in 85 (24.2%) (mitral and aortic in 83 and mitral and tricuspid in 2), and triple-valve replacement in 4 (1.1%). Hospital mortality was 6.2%. Follow-up was 97.7% complete. The overall actuarial 8-year survival rate was 77.2%. The linearized incidence of valve-related complications was as follows: thromboembolism, 1.5%/patient-year; reoperation, 1.5%/patient-year; endocarditis, 1.25%/patient-year; hemolysis, 0.52%/patient-year; anticoagulant-related hemorrhage, 0.39%/patient-year; and noninfection-related paraprosthetic leak, 0.33%/patient-year. There were no instances of structural failure. We conclude that after 8 years of follow-up, the Medtronic-Hall valve prosthesis has an excellent clinical performance and a low range of valve-related complications.

Selective and adjustable pericardial flap to protect internal mammary artery grafts.

We describe the surgical technique of a localized and adjustable pericardial flap to protect internal mammary artery grafts. This flap allows selective pulmonary retraction, maintains pleural integrity, and saves most of the pericardium for later closure. This technique has proved to be simple and highly effective. We have used it in 80 patients and have not had any related complications.

[Guidelines of the Spanish Society of Cardiology on valve heart disease]. / Guías de práctica clínica de la Sociedad Española de Cardiología en valvulopatías.

Valvular heart diseases, which continue to be a major cause of morbidity and mortality world wide, have undergone radical changes since the first valve prostheses were implanted 40 years ago. These changes have been the result of both scientific progress and improved standard of living in developed countries. The availability of penicillin to treat streptococcal pharyngitis and less crowded living conditions have now made rheumatic fever uncommon in these countries. However, other forms of valve impairment have appeared over the past several years. The etiology of some of these valvular diseases remains obscure (e. g. myxomatous mitral valve); others, such as the senile type of calcific aortic valve stenosis, seem to be the price to be paid for the extension of life expectancy. With regard to diagnosis, echocardiography has constituted a formidable tool for visualizing anatomic valve changes, interpreting complex hemodynamic derangements, and evaluating repercussion on the left ventricle. In addition, the iteration of this non-invasive examination has allowed a much better understanding of the natural history of non-severe valvular disease and therefore of the precise timing for surgical intervention, without awaiting, in most cases, the appearance of advanced symptomatology. This has also been possible because of the great advances in cardiac surgery which can be summarised as: a) the improvement in extracorporeal circulation and myocardial preservation techniques; b) the greatly improved biologic and mechanic valve substitutes; c) the introduction of imaginative mitral valve repair procedures, and d) the use of intraoperative transesophageal echocardiography to assess the adequacy of valve repair. At the same time, percutaneous catheter balloon valvuloplasty has emerged as a valid alternative to mitral surgical commissurotomy for mitral stenosis. All these changes, and many more that can not be described in this brief summary, make a review of the management of patients with valve heart disease appropriate.

[Myocardial revascularization surgery during a developing infarction]. / Cirugía de revascularización miocárdica en el infarto en evolución.

Our results with surgical revascularization for evolving myocardial infarction in 30 patients are analyzed. There were 25 men and 5 women (mean age 55 +/- 10 years), most with unstable angina (80%), which sustained an acute myocardial infarction secondary to either a severe stenosis (23%) or a complete obstruction (77%) of a mayor coronary artery during a diagnostic coronarography (27%) or a percutaneous transluminal coronary angioplasty (73%). The most frequently involved vessels were the left anterior descending and right coronary arteries (11 cases), followed by the left main stem (5 cases) and the circumflex artery (3 cases). Nineteen patients (group I) developed electrocardiographic and/or enzymatic evidence of established myocardial necrosis despite early reperfusion, whereas 11 patients did not (group II). These groups were compared according to different clinical, angiographic, hemodynamic, and operative variables. Group I patients had a more recent disease and a better segmentary contraction. The same variables were compared between the 5 patients with early cardiac death (group III) and the remainder 25 (group IV). Refractory cardiac arrest, jeopardized myocardial mass and coronary perfusion indexes after the infarction-related complication, all were more desfavorable in group III. The ischemic interval between infarction onset and reperfusion was not different between the groups. The potential of surgery for myocardial salvage in the setting of evolving necrosis is emphasized as well as the influence of the magnitude of involved myocardium and its clinical repercussion on early mortality.

[The midterm (6 years) clinical results of the Carpenter-Edwards supra-annular bioprosthesis]. / Resultados clínicos a medio plazo (6 años) de la bioprótesis de Carpentier-Edwards supraanular.

We present here the clinical results with a second-generation porcine bioprosthesis, the Carpentier-Edwards supra-annular valve (CESA). Two-hundred and twenty-two CESA bioprostheses were implanted in 189 patients during a four-year period (from 1984 to 1987), either as an isolated procedure or associated to mitral or tricuspid repair. The mid-term clinical results have been evaluated after a mean follow-up of 3.4 years, being 96% complete. There were 16 in-hospital deaths (8.4%) and 6 late, potentially valve-related, cardiac deaths (1.1% patients/year). Overall, 86.7 +/- 2% of the patients were free from cardiac death at 6 years (95.1 +/- 2% of the patients surviving the operative period). Linearized rates of valve related complications were the following: 1.4% patients/year for thromboembolism (including valve thrombosis), 0.5% patients/year for treatment-related hemorrhage and 0.7% patients/year for endocarditis. We did not found any case of either intrinsic or extrinsic valve failure, unrelated to infection of thrombosis. Two patients were reoperated, one because of valve thrombosis and the other due to prosthetic valve endocarditis (reoperation rate of 0.3% patients/year). When lethal and nonlethal valve-related complications (including in-hospital deaths) were considered all together, 75.8 +/- 8.4% of the patients remained alive and free of morbid events at 6 years. When patients were grouped according to the valve replaced (aortic, mitral and multiple), best results were found with patients submitted to isolated aortic valve replacement. We conclude that the CESA bioprosthesis has an excellent mid-term clinical performance. However, longer follow-up is necessary to know if improvement in valve design and manufacturing results in increased valve durability.

[Long-term experience with multivalve replacement with the Medtronic-Hall mechanical prosthesis]. / Experiencia a largo plazo en las sustituciones polivalvulares con la prótesis mecánica de Medtronic-Hall.

During the period from January to September 1986, 182 Medtronic-Hall (M-H) heart valve prostheses were implanted in 89 patients, mainly because of rheumatic valve disease (68.5%). The patients were divided in two groups. Group I consisted of 83 patients with aortic and mitral valve replacement. Six patients with tricuspid valve replacement plus aortic and/or mitral valve replacement constituted group II. In group I the majority of the patients (86.7%) were in functional class III or IV (NYHA). Twenty three patients had undergone at least one previous cardiac operation. Hospital mortality was 6.02% (5/83). In group II the patients were in functional class III or IV (NYHA). Hospital mortality was 33.3% (2/6). Death occurred in the operating room in only one instance. Follow-up was completed in 98.9% and extended from 27 months to 8 years (348.7 patient years in group I and 23.08 patient years in group II). The overall 5 and 8 years actuarial survival, freedom of thromboembolism and freedom from endocarditis rates in group I were: 80.8 +/- 4.4% and 72.7 +/- 5.2%; 89.8 +/- 4% and 85.8 +/- 4.7%; 94.8 +/- 1.2 and 93.1 +/- 1.7%. In group II, actuarial studies were not carried out because of the scanty number of cases. There were another complications in group I: haemorrhage due to anticoagulation in 6 cases, hemolysis in 8 instances and periprosthetic leaks in 2 cases. There were no cases of structural failure. We conclude that after 8 years of follow-up the M-H valve prosthesis shows an excellent clinical performance and mechanical reliability, and the incidence of valve-related complications was in the low range of that reported with other mechanical prostheses.

[Severe chronic ischemic ventricular dysfunction. Determinants of surgical risk and long-term clinical outcome]. / Disfunción ventricular isquémica crónica severa. Determinantes del riesgo quirúrgico y del resultado clínico a largo plazo.

INTRODUCTION: In patients with chronic ischemic heart disease, a severe ventricular dysfunction is associated with a higher operative risk and to a worse late clinical outcome. However, when there is sufficient viable myocardium, surgical revascularization can improve ventricular performance and above all the functional capacity and survival of these patients. OBJECTIVES: To analyze long-term results of a large series of patients with an ejection fraction < or = 0.30 that underwent isolated coronary artery bypass surgery and to investigate factors, mainly clinical, that determined favorable clinical results: being that the patient was alive and free of incapacitating symptoms. PATIENTS AND METHODS: This series included 100 patients, 93 males and 7 females, with a mean age of 62 +/- 8 years. The predominant clinical manifestation was angina in 37, congestive heart failure in 22 and both in 41. Seventy-nine patients were in functional class III or IV, and 19 had emergency surgery. RESULTS: There were 10 in-hospital deaths, 6 of which occurred in patients who had emergency surgery. Mortality in the elective cases was 4.9%. Only age (p < 0.05), functional class (p < 0.05) and emergency surgery (p < 0.0001) were identified as independent predictors of early mortality. Actuarial survival rates after 5 and 8 years were 65 and 52% respectively. Long-term clinical outcome was considered favorable in 66 patients. We did not find any preoperative clinical variables that were predictors of the clinical outcome. Only preoperative mitral insufficiency correlated with a poor long-term clinical result. CONCLUSIONS: Patients with chronic and severe ventricular dysfunction secondary to coronary artery disease have an acceptable surgical risk when they are operated on electively, before their clinical condition deteriorates. Long-term results are satisfactory in the majority of the patients. In these types of patients clinical manifestations are of limited value in the selection process for surgical revascularization.

[Complex implantation of an automatic defibrillator-cardioverter through a left superior vena cava]. / Implantación compleja de desfibrilador-cardioversor automático a través de una vena cava superior izquierda.

We describe the case of a 19-year-old girl with a left superior vena cava and a surgically corrected complete atrioventricular canal defect. After an inhospital sudden death an automatic defibrillator-cardioverter was implanted through her left superior vena cava. During the postoperative course, multiple inappropriate discharges caused by myopotential oversensing indicated the relocation of the electrode and, finally, insertion of two epicardial leads by a left submammarian thoracotomy approach, produced an optimal result.

[Reoperations of myocardial revascularization]. / Reoperaciones de revascularización miocárdica.

UNLABELLED: Coronary by-pass grafting is a well established procedure for ameliorating ischemic coronary disease. From time to time it is necessary to re-operate these patients. The objective of our paper is to present our experience in this field. Retrospective analysis of 128 patients operated on between February 1978 and November 1996, has been analyzed. The mean age was 57.4 +/- 0.7 years. 77.2 +/- 5 months elapsed between operations. Stable angina (20.4%) or unstable angina (76.3%), myocardial infarction (48%) and congestive heart failure (17%) were the predominant clinical manifestations. RESULTS: Hospital mortality was 10.9% (14 patients) and in the follow-up there were 16 deaths (14%). Perioperative myocardial infarction was the main cause of in-hospital mortality. In the follow-up there were 4 deaths due to myocardial infarction and another 4 patients died from neoplasms. Perioperative myocardial infarction was present in 9.3% (12 patients) IN CONCLUSION: a) Re-do coronary by-pass grafting is still a good procedure for solving myocardial ischemia in spite of a higher mortality and morbidity than in the original operation. b) There is no progression in the number of patients according to our experience, probably due to better techniques and the frequent actions by an intervention cardiologist. c) The long-term results are good enough, but with a higher mortality.

[Clinical results of double versus single mammary artery myocardiac revascularization: 15 years of follow-up]. / Resultados clínicos de la revascularización miocárdica con doble arteria mamaria frente a única: 15 años de seguimiento.

INTRODUCTION: Use of the left internal mammary artery to bypass the left anterior descending coronary artery reduces cardiac events and increases survival. However, there is some controversy as to the benefits of using both mammary arteries. OBJECTIVES: To assess the long-term outcome of the use of both mammary arteries in comparison with the use of only one. PATIENTS AND METHOD: A retrospective cohort study with a mean follow-up of 9.0 +/- 4.2 years was performed including 108 patients consecutively revascularized using both mammary arteries (II) and 108 patients randomly chosen in whom one mammary artery (I) was used for this purpose. RESULTS: Both groups were similar. There were no differences between the groups in operative morbidity or mortality. The survival at 10 years was similar (II: 84.61 +/- 4%; I: 85.18 +/- 3.8%), whereas recurrence of angina (II: 29.63 +/- 5.3%; I: 47.55 +/- 5.6%) (p = 0.012), the requirement for percutaneous angioplasty (II: 3.98 +/- 2%; I: 12.99 +/- 4.1%) (p = 0.009) and cardiologic events (II: 33.48 +/- 5.5%; I: 48.48 +/- 5.5%)(p = 0.022) were all lower in the group in which both mammary arteries were used. In the multivariate analysis, the use of both mammary arteries was an independent protective factor against angina recurrence (RR = 0.55), angioplasty (RR = 0.18) and cardiologic event (RR = 0.60). CONCLUSIONS: The use of both mammary arteries for revascularization does not increase operative morbidity. Since this procedure acts as an independent factor against angina recurrence, angioplasty and cardiologic event

[Myocardial revascularization: isoflurane and halothane. Our experience]. / Revascularización miocárdica: isofluorano y halotano. Nuestra experiencia.

The use of isofluorane in coronary patients has been questioned due to the coronary steal syndrome that this agent is said to produce with changes in the myocardial lactate extraction, ST segment changes or T wave inversion. Three hundred fifty nine patients underwent coronary revascularization were studied. The anaesthesia was carried out with halothane (146 patients) or isofluorane (213 patients) as volatile agents of a balanced anesthetic technique based on high doses of narcotics. We found no correlation between the use of isofluorane and ST changes or T wave inversion. The appearance of myocardial infarction between the 2 groups was also no statistically difference (p = 0.61).