[Red cell transfusion and long-term survival in non-complicated heart surgery]. / Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada.

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n=703) and those who did (n=959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. STUDY ENDPOINTS: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P=.02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio=1.4, 95%CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality.

Respiratory tract infections after cardiac surgery: impact on hospital morbidity and mortality.

AIM: Nosocomial pneumonia (NP) and tracheobronchitis after cardiac surgery are associated with worse outcomes. The aim of this study was to identify risk factors associated with NP and tracheobronchitis after cardiac surgery and to determine the impact of these infections on hospital morbidity and mortality. METHODS: We evaluated 1600 adult patients undergoing cardiac surgery under standard cardiopulmonary bypass. Data were collected prospectively. All NP and tracheobronchitis episodes were confirmed by a semiquantitative culture of endotracheal aspirate. Logistic regression analysis was done to identify risk factors for respiratory tract infection and mortality. RESULTS: The rate of NP was 1.2% (15.6 episodes per 1000 days of mechanical ventilation) and that of tracheobronchitis was 1.6% (21 episodes per 1000 days of mechanical ventilation). Significant independent risk factors for respiratory tract infection (pneumonia or tracheobronchitis) were: left ventricular ejection fraction < 30% (P = 0.001), chronic renal failure (P < 0.0001) and urgent surgery (P < 0.0001). Patients with NP had significantly higher mortality (42% versus 0.9%, P < 0.0001) than patients without respiratory tract infection. The median hospital length of stay was significantly longer in patients with pneumonia (42 days) and tracheobronchitis (28 days) than in patients without any respiratory tract infection (11 days, P < 0.0001). CONCLUSION: NP after cardiac surgery is associated with severe outcomes. Independent risk markers for respiratory tract infection were left ventricular ejection fraction < 30%, chronic renal failure and urgent surgery.

Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE). / Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE).

Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

[Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital]. / Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario.

OBJECTIVE: This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. METHODS: The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. RESULTS: Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). CONCLUSIONS: The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9).

Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients.

BACKGROUND: Pulmonary autograft aortic valve replacement has been introduced in our institution in selected adult patients in light of the known disadvantages and limitations of conventional prosthetic valves. METHODS: We prospectively evaluated the use of the pulmonary autograft in a series of 70 young adults (31.2+/-8.7 years, range 16 to 49 years) operated on from March 1992 to April 1997 with aortic root replacement only. RESULTS: There were no in-hospital deaths and two noncardiac-related late deaths during follow-up of up to 62 months (mean 33 months). Thromboembolic complications were not observed. One patient required reoperation for infective endocarditis 4.3 years after surgery. Discharge echo-Doppler studies showed normal autograft and allograft valve function. Serial echo-Doppler studies showed no significant progression of aortic insufficiency and no dilatation of the autograft. A severe stenosis of the pulmonary allograft developed in 1 patient. CONCLUSION: Aortic root replacement with a pulmonary autograft, although more complex than conventional prosthetic valve replacement, is a safe, effective, and reproducible procedure in properly selected adult patients. Long-term results remain to be evaluated.

Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement.

BACKGROUND: We evaluated the midterm results of the Ross operation in active advanced endocarditis. METHODS: Between June 1994 and June 2000 a pulmonary autograft aortic root replacement was performed in 11 consecutive patients who had urgent or emergent procedures for active endocarditis with extensive involvement of the aortic root (10 native, 1 prosthetic). Patients ranged in age from 26 to 45 years (median, 33 years). Indications for operation were uncontrolled infection (n = 5), hemodynamic deterioration (n = 3), or both (n = 3). Four patients were in the New York Heart Association class III, 6 in class IV, and 1 was operated on while in cardiogenic shock. Four patients (36%) suffered an embolic cerebrovascular accident preoperatively. The endocarditis affected the mitral valve in 2 patients and the tricuspid valve in 1 patient. RESULTS: There was no early or late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period ranging up to 72 months (median, 40 months). CONCLUSIONS: The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis.

Intramural hematoma of the thoracic aorta: precursor sign to thoracic aortic dissection.

A 60-year-old man was admitted at his local hospital for persistent chest pain and suspicion of aortic dissection. No evidence of aortic dissection or intimal disruption was noted by means of computed tomography and transesophageal echocardiography. A localized intramural hematoma of the ascending aorta was found. He was first treated medically and remained asymptomatic for 8 days when he developed a new episode of chest pain. He was found to have an acute type A dissection by computed tomography. He underwent graft replacement of the ascending aorta and had an uneventful post-operative course. This case report describes the development of true aortic dissection in a patient who previously had a localized intramural hematoma.

[Widening plasty of the anterior cusp in rheumatic mitral insufficiency]. / Plastie d'élargissement de la valve antérieure dans l'insuffisance mitrale rhumatismale.

UNLABELLED: The mechanism of insufficiency in rheumatic valve disease includes 1. annulus dilatation and 2. restricted leaflet motion. Aiming at improving the treatment of restriction, augmentation of the anterior mitral leaflet (AML) was achieved with a piece of autologous pericardium. METHODS: between January 1995 and December 1999, out of 274 patients refered for rheumatic mitral disease, 143 patients underwent a repair (52%), 81% of them had pure regurgitation with no stenosis. Ring annuloplasty was performed in all cases. Two techniques used for treating the restrictive componant of the regurgitation were compared in two consecutive cohort of patients: no AML augmentation (n=62) and AML augmentation (n=81). Mean age was 42 + 3 years and all preoperative variables were comparable except for the incidence of redo patients who all underwent AML extension. RESULTS: in hospital mortality was 0.7% (n=1 with AML extension) and there was one early reoperation for a pericardial patch dehiscence. After a mean follow-up of 3.2 years, there was one sudden death (no AML extension). The reoperation rate was lower with (2.5%) than without (12.9%) AML augmentation (p<0.05). Echographic study showed a lower incidence of recurrency of mitral insufficiency when AML augmentation had been performed (grade 2: 9% and grade 3: 3%) as compared to no AML augmentation (grade 2: 35% and grade 3: 14%) (p<0.05). The mitral orifice area was larger (AML augmentation: 2.2 + 0.3 cm2 vs no AML augmentation: 1.8 + 0.4 cm2). CONCLUSION: ring annuloplasty alone failed to correct rheumatic mitral insufficiency in all cases. AML augmentation improved the quality of the repair and decreased the risk of reoperation.

[Preoperative anemia in coronary surgery: a risk factor?]. / Anemia preoperatoria en la cirugía coronaria: ¿un factor de riesgo?

INTRODUCTION AND OBJECTIVES: Preoperative anemia as a risk factor of adverse outcomes after coronary surgery has not been well-established. This study has aimed to analyze the association between preoperative anemia and postoperative adverse events and in-hospital mortality in the patients undergoing isolated coronary artery bypass graft surgery in the Son Dureta hospital. METHODS: All the patients undergoing isolated coronary artery bypass graft surgery with extracorporeal circulation from November 2002 to June 2007 were included. Preoperative anemia was defined as hemoglobin (Hb)<13g/dL in men and Hb<12g/dL in women. The association between postoperative cardiac and noncardiac adverse events and the presence or absence of preoperative anemia and concomitant surgical risk, assessed by logistic EuroScore, were analyzed. RESULTS: A total of 623 patients were included. The rate of preoperative anemia was 34.5%. Patients with Euroscore > or =4 had higher incidence of preoperative anemia than patients with Euroscore<4 (41% vs. 27%; p=0.0001). There were no statistically significant differences in the rate of postoperative adverse events related to the presence or absence of preoperative anemia. Median ICU and hospital length of stay were longer in patients with preoperative anemia than in patients without preoperative anemia (ICU: 3.2+/-2.5 days vs. 3.7+/-2.8, p=0.004; in-hospital: 17.5+/-11.3 days vs. 14.7+/-10.2, p=0.001). Hospital mortality rate was 0.8% (95% CI 0.3-1.9). There were no differences in the mortality rate of the patients with and without preoperative anemia (0.9% vs 0.7%, p=0.8). CONCLUSIONS: In this study, preoperative anemia in patients undergoing coronary artery bypass graft surgery was not associated with increased hospital morbidity-mortality. However, ICU and hospital length of stay were longer in patients with preoperative anemia. The limitation of the sample size prevents us from confirming whether preoperative anemia is a risk factor after coronary surgery or not.