Venoarterial Extracorporeal Membrane Oxygenation as A Bridge to Surgery in Post-Myocardial Infarction Ventricular Septal Defect with Cardiogenic Shock: Case Report

ABSTRACT We describe a 60-year-old woman with post-myocardial infarction (MI) ventricular septal defect (VSD) and cardiogenic shock who was successfully stabilized with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge therapy for the surgical closure of her VSD. This case highlights the role of VA-ECMO in the management of post-MI VSD to improve the results of surgical repair and patient survival.

Evaluación teórica de la exposición dietaria a la bacteriocina nisina como conservante natural para aderezos de tipo mayonesa vegetal en Chile

Actualmente, existe una necesidad en la industria alimentaria de buscar preservantes de origen natural que tengan una mejor aceptación por el consumidor. Una alternativa interesante que ha emergido en los últimos años es el uso de antimicrobianos naturales, los cuales además de ser efectivos en el control de microorganismos, son inocuos para la salud. La nisina es una bacteriocina producida por bacterias ácido lácticas que se utiliza actualmente como preservante en varios productos alimenticios. En Chile, el uso de la nisina como aditivo está restringido a quesos y cremas naturales o nata cuajada, pero existen otros alimentos que podrían beneficiarse del uso de este preservante, como es el caso de los aderezos tipo mayonesa vegetal. En el presente trabajo, se analiza de manera teórica, como el uso de nisina en estos aderezos impactaría el consumo máximo permitido para este aditivo en la población chilena. Para esto, se analizó cuál es el consumo teórico actual de nisina en Chile, y cómo este se vería afectado si se utilizara nisina como preservante en aderezos tipo mayonesa vegetal. Finalmente, los datos obtenidos se compararon con el valor de ingesta diaria admisible (IDA) para la nisina, evidenciándose que existe una ventana de oportunidad para el uso de nisina en otros productos alimenticios.

Currently, there is a need in the food industry for natural preservatives that have good consumers acceptance. Natural antimicrobials are a novel alternative, effective in controlling microbial growth, and safe to consume. Nisin is a bacteriocin produced by lactic acid bacteria that is currently used as a preservative in several food products. In Chile, nisin is regulated and restricted as an additive to cheeses and natural creams or curds. However, other food products could benefit from using nisin as a preservative, such as plant-based mayonnaise, where the consumer expects to find natural preservatives. In this review, we make a theoretical analysis of how adding nisin to plant-based mayonnaise would impact the daily intake of this additive in the Chilean population. Finally, we compare this data with the acceptable daily intake for nisin to conclude that there is an opportunity for using nisin as a preservative in plant-based mayonnaise without affecting consumers´ health.

Reemplazo valvular tricuspídeo: prótesis mecánica versus prótesis biológica: trabajo observacional-descriptivo / Tricuspide valve replacement: comparison of biological versus mechanical valve: a descriptive observational study

ANTECEDENTES: El reemplazo protésico de la válvula tricúspide es un procedimiento infrecuente, con elevada mortalidad y morbilidad operatoria, independientemente de la etiología de la insuficiencia tricuspídea. Persiste aún una discusión respecto al tipo de prótesis a utilizar, mecánica o biológica. OBJETIVO: Analizar nuestros resultados perioperatorios y alejados en el reemplazo valvular tricuspídeo, comparando ambos tipos de prótesis. MÉTODO: Revisión de la Base de Datos de nuestro Servicio de Cirugía Cardiovascular para el periodo enero 1991 - diciembre 2017. Identificados los pacientes con reemplazo valvular tricuspídeo (RVT); se revisaron los protocolos operatorios y los ecocardiogramas. La supervivencia se certificó a través del Registro Civil e Identificación de Chile. RESULTADOS: Se identificaron 83 pacientes con RVT (76% mujeres), los que representaron el 0,7% del total de las cirugías con circulación extracorpórea y el 2,1% de las cirugías valvulares para el periodo en estudio. La edad promedio fue 49±16,5 años. Cuarenta y nueve casos (59%) correspondieron a reoperaciones y otros 49 tuvieron un procedimiento asociado. En 40 pacientes (48%) se utilizó una prótesis mecánica y en 43 (52%) una biológica. La mortalidad operatoria global fue 9,6% (8 pacientes, 4 con una prótesis mecánica y 4 con una biológica). El seguimiento se completó en el 100%, con un promedio de 7,1 años. Veintiocho pacientes fallecieron durante el seguimiento; la principal causa fue insuficiencia cardiaca. Así, la supervivencia a 5 años fue 70,3 ± 5,3% y a 10 años 58 ± 6,3%, sin diferencia significativa entre ambos tipos de prótesis. Siete pacientes se reoperaron durante el seguimiento (5 casos con prótesis biológica y 2 mecánica). CONCLUSIÓN: El RVT continúa siendo un procedimiento infrecuente, con mayor incidencia en mujeres, en la quinta década de la vida. La mayoría de los pacientes presentaba comorbilidad y había tenido cirugía cardiovascular previa. La mitad de estos recibió una prótesis mecánica y la otra, biológica. No hubo diferencias significativas entre ambos tipos de prótesis en cuanto a mortalidad operatoria, supervivencia alejada o reoperación.

BACKGROUND: Tricuspid valve replacement (TVR) is an uncommon surgical procedure, associated with high mortality and morbidity. The use of biological or mechanical prostheses in TVR has advantages and disadvantages and, therefore, there persists a debate regarding the choice of one or other type of prostheses. AIM: To analyze our operative and long-term surgical results, comparing both types of prosthetic valves. METHODS: The Data Base of the Cardiovascular Surgery Service was reviewed for the period between January 1991 and December 2017. 83 patients with TVR were identified, the operative notes and echocardiogram reports were analyzed. Survival was obtained from the Chilean Civil Identification Service. RESULTS: 83 patients (76% women) had TVR. They represented 0.7% of the total cases operated on with extracorporeal circulation and 2.1% of all valve disease cases, for the study period. Mean age was 49±16.5 years. 49 cases (59%) were reoperations and another 49 had an associated procedure. In 40 patients (48%) a mechanical prosthesis was used and in 43 (52%) a biological one was implanted. Operative mortality rate was 9.6% (8 patients, had a mechanical valve and the other 8, a biological one). Follow-up was 100% completed, with an average of 7.1 years. 28 patients died during follow-up; the main cause of death was heart failure. Five-year survival rate was 70.3 ± 5.3% and at 10 years it was 58 ± 6.3%, without significant difference the type of prostheses. Seven patients were re-operated during follow-up (5 cases corresponded to a biological prostheses and 2 to a mechanical one). CONCLUSION: TVR is still an infrequent surgical procedure, more commonly performed in women, on the fifth decade of life. Most patients presented comorbidities and had a previous cardiovascular surgical operation. Half of them received a mechanical prosthesis and half a biological one. There was no significant difference between both types of prostheses related to surgical mortality, long-term survival or reoperation.

Embolismo de líquido amniótico / Amniotic fluid embolism

Resumen El embolismo de líquido amniótico es una complicación seria y potencialmente mortal del embarazo, la cual es considerada imprevenible e impredecible. La mayoría de los casos ocurren durante la labor de parto, sin embargo hasta un tercio ocurren en el postparto inmediato. Su presentación es abrupta y se cree se debe a una respuesta anormal ante el paso de tejido fetal a la circulación materna, a través del sitio de inserción de la placenta. Ante la ausencia de criterios diagnósticos establecidos o pruebas de laboratorio específicas, los signos y síntomas clásicos como hipoxia, hipotensión y coagulopatía, en ausencia de otra explicación, conforman el diagnóstico clínico. Estos deben ser rápidamente identificados y tratados por parte de un equipo multidisciplinario, con el fin de reducir la morbilidad y mortalidad materna.

Abstract Amniotic fluid embolism is a serious and life-threatening complication of pregnancy, it is considered unpreventable and unpredictable, most cases occur during labor, however up to a third occur in immediate postpartum, its presentation is abrupt and is believed to be due to an abnormal response to the passage of fetal tissue to maternal circulation through the insertion site of the placenta. Due to the lack of established diagnostic criteria or specific laboratory tests, classic signs and symptoms such as hypoxia, hypotension and coagulopathy, in the absence of another explanation, make up the clinical diagnosis, these must be quickly identified and treated by a multidisciplinary team, in order to reduce maternal morbidity and mortality.

Endometriosis / Endometriosis

Resumen La endometriosis es una enfermedad inflamatoria benigna, dependiente de estrógeno, que se caracteriza por la presencia de glándulas y estroma endometrial en un sitio distinto a la cavidad uterina. Las principales teorías sobre su patogénesis involucran la menstruación retrograda, La metaplasia del epitelio germinal, y la diseminación metastásica. Las lesiones típicamente se localizan en la pelvis; en ovarios, ligamentos uterosacros y saco de Douglas, sin embargo también pueden encontrarse fuera de esta. La enfermedad ocasiona un cuadro clínico variado que involucra dismenorrea, dispareunia, dolor pélvico e infertilidad. Su diagnóstico definitivo ES quirúrgico. El tratamiento médico es solo sintomático y no curativo, mientras que el quirúrgico pese a ser curativo, presenta variables tasas de recurrencia. Las técnicas de reproducción asistida mejoran significativamente las tasas de nacimientos en caso de infertilidad asociada a la enfermedad.

Abstract Endometriosis is a benign, estrogen dependent, inflammatory disease, which is characterized by the presence of endometrial glands and stroma in a site different from the uterine cavity. The main theories about it's pathogenesis involve retrograde menstruation, metaplasia of the germinal epithelium, and metastatic spread. The lesions are typically located in the pelvis; in ovaries, utero sacral ligaments and Douglas pouch, but can also have an extra pelvic location. This disease has a variable clinical presentation that involves dysmenorrhea, dyspareunia, pelvic pain and infertility. It's definitive diagnosis is surgical. Medical treatment is only symptomatic and non-curative, while the surgical treatment despite being curative has important recurrence rates. Assisted reproduction techniques are very useful to improve birth rates in case of infertility associated with the disease.

Enfermedad trofoblastica gestacional / Gestational trophoblastic disease

Resumen La enfermedad trofoblástica gestacional engloba un conjunto de patologías con potencial maligno y neoplásicas propiamente, las cuales pueden ser adquiridas tras la gestación. Aunque estos tumores abarcan menos del 1% de los tumores ginecológicos, representan una amenaza para la vida de las mujeres en edad reproductiva. Es importante que los médicos comprendan su etiología, evolución natural y manejo, debido a su alto potencial de curación con la posibilidad de preservar la función reproductiva si se diagnostica a tiempo y se trata adecuadamente según sus criterios de riesgo y pronóstico.

Abstract The gestational trophoblastic disease englobes a set of neoplastic pathologies and pathologies with malignant potential, which can be acquired after gestation. Even though these tumors include less than 1% of gynecological tumors, they represent a threat to the life of women in reproductive age. It is important that physicians understand its etiology, natural evolution and control. If it is diagnosed on time and treated appropriately according to its risk and prognosis criteria, there's a high healing potential including the ability of preserving reproductive function.

Síndrome de muerte súbita del lactante / Sudden Infant Death Syndrome (SIDS)

Resumen El síndrome de muerte súbita del lactante es la principal causa de muerte infantil post neonatal en los países desarrollados. El mismo se caracteriza por una muerte repentina e inexplicable de un infante menor a un año. La compleja interacción de múltiples factores en su patogénesis se ilustra con la teoría del triple riesgo, la cual involucra un infante vulnerable en un periodo crítico de su desarrollo ante un factor de riesgo externo. Por medio de educación a los cuidadores y padres se ha documentado una disminución importante en su incidencia, aunque la misma continúa siendo muy alta.

Abstract Sudden infant death syndrome is the leading cause of post neonatal infant death in the developed countries. It is characterized for the sudden and unexplained death of an infant younger than one year old. The interaction of multiple factors in its pathogenesis is illustrated by the triple risk theory, which involves a vulnerable infant at a critical moment of its development facing an external risk factor. Through education to caregivers and parents a drop in incidence has been documented, although it is still very high.

Resultados de un programa nacional de trasplante cardiaco pediátrico: fortalezas y debilidades / Results of a national program of pediatric heart transplantation: strengths and weakness

El trasplante cardiaco pediátrico es una terapia efectiva para tratar la insuficiencia cardiaca avanzada. Objetivos: Analizar los resultados inmediatos y a mediano plazo de niños enlistados para trasplante cardiaco. Pacientes y Método: Se analizó el registro de pacientes enlistados para trasplante, entre octubre de 2001 y julio de 2016, analizando datos demográficos, diagnósticos, status de enlistamiento, tiempo de espera, datos de donantes, uso de asistencia ventricular, complicaciones y mortalidad. Resultados: La serie abarca 30 pacientes con edad promedio de 9,4 años (1 mes a 15 años). El diagnóstico principal fue miocardiopatía dilatada en 24 pacientes (80%). El status de ingreso fue I (urgencia) en 19 casos y II (no urgencia) en 11. Fallecieron 10 en la lista de espera (33,3%) en un promedio de 52 días (13 a 139 días). Catorce pacientes fueron trasplantados (46.7%), con un tiempo de espera de 199,6 días (4 a 586 días). Requirieron asistencia ventricular 9 pacientes (30%). Todos recibieron inmunosupresión tri asociada. Un paciente falleció a los 16 días por falla primaria del injerto (7,1%). El seguimiento promedio fue de 43 meses (0,5 a 159 meses). Dos pacientes fallecieron alejadamente (55 y 82 meses) por rechazo secundario al abandono de tratamiento inmunosupresor. La supervivencia a 1 y 5 años fue 93% y 74%, respectivamente. Conclusiones: Nuestro programa ha trasplantado al 50% de los pacientes enlistados con buena supervivencia a mediano plazo. Una proporción significativa de pacientes se enlistó con carácter de urgencia y un 34.5% de los pacientes fallecieron en la lista de espera.

Pediatric heart transplantation is an effective therapy to treat advanced heart failure in children. Objectives: To analyze the immediate and mid-term results of pediatric patients listed for heart transplantation. Patients and Methods: Registration of patients admitted to our transplant protocol between October 2001 and July 2016 were reviewed, analyzing demographic data, diagnosis, status at the time of listing, waiting time until transplantation, donor data, use of ventricular assist device, hemodynamic data, complications and global mortality. Results: Thirthy patients where included with a mean age of 9.4 years (1 month to 15 years). The most frequent diagnosis was dilated cardiomyopathy in 24 patients (80%). The status was I (urgency) in 19 cases and II in 11 cases. Ten patients died on the waiting list (33.3%) at an average of 52 days (13-139 days). Fourteen were transplanted (46.7%), with a waiting time of 199.6 days (4-586 days). Nine patients required mechanical support (30%). All patients received triple association of immunosuppression. One patient died 16 days post transplant due to primary graft failure (7.1%). The average follow-up was 43 months (0.5-159 months). Two patients died later on (82 and 55 months), both due to secondary rejection because of voluntary cessation of immunosuppressive therapy. Survival at 1 and 5 years was 93% and 74%, respectively. Conclusions: Our program has successfully transplanted 50% of patients enrolled, with good medium-term survival. A significant proportion of patients were listed as a medical emergency and 34.5% died on the waiting list.

Síncope secundario a mixoma gigante del anillo mitral: reporte de un caso / Large mitral annulus myxoma presenting with syncope: report of one case

We report a 23-year-old woman, with three recent exertional syncopes. Transthoracic (TTE) and transesophageal (TEE) echocardiography found a large heterogeneous mass (38 x 35 mm) arising from the posterior mitral annulus, protruding in systole through the left ventricular outflow tract (LVOT). Heart MRI confirmed the echocardiography findings, suggesting a cardiac myxoma. Cardiac surgery accomplished the complete resection of the lesion, confirming a mass arising from the posterior mitral annulus and preserving mitral anatomy and function. Pathology was positive for a myxoma. Uneventful evolution allowed the discharge of the patient at the fifth postoperative day. Control TTE discarded any complication.

Infección del sitio quirúrgico en niños sometidos a cirugía cardíaca con cierre esternal diferido: estudio de casos y controles / Surgical site infections in children undergoing cardiac surgery with delayed sternal closure: case-control study

Introduction: Surgical site infections (SSI) are an important cause of morbidity in pediatric cardiac surgery. Risk factors in patients requiring delayed sternal closure (DSC) are unknown. Aim: To report the rate of SSI in children undergoing cardiac surgery with DSC and determine the risk factors. Methodology: A retrospective case-control study, in patients younger than 15 years old undergoing cardiac surgery with DSC in our center between 2009 and 2010. SSI was diagnosed according to the criteria of the nosocomial infections committee of our institution, based on international recommendations. Univariate and multivariate analysis of variables was performed. A p < 0.05 was considered significant. Results: 58 patients were included; the average age was 9.5 days. The most frequent diagnosis were transposition of the great arteries (36%) and hypoplastic left heart syndrome (27%). 13 patients had SSI (22%); 11 incisional and 2 mediastinitis. It was independently associated to SSI by-pass (BP) time longer than 200 min (OR adjusted = 9,53; IC 95% 1,37-66,35) and mechanical ventilation (MV) more than 5 days (OR adjusted = 8,98; IC 95% 1,16-69,40). Conclusion: The duration of BP and MV are risk factors of SSI in children undergoing cardiac surgery with DSC.

Introducción: Las infecciones del sitio quirúrgico (ISQ) son importante causa de morbilidad en cirugía cardíaca pediátrica. Los factores de riesgo en pacientes que requieren cierre esternal diferido (CED) se desconocen. Objetivos: Reportar la tasa de ISQ en niños sometidos a cirugía cardíaca con CED y determinar factores de riesgo de ISQ. Metodología: Estudio retrospectivo de casos y controles en pacientes bajo 15 años de edad, sometidos a cirugía cardíaca con CED, en los años 2009 y 2010. Se consideró casos aquellos con ISQ diagnosticada según criterios del comité de IAAS local. Se realizó análisis uni y multivariado de las variables. Se consideró significativo un p < 0,05. Resultados: Se incluyeron 58 pacientes; la mediana de edad fue 9,5 días. Diagnósticos más frecuentes fueron transposición de grandes arterias (36%) e hipoplasia de ventrículo izquierdo (27%). Trece pacientes presentaron ISQ (22%); 11 incisionales y 2 me-diastinitis. Se asociaron de manera independiente a ISQ: circulación extracorpórea (CEC) mayor a 200 min (OR ajustado = 9,53; IC 95% 1,37-66,35) y ventilación mecánica invasora (VMI) más de 5 días (OR ajustado = 8,98; IC 95% 1,16-69,40). Conclusión: La duración de CEC y VMI son factores de riesgo de ISQ en niños sometidos a cirugía cardíaca con CED.

Método de clasificación de mortinatos según condición obstétrica relevante de la muerte fetal, en un hospital público de Chile (Método CORM) / A new fetal death classification system

Background: Stillbirth is the mayor contributor to perinatal mortality. Aim: To report a system for classification of fetal deaths. Material and Methods: Retrospective cohort study of 29,916 births with 258 fetal deaths that occurred in a public hospital. Data were obtained from audit reports of stillbirths. The method for classification “obstetric condition relevant to the death” was applied, based on obstetric and placental pathological findings analyzed exclusively by a single obstetrician and a single pathologist. Results: Ninety two percent of obstetric conditions causing fetal death were identified. The most commonly reported were ascending bacterial infection in 26%, congenital anomalies in 19%, arterial hypertension in 12% and placental pathology in 12%. Fetal growth restriction was identified in 50% of stillbirths. Ninety percent were secondary to a primary obstetric condition and 10% had an unexplained cause. Placental abruption as the final cause of fetal death was identified in 60% of cases with arterial hypertension, 43% of cases with placental pathology and 37% of ascending infections. Fetal deaths occurred during pregnancy in 82% of cases and during labor in 17%. Intrapartum asphyxia occurred in 0.8% of stillbirths and presented in term pregnancies. Conclusions: The “obstetric condition relevant to the death” method for classification of fetal death is effective to identify the originating obstetric cause of stillbirth and reduces the impact of fetal growth restriction and intrapartum asphyxia as the leading causes of death.

Síndrome de hipoplasia de corazón izquierdo: experiencia de 10 años de un programa de etapificación quirúrgica / Hypoplastic left heart syndrome: 10 year experience with staged surgical management

Resumen El síndrome de hipoplasia de corazón izquierdo (SHCI) es una cardiopatía congénita con letalidad superior al 95%. La etapificación quirúrgica es la principal vía de tratamiento, y se inicia con la operación de Norwood; la sobrevida a largo plazo de los pacientes tratados es desconocida en nuestro medio. Objetivos 1) Revisar nuestra experiencia en el manejo de todos los pacientes con SHCI evaluados entre enero 2000 y junio 2010. 2) Identificar factores de riesgo de mortalidad quirúrgica. Pacientes y método Estudio retrospectivo de una única institución con una cohorte de pacientes con SHCI. Se revisan antecedentes clínicos, quirúrgicos, y registros de seguimiento. Resultados Se evaluaron 76 pacientes con SHCI; 9/76 tenían comunicación interauricular (CIA) restrictiva, y 8/76, aorta ascendente de < 2 mm; 65/76 fueron tratados: 77% tuvieron operación de Norwood con conducto entre ventrículo derecho y ramas pulmonares como fuente de flujo pulmonar, 17% Norwood con shunt de Blalock-Taussig, y 6% otra cirugía. La mortalidad en la primera etapa quirúrgica fue del 23%, y en operación de Norwood, del 21,3%. En el período 2000-2005 la mortalidad en la primera etapa quirúrgica fue del 36%, y entre 2005-2010, del 15% (p = 0,05). La sobrevida global fue del 64% a un año y del 57% a 5 años. Por análisis multivariado fueron factores de riesgo para mortalidad la presencia de aorta ascendente diminuta y CIA restrictiva. Conclusiones Nuestros resultados inmediatos y a largo plazo en la etapificación quirúrgica de SHCI son similares a la experiencia de grandes centros. Hay una mejoría en mortalidad operatoria en la segunda mitad de la serie. Se identifican factores de riesgo de mortalidad.

Abstract Hypoplastic left heart syndrome (HLHS) is a lethal congenital heart disease in 95% of non-treated patients. Surgical staging is the main form of treatment, consisting of a 3-stage approach, beginning with the Norwood operation. Long term survival of treated patients is unknown in our country. Objectives 1) To review our experience in the management of all patients seen with HLHS between January 2000 and June 2012. 2) Identify risk factors for mortality. Patients and method Retrospective analysis of a single institution experience with a cohort of patients with HLHS. Clinical, surgical, and follow-up records were reviewed. Results Of the 76 patients with HLHS, 9 had a restrictive atrial septal defect (ASD), and 8 had an ascending aorta ≤ 2 mm. Of the 65 out of 76 patients that were treated, 77% had a Norwood operation with pulmonary blood flow supplied by a right ventricle to pulmonary artery conduit, 17% had a Norwood with a Blalock-Taussig shunt, and 6% other surgical procedure. Surgical mortality at the first stage was 23%, and for Norwood operation 21.3%. For the period between 2000-2005, surgical mortality at the first stage was 36%, and between 2005-2010, 15% (P = .05). Actuarial survival was 64% at one year, and 57% at 5 years. Using a multivariate analysis, a restrictive ASD and a diminutive aorta were high risk factors for mortality. Conclusions Our immediate and long term outcome for staged surgical management of HLHS is similar to that reported by large centres. There is an improvement in surgical mortality in the second half of our experience. Risk factors for mortality are also identified.

Tratamiento endovascular exitoso de aneurisma de aorta torácica secundario a infección de catéter de arteria umbilical en un recién nacido pretérmino / Successful endovascular treatment of thoracic aortic aneurysm secondary to infection of the umbilical artery catheter in preterm infants

Los aneurismas aórticos en la población pediátrica son poco frecuentes. El uso de catéteres de arteria umbilical en neonatos se ha asociado a infección y en algunas oportunidades a formación de aneurismas aórticos. La reparación quirúrgica de estos aneurismas es una forma de terapia; sin embargo, la intervención percutánea con stents pudiese proveer una vía alternativa de tratamiento con menores complicaciones. El objetivo de este reporte es dar a conocer el alcance terapéutico de un procedimiento híbrido, en el que el desarrollo de la técnica quirúrgica y percutánea en conjunto ofrece otra alternativa terapéutica menos invasiva que la cirugía vascular abierta, para la reparación de aneurismas aórticos o de sus ramas principales. Caso clínico: Recién nacido de pretérmino, 30 semanas, peso 1.335 g. Se instaló catéter en arteria umbilicar que se retiró a los 14 días por infección. Evolucionó con sepsis a Staphylococcus aureus. Ecocardiograma y angiotac confirman AAT, se manejó mediante procedimiento híbrido, cirugía e instalación endovascular de 2 stents recubiertos (Atrium V12 XR Medical Corp, Hudson, NH). Los controles clínicos post procedimiento como la ecotomografía abdominal confirmaron el éxito del tratamiento. Conclusión: El procedimiento endovascular de reparación de aneurisma de la aorta en recién nacidos prematuros puede ser considerado en el momento de decir la terapéutica de esta enfermedad y podría evitar los riesgos asociados a cirugía abierta. Sin embargo, obliga a un seguimiento y control durante el crecimiento del paciente por la eventual necesidad de redilatar los stents implantados. Se desconoce cómo será la evolución de los procedimientos endovasculares neonatales en el futuro.

Aortic aneurysms (AA) in the paediatric population are uncommon. The use of umbilical catheters in neonates has been associated with infections and, on some occasions, the formation of aortic aneurysms. The surgical repair of these aneurysms is one type of treatment; however, percutaneous intervention with stents could provide an alternative treatment route, with fewer complications. The aim of this report is to present the therapeutic scope of a hybrid procedure, in which the combined surgical and percutaneous technique offers a less invasive alternative to open surgery for the repair of aortic aneurysms or their main branches. Clinical case: The case concerns a pre-term newborn of 30 weeks weighing 1,335 g. An umbilical catheter was introduced, which was withdrawn at 14 days due to an infection. It developed as Staphylococcus aureus with sepsis. The echocardiogram and Angio-CT confirmed AA, which were managed using a hybrid procedure of surgery and the endovascular implantation of 2 coated stents (Atrium V12 XR Medical Corp, Hudson, NH). The post-procedure clinical follow-ups, including abdominal echo-tomography, confirmed the success of the treatment. Conclusion: The endovascular aortic aneurysm repair procedure in premature newborns may be considered when deciding treatment of this disease, and could avoid the risks associated with open surgery. However, follow-up and monitoring is required while the patient grows up, due to the possibility that the implanted stents require re-dilating. The outcomes of neonatal endovascular procedures in the future are unknown.

Remoção, regeneração e reinstalação de implante osseointegrável em área estética: relato de caso / Removal, regeneration and reinstallation of osseointegrated implant in the esthetic zone: a case report

Há muitos anos os implantes estão sendo utilizados para reabilitar pacientes edêntulos. Atualmente, há uma grande exigência estética envolvida nessas reabilitações. O objetivo do presente artigo é descrever, por meio do relato de um caso clínico, o tratamento realizado para solucionar a queixa estética de uma paciente que apresentava um implante mal posicionado na região anterior da maxila. A paciente, com 39 anos de idade, compareceu à clínica de Implantodontia do Instituto Latino Americano de Pesquisa e Ensino Odontológico (ILAPEO) relatando insatisfação com o implante da região do elemento 22, que “aparecia ao sorrir”. Após avaliação, verificou-se que o implante estava vestibularizado, com perda óssea, comprometimento dos tecidos moles e com a coroa clínica maior que a do elemento 12. Para a resolução do caso, foi realizada, no primeiro procedimento cirúrgico, a remoção do implante, seguida de enxerto ósseo autógeno na região. Após cinco meses de cicatrização, um novo implante foi instalado e feito enxerto ósseo com GenOx Inorgânico (Baumer - São Paulo, Brasil) na vestibular, para melhorar o contorno. A reabertura foi realizada com técnica de manipulação de tecidos moles, o intermediário foi instalado e a coroa provisória, confeccionada. A paciente foi encaminhada para a clínica de prótese para finalização do caso. Diante das características do caso, a forma de tratamento realizada se mostrou eficaz, uma vez que solucionou a queixa estética da paciente, com previsibilidade e funcionalidade...

For many years the implants are being used to rehabilitate edentulous patients. Currently, there is a great aesthetic requirements involved in these rehabilitations. The purpose of this article is to describe, through the report of a case, the treatment performed to solve the aesthetic complaint from a patient with a poorly positioned implant in the anterior maxilla. The patient, 39 years old, attended the clinic Implantology of the Latin American Institute of Research and Dental Education (ILAPEO) reporting dissatisfaction with the implant of the element 22 region, which "appeared to smile." After evaluation, it was found that the implant was buccally with bone loss, breakdown of soft tissue and the greater the clinical crown element 12. For the resolution of the case, was carried out, the first surgical procedure, removal of the implant followed by autogenous bone graft in the region. After five months of healing, a new implant was installed and made bone graft with GenOx Inorganic (Baumer - São Paulo, Brazil) in the entrance exam to improve the contour. The reopening was performed with soft tissue manipulation technique has been installed intermediate and provisional crown made. The patient was referred to the clinic prosthesis for completion of the case. Before the case characteristics, the form of treatment performed was effective, since resolved the aesthetic complaint of patient, predictability and functionality...

Uso de recursos de salud por parte de pacientes adultos con cardiopatía congénita en Chile / Health resources used by adults with congenital heart disease in Chile

Reportes internacionales han descrito el mayor uso de recursos de salud por parte de los pacientes adultos con cardiopatía congénita (CC). Objetivo: Describir el uso de recursos de salud por parte de esta población en términos de frecuencia de controles médicos, consultas a servicio de urgencia, hospitalizaciones y procedimientos realizados. También se buscó explorar la frecuencia de control odontológico y la indicación de profilaxis de endocarditis como una medida de calidad de atención. Metodología: Se realizó un estudio cuantitativo de corte transversal, analítico e individual en pacientes controlados en el Instituto Nacional del Tórax, durante el período 2014-2015. Los pacientes respondieron una encuesta en forma autónoma. Se realizó análisis por grupos según sexo y tipo de CC según el consenso de Bethesda (simple, moderada o compleja). El análisis estadístico se realizó a través del programa SPSS. Resultados: Se recolectaron 363 encuestas válidas que correspondieron a 180 hombres (49,6%) y con una edad promedio de 29,2±13,3 años. Según el tipo de CC: simple 78 pacientes (21,5%), moderada 161 (44,4%) y compleja 124 (34,2%). 296 pacientes (84,6%) tuvieron el último control médico hace menos de un año. 151 pacientes (41,6%) han consultado una o más veces al servicio de urgencia. 76 pacientes (20,9%) han sido hospitalizados una o más veces y 54 pacientes (14,9%) se han realizado uno o más procedimientos en el último año. En el análisis por tipo de CC no se encontraron diferencias significativas en ninguno de los parámetros evaluados. En el análisis según sexo, se observó que las mujeres consultan más al servicio de urgencia que los hombres (48,1% vs 35%, p<0,05). En cuanto a salud oral, 122 pacientes (33,6%) no ha realizado un control odontológico hace más de 1 año y de aquellos pacientes que asistieron al dentista, 165 de ellos (45,5%) no recibió profilaxis antibiótica para endocarditis en su última atención. Conclusiones: Los adultos con CC reportan una demanda de recursos de salud expresada en controles médicos, consultas de urgencia, hospitalizaciones y procedimientos, que aparentemente no es sólo por factores relacionados a sus patologías. Es necesario elaborar estrategias de atención en salud para responder a las necesidades de esta creciente población y que permitan un uso razonable de recursos. Es perentorio estimular el control periódico dental y la profilaxis de endocarditis.

A greater use of health resources by adults with congenital heart disease has been reported in international studies. Aim: to describe the use of health resources by adults with CHD in Chile including frequency of medical controls, emergency consultations, hospitalization and medical procedures. Dental consultations and prophylaxis for infective endocarditis were also evaluated Methods: a cross sectional analytic study was per-formed on patients with CHD followed in the Instituto Nacional del Tórax, Santiago, Chile, during 2014 and 2015. Patients were asked to answer a questionnaire and data was analyzed according to gender, and type of CHD (Bethesda classification). Statistics were computed using SPSS. Results: Valid answers were obtained from 363 sub-jects, 180 males (49.6%). Mean age was 20.2 ± 13.3 years. 78 patients (21.5%) had simple, 161 (44.4%) moderate and 124 (34.2%) severe CHD. 296 (84.6%) patients had a medical control within the last year. 151 (41.6%) had attended a medical emergency service > 1 occasion, 76 (20.9% had >= 1 hospitalizations and 54 (14.9%) had been subjected to a medical procedure related to their CHD. Women had more medical controls than males (48,1% vs 35%, p<0,05). 122 (33.6%) had no dental control in the last year and 45% of those attending had no prophylaxis for IE Conclusión: Adults with CHD use health resources including medical visits, hospitalizations and procedures, apparently not all of them related to their CHD. Strategies to optimize use of health resources should be designed. Emphasis on dental controls and prophylaxis for infective endocarditis is needed.

Rotura espontánea de válvula tricúspide en un paciente con hipertensión pulmonar secundaria a VIH / Spontaneous rupture of tricuspid valve papillary muscle in pulmonary hypertension secondary to HIV infection.Report of one case

Acute primary tricuspid regurgitation (TR) secondary to papillary muscle rupture is an extremely rare clinical situation. We report a 42-year-old male with pulmonary artery hypertension (PAH) secondary to HIV infection, who presented with an acute TR due to spontaneous papillary muscle rupture. He remained in cardiogenic shock despite therapy with inotropic drugs and pulmonary vasodilator therapy. He was subjected to a tricuspid valve replacement. In the postoperative period the patient had severe PAH, which was successfully controlled with inhaled nitric oxide. Tricuspid valve replacement and adjunctive use of pulmonary vasodilator therapy can be a life saving and useful approach in this condition.

Efeito de diferentes níveis de torques na resistência ao destorque do parafuso e dos pilares de duas peças em junções cone-morse. Estudo in vitro / The effect of different torque levels on detorque resistance of a two-piece, cone Morse abutment and screw. An in vitro study

Objetivos: determinar se a quantidade da pré-carga influencia a resistência ao destorque do parafuso e pilar de duas peças com junção cone-morse indexada. Material e métodos: foram utilizados 60 análogos de implantes conexão tipo cone-morse de 11,5° com indexador hexagonal e 60 munhões universal cone-morse parafuso passante (4,5 mm de diâmetro, 2,5 mm de altura cinta de transmucoso e 4 mm de altura, não indexados), divididos em três grupos segundo o torque aplicado: 15 Ncm (G1); 20 Ncm (G2) e 25 Ncm (G3). A análise de variância fator único (Anova) e o teste LSD foram usados para as comparações entre os grupos (nível de significância 5%). Imagens em MEV foram realizadas na cabeça do parafuso e na chave de aplicação de torque. Resultados: os valores médios para os destorques dos parafusos foram: G1=17,48 Ncm, G2=21,16 Ncm e G3=26,42 Ncm, com diferencas estatisticamente significativas (p < 0,001) entre todos os grupos. Os valores médios para os destorques nos pilares foram: G1=15,17 Ncm, G2=19,58 Ncm e G3=21,64 Ncm, sendo (G1 e G2) e (G1 e G3) (p < 0,001); e G2 e G3 (p=0,02). Conclusão: 1) o aumento do torque no parafuso gerou valor médio aumentado do destorque em todos os grupos; 2) o aumento do torque gerou valor médio de destorque equivalente ao torque inicial dado para o G1 e G2, sendo este aumento menor no G3; 3) torques maiores do que os indicados pelo fabricante foram capazes de promover a deformação plástica na cabeça do parafuso após apertos repetidos

Objectives: to determine whether the applied preload influences on detorque resistance of abutment and abutment screw of a two-piece, indexed cone-morse taper connection. Material and methods: Sixty implant analogs (cone-morse taper=11,5 degrees) with internal hexagonal indexing and sixty cone morse universal abutments (4.5 mm diameter, 2.5 mm collar height, and 4 mm in height, non-indexed), were divided into three groups according to applied torques: 15 Ncm (G1); 20 Ncm (G2), and 25 Ncm (G3). The one-way Anova and LSD tests were used for comparisons among groups (at 5% level). Representative SEM images were obtained from screw heads and key drivers. Results: mean detorque abutment screw values were as follows: G1=17.48 Ncm, G2=21.16 Ncm, and G3=26.42 Ncm, with statistically significant differences (p < 0,001) among all tested groups. Also, the mean detorque abutment levels were: G1=15.17 Ncm, G2=19.58 Ncm, and G3=21.64 Ncm, being (G1 and G2); (G1 and G3) (p < 0.001); and G2 and G3 (p=0.02). Conclusion: 1) an increase on abutment screw torque level also increases detorque values for all groups; 2) an increase on abutment torque level provided detorque values proportional to that found in G1 and G2, being this lower for G3; 3) torque values higher than those preconized by the manufacturer lead to plastic deformation at screw heads after repeated tightening sequences