Trombosis sobre válvula protésica biológica. Reporte de caso / Thrombosis on biological prosthetic valve. Case report

Resumen: El siguiente artículo reporta el caso clínico de una paciente portadora de trombosis valvular bioprotésica en posición aórtica. La trombosis sobre válvula bioprotésica es una patología de baja prevalencia pero que puede conducir a un aumento en la tasa de accidentes cerebrovasculares, así como a largo plazo ser un factor coadyuvante de degeneración bioprotésica. Actualmente, el diagnóstico de la misma se realiza mediante ecocardiografía por el hallazgo de un incremento del gradiente medio transvalvular mayor a 50%, engrosamiento de los velos o movimiento anormal de los mismos, con una especificidad de 93%. El tratamiento con warfarina mostró ser efectivo en 83% de los pacientes, según un estudio prospectivo, así como en el caso de nuestra paciente que luego del tratamiento presenta una clara mejoría sintomática con disminución de los gradientes transvalvulares.

Summary: The following article reports a clinical case of a patient with bioprosthetic valvular thrombosis in aortic position. Bioprothesis valve thrombosis is a pathology of low prevalence but it can result in an increase in the rate of stroke as well as in the long term, a factor promoting bioprosthetic degeneration. Currently the diagnosis of the bioprothesis valve thrombosis is made by echocardiography by the finding of an increase in the mean transvalvular gradient greater than 50%, thickening of the cups and / or an abnormal movement of them with a specificity of 93%. Treatment with warfarin has shown to be effective in 83% of patients according to a prospective study, as well as in the case of our patient, with a clear symptomatic improvement as well as a decrease in mean transvalvular gradient after treatment.

Experiencia cubana en el uso de la malla Laparomesh / Cuban experience in the Laparomesh mesh use

Introducción: las hernias incisionales constituyen un problema que diariamente enfrentan los cirujanos. Las técnicas protésicas ofrecen múltiples formas de resolverlas y prevenirlas. Objetivo: interpretar los beneficios de la malla Laparomesh en la reparación y prevención de las hernias incisionales. Métodos: se realizó un estudio observacional, descriptivo, longitudinal y prospectivo en 37 pacientes intervenidos en los hospitales universitarios Comandante Manuel Fajardo de La Habana y Juan Bruno Sayas de Santiago de Cuba, de noviembre de 2008 a junio de 2013, con hernias múltiples de la línea media o riesgo de desarrollar hernias incisionales, a los cuales se les realizó hernioplastia con la malla Laparomesh. Resultados: la media de edad fue 46 años y predominó el sexo masculino. Se utilizó la anestesia espinal o general y cefazolina como profilaxis antibiótica. Conclusiones: no existieron hasta el momento manifestaciones de rechazo al material protésico, ni complicaciones inmediatas. No recidiva herniaria con seguimiento promedio de 36 meses(AU)

Introduction: incisional hernias are a regular problem faced by the surgeon where prosthetic techniques provide many choices for solution and prevention. Objective: to show the advantages of the Laparomesh mesh for the prevention and repair of incisional hernia. Methods: an observational, descriptive, longitudinal and prospective study was conducted in 37 patients who had been operated on in Manuel Fajardo and Juan Bruno Sayas teaching hospitals in Havana and Santiago de Cuba, respectively, from November 2008 to June 2013. They had midline incisional hernias or were at risk of developing them, so they underwent hernioplasty with Laparomesh mesh. Results: the average age was 46 and males prevailed. Spinal or general anesthesia was used as well as prophylaxis with cefazolin. Conclusions: there have been no manifestations of rejection to the prosthetic material up to now. Neither immediate complications norhernial recurrence have been so far observed with an average follow-up of 36 months(AU)

Aspectos clínicos y quirúrgicos de las hernias incisionales complejas / Clinical and surgical aspects of the complex incisional hernias

El diagnóstico y tratamiento de las hernias incisionales complejas constituye un tema obligado para todos los cirujanos, cuyo desafío es prevenir las complicaciones y disminuir las recurrencias, lo que justifica la realización de este estudio con el objetivo de identificar sus aspectos clínicos y quirúrgicos más relevantes. Métodos: se realizó un estudio observacional, descriptivo de serie de casos correspondiente a 320 pacientes operados electivos por hernias incisionales complejas en el servicio de cirugía del Hospital Universitario Dr Juan B Zayas de Santiago de Cuba durante 15 años (1994-2009). Resultados: predominó el sexo femenino y el grupo etario de 31 a 60 años. Las hernias suprapúbicas fueron las más frecuentes en ambos sexos; en mujeres con intervenciones ginecológicas previas y en hombres, prostáticas. El neumoperitoneo progresivo preoperatorio y la antibioticoterapia profiláctica se aplicaron a todos los pacientes. Las técnicas quirúrgicas más utilizadas fueron las de Jean Rives y Robert Bendavid y la bioprótesis de polipropileno. Índice de recurrencia de 6,5 por ciento con predominio del sexo masculino. El tiempo quirúrgico fluctuó de 1 a 2 horas y la estadía hospitalaria entre 1 y 3 días. Fallecieron 4 pacientes, el 1,3 por ciento de la serie. Conclusiones: el único tratamiento efectivo para las hernias incisionales complejas radica en la técnica quirúrgica sin tensión con aplicación correcta de la bioprótesis indicada y su fijación con la sutura de su mismo material, por lo que se recomienda la protocolización y clasificación de estas hernias para unificar criterios con respecto a su diagnóstico y tratamiento(AU)

Diagnosis and treatment of complex incisional hermias is a compulsory topic for all surgeons. The challenge ahead is to prevent complications and to reduce relapses, which warrants the conduction of a study with the objective of identifying their most relevant clinical and surgical aspects. Methods: Observational and descriptive study of a case series involving 320 patients operated on from complex incisional hernias at the surgery service of Dr Juan B Zayas university hospital in Santiago de Cuba during 15 years (1994-2009). Results: Females and 31-60 years age group predominated. The suprapubic hernias were the most frequent in both sexes; in females who underwent previous gynecological interventions and in men who underwent prosthatic procedures. Preoperative progressive pneumoperitoneum and prophylactic antibiotic therapy were applied to all patients. The most used surgical techniques were Jean Rives' and Robert Bendavid's and the polypropylene bioprothesis. The relapse index was 6.5 percent and males predominated. The surgical time ranged 1 to 2 hours and the stay at hospital lasted one to 3 days. Four patients died, which accounted for 1.3 percent of the case series. Conclusions: The only effective treatment for complex incisional hernias lies in non-tensile surgical technique with correct application of the indicated bioprothesis and its fixing with a suture of the same material, so protocoling and classification of these hernias are recommended in order to unify criteria with respect to their diagnosis and treatment(AU)

Aplicación del análisis de factor decorrespondencia múltiple en un estudio deválvulas cardíacas en porcinos / Application of Multiple correspondence factor analysis to a heart valve study in pigs

El análisis factorial de correspondencia múltiple es una extensión del análisis de correspondenciasimple al análisis de dos conjunto de características. Permite estudiar las relaciones de interdependenciaentre variables categóricas o cualitativas; es decir, no métricas. Esta técnica va más allá de analizar larelación existente entre las variables, porque permite conocer como esta estructurada esta relación. Esteanálisis ha tenido amplia difusión en diferentes campos de investigación principalmente en cienciashumanas. El objetivo de este trabajo, fue entonces, aplicar esta técnica a una investigación relacionadacon aspectos de la Medicina veterinaria, específicamente, sobre el estudio “Estudio anatomopatológico deválvulas aórticas porcinas a seleccionar para la elaboración de bioprótesis cardiacas”. El trabajo permitióestablecer correlaciones entre los hallazgos de lesiones macroscópicas y microscópicas para los dos gruposde válvulas aórticas estudiados, con lesión y sin lesión valvular. Se destacan las relaciones entre lesionesdegenerativas tipo endocardiosis y alteraciones vasculares como las hemorragias y las congestiones.

The multiple correspondence factorial analyses is an extension of simple correspondence analysisfor two set of characteristics. It permits the study of interdependence relationship between categoricalor qualitative variables, that is, not metric. This model goes beyond the analysis of existing relationshipbetween variables, because it allows knowing how this relationship is structured. This analysis hashad a wide diffusion in different fields of research mainly in life sciences. The aim of this study wasto apply this model to a previously reported study focused on the analysis of pig aortic valves entitled“Estudio anatomopatológico de válvulas aórticas porcinas a seleccionar para la elaboración de bioprótesiscardiacas”. By this model, it was possible to establish interrelationships between findings of macroscopic and microscopic lesions for two groups of aortic valves studied, with or without valve lesions. Of keyrelevance were the relationship found between endocardiosis-like degenerative lesions and vascularalterations like hemorrhage and congestion.

Uso del pericardio bovino tratado con glutaraldehído / Use of glutaraldehide-treated bovine pericardium

El uso de las prótesis mecánicas y biológicas surgió de la necesidad de reemplazar quirúrgicamente la falta o la falla de un órgano. Las bioprótesis están hechas a partir de tejido autólogo, homólogo y heterólogo. La bioprótesis de pericardio bovino tratada con glutaraldehído es la más estudiada y se utiliza principalmente como bioprótesis cardiaca. Debido a su fácil preparación y uso, este material se ha empleado para reparar defectos hemiarios de la pared abdominal, la pared torácica, de diafragma y para sustituir vasos y tráquea; sin embargo, causa reacción de rechazo y tipo cuerpo extraño, los que han sido estudiados ampliamente para evitarlos. Presentamos una revisión de la literatura sobre el uso y estudio de la bioprótesis de pericardio bovino tratado con glutaraldehído.

The use of biological and mechanical prostheses arose from the need to replace a failing organ or function. Bioprostheses can be manufactured from autologous, homologus or heterologus tissue; glutaraldehyde treated bovine pericardium bioprostheses have been used extensively to repair diaphragmatic, abdominal and chest wall defects and to replace heart valves, blood vessels and tracheal segments, but the implanted tissue can elicit rejection or foreign body reaction; these have been extensively studied in order to avoid them. We review the literature regarding glutaraldehyde treated bovine pericardium bioprostheses.

Pulsatile-flow-cultivation recellularization of homograft bioprosthetic valve / 中华胸心血管外科杂志

Objective Using a bioreactor to culture reendothelializing homograft bioprosthetic valve (HBV) in order to ultimately form viable tissue in vitro, so as to provide basic material for animal experiment and clinical application. Methods The reendothelializign HBV was placed in a pulse duplicator system (“bioreactor”), designed and fabricated by us. These grown under gradually increasing nutrient media flow and pressure for additional 14 days: 125 ml/min at 30 mm Hg (days 1-4), 250 ml/min at 40 mm?Hg (days 5-7), 500 ml/min at 50 mm Hg (days 8-10), 750 ml/min at 75 mm Hg (days 11 to 14). Throughout the studies, the flow device was placed in an incubator with 95% humidity and 5% carbon dioxide. The morphologic structure was observed and photographed by stereomicroscope with 0.5% silver nitrate (AgNO_3)staining and SEM on the 7th, 10th and 14th day. The retention rate of the ECs overlaid onto the HBV was evaluated with the percentage (%). Results The reendothelization level on the surface of the leaflets was 92% before pulsatile-flow-cultivation. But the rate of ECs retention on the scaffold exposured to pulsatile flow was only 36%, 23% and 11% on the 7th, 10th and 14th day, respectively. Conclusion The retention rate of ECs on the scaffold was low for pulsatile-flow-cultivation in vitro. Problems, including deficiency of mature stress fibers in the endothelial cells from MSCs deficiency of the adherence and growth factors still need improvement.

Retalho de submucosa de intestino delgado autólogo para aumento da capacidade da bexiga: estudo experimental em cães / Small intestine submucosa as an autologous patch to enlarge bladder capacity: experimental study on dogs

OBJETIVO: Os procedimentos disponíveis para correção de lesões do trato urinário não são livres de complicações. Recentemente, uma nova opção tem sido investigada: o uso da submucosa de intestino delgado (SIS). Constituída de uma matriz extracelular que não apresenta tendências à rejeição, a SIS é capaz de permitir o crescimento de vasos sangüíneos, participar de processos de diferenciação celular e de ser resistente contra o desenvolvimento de processos infecciosos. O objetivo deste estudo foi avaliar a histocompatibilidade de um enxerto autólogo de submucosa de intestino delgado (SIS), quando utilizado para a ampliação da bexiga urinária. MÉTODO: Utilizaram-se oito cães adultos, pesando entre 10 e 15kg. Realizou-se laparotomia mediana e enterectomia de um segmento de jejuno de 10cm, localizado a 20cm da flexura duodeno-jejunal, seguida de anastomose terminoterminal. Desse segmento de intestino obteve-se, por dissecção, a camada submucosa. Após esvaziamento da bexiga por punção, fez-se uma incisão mediana de 3cm em sua parede, compreendendo todas as camadas. Um segmento de 3 x 2,5cm de SIS foi fixado às bordas da incisão com sutura contínua, laçada de fio absorvível 3.0 de poliglecaprone-25. No 30º dia de pós-operatório os animais foram submetidos à retirada da bexiga para estudo histopatológico. RESULTADOS: Não se observou reação inflamatória aguda. Reação inflamatória crônica esteve presente com graus discreto e moderado. A infiltração fibroblástica foi moderada. A presença de células gigantes de corpo estranho foi mínima. A epitelização foi satisfatória, não sendo completa em apenas um dos oito implantes. Ocorreu incorporação predominante de fibras colágenas tipo III, cuja média correspondeu a 70,7 por cento do colágeno total. A reabsorção da mucosa foi moderada em 7/8 dos implantes. CONCLUSÃO: Os resultados indicam que ocorre regeneração da bexiga, quando é utilizada a submucosa de intestino delgado como substrato. A submucosa de ...

BACKGROUND: Many materials, including organic and synthetic prosthesis, have been described as substitutes of the genitourinary tract. The most commonly used is the ileum, which has many advantages, as easy mobilization and regular vascular pattern. However, the ideal substitute for urinary tract has not been found yet. Ileocystoplasty is not a harmless procedure, and so, investigations are constantly being made to find new substitutes. Small intestinal submucosa (SIS) is an extracelular matrix that can be used as a reabsorbable scaffold for tissue engineering. It allows blood vessels ingrowth, epithelial and connective cells proliferation, induces growing factors production and acquires macro and microscopic characteristics similar to the native tissue. In the urinary tract, previous experimental studies have demonstrated that SIS promotes bladder regeneration. The aim of the present study was to evaluate the biocompatibility of an autologous SIS implant used for bladder augmentation. METHOD: Eight mongrel dogs, weighing between 8 and 15 kg, were prepared for surgery under general anesthesia. A 3cm full-thickness midline cystotomy was performed, followed by immediate augmentation with autologous small intestine submucosa patch graft. On the 30th post-operative day, the animals were re-operated and a fragment of the urinary bladder wall including its patch was removed for histopathogical study. RESULTS: All implants were well incorporated. Macroscopically, SIS could not be distinguished from the native bladder tissue. Mild adherences occurred on the anterior parietal peritoneum. No other macroscopic complications were found. Acute inflammatory response was absent, and chronic inflammatory cells were seen in mild degree. Foreign body reaction was not present, implying satisfactory biological acceptation of the SIS patch graft. Epithelialization was complete in 7/8 implants. Fibroblastic proliferation was moderate. The densitometry of collagen...

Preliminary study of fabricating homologous tissue engineering heart valve in vitro / 中华胸心血管外科杂志

105 cells/cm 2), and statically cultured in vitro for 20 days. The morphologic structure was observed and photographed by scanning electron microscope (SEM). Results: The ECs of the HBV were not only removed completely, but also reserved collagen and elastic fibers integrally, which are two of main components of extracellular matrix. The ECs from MSCs differentiated were successful implanted on the HBV scaffold, which the recellularization level on the seventh, fourteenth and twentieth day was 73%, 85% and 92% respectively. Conclusion: Application of differentiating ECs from MSCs as seed cells, fabricating TEHV by us was primary realized prospective recellularization goal under static culture in vitro.

Configuraçäo esférica do aparelho valvar aórtico / Spherical configuration of the aortic valve apparatus

Objetivo - Estudar o anel aórtico humano e verificar a possibilidade de reproduzí-lo artificialmente. Métodos - A configuração anatômica de seis valvas aórticas normais foi estudada através de injeção de borracha de silicone na aorta ascendente, obtendo-se moldes rigidos do aparelho valvar aórtico. A partir desses moldes, obtiveram-se modelos de epoxi correspondentes ao anel valvar aórtico. Foram considerados os seguintes parâmetros: diâmetro da base (Db), diâmetro das comissuras (Dc), altura (h) e a relação Db/Dc e Db/h. Foram determinados a média e o desvio padrão dos valores obtidos. Resultados - A análise dos moldes indica que o anel valvar aórtico deriva de uma esfera. As medidas obtidas foram: Db = 22 ± 1,67 mm Dc = 19,67 ± 1,3 mm; h = 16,00 ± 1,09 mm; Db/ Dc = 1,12 ± 0,04 e Db/h = 1,38 ± 0,10. Conclusão - A partir destas figuras foi possível definir a configuração esférica ou semi-esférica do anel valvar aórtico e reproduzir sua configuração na confecção da biopr

Purpose - To study the normal human aortic valvular ring, and to evaluate the possibility of reproducing its shape artificially. Methods - The anatomical configuration of six normal aortic valves was studied through the injection of silicone rubber in the ascending aorta. From the resulting casts, epoxi models corresponding to the aortic annulus were obtained. The following parameters were determined: diameter of the base (Db), diameter of the commissures (Dc), height (h) and the Db/Dc and Db/h relationships. The mean value (x) and the standard deviation (SD) of each parameter were studied. Results - The observation of the casts indicate that the aortic valvular ring derives from a sphere. The measures obtained were: Db = 22 ± 1.67 mm; Dc = X 19.67 ± 1.3 mm; h = 16.00 ±1.09 mm; Db/Dc = X = 1.12 ± 0.04 and Db/h =1.38 ± 0.10. Starting from these figures it was possible to define the spheric configuration of the aortic valvular ring, as well as to reproduce it artificially. Conclusions - The aortic valvular ring has a configuration derived from a sphere or hemi-sphere. The parameters obtained from the above program, it was possible to reproduce theconfiguration of the aortic valvular ring and to use it for a bioprothesis