ABSTRACT
Acute kidney injury (AKI), a recognized complication of cardiac surgery with cardiopulmonary bypass (CPB) is associated with increased morbidity and mortality (15-30%) with approximately 1% of all the affected patients requiring dialysis. Early detection of AKI would enable intervention before occurrence of irreversible injury and might minimize the morbidity and mortality. Recently developed biomarkers of AKI facilitate its earlier discovery and help assessment of its severity and prognosis. In this article, we review the causes of well-known yet inexplicable association between CPB and AKI, the advances in pathophysiologic basis, the diagnostics and the management options.
Subject(s)
Acute Kidney Injury/etiology , Acute Kidney Injury/therapy , Biomarkers , Cardiac Surgical Procedures/adverse effects , Cardiac Surgical Procedures/mortality , Cardiopulmonary Bypass/adverse effects , Cardiopulmonary Bypass/mortality , Humans , Morbidity , Mortality , Renal Dialysis/methods , Thoracic Surgery/adverse effects , Thoracic Surgery/complications , Thoracic Surgery/mortalityABSTRACT
The mortality for congenital heart surgery is now so low that the focus has shifted to improving the quality of life for children after heart surgery. Neurodevelopmental deficit is the most important surgical morbidity in congenital heart disease. This review article describes both clinical and laboratory studies in this area, most of which were performed at Children's Hospital Boston over the last 15 years. An epidemic of choreoathetoses at Children's Hospital in the late 1980[s] was the initial stimulus for studies of neurological injury after congenital heart surgery. A high index of suspicion associated the epidemic with a change in pH strategy from the more acidosis pH stat strategy to the alpha stat strategy during cardiopulmonary bypass. A more alkaline pH like alpha stat in a shift in the oxyhemoglobin dissociation curve to the left, i.e. tighter binding of oxygen with hemoglobin. Other potential factors that limit cerebral oxygen delivery during cardiopulmonary bypass include reduced perfusion flow rate of the cardiopulmonary bypass ump, a significant reduction in oxygen delivery secondary to hemodilution, a shift to the left of oxyhemoglobin dissociation secondary to hypothermic blood temperature, and run off the systemic circulation to the pulmonary circulation through collaterals and bronchial vessels. In addition venous cannulation in neonates and young infants can be tenuous. The fact that young children are free of arteriosclerosis potentially makes them an ideal population for studying the effects of cardiopulmonary bypass on neurodevelopmental outcome. On the other hand the heterogeneity of congenital heart defects as well as genetic associations such as microdeletion of chromosome 22 can complicate the interpretation of clinical studies in neurodevelopmental outcome after cardiac surgery. The results of several prospective and retrospective studies of neurological and developmental outcome after pediatric cardiac surgery as well as laboratory studies have led us to the following inferences: 1] the use of circulatory arrest should be minimized; 2] pH stat strategy is preferred for infant cardiopulmonary bypass over the alpha stat strategy; 3] a higher hematocrit, e.g. 30% may be preferable to 20%; 4] a hyperoxic perfusion strategy is preferred over a normoxic strategy; and 5] postoperative fever should be strenuously avoided
Subject(s)
Humans , Nervous System/physiopathology , Brain Ischemia/etiology , Thoracic Surgery/adverse effects , ChildABSTRACT
This study was conducted to assess the incidence of abnormalities of ventricular depolarization [late potentials] in children with sinus rhythm after open heart surgery and their relation to spontaneous ventricular tachycardia. Open heart surgery, particularly operations involving ventriculotomy, may predispose patients to the development of ventricular tachycardia [VT] or ventricular fibrillation [VF]. Previous studies on children with right bundle branch block [RBBB] have shown that late potentials may be a risk factor for developing VT or VF following open heart surgery. After corrective surgery for congenital heart defects, scars may create fractionation and delay of the electrical signals in the heart muscle, providing a substrate for arrhythmias and sudden cardiac death. To find normal values of signal averaged EKG [SA-EKG] indices in children and their changes following open heart surgery, we studied 20 normal children and 20 children with congenital heart disease [CHD] following total correction of heart defects without ventriculotomy. All patients were in normal sinus rhythm and did not have RBBB. The mean age was 8.8 +/- 2.6 years for the control group and 8.1 +/- 2.1 years for the operated patients. SA-EKG was performed for the operated group on the day before and on the 2nd and 4th days after operation. Noise level was less than 1 microvolt. The SA-EKG parameter values were as follows: control group: filtered QRS-duration 40Hz [F. QRS-d], 84.2 +/- 9.5 ms; high frequency low amplitude signals [HFLA], 18.9 +/- 9.5 ms; root mean square 40 [RMS 40], 181.0 +/- 89.4[micro]v; patients: F. QRS-d, 97.2 +/- 19.3*, 116.4:t21.2 * and 122.2 +/- 220A before operation, 2nd day post-op and 4th day post-op, respectively; HFLA, 205 +/- 22.3, 8.9 +/- 7.0*, and 15.4 +/- 16.4 ms, respectively; RMS 40, 146.4 +/- 110.9,92.1 +/- 65.9,and 112.8 +/- 60.3, respectively. Values marked with an asterisk are statistically significant. Except for a significant difference between the QRS duration of normal children and pre-op values of operated patients [p<0.05], there was no remarkable difference between the SA-EKG values pre- and postoperatively. This study in which there was no RBBB, contrary to previous studies, shows that SA-EKG indices are not a predictive value for VT or VF postoperatively. Increased thickness of the ventricular myocardium may be a reason for the increased QRS duration before operation
Subject(s)
Humans , Male , Female , Tachycardia, Ventricular/etiology , Thoracic Surgery/adverse effects , Child , ElectrocardiographyABSTRACT
The short term and medium term results of 243 myocardial revascularization with coronary artery bypass are analysed and the prognosis factors of this surgery are shown. The studied population of patients operated between June 1992 and June 1995 showed a sex ratio of 220 men and 23 women. 45 patients were operated as an emergency cases and the 198 others as scheduled cases. History of myocardial infarction existed in 46% of the cases. Overall operative mortality was 9.8% [24patients] and the mortality factors were analysed according to the extend of the coronary disease, the surgical procedure and the operative conditions. Univariate analysis showed that the mortality factors were: age superior to 70 years, emergency surgery stage IV angina, left ventricular dysfunction, multiple coronary lesions and left main stem stenosis associated with right coronary lesions
Subject(s)
Humans , Male , Female , Coronary Artery Bypass , Thoracic Surgery/adverse effects , Prognosis , Coronary Disease/surgery , Coronary AngiographyABSTRACT
O bloqueio atrioventricular de alto grau (BAVG) pode se manifestar, em pequena incidência (2,1 por cento), no pós-operatório de cirurgia cardíaca e ter caráter temporário ou permanente. Na ausência de critérios de reversibilidade, o tempo de permanência superior a 15 dias é indicativo de marcapasso cardíaco permanente (MPCP). Casos isolados poderäo reverter após este período. Num estudo de 4 casos de bloqueio em 300 intervençöes cardíacas, os autores confirmam que a freqüência cardíaca e a comparaçäo das características do QRS nos períodos antes, durante e após o bloqueio näo constituem critérios de reversibilidade; o eletrograma do feixe de His é dispensável na adoçäo da conduta: o período de 15 dias é adequado para a indicaçäo do MPCP e o tempo corrigido de recuperaçäo do marcapasso é indicativo de atividade juncional ou idioventricular incerta e deve ser estudado como critério de reversibilidade.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Heart Block/therapy , Cardiac Pacing, Artificial/methods , Thoracic Surgery/adverse effects , Heart Rate , Retrospective Studies , Time FactorsABSTRACT
Between June 1996 and March 1997, 20 patients of different groups had been submitted to closed mitral commissurotomy for their rheumatic mitral stenosis. There were inclusion criteria for symptoms. Mitral valve area, pliability of the valve associated lesions, thrombus in the left atrium and patients age had improved significantly following the surgical procedure as evaluated clinically by 2D echo-Doppler study. The inclusion criteria on which the mitral commissurotomy were indicated, MVA, which measured by 2D echo and Doppler and MVA should be less than 1 cm and 2nd criteria PG across the mitral valve should be more than 18 mmHg. Also, the MV should be pliable, not calcific and not associated with LA thrombus. Block, 1990 had selected his cases for mitral commissurotomy, where most were isolated MS or associated with aortic regurgitation <2/4 detected by Doppler echo cardiography and /or angiography. Also, most cases had selected for their age [most their age were more than 10 y]
Subject(s)
Humans , Male , Female , Rheumatic Heart Disease , Heart Valve Diseases/surgery , Thoracic Surgery/adverse effectsABSTRACT
Veinte niños de 2 a 12 años, operados de comunicación interventricular (CIV) (reparación completa, con hipotermia profunda) y sin otras malformaciones fueron citados, junto con sus hermanos sanos (grupo control) y evaluados 2,9 años (rango: 0,99-4,63 años) después de la intervención quirúrgica. La edad úsea, peso y talla postquirúrgicos fueron normales, con una ganancia respecto a las mediciones prequirúrgicas de 0,89 y 1,65 DE para peso y talla respectivamente (p < 0,001). No hubo diferencias significativas en el cociente intelectual (Terman Merrill-Wisc) entre los pacientes y controles. Los niños operados mostraron en el dibujo de la figura humana (Goodenough-Koppitz) un mayor número de rasgos indicadores de perturbaciones emocionales (p < 0,05), tuvieron mayor ausentismo y menor rendimiento escolar, mayores limitaciones físicas y, en una encuesta dirigida a los padres, menor autonomía que los hermanos sanos (p < 0,05). Los resultados muestran que, a pesar de una reparación anatómica y un catch up físico completos, los niños operados de CIV persisten, años después, con secuelas psicológicas de carácter invalidante y obligan a replantear los criterios de curación y seguimiento en pediatría (por parte de pediatras y cardiólogos) y a introducir programas de psicoprofilaxis prequirúrgica
Subject(s)
Humans , Infant , Child, Preschool , Child , Thoracic Surgery/adverse effects , Developmental Disabilities/etiology , Heart Septal Defects, Ventricular/psychology , Heart Defects, Congenital/complications , Heart Defects, Congenital/psychology , Case-Control Studies , Thoracic Surgery/psychology , Developmental Disabilities/psychology , Heart Septal Defects, Ventricular/complications , Heart Septal Defects, Ventricular/surgery , Postoperative ComplicationsABSTRACT
Introducción. La frecuencia de cirugía de corazón abierto se ha incrementado en las últimas décadas en el paciente de edad avanzada. Objetivo. Determinar la frecuencia de cirugía cardiaca en los pacientes seniles y su impacto en la morbimortalidad postoperatoria. Pacientes y métodos. Estudiamos prospectivamente 193 pacientes que ingresaron a nuestro departamento de terapia intensiva, en un periodo de trece meses. Se dividieron en dos grupos de acuerdo a su edad: abajo y arriba de 70 años para los grupos 1 y 2, respectivamente. Resultados. La frecuencia de cirugía de revascularización coronaria en los pacientes mayores de 70 años fue de 7.25 por ciento; no se observaron diferencias significativas entre las variables pre y transoperatorias, pero la mortalidad y morbilidad fue alta en pacientes mayores de 70 años. La mortalidad fue de 5.02 por ciento y 21.4 por ciento en los pacientes por abajo y arriba de 70 años, respectivamente (p<0.01). Conclusiones. La edad parece ser un factor de riesgo importante para la morbimortalidad postoperatoria de cirugía cardiaca en los pacientes ancianos
Subject(s)
Humans , Aged , Age Factors , Aged , Coronary Disease/surgery , Morbidity/trends , Mortality/trends , Postoperative Complications/etiology , Myocardial Revascularization , Risk Factors , Thoracic Surgery/adverse effectsABSTRACT
Com o objetivo de avaliar a eficácia do tratamento da mediastinite com irrigaçao contínua com soluçao de polivinilpirrolidona-iodo (PVPI) a l por cento, associada a antibioticoterapia e analisar os fatores de risco desta grave infecçao, foram estudados, retrospectivamente, ll13 pacientes submetidos a cirurgia para correçao de lesoes cardíacas, entre janeiro de 1993 e abril de 1995, no Instituto do Coraçao do Hospital Madre Teresa, Belo Horizonte, Minas Gerais. Onze fatores de risco para mediastinite foram analisados (idade, sexo, peso, diabetes, hipertensao arterial sistêmica, tabagismo, transfusao sangüínea, tempo de circulaçao extracorpórea, utilizaçao de enxerto de artéria torácica interna, drenagem pleural e tempo de internaçao pré-operatório). A análise estatística demonstrou serem fatores de risco: peso (p=O,OOOl), utilizaçao de enxerto de artéria torácica interna (p=O,OOl), drenagem de pleura (p=O,OOl) e tempo de internaçao pré-operatório (p=O,Ol). Dezoito (l,6 por cento) pacientes desenvolveram mediastinite no pós-operatório e foram submetidos a tratamento por desbridamento cirúrgico, ressutura de esterno e instalaçao de irrigaçao contínua com soluçao de PVPI a l por cento, por um período médio de 8 dias. A média de internaçao hospitalar foi de 37 dias neste grupo de pacientes. O germe predominante foi o S. Aureus (72 por cento). A mortalidade foi de 27 por cento (5 pacientes), devido a infecçao fora de controle. Os autores consideram que a facilidade de emprego e manejo da irrigaçao contínua com soluçao de PVPI a l por cento, associada a baixa taxa de mortalidade, demonstrou ser um método eficaz no tratamento desta grave complicaçao pós-operatória.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Postoperative Complications/epidemiology , Postoperative Complications/drug therapy , Mediastinitis/drug therapy , Mediastinitis/epidemiology , Povidone-Iodine/therapeutic use , Therapeutic Irrigation , Thoracic Surgery/adverse effects , Retrospective Studies , Risk Factors , Treatment OutcomeABSTRACT
Relata-se a restauraçao da resistência vascular sistêmica com o uso do azul de metileno (AM) em pacientes submetidos a cirurgia cardíaca com e sem circulaçao extracorpórea. Todos os pacientes apresentaram no pós-operatório imediato quadro de taquicardia, oligúria, manutençao da perfusao periférica e importante hipotensao arterial sistêmica, refratária a grandes doses de catecolaminas. As avaliaçoes hemodinâmicas pela técnica de termodiluiçao com cateter de Swan-Ganz mostraram padrao compatível com síndrome vasoplégica, com índice de resistência vascular sistêmica média de 868 dina.s.cm(5), sem resposta a drogas vasoativas. A semelhança do choque endotóxico, a síndrome foi interpretada como decorrente da estimulaçao da enzima óxido nítricosintetas com conseqüente formaçao de óxido nítrico (NO) pelas células endoteliais. Utilizou-se entao AM, como bloqueador do NO no sistema guanililciclase/guanino-monofosfatociclase, na dose de 1,5 mg/Kg peso, em infusao intravenosa por uma hora. O restabelecimento do tônus vascular sistêmico (IRVS = 1693 dina.s.cm(5)) com normalizaçao da pressao arterial e do quadro clinico, foi efetivo e rápido, mostrando ser o AM uma promissora droga na diminuiçao da morbi-mortalidade da síndrome vasoplégica.
Subject(s)
Humans , Male , Female , Middle Aged , Extracorporeal Circulation/adverse effects , Postoperative Complications/drug therapy , Hypotension/drug therapy , Methylene Blue/therapeutic use , Thoracic Surgery/adverse effects , Vascular Resistance , Analysis of Variance , Hypotension/etiology , Methylene Blue/pharmacology , Nitric Oxide/antagonists & inhibitors , Myocardial Revascularization/adverse effects , Syndrome , Vascular Resistance/drug effectsABSTRACT
Introducción. La predicción de la morbi-mortalidad es importante en los pacientes sometidos a cirugía cardiaca para el tratamiento postoperatorio. Objetivo. Estudiar el riesgo de morbi-mortalidad en los pacientes sometidos a cirugía cardiaca a través de la fracción de eyección del ventrículo izquierdo (FE). Pacientes y métodos. Estudiamos retrospectivamente los expedientes de 93 pacientes que ingresaron a una UCI después de cirugía cardiaca, durante 1993. Se dividieron de acuerdo a la FE preoperatoria en dos grupos: I) FE < 60 por ciento, II) FE > 60 por ciento. Resultados. Se analizaron 43 casos: grupo I (15 pacientes, edad media 42.4 ñ 15.6 años) y grupo II (28 pacientes, edad media 38.1 ñ 15.5 años), p= 0.394. Después de la cirugía los pacientes tuvieron: falla cardiaca 3 vs 9 apoyo inotrópico 12 vs 11 y días de ventilación mecánica 2.4 ñ 2.1 vs 1.3 ñ 0.87 respectivamente para los grupos I y II (p < 0.05). Dos pacientes murieron en el grupo I. Conclusión. Una FE baja aumenta el riesgo de complicaciones postoperatorias en pacientes sometidos a cirugía cardiaca
Subject(s)
Humans , Middle Aged , Hepatic Insufficiency/etiology , Mortality , Preoperative Care , Renal Insufficiency/etiology , Stroke Volume , Thoracic Surgery/adverse effectsABSTRACT
Objetivo: Informar sobre el primer trasplante cardiopulmonar que se realiza en México. Diseño: Informe de caso clínico. Se trató de paciente femenino de 47 años de edad, con hipertensión pulmonar severa y defecto septal auricular en clase funcional III. El día 4 de junio de 1995, en el Hospital de Cardiología del Centro Médico Nacional Siglo XXI se obtuvo bloque cardiopulmonar a partir de donación múltiple y se traspantó a la paciente. Resultados: El tiempo de hipotermia isquémica fue de 3 horas. La actividad cardíaca reinició a los 14 segundos de reperfusión. El destete de la derivación cardiopulmonar se efectuó sin problemas. A las 36 horas presentó abdomen agudo por hemoperitoneo, se requirió laparotomía por hemostasia, además de detectarse pancreatitis. El bloque cardiopulmonar funcionó adecuadamente por 5 días al cabo de los cuales presentó aumento de cortocorcuitos, hipoxemia, bajo gasto cardíaco y falleció al sexto día. El informe de la autopsia fue: pancreatitis edematosa, rechazo de corazón y pulmón, cambios isquémicos del miocardio y edema pulmonar. Conclusión: Es factible realizar trasplante cardiopulmonar en nuestro país. Las complicaciones coinciden con las descritas en la literatura mundial
Subject(s)
Middle Aged , Humans , Female , Cardiac Output, Low/complications , Graft Rejection/mortality , Heart Transplantation/trends , Hypoxia/complications , Myocardial Ischemia/physiopathology , Lung Transplantation/trends , Organ Transplantation , Pancreatitis/etiology , Pulmonary Edema/etiology , Pulmonary Heart Disease/surgery , Thoracic Surgery/adverse effectsABSTRACT
Definir el riesgo en el paciente cardiopata sometido a cirugía cardiaca es en algunas ocasiones difícil de valorar, ya que se encuenctran implícitos algunos factores de riesgo individual que pueden ser interpretados de difretentes manera. Es por ello que han sido elaborados difrentes escalas con la finalidad de emitir un pronóstico más preciso dependiendo de las características individuales de cada enfermo. El objetivo de este artículo es la revisión individual de cada factor descrito, así como también las diferentes escalas utilizadas
Subject(s)
Aged , Humans , Male , Female , Thoracic Surgery/adverse effects , Thoracic Surgery/mortality , Cardiovascular System/physiopathology , Indicators of Morbidity and Mortality , Risk Factors , Heart Diseases/surgery , Intraoperative Complications/etiology , Intraoperative Complications/physiopathology , Intraoperative Complications/mortalityABSTRACT
Las complicaciones intra-abdominales en cirugía cardiaca son poco frecuentes (0.41-2 por ciento) pero se asocian a una elevada mortalidad (25-66 por ciento). En un periodo de seis años en el Hospital American British Cowdray en la ciudad de México, se operaron del corazón 228 pacientes, de los cuales cuatro (1.75 por ciento) desarrollaron cinco complicaciones intra-abdominales: dos colecistitis alitiásica aguda, uno sangrado del tubo digestivo alto, uno perforación intestinal por úlcera isquémica, y uno hematoma de la pared abdominal. Tres pacientes requirieron cirugía. El diagnóstico de síndrome abdominal agudo en pacientes posoperados de cirugía cardiaca ofrece gran dificultad, pero su pronto reconocimiento y tratamiento médico o quirúrgico, contribuyen a disminuir su alta morbilidad y mortalidad
Subject(s)
Aged , Humans , Male , Female , Cholecystitis/etiology , Gastrointestinal Hemorrhage/etiology , Hematoma/complications , Hematoma/etiology , Abdominal Muscles/physiopathology , Thoracic Surgery/adverse effectsABSTRACT
Se comunican los resultados de un estudio sobre el efecto de la cirugía de corazón abierto y cerrado en el estado inmunitario de pacientes pediátricos. El estudio se realizó en el Hospital Central Sur de Alta Especialidad (PEMEX) y en la unidad de cuidados intensivos pediátricos. El material de esta unidad de cuidados intensivos pediátricos. El material de estudio fueron 16 enfermos en quienes se realizó cirugía correctiva por enfermedad cardiaca congénita (con límite de edad de 16 meses y 14 años). La cuenta de leucocitos se encontró aumentada con linfopenia en el grupo de cirugía de corazón abierto y cerrado en forma significativa (p< 0.05), los niveles séricos de complemento (C3-C4) estuvieron altos, los de inmunoglobulinas IgG, IgA e IgM se encontraron bajos (p < 0.01). Dos pacientes resultaron con infección de la herida quirúrgica. Se concluye que la cirugía cardiovascular causa inmunodeficiencia transitoria con recuperación al quinto día del procedimiento