Durabilidad de prótesis valvulares aórticas biológicas: deterioro estructural e incidencia de eventos en el seguimiento alejado / Durability of Bioprosthetic Aortic Valves: Structural Deterioration and Incidence of Events at Long-Term Follow-Up

RESUMEN Introducción: En el tratamiento de la estenosis aórtica grave ha habido un cambio en la elección del tipo de prótesis valvular, con priorización de la utilización de válvulas biológicas. En la actualidad, a nivel mundial, en el 80% de los recambios valvulares aórticos se utilizan prótesis biológicas, cuya menor durabilidad alejada representa su mayor limitación. No contamos con evaluación reciente en nuestro medio de la durabilidad de las válvulas biológicas y la incidencia de eventos a largo plazo. Objetivos: Evaluar el comportamiento alejado de las prótesis valvulares aórticas biológicas, respecto de su sobrevida e incidencia ecocardiográfica de deterioro valvular estructural (DVE). Material y Métodos: Estudio retrospectivo sobre 2365 pacientes operados entre enero de 2003 y diciembre de 2023. Se evaluó la sobrevida alejada y la incidencia de DVE de acuerdo con las modificaciones del gradiente medio transprotésico (GMt) según la edad (dicotomizada en 60 años) y el tamaño de la prótesis utilizada (dicotomizado en 23 mm). Resultados: La edad promedio fue de 73 ± 3,05 años (105 pacientes < 60 años y 2530 pacientes ≥60 años). Sexo masculino en 63,4 %. Seguimiento alejado en el 92 % de los pacientes, media de 5,9 ± 3,2 años. Sobrevida a 5 y 10 años según edad: en < 60 años: 98,3 y 91,7 % vs. ≥ 60 años: 81,7 y 65,7 % (p=0,007) respectivamente. Seguimiento ecocardiográfico global en 1399 (59,7 %) pacientes. Valores del GMt basal, y a 5 y 10 años: a) según edad: en < 60 años: 16 ±3 mmHg, 16 ± 6 mmHg y 19 ± 5 mmHg, vs. en ≥ 60 años: 15 ± 5 mmHg, 16 ± 7 mmHg y 18± 7 mmHg (p=NS); b) según tamaño de la prótesis: en < 23 mm: 17±6 mmHg, 19±7 mmHg y 22± 7 mmHg, vs. en ≥ 23 mm: 15± 5 mmHg, 16± 6 mmHg y 18± 6 mmHg (p= 0,001). Conclusiones: Los pacientes con prótesis valvulares biológicas presentaron una elevada sobrevida alejada con diferencias según el grupo etario. Se registraron en el seguimiento diferencias del GMt (<10 mmHg) en las válvulas < 23 mm, demostrando baja incidencia de DVE grave.

ABSTRACT Background: In the treatment of severe aortic stenosis there has been a shift in the choice of the valve prosthesis type toward the use of biological valves. At present, bioprosthetic valves are used in 80% of aortic valve replacements worldwide. Their main limitation is their reduced long-term durability. No assessment has been yet performed in our setting regarding the durability of bioprosthetic valves and the incidence of long-term events. Objectives: To evaluate the long-term performance of bioprosthetic aortic valves related to survival and echocardiographic incidence of structural valve deterioration (SVD). Methods: A retrospective study of 2365 patients undergoing aortic valve replacement with biological prosthesis between January 2003 and December 2023. We analyzed the long-term survival and the incidence of SVD pursuant to changes in the mean transprosthetic gradient (mTPG) according to age (< or ≥60 years) and prosthetic valve size (< or ≥ 23 mm). Results: Mean age was 73±3.05 years (105 patients <60 years and 2530 patients ≥60 years). A total of 63.4% was male. Of patients, 92% completed a long-term follow-up, mean 5.9±3.2 years. Survival at 5 and 10 years according to age was: in patients <60 years: 98.3 and 91.7% vs. patients ≥60 years: 81.7 and 65.7% (p=0.007), respectively. A total of 1399 (59.7%) patients had an overall echocardiographic follow-up. The values of mTPG at baseline, 5 and 10 years were: a) according to age: in patients <60 years: 16±3 mmHg, 16±6 mmHg and 19±5 mmHg, vs. in patients ≥60 years: 15±5 mmHg, 16±7 mmHg and 18±7 mmHg (p=NS); b) according to prosthesis size: <23 mm: 17±6 mmHg, 19±7mmHg and 22±7 mmHg, vs. ≥23 mm: 15±5 mmHg, 16±6 mmHg and 18±6 mmHg (p= 0.001). Conclusions: Patients with bioprosthetic valves experienced high long-term survival with some differences according to age group. At follow-up, differences in mTPG (<10 mmHg) were observed in prosthetic valve sizes <23 mm, showing low incidence of severe SVD.

Pyloric hypertrophy in adults: case report

Pyloric hypertrophy is a benign condition characterized by narrowing of the pyloric canal, which may be associated with other pathologies. It is believed to manifest as a mild form of hypertrophy from childhood into adulthood. Symptoms can be nonspecific, such as nausea, vomiting, oral intolerance, and weight loss. Diagnosis can be challenging for physicians, and accurate reporting of cases is difficult due to some patients remaining asymptomatic.

Rare presentation of esophageal atresia with supra-esophageal atresia: a case report and management challenges

Esophageal atresia (EA), often regarded as 'the epitome of modern surgery', typically presents with tracheoesophageal fistula (TEF) and occurs in about 1 in 2400 to 1 in 3000 newborns, frequently accompanied by other congenital malformations. Rarely, EA is associated with congenital esophageal stenosis (CES), a condition first identified by Spitz. EA and TEF result from the incomplete development of the esophagus and trachea, with polyhydramnios in the third trimester being a potential indicator. This case study described a 43-year-old multiparous woman who, during an antenatal care examination, was found to have a fetus with abnormalities and excessive amniotic fluid, necessitating two amnioreduction procedures. Despite the interventions, the fetus exhibited signs of supra-esophageal atresia, leading to an elective cesarean section. The newborn, a girl with a birth weight of 3200 grams and an Apgar score of 5/6, could not be fitted with an orogastric tube, although karyotyping showed no chromosomal abnormalities. The discussion highlights the association of EA with various tracheobronchial anomalies and emphasizes the need for preserving the native esophagus in cases of CES. Gastroesophageal reflux disease (GERD) is common in EA patients, often requiring long-term follow-up and possible antireflux surgery. The case underscores the importance of diligent monitoring and intervention in high-risk pregnancies, with regular ANC examinations and accurate diagnoses being crucial for effective management.

Colesteatoma del conducto auditivo complicado con absceso retroauricular

El Colesteatoma del Conducto Auditivo Externo (CCAE) constituye una patología poco frecuente. Su diagnóstico es fundamentalmente clínico, se apoya en los estudios de imagen y confirmación final anatomopatológica. Algunos casos pueden ser asintomáticos y otros casos pueden presentar complicaciones como parálisis facial, afectación del oído medio, etc. Su tratamiento es quirúrgico con una serie de técnicas denominadas canaloplastias, las cuales tienen como objetivo retirar el tejido colesteatomatoso y crear un mecanismo de autoevacuación. Presentamos la descripción de un caso de colesteatoma del conducto auditivo complicado con absceso retroauricular en una paciente joven con estenosis congénita, discutimos los aspectos relevantes respecto a la clínica, diagnósticos diferenciales y opciones terapéuticas en una revisión de la literatura disponible.

Cholesteatoma of the External Auditory Canal (CCAE) is a rare pathology. Its diagnosis is fundamentally clinical, based on imaging studies and final anatomopathological confirmation. Some cases can be asymptomatic and other cases can present complications such as facial paralysis, middle ear involvement, etc. Its treatment is surgical with a series of techniques called canaloplasties, which aim to remove the cholesteatomatous tissue and create a self-evacuation mechanism. We present the description of a case of cholesteatoma of the auditory canal complicated with retroauricular abscess in a young patient with congenital stenosis, discuss the relevant aspects regarding the clinic, differential diagnoses, and therapeutic options in a review of the available literature.

Clinical case of stenting of the left main coronary artery under artificial circulation: a case report

This case report documents the intricate management of a 61-year-old patient presenting with acute coronary syndrome, permanent atrial fibrillation (AF), and a history of prior cardiac interventions. Coronary angiography revealed significant left coronary artery pathology, necessitating intervention under artificial circulation. Percutaneous coronary intervention was deemed unsuitable due to high risk, prompting the installation of an intra-aortic balloon counter pulsation system. Subsequent interventional stenting of the left main coronary artery (LCA) was successfully performed. Despite post-operative complications, including pneumonia and renal dysfunction, the patient exhibited steady improvement, highlighting the importance of tailored, multidisciplinary care in complex cardiovascular cases.

A study of clinical and etiological profile of mitral valve dysfunction

Background: Heart valve diseases are a leading cause of cardiovascular morbidity and mortality globally; putting a significant strain on healthcare resources. In developing countries, rheumatic heart disease (RHD) remains the most common type of heart valve disease. Mitral valve disease is the most frequent of the valvular heart diseases. Mitral valve disease is a distressing and painful condition, and requires immediate attention before they result in death. Methods: This was a prospective observational study done from September 2019 to February 2021, at the Department of General Medicine, Goa Medical College and Hospital, Bambolim, Goa: A tertiary care hospital in Goa. Results: Out of the 50 patients enrolled in the study 44% patients had MS ,18% had MR and 38%had MR+MS. Mean age of the study population was 41 to 50 years of which 54% patients were females. All isolated Mitral Stenosis patients were rheumatic origin. Of the 9 MR patients, predominant form of MR was ischemic (66.66%), followed by rheumatic (22.22%) and MVP (11.11%). 19 patients had MR+MS, predominant form was rheumatic (84.21%). It was also observed that 42% each of total patients had pulmonary hypertension and congestive cardiac failure, 40% had pulmonary edema, while 30% had atrial fibrillations complications. Conclusions: Our study revealed that the most common valve dysfunction observed is mitral stenosis, with a female preponderance and its most common etiology being rheumatic. Further it was also observed that the most common complication is pulmonary hypertension and congestive cardiac failure.

Curva de Aprendizagem da Mortalidade Hospitalar da Substituição da Válvula Aórtica Transcateter: Insights do Registro Nacional Brasileiro / Learning Curve for In-Hospital Mortality of Transcatheter Aortic Valve Replacement: Insights from the Brazilian National Registry

Resumo Fundamento Dados robustos sobre a curva de aprendizagem (LC) da substituição da válvula aórtica transcateter (TAVR) são escassos nos países em desenvolvimento. Objetivo Avaliar a LC da TAVR no Brasil ao longo do tempo. Métodos Analisamos dados do registro brasileiro de TAVR de 2008 a 2023. Pacientes de cada centro foram numerados cronologicamente em número sequencial de caso (NSC). A LC foi realizada usando um spline cúbico restrito ajustado para o EuroSCORE-II e o uso de próteses de nova geração. Ainda, os desfechos hospitalares foram comparados entre grupos definidos de acordo com o nível de experiência, com base no NSC: 1º ao 40º caso (experiência inicial), 41º ao 80º caso (experiência básica), 81º ao 120º caso (experiência intermediária) e 121º caso em diante (experiência alta). Análises adicionais foram conduzidas de acordo com o número de casos tratados antes de 2014 (>40 e ≤40 procedimentos). O nível de significância adotado foi p <0,05. Resultados Foram incluídos 3194 pacientes de 25 centros. A idade média foi 80,7±8,1 anos e o EuroSCORE II médio foi 7±7,1. A análise da LC demonstrou uma queda na mortalidade hospitalar ajustada após o tratamento de 40 pacientes. Um patamar de nivelamento na curva foi observado após o caso 118. A mortalidade hospitalar entre os grupos foi 8,6%, 7,7%, 5,9%, e 3,7% para experiência inicial, básica, intermediária e alta, respectivamente (p<0,001). A experiência alta foi preditora independente de mortalidade mais baixa (OR 0,57, p=0,013 vs. experiência inicial). Centros com baixo volume de casos antes de 2014 não mostraram uma redução significativa na probabilidade de morte com o ganho de experiência, enquanto centros com alto volume de casos antes de 2014 apresentaram uma melhora contínua após o caso de número 10. Conclusão Observou-se um fenômeno de LC para a mortalidade hospitalar do TAVR no Brasil. Esse efeito foi mais pronunciado em centros que trataram seus 40 primeiros casos antes de 2014 que naqueles que o fizeram após 2014.

Abstract Background Robust data on the learning curve (LC) of transcatheter aortic valve replacement (TAVR) are lacking in developing countries. Objective To assess TAVR's LC in Brazil over time. Methods We analyzed data from the Brazilian TAVR registry from 2008 to 2023. Patients from each center were numbered chronologically in case sequence numbers (CSNs). LC was performed using restricted cubic splines adjusted for EuroSCORE-II and the use of new-generation prostheses. Also, in-hospital outcomes were compared between groups defined according to the level of experience based on the CSN: 1st to 40th (initial-experience), 41st to 80th (early-experience), 81st to 120th (intermediate-experience), and over 121st (high-experience). Additional analysis was performed grouping hospitals according to the number of cases treated before 2014 (>40 and ≤40 procedures). The level of significance adopted was <0.05. Results A total of 3,194 patients from 25 centers were included. Mean age and EuroSCORE II were 80.7±8.1 years and 7±7.1, respectively. LC analysis demonstrated a drop in adjusted in-hospital mortality after treating 40 patients. A leveling off of the curve was observed after case #118. In-hospital mortality across the groups was 8.6%, 7.7%, 5.9%, and 3.7% for initial-, early-, intermediate-, and high-experience, respectively (p<0.001). High experience independently predicted lower mortality (OR 0.57, p=0.013 vs. initial experience). Low-volume centers before 2014 showed no significant decrease in the likelihood of death with gained experience, whereas high-volume centers had a continuous improvement after case #10. Conclusion A TAVR LC phenomenon was observed for in-hospital mortality in Brazil. This effect was more pronounced in centers that treated their first 40 cases before 2014 than those that reached this milestone after 2014.

Escala Eagle para riesgo cardiovascular prequirúrgico en endarterectomía de arteria carótida interna / Eagle score presurgical cardiovascular risk in endarterectomy of the internal carotid artery

Resumen Introducción: La endarterectomía carotídea se emplea para el tratamiento de pacientes con estenosis severa (> 70 %) o síntomas cerebrovasculares por enfermedad de la carótida interna. La escala Eagle ha sido usada como predictor de eventos cardiacos luego de una cirugía mayor. Este estudio busca determinar el uso de la escala Eagle como predictor de eventos mayores luego de endarterectomía carotídea. Materiales y métodos: En este estudio observacional retrospectivo de corte transversal, se revisaron historias clínicas de pacientes sometidos a endarterectomía carótida entre los años 2017 y 2021, donde la escala Eagle se realizó durante la visita prequirúrgica, para evaluar el riesgo de complicaciones mayores luego de una endarterectomía carotídea hasta finalizar la hospitalización. Discusión: Un total de 19 pacientes fueron evaluados prequirúrgicamente con el puntaje de la escala de Eagle y fueron tratados con endarterectomía carotídea, con un promedio de edad de 77 años. El procedimiento quirúrgico se realizó con mayor frecuencia en pacientes sintomáticos (89,40 %), incluyendo 10 (59 %) con antecedentes de ataque isquémico transitorio (AIT) y 7 (41 %) con ataque cerebrovascular. Las imágenes diagnósticas indicaron estenosis severa de la arteria carótida en 18 pacientes (94,7 %) y la mayoría de los pacientes presentaron riesgo moderado (68,42 %) según la escala Eagle, además, 5 presentaron complicaciones menores y ninguno presentó complicaciones mayores. Conclusiones: Un puntaje moderado en la escala de Eagle indica riesgo de desarrollar complicaciones cardiovasculares menores luego de endarterectomía carotídea, pero se requieren estudios con mayor tamaño de muestra para dilucidar el papel del puntaje Eagle como predictor de complicaciones cardiovasculares mayores luego de una endarterectomía carotídea.

Abstract Introduction: Carotid endarterectomy is used for treating patients with severe stenosis (>70%) or cerebrovascular symptoms secondary to internal carotid disease. Eagle score has been used as a predictor of cardiovascular events after major surgery. This study aims to assess the use of Eagle Score as a predictor of major cardiovascular events after carotid endarterectomy. Materials and methods: A retrospective observational cross-sectional study was conducted. Medical records of patients who underwent carotid endarterectomy between 2017 and 2021 were reviewed. The EAGLE scale was performed pre-surgically to assess the risk of the risk of major complications after carotid endarterectomy from surgery to the last day of hospitalization. Discussion: A total of 19 patients were assessed pre-surgically using the Eagle scale score and subsequently underwent carotid endarterectomy (Mean age of 77 years-old). The surgical procedure was predominantly performed on symptomatic patients (89.4%), including 10 patients (59%) with a history of transient ischemic attack (TIA) and 7 patients (41%) with a cerebrovascular attack. Previous diagnostic imaging indicated severe carotid artery stenosis in 18 patients (94.7%). According to the EAGLE Scale, the majority presented a moderate risk (68.42%), among whom 5 patients experienced minor complications, and none experienced major complications. Conclusions: Patients with minor cardiovascular complications after carotid endarterectomy were most commonly adjudicated as moderate risk according to the Eagle score. Further studies with large sample sizes are required to elucidate the role of Eagle Score as predictor of major cardiovascular events after carotid endarterectomy.

Gastric outlet obstruction secondary to adult hypertrophic pyloric stenosis: case report and literature review

Adult hypertrophic pyloric stenosis is a rare entity; the most common type is secondary to underlying gastrointestinal pathologies, such as peptic ulcer, malignant tumors, and certain inflammatory diseases. A rare case of hypertrophic pyloric stenosis is presented in an adult patient secondary to acid peptic disease, presenting with gastric outlet obstruction, treated in the first instance with pyloric dilation successfully, however, the clinical picture has recurred now with 90% hypertrophic pyloric stenosis, it was decided to perform a surgical procedure with roux-en-Y gastrojejunal diversion, progressing with adequate evolution. There is no consensus on which is the most effective treatment. However, most authors seem to favor gastric resection due to the risk of malignancy secondary to long-standing hypertrophic pyloric stenosis.

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

SUMMARY: The aim of this study was to compare the clinical value of vertebral artery ultrasound (VAU), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) on vertebral artery stenosis in patients with posterior circulation ischemia. Seventy-three patients with posterior circulation ischemia underwent vertebral artery ultrasound and magnetic resonance angiography as well as digital subtraction angiography, and the diagnosis of vertebral artery stenosis (VAS) and the degree of stenosis (normal, mild stenosis, moderate stenosis, severe stenosis, and occlusion) were recorded and compared between digital subtraction angiogram and vertebral artery ultrasound and magnetic resonance angiography. The vertebral artery stenosis rates on digital subtraction angiography and vertebral artery ultrasound were 87.30 % (55/63) and 49.20 % (31/63), respectively, and the difference was statistically significant. The rates of vertebral artery stenosis on digital subtraction angiography and, magnetic resonance angiography was 90.38 % (47/52) and 88.46 % (46/ 52), respectively, and the differences was not statistically significant. The sensitivity, accuracy, negative predictive value, and positive predictive value of vertebral artery ultrasound in diagnosing vertebral artery stenosis were 51.35 %, 54.76 %, 18.18 %, and 95.00 %, respectively, lower than those of magnetic resonance angiography, which were 91.89 %, 90.48 %, 57.14 %, and 97.14 %, respectively. Of the noninvasive imaging techniques, vertebral artery ultrasound does not accurately characterize vertebral artery stenosis and its degree of stenosis. Magnetic resonance angiography effectively screens for vertebral artery stenosis and its degree of stenosis, and can be used as a reliable tool for vertebral artery stenosis in posterior circulation cerebral infarction, and can be used in conjunction with digital subtraction angiogram in order to improve diagnostic convenience and accuracy.

El objetivo de este estudio fue comparar el valor clínico de la ecografía de la arteria vertebral (VAU), la angiografía por resonancia magnética (ARM) y la angiografía por sustracción digital (DSA) en la estenosis de la arteria vertebral en pacientes con isquemia de la circulación posterior. A 73 pacientes con isquemia de la circulación posterior se les realizó una ecografía de la arteria vertebral y una angiografía por resonancia magnética, así como una angiografía por sustracción digital, y se les diagnosticó estenosis de la arteria vertebral (EVA) y el grado de estenosis (normal, estenosis leve, estenosis moderada, estenosis grave, y oclusión) se registraron y compararon la angiografía por sustracción digital y la ecografía de la arteria vertebral y la angiografía por resonancia magnética. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la ecografía de la arteria vertebral fueron del 87,30 % (55/63) y del 49,20 % (31/63), respectivamente, y la diferencia fue estadísticamente significativa. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la angiografía por resonancia magnética fueron del 90,38 % (47/52) y del 88,46 % (46/52), respectivamente, y las diferencias no fueron estadísticamente significativas. La sensibilidad, precisión, valor predictivo negativo y valor predictivo positivo de la ecografía de la arteria vertebral en el diagnóstico de estenosis de la arteria vertebral fueron 51,35 %, 54,76 %, 18,18 % y 95,00 %, respectivamente, inferiores a los de la angiografía por resonancia magnética, que fueron 91,89 %, 90,48 %, 57,14 % y 97,14 %, respectivamente. De las técnicas de imagen no invasivas, la ecografía de la arteria vertebral no caracteriza con precisión la estenosis de la arteria vertebral y su grado de estenosis. La angiografía por resonancia magnética detecta eficazmente la estenosis de la arteria vertebral y su grado de estenosis, y puede usarse como una herramienta confiable para la estenosis de la arteria vertebral en el infarto cerebral de circulación posterior, y puede ser utilizada junto con la angiografía por sustracción digital para mejorar el diagnóstico y la exactitud.

Implante valvular percutáneo valve-in-valve en tricúspide. Primer reporte de caso de paciente pediátrico en Colombia / Percutaneous valve-in-valve valve implantation in tricuspid position. First case report of a pediatric patient in Colombia

Resumen Las anormalidades de la válvula tricúspide tienen una incidencia menor respecto a los defectos del resto de válvulas cardiacas y pueden deberse a causas primarias o secundarias. Recientemente, se ha estudiado su fisiopatología y su importancia en la morbimortalidad por causas cardiacas. En este sentido, la cirugía valvular tricúspide abierta tiene una tasa de morbimortalidad elevada, más aún cuando se trata de una reoperación. Es por esto que estos procedimientos endovasculares transcatéter cobran relevancia y recientemente se han publicado a lo largo del mundo algunos casos de intervenciones por este método, por medio de implante valvular percutáneo valve-in-valve en posición tricúspide. Se presenta el primer caso reportado de este procedimiento en Colombia en una paciente pediátrica, el cual transcurrió sin complicaciones y con el que se logró una mejoría significativa en la función valvular como paso inicial para continuar desarrollando la técnica y realizando este procedimiento en el país.

Abstract Abnormalities in the tricuspid valve have a lower incidence than defects in the rest of the heart valves and may be due to primary or secondary causes. Recently, its pathophysiology and importance in morbidity and mortality due to cardiac causes have been widely studied. Open tricuspid valve surgery has a high rate of morbidity and mortality, and even more so when it comes to reoperation. For this reason, it is important to carry out these procedures endovascularly via a transcatheter catheter and some cases of exacerbations by this method have recently been published throughout the world, by means of percutaneous valve-in-valve implantation in the tricuspid position. We present the first reported case of this procedure in Colombia in a pediatric patient, whose procedure was uneventful and a significant improvement in valve function was impaired, as an initial step to continue developing the technique and performing the procedure in this country.

Endarterectomía carotídea, resultados a corto plazo

Objetivo: Analizar los factores de riesgo y resultados de la endarterectomía carotídea (EC) en el hospital Metropolitano de la Florida Dra. Eloísa Díaz Insunza. Materiales y métodos: Se trata de un estudio observacional, retrospectivo y descriptivo, donde se analizan 89 endarterectomías carotídea, en un período de 8 años (enero del 2015 a enero de 2023) realizadas en 85 pacientes, los pacientes fueron divididos en 2 grupos, sintomáticos y asintomáticos, con respecto a las complicaciones fueron clasificadas en mayores y menores. Resultados: Se realizaron 89 endarterectomías carotídeas desde enero del 2015 hasta enero del 2023. El grupo sintomático corresponde a 78 (87,64%) pacientes, el grupo asintomático 11 (12,35%). 62 en hombres (69,66%) y 27 en mujeres (30,33%). Hubo muerte en 1 (1,12%) solo paciente, perteneciendo éste al grupo sintomático. Accidentes vasculares perioperatorios en 3 (3,37%) pacientes, todos con secuelas neurológicas presentes a 30 días post-operatorios (uno de estos fallecido en post-operatorio inmediato). Hematomas en 5 (5,61%) casos, 4 (3,56%) que requirieron intervención quirúrgica para drenaje del mismo. Lesión neurológica periférica en 1 (1,12%) solo paciente que corresponde a lesión del laríngeo recurrente. 1 (1,12%) caso de infección superficial de herida operatoria. 1 (1,12%) caso de síndrome de reperfusión cerebral Discusión: Todas las grandes series y guías internacionales demuestran el amplio beneficio de la endarterectomía carotídea en la prevención de eventos neurológicos. Conclusión: La endarterectomía carotídea sigue siendo el tratamiento de elección en la estenosis carotídea sintomática, realizada en centros con experiencia presenta resultados excelentes en cuanto a la prevención de nuevos eventos neurológicos.

Objective: To analyze the risk factors and short-term results of the carotid endarterectomy in our hospital. Materials and method: The present is an observational, retrospective and descriptive study, where 89 carotid endarterectomies are analyzed in a period of 8 years (January 2015 to January 2023) performed in 85 patients, the patients were divided in to two groups, symptomatic and asymptomatics, as for the complications there were divided in minor and mayor. Results: 89 carotid endarterectomies where perform between January 2015 to January 2023. In the symptomatic group are 78 (87.64%) patients, in the asymptomatic group there are 11 patients (12.35%). 62 where male (69.66%) and 27 where women (30.33%). Only 1 (1.12%) patient died, this one from the symptomatic group. Perioperatory stroke in 3 (3.37%) patients, all of them with neurologic secuela at 30 days of post operatory. 5 (5.61%) cases of post operatory hematomas 4 of them requiring reintervention. There was 1 (1.12%) patient with neurologic affection. 1 (1.12%) case of superficial wound infection. Conclusion: The carotid endarterectomy remains as the gold standard to prevent strokes in symptomatic patients. Performed in high volume centers it has excellent results as for the prevention of new strokes.

Self-dilatation: An Alternative for Managing Refractory Esophageal Strictures / Autodilatación: una alternativa para el manejo de las estenosis esofágicas refractarias

Abstract We present the case of a patient with post-caustic stenoses who required surgical management and whose anastomosis was narrowed, requiring dilations using Savary, strictureplasty, and injection therapy without success. Given the recurrence, we decided to train him to do self-dilatation, which was successful since the patient could resume his daily activities. In addition to the photos, the case report provides a video explaining step-by-step the methods used in managing the patient.

Resumen Se trata del caso de un paciente con estenosis poscáusticas que requirió manejo quirúrgico y cuya anastomosis se estenosó, por lo que requirió dilataciones con Savary, estricturoplastia y terapia de inyección, sin éxito. Ante la recurrencia se decidió darle un entrenamiento para que se hiciera autodilataciones, lo cual fue exitoso dado que le paciente pudo reasumir sus actividades diarias. El reporte de caso muestra, además de las fotos, un video donde se explica paso a paso los métodos que se usaron en el manejo del paciente.

Manejo del tracto de salida del ventrículo derecho con implante percutáneo de válvula Melody en pacientes pediátricos: experiencia en un centro de alta complejidad en Colombia / Management of right ventricular outflow tract with percutaneous Melody valve implantation in pediatric patients: experience in a high complexity center in Colombia

Resumen Antecedentes: Las cardiopatías congénitas plantean un desafío terapéutico, específicamente la estenosis de la válvula pulmonar. Esta ha sido tratada durante muchos años con procedimientos invasivos e inserción de bioprótesis, que con el tiempo se vuelven disfuncionales y pueden reestenosarse por acumulación de tejido fibroso y calcificación. Debido a las complicaciones generadas por la injuria quirúrgica, se han descrito medidas menos invasivas para el manejo de la estenosis residual e inicial por medios endovasculares en adultos y más recientemente en población pediátrica. Objetivo: El objetivo de este reporte es describir la misma en el manejo endovascular del tracto de salida del ventrículo derecho, como el inicio de un trabajo continuo para la mejoría de los resultados pediátricos en países en vía de desarrollo. Métodos: Se presentan siete casos pediátricos de manejo endovascular del tracto de salida derecho; tres de ellos sometidos a valvuloplastia quirúrgica con persistencia de la estenosis pulmonar, por lo cual se decidió inserción percutánea de una válvula pulmonar (IVPP) transcatéter con válvula Melody utilizando la técnica valve-in-valve, con lo que se consiguió una resolución del 100% de la estenosis y no se presentó ningún tipo de complicación asociada al procedimiento. Resultados: En cuatro pacientes se logró una implantación exitosa de la válvula por vía percutánea en diferentes cardiopatías congénitas, siendo uno de ellos en tracto nativo; además, destaca el caso de un paciente en quien se realizó fractura intencional de la válvula pulmonar, procedimiento innovador en el manejo endovascular pediátrico en Colombia. Conclusiones: En estos pacientes el procedimiento resultó ser poco invasivo, seguro y efectivo. La técnica IVPP podría ser considerada una opción viable en Colombia (y en otros países en desarrollo) para el manejo de implantes valvulares primarios fallidos o incluso en tractos nativos.

Abstract Background: Congenital heart disease poses a therapeutic challenge, specifically pulmonary valve stenosis. This has been treated for many years with invasive procedures and bioprostheses, which over time, become dysfunctional due to the accumulation of fibrous tissue and calcification. Objective: The aim of this study is to describe the use of endovascular management in the right ventricular outflow tract, as the beginning of an ongoing effot to improve pediatric outcomes in developing countries. Methods: Seven pediatric patients with endovascular management of the right outflow tract are presented. Three of them underwent surgical valvuloplasty with persistent pulmonary stenosis. They decided to insert a percutaneous transcatheter pulmonary valve (PPVI) with a Melody valve using the valve-in-valve technique, with 100% stenosis and no complications associated with the procedure. Results: Four patients with successful percutaneous valve implantation had different congenital heart diseases. In addition, the case of a patient in whom an intentional pulmonary valve fracture was performed, an innovative procedure in pediatric endovascular management in the country, is highlighted. Conclusions: The procedure was minimally invasive, safe, and effective. The IVPP technique could be a viable option in our country for managing failed primary valve implantations or even in native tracts.

Prevalencia de estenosis aórtica moderada-grave en pacientes con amiloidosis cardiaca en un centro de referencia / Prevalence of moderate-severe aortic stenosis in patients with cardiac amyloidosis in a referral center

Resumen Antecedentes: La estenosis aórtica (EA) es actualmente la enfermedad valvular más frecuente, con una prevalencia estimada de más del 4 % en octogenarios. Objetivo: Describir la prevalencia de estenosis aórtica (EA) moderada-grave en pacientes con amiloidosis por transtiretina wild type (ATTRwt). Además, describir las características clínicas, ecocardiográficas y la evolución en este grupo de pacientes. Método: Estudio de cohorte retrospectiva de pacientes con diagnóstico de ATTRwt, pertenecientes al Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, en el periodo del 30/11/2007 al 31/05/2021. El seguimiento de los pacientes se realizó a través de la historia clínica electrónica de la institución. Se estimó la prevalencia de EA moderada-grave, que se presenta como porcentaje con su intervalo de confianza del 95% (IC 95%). Se compararon las características por grupos según tuvieran o no EA moderada-grave. Resultados: Se incluyeron 104 pacientes con diagnóstico de ATTRwt. La mediana de seguimiento fue de 476 días [rango intercuartílico: 192-749]. La prevalencia de EA moderada-grave al momento del diagnóstico de ATTRwt fue del 10.5% (n = 11; IC95%: 5-18%). La mediana de edad de los pacientes con EA fue de 86 años [78-91] y predominó el sexo masculino (81.8%). La mayoría de los pacientes tenían el antecedente de insuficiencia cardiaca (n = 8) y fibrilación auricular (n = 8). Predominaron los pacientes con EA grave de bajo flujo y bajo gradiente (n = 7). Cuatro pacientes fueron sometidos a alguna intervención en la válvula aórtica. Durante el seguimiento, 5 pacientes (46%) tuvieron internaciones por insuficiencia cardiaca descompensada y 4 (36%) fallecieron. Conclusiones: En nuestra cohorte, la coexistencia de ambas patologías tuvo una prevalencia similar a la reportada en la literatura internacional. Se trató de una población añosa con alto porcentaje de fibrilación auricular y antecedente de insuficiencia cardiaca. La mayoría presentaron EA grave de bajo flujo y bajo gradiente.

Abstract Background: Aortic stenosis (AS) is currently the most common valvular disease, with an estimated prevalence of over 4% in octogenarians. Objective: To describe the prevalence of moderate-severe aortic stenosis (AS) in patients with wild type transthyretin amyloidosis (ATTRwt). Also, describe the clinical features, echocardiographic characteristics and clinical evolution. Method: Retrospective cohort of patients with diagnosis of ATTRwt, belonging to Hospital Italiano de Buenos Aires Institutional Amyloidosis Registry, from 30/11/2007 to 31/05/2021. Patients follow up was carried out through the institution clinical history. The prevalence of moderate-severe AE was estimated and presented as a percentage with its 95% confidence interval (95% CI). The characteristics were compared by groups according to whether or not they had moderate-severe AS. Results: 104 patients with ATTRwt were included. Median follow up was 476 days [interquartile range: 192-749]. Moderate-severe AS prevalence at the ATTRwt time of diagnosis was 10.5% (n = 11; 95% CI: 5-18%). The median age of patients with AS moderate-severe at the time of diagnosis of ATTRwt was 86 years [78-91] and the male sex predominated (82%). Most of the patients had a history of heart failure (n = 8) and atrial fibrillation (n = 8) prior to the diagnosis of ATTRwt. Most of the patients were subclassified as low flow low gradient severe AS group (n = 7). Four patients underwent some intervention on the aortic valve. During follow-up, 5 patients (46%) were hospitalized for decompensated heart failure and 4 (36%) died. Conclusions: In our cohort, the coexistence of both pathologies had a similar prevalence as reported in the international literature. It was an elderly population with a high percentage of atrial fibrillation and history of heart failure. Most of the patients presented with severe AS with low flow low gradient.

The effect of dual antiplatelet therapy for improvement of extracranial and intracranial artery stenosis evaluated by digital subtraction angiography

Background: Stroke involving extracranial carotid (ECAS), vertebral (EVAS), and intracranial arteries (IAS) contributed to an annual stroke rate of 0.1-3.3%. Even though endarterectomy and/or angioplasty and stenting had revolutionized its� management, best medical treatment (BMT) is still the mainstay of therapy to prevent secondary stroke/transient ischemic attack. This study aimed to evaluate the effect of BMT to reduce the degree of stenosis by using six-months double antiplatelet therapy (DAPT). Methods: A retrospective cohort study was conducted in a secondary private hospital in Indonesia, in January-December 2022. Adults ?18 years old with ECAS, EVAS, or IAS detected using digital subtraction angiography (DSA), receiving DAPT for at least six months, and those who had second DSA evaluation were included. Any subjects with other brain pathologies or recorded incompliance to DAPT were excluded. Age, gender, stenosis degree, stenosis location, and conversion of stenosis degree were recorded and compared between pre-DAPT and post-DAPT group. Results: Of 30 subjects, there were insignificant changes (46.5�.3% to 50.8�.9%, p=0.09) of ECAS, EVAS, and IAS. There were 14 cases with constant stenosis (51.4�.5%), 8 cases with decreasing stenosis (46.9�.2% to 40.1�.8%, p=0.012), and 12 cases with increasing stenosis (40.4�.9% to 57.1�.0%, p=0.002). No significant association were found among those groups related to traditional vascular risk factors. Conclusions: There was no difference in respect to the degree of stenosis following six months of DAPT in either ECAS, EVAS, or IAS. Routine evaluation as well as recognizing features of high-risk stroke/TIA are important to help decide individual who may be candidates of endovascular procedures earlier.

Interesting case of subglottic hemangioma presented with stridor

Subglottic hemangioma is a very rare infantile form of hemangioma as compared to cutaneous hemangioma but if left undiagnosed or untreated can be life-threatening. Here we report one case of preterm who presented with sudden onset of inspiratory stridor and respiratory distress in OPD in a previously normal child. The patient was initially misdiagnosed as croup which did not improve after nebulized adrenaline and steroids later on direct laryngobrochoscopy showed subglottic stenosis. A CT scan was done later which revealed subglottic hemangioma which showed complete remission in symptoms after starting oral propranolol. A careful approach towards diagnosing and managing the sudden onset of stridor with probable structural cause is necessary for a favorable outcome.

Diagnosis and treatment strategies for vascular complications after kidney transplantation / 器官移植

With persistent progress in donor-recipient evaluation criteria, organ procurement and preservation regimens and surgical techniques, the incidence of vascular complication after kidney transplantation has been declined, whereas it is still one of the most severe surgical complications of kidney transplantation, which may lead to graft loss and recipient death, and seriously affect the efficacy of kidney transplantation. Therefore, the occurrence, clinical manifestations, diagnosis and treatment strategies of common vascular complications after kidney transplantation, including vascular stenosis, arterial dissection, pseudoaneurysm, vascular rupture and thrombosis were reviewed in this article. In combination with the incidence, diagnosis and treatment of vascular complications after kidney transplantation in the First Affiliated Hospital of Xi'an Jiaotong University, diagnosis and treatment strategies for common vascular complications after kidney transplantation were summarized, aiming to provide reference for clinical diagnosis and treatment of vascular complications after kidney transplantation, lower the incidence of vascular complications, and improve clinical efficacy of kidney transplantation and survival rate of recipients.

Diagnosis and treatment of the portal vein complications for children undergoing spilt liver transplantation / 器官移植

Objective To investigate the diagnosis and treatment strategy of the portal vein complications in children undergoing split liver transplantation. Methods The clinical data of 88 pediatric recipients who underwent split liver transplantation were retrospectively analyzed. Intraoperative anastomosis at the bifurcating site of the portal vein or donor iliac vein bypass anastomosis was performed depending on the internal diameter and development of the recipient's portal vein. A normalized portal venous blood stream monitoring was performed during the perioperative stage. After operation, heparin sodium was used to bridge warfarin for anticoagulation therapy. After portal vein stenosis or thrombosis was identified with enhanced CT or portography, managements including embolectomy, systemic anticoagulation, interventional thrombus removal, balloon dilatation and/or stenting were performed. Results Among the 88 recipients, a total of 10 children were diagnosed with portal vein complications, of which 4 cases were diagnosed with portal vein stenosis at 1 d, 2 months, 8 months, and 11 months after surgery, and 6 cases were diagnosed with portal vein thrombosis at intraoperative, 2 d, 3 d (n=2), 6 d, and 11 months after surgery, respectively. One patient with portal vein stenosis and one patient with portal vein thrombosis died perioperatively. The fatality related to portal vein complications was 2% (2/88). Of the remaining 8 patients, 1 underwent systemic anticoagulation, 2 underwent portal venous embolectomy, 1 underwent interventional balloon dilatation, and 4 underwent interventional balloon dilatation plus stenting. No portal venous related symptoms were detected during postoperative long term follow up, and the retested portal venous blood stream parameters were normal. Conclusions The normalized intra- and post-operative portal venous blood stream monitoring is a useful tool for the early detection of portal vein complications, the early utilization of useful managements such as intraoperative portal venous embolectomy, interventional balloon dilatation and stenting may effectively treat the portal vein complications, thus minimizing the portal vein complication related graft loss and recipient death.

Analysis of three-dimensional visualization imaging of severe portal vein stenosis after liver transplantation and clinical efficacy of portal vein stent implantation / 器官移植

Objective To analyze three-dimensional imaging characteristics and advantages for severe portal vein stenosis after liver transplantation, and to evaluate clinical efficacy of portal vein stent implantation. Methods Clinical data of 10 patients who received portal vein stent implantation for severe portal vein stenosis after liver transplantation were retrospectively analyzed. Imaging characteristics of severe portal vein stenosis, and advantages of three-dimensional reconstruction imaging and interventional treatment efficacy for severe portal vein stenosis were analyzed. Results Among 10 patients, 3 cases were diagnosed with centripetal stenosis, tortuosity angulation-induced stenosis in 2 cases, compression-induced stenosis in 2 cases, long-segment stenosis and/or vascular occlusion in 3 cases. Three-dimensional reconstruction images possessed advantages in accurate identification of stenosis, identification of stenosis types and measurement of stenosis length. All patients were successfully implanted with portal vein stents. After stent implantation, the diameter of the minimum diameter of portal vein was increased [(6.2±0.9) mm vs. (2.6±1.7) mm, P<0.05], the flow velocity at anastomotic site was decreased [(57±19) cm/s vs. (128±27) cm/s, P<0.05], and the flow velocity at the portal vein adjacent to the liver was increased [(41±6) cm/s vs. (18±6) cm/s, P<0.05]. One patient suffered from intrahepatic hematoma caused by interventional puncture, which was mitigated after conservative observation and treatment. The remaining patients did not experience relevant complications. Conclusions Three-dimensional visualization technique may visually display the location, characteristics and severity of stenosis, which is beneficial for clinicians to make treatment decisions and assist interventional procedures. Timely implantation of portal vein stent may effectively reverse pathological process and improve portal vein blood flow.