[Spinal cord protection during open and endovascular surgery in thoracic and thoracoabdominal aorta diseases]. / Protección medular en la cirugía abierta y endovascular de las enfermedades de la aorta torácica y toracoabdominal.

In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.

[Mortality following cardiac surgery in the National Health Service Hospitals of the Community of Valencia in 2007: a descriptive analysis]. / Análisis descriptivo de mortalidad en cirugía cardiaca en los hospitales públicos de la Comunidad Valenciana en el año 2007.

OBJECTIVE: To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007. METHODS: Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit. RESULTS: The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%. CONCLUSIONS: The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

[Perioperative management of a ruptured sinus of Valsalva aneurysm]. / Manejo perioperatorio de un aneurisma de seno de Valsalva roto.

Congenital sinus of Valsalva aneurysms are extremely rare in Spain. The lesion consists of a defect that allows the aortic media to separate from the annulus fibrosus of the aortic valve, causing it to dilate with arterial pressure. The natural course of the aneurysm involves the risk of complication due to bacterial endocarditis, with conduction blocks or myocardial ischemia. Rupture of the aneurysm, usually into a right chamber, causes a left-right shunt that leads to heart failure and death if untreated. We present the case of a previously asymptomatic 60-year-old woman who presented with a clinical picture that led to a diagnosis of hyperthyroidism, and in whom there occurred a coincident rupture of a congenital sinus of Valsalva aneurysm. We describe the anesthetic procedure and emphasize the importance of intraoperative echocardiography throughout the resection of the aneurysm.

[Perioperative morbidity and mortality in surgery for dissecting aneurysm of the ascending aorta]. / Morbimortalidad perioperatoria de la cirugía de la disección de aorta ascendente.

OBJECTIVE: To describe complications and mortality in patients diagnosed of Stanford's type A (Daily) dissection of the ascending aorta requiring circulatory arrest for emergency placement of an aortic graft. PATIENTS AND METHODS: Retrospective study of 21 patients treated between December 1992 and November 1997. RESULTS: Hypertension was the disease most often associated with the diagnosis (in 8 of the 21 patients). Preoperative mortality was 9.5% (2 of the 21 patients), no deaths occurred in the operating room and postoperative mortality was 15.8% (3 of the 19 patients who underwent surgery). Durations in mean time (SD) in minutes were as follows: anesthesia-surgery 437.9 (92), extracorporeal circulation 192.5 (47), aortic clamping 82.6 (20), circulatory arrest 30.5 (8). Retrograde cerebral circulation was carried out during circulatory arrest in all cases. Mean temperature during this period was 14.9 degrees C. During the postoperative period we recorded three permanent neurological complications, six cases of acute renal failure and seven respiratory complications, specifically one instance of adult respiratory distress syndrome and six of pneumonia, the most common. Consumption of blood products was high, with great interindividual variation. CONCLUSION: Anesthesia for and recovery from surgery for acute aortic dissection is complex and associated with a high rate of postoperative complication and high consumption of blood products.

[Oxygen consumption during anaphylactic shock]. / Consumo de oxígeno durante un shock anafiláctico.

We report the case of a 49-year-old man who suffered anaphylactic/anaphylactoid shock within the first few minutes of reaching the recovery room after unremarkable coronary surgery and revascularization. Adequate monitoring permitted differential diagnosis and establishment of specific treatment Monitoring also allowed us to document hemodynamic changes and oxygen consumption during this instance of anaphylactic/anaphylactoid shock. Anaphylactic/anaphylactoid shock caused significant vasoparalysis with decreases in arterial pressures, reduction of oxygen consumption and discrete changes in oxygen exchange. The reposition of volume and administration of adrenaline were insufficient. Appropriate management of noradrenaline perfusion, which was made possible by complete monitoring, was essential for reestablishing normal hemodynamic and oximetric readings and preventing myocardial ischemia.