Case-control study of risk factors for mediastinitis after cardiovascular surgery.

We report results of a case-control study in which we evaluated 41 risk factors potentially associated with the development of postsurgical mediastinitis. There were 163 case patients and 326 control patients. Independent risk factors kept in the final multivariate logistic regression model were obesity (defined as a body mass index of greater than 30), diabetes mellitus, chronic obstructive pulmonary disease, preoperative stay longer than 1 week, pulmonary hypertension, perioperative myocardial infarction, and reoperation.

Living anatomy of the atrioventricular junctions. A guide to electrophysiologic mapping. A Consensus Statement from the Cardiac Nomenclature Study Group, Working Group of Arrhythmias, European Society of Cardiology, and the Task Force on Cardiac Nomenclature from NASPE.

Current nomenclature for the atrioventricular (AV) junctions derives from a surgically distorted view, placing the valvar rings and the triangle of Koch in a single plane with antero-posterior and right-left lateral coordinates. Within this convention, the aorta is considered to occupy an anterior position, although the mouth of the coronary sinus is shown as being posterior. Although this nomenclature has served its purpose for the description and treatment of arrhythmias dependent on accessory pathways and atrioventricular nodal reentry, it is less than satisfactory for the description of atrial and ventricular mapping. To correct these deficiencies, a consensus document has been prepared by experts from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. It proposes a new anatomically sound nomenclature that will be applicable to all chambers of the heart. In this report, we discuss its value for description of the AV junctions, establishing the principles of this new nomenclature.

Direct extension of bronchogenic carcinoma through the pulmonary veins.

We present two surgically treated cases of lung cancer that showed progression of the tumor through the pulmonary veins toward the left atrium. The surgical technique and the influence of improper handling on the production of systemic emboli are discussed.

Paroxysmal nodal reentrant tachycardia. Surgical cure with preservation of atrioventricular conduction.

In a patient with repetitive disabling tachycardias refractory to pharmacologic treatment, the electrophysiologic study suggested the existence of atrioventricular nodal reciprocating tachycardia. During ventricular pacing, endoepicardial mapping of the lower atrium showed the atrial breakthrough point in an area of the lower interatrial septum close to the AV node crista. A selective atriotomy was performed. The postoperative electrophysiologic studies showed absence of ventriculoatrial conduction at several ventricular pacing rates, while antegrade conduction is preserved. The patient remained free of arrhythmias 21 months after surgery, taking no antiarrhythmic drugs.

Supravalvular stenotic mitral ring. A new case with surgical correction.

In this report, we present a case of supravalvular stenotic mitral ring in a child. The lesion created a picture of severe mitral stenosis and was successfully managed by resection of the ring. No other malformations of the mitral apparatus or left ventricular outlfow tract were found. On analyzing the diagnostic criteria, we concluded that there appears to be only one useful criterion--the angiographic morphology. However, when ther- is an associated ventricular septal defect or findings of Shone's complex, we should suspect supravalvular ring rather than any other form of mitral stenosis.

Impact of mild pulmonary hypertension on mortality and pulmonary artery pressure profile after heart transplantation.

BACKGROUND: Pulmonary hypertension is a risk factor for early mortality after transplantation, but the risk threshold is debated. Also, little is known about the evolution of pulmonary circulation after transplantation. The aim of this study was to determine the influence of current risk pulmonary pressure parameters on early post-operative mortality and to assess the time-related changes in pulmonary pressure after surgery. METHODS: One hundred twelve consecutive transplanted patients were studied retrospectively to determine the influence of trans-pulmonary gradient of >12 mm Hg and pulmonary vascular resistance of >2.5 Wood units, at baseline or after vasodilator test, on early mortality. A multivariate analysis was used to study the hemodynamic parameters associated with early mortality. The pulmonary pressures of all surviving patients were studied for up to 3 years after surgery. RESULTS: Early mortality in the groups with and without pulmonary hypertension were 24.4% and 5.6%, respectively (p =.009). The only variable that was independently associated with early mortality was the pulmonary vascular resistance index (odds ratio = 1.459). Mild pulmonary hypertension disappeared 1 year after heart transplantation. CONCLUSIONS: Mild pulmonary hypertension is a risk factor for early postoperative mortality. The hemodynamic parameter most closely associated with early mortality is pulmonary vascular resistance index. The hemodynamic profile of pulmonary circulation after heart transplantation is partially dependent on the level of pulmonary hypertension before transplantation, at least during the first year after surgery.

Prosthetic valve endocarditis by opportunistic pathogens.

The incidence of endocarditis produced by the so-called "opportunists" as a complication of prosthetic valve surgery is progressively increasing in frequency and gradually transforming the clinical picture habitually associated with this disease. We report six cases of endocarditis produced by opportunistic microorganisms (two cases by Candida, and the remaining by Serratia, Actinobacillus, Acinetobacter calcoaceticus, and Bacteroides fragilis, and by Corynebacterium diphtheriae) in four male and two female patients, making special comment on our findings, diagnostic criteria, and treatment. The patients' ages ranged from 9 to 54 years, and all six patients had long-term complications, with symptoms appearing between 45 days and four years after prosthetic valve surgery. The progressive increase of this new type of prosthesis infection is favored by the indiscriminate use of certain drugs and especially by the prophylactic use of antibiotics.

Long-term results of cardiac valve replacement with the Delrin-disc model of the Björk-Shiley valve prosthesis.

One hundred two Björk-Shiley valve prostheses with the Delrin-disc occluder were implanted in 83 patients between January, 1971, and July, 1972. Fifty-eight were in the mitral position, 42 in the aortic, and 2 in the tricuspid. Complete follow-up until 1981 was obtained in 93% of the patients (mean follow-up, 66.8 months). Hospital mortality was 18% and late mortality, 19%. Survival according to actuarial methods was 84.8% at 5 years and 78.1% at 9 years after operation. Thromboembolism was detected in 8.8% of patients but caused no deaths. The incidence was 1.2% and 1.5% per year in those patients treated with Coumadin and antiplatelet agents, respectively. Reoperation was necessary in 13% of the patients. Most survivors (72%) are in New York Heart Association Functional Class I, despite a preoperative status of Class III or IV in 57% of the patients. Hospital mortality may be due to poorer understanding of patient management and less refined techniques of myocardial protection. Long-term survival with this prosthesis is similar to that in more recent studies, and rates of thromboembolism and malfunction compare favorably with other prosthetic valves.

Coarctation of the aorta and severe aortic insufficiency: What to repair first?

A new surgical approach is proposed for patients with coarctation of the aorta associated with severe aortic valvular insufficiency. The valvular lesion should be repaired first and the coarctation corrected during a second operation; both interventions should be done during the same hospital stay. We base our approach on the belief that improved coronary perfusion can be achieved when the aortic insufficiency is corrected first. The disadvantages of the opposite surgical approach, such as anticoagulation problems, renal underperfusion, and hypertensive complications are easily avoided.

Spontaneous left atrial haematoma.

We present a woman with paroxysmal atrial fibrillation and a mass in the left atrium. Cross-sectional echocardiography defined the lesion as cystic, while magnetic resonance imaging depicted it as a solid mass with areas of focal bleeding. Surgical resection showed a partially organized haematoma within the left atrial wall. The patient did well after surgery, although atrial fibrillation recurred. The presence of an atrial haematoma is rare, specially when spontaneous, and we stress the usefulness of magnetic resonance in reaching an aetiologic diagnosis.

Intracardiac thrombus trapped in a patent foramen ovale.

We describe a case of impending paradoxical embolism due to a thrombus trapped in a patent foramen ovale in a 22-year-old woman. Transthoracic and transesophageal echocardiography detected the thrombus. She was operated on and discharged asymptomatic.

A new approach to cardiac valve replacement through a small midline incision and inverted L shape partial sternotomy.

OBJECTIVE: Minimally invasive cardiac surgery is becoming more popular as an alternative technique in some cardiac operations. We report our experience with an inverted 'L' ministernotomy in 25 patients and describe the technical details of this new approach. METHODS: From June 1996 to February 1997 we performed 25 ministernotomy approaches for cardiac surgery, 17 aortic and 7 mitral valve replacements and 1 atrial septal defect closure. A comparison group included all patients (n = 126) operated on for mitral or aortic valve replacement through a median sternotomy since June 1996. RESULTS: Ventilatory support, Intensive Care Unit stay and hospital stay were 8.3 h (SD = 4 h), 25 h (SD = 8 h) and 5.5 days (SD = 3 days) in the L ministernotomy group and 11.5 h (SD = 5), 53 h (SD = 11) and 9.1 days (SD = 4 days) in the median sternotomy group (P < 0 05). Mortality and morbidity are similar to conventional sternotomy (hospital mortality 4% vs. 5.5%; P not significant). CONCLUSIONS: We conclude that inverted L ministernotomy for cardiac surgery is a safe approach and can offer some advantages over the conventional approach.

Isolated mitral valve replacement with the Björk-Shiley prosthesis in 100 consecutive patients. Short- and long-term results.

Single mitral valve replacement with the Björk-Shiley tilting disc prosthesis was performed in 100 consecutive patients between March 1971 and December 1973. The hospital mortality was 13% and the late mortality was 6%. 74 of the patients were followed for periods ranging between 12 and 46 months (mean follow-up: 24 months): clinical improvement was noted in 92%. The incidence of postoperative embolism, including 1 case of prosthesis thrombosis, was 6.7%, and all cases occurred within the first 9 months after surgery. 6 patients required reoperation because of prosthesis dysfunction due to thrombosis (1 patient), leakage (3), and late disc entrapment (2).

[Agenesis of the left coronary trunk. A case report and bibliographic review]. / Agenesia del tronco coronario izquierdo. Descripción de un caso y revisión de la bibliografía.

Clinical and angiographic features are described in a fifty-five years old man, with long-standing clinical manifestations of ischemic heart disease. In addition to severe coronary atherosclerosis, congenital atresia of the left main coronary was present. A description of the coronary anomaly found and a discussion of its meaning and significance are presented.

[The emergency heart transplant]. / Trasplante cardíaco de urgencia.

From the International Registry on Cardiac Transplantation we can not infer a higher mortality in urgent or emergent Cardiac Transplantation. The data in the Spanish Registry and in the literature show that the risk is higher in these patients compared to non urgent transplantation, implying ethical considerations which are discussed in the article. A different approach to urgent transplantation could be based on previous circulatory support, or heart assist systems as a bridge to transplantation.

[Scales of risk assessment in coronary surgery and their usefulness]. / Escalas de valoración de riesgo en cirugía coronaria y su utilidad.

Currently, there is an increasing interest in the fields of cardiology and cardiac surgery related to systems of risk assessment of cardiac surgery procedures. The main benefit of these systems is quality control of results obtained. Nevertheless, there are other interesting implications. Currently, most of the available scales make estimations of mortality risk with a defined operative technique, using preoperative variables. Other systems can make predictions on postoperative length of stay. Scales are built using the results of a large series, processed with different mathematical models. An important condition is the simplicity of use. There is a wide range of available systems originating from clinical experience in Europe and North-America. All of them include a common number of predictive factors, although the assigned weight can vary significantly. We recommend the routine use of these scales as a quality control system and as a method of characterization of our populations in order to make adequate comparisons among different groups.

[Surgical reconstruction of intervalvular fibrous body in active infective endocarditis]. / Cirugía de reconstrucción del cuerpo fribroso intervalvular en la endocarditis infecciosa activa.

INTRODUCTION AND OBJECTIVES: Surgery for infective endocarditis with paravalvular abscesses and fibrous body destruction has the highest mortality and morbidity rates in this disease with high surgical risk. We report a new approach of radical resection of the abscess and affected tissues and reconstruction of the heart with pericardium as an alternative to conventional surgery. METHODS: In the last two years six patients with infective endocarditis, paravalvular abscesses and fibrous body destruction underwent surgery (five prostheses with infective endocarditis). The main indication for surgery was persistent sepsis despite adequate antibiotic treatment in five patients and congestive heart failure in one. After wide resection of the abscesses and fibrous body the heart was reconstructed with glutaraldehyde-fixed bovine pericardium. RESULTS: There was no hospital mortality. The median bypass and clamp times were 198 and 174 minutes, respectively. One patient presented complete AV block and a permanent transvenous pacemaker was implanted. Doppler echocardiographic studies performed in all the patients prior to discharge indicated that no patient had patch dehiscence or paravalvular leaks. Patients were followed a mean of 15 months with no deaths or other complications being reported. CONCLUSIONS: Resection of the abscesses and fibrous body, and reconstruction of the heart with glutaraldehyde-fixed bovine pericardial patch is a radical, feasible technique with all infected tissues being resected to thereby prevent reinfection or paravalvular leaks.

[Thromboendarterectomy as a treatment for chronic pulmonary hypertension]. / Tromboendarterectomía como tratamiento de la hipertensión pulmonar crónica.

Chronic pulmonary hypertension is an extremely difficult disease to diagnose and is usually identified by the exclusion of other more recognized causes of enlargement in mean pulmonary arterial resistance. Up to now, treatments proposed for this disease, have not been very successful. Medical procedures are not a long term proper solution which leads the process to an irreversible point whose only solution should be a pulmonary transplantation. In recent years, study groups have established a surgical method, alternative to transplantation, which has been able to increase, with a decrease in mortality rates, a longer and a better quality of life for the patients affected by this disease: we are talking about pulmonary thromboendarterectomy.

[Aortic valve replacement via ministernotomy]. / Sustitución valvular aórtica por miniesternotomía.

Minimally invasive cardiac surgery is arising as an alternative technique in some cardiac operations. We present the first aortic valve replacement via ministernotomy. We describe in detail the technique of ministernotomy and the limitations that this new approach would have. We conclude with the advantages of minimally invasive cardiac surgery over conventional approach and review other techniques described in the literature.

[The protection of an internal mammary artery graft with a tubular prosthesis made of polytetrafluoroethylene]. / Protección del injerto de arteria mamaria interna con prótesis tubular de politetrafluoroetileno.

A polytetrafluoroethylene tubular prosthesis was used to protect an internal mammary artery graft in a patient with high risk of reoperation. This technique was used to avoid the risk of damage of the graft and to reduce the difficulties of the injection of cardioplegia during the reoperation procedure. The usefulness of this technique is discussed in the article.