[Vena cava thrombectomy in kidney cancer. Report of 32 nephrectomies]. / Nefrectomía radical con trombectomía de vena cava: 20 años de cirugías por tumor renal.

BACKGROUND: Vena cava (VC) involvement in kidney tumors occurs in 4 to 10% of cases, and is associated with a higher mortality. Nephrectomy with thrombectomy of the VC, performed by a multidisciplinary team, improves survival. AIM: To report a series of consecutive nephrectomies with caval thrombectomy performed in an academic center. PATIENTS AND METHODS: We report 32 patients with cT3b and 3c renal tumors, who underwent radical nephrectomy with VC thrombectomy between 2001 and 2021. A descriptive analysis of clinical, surgical and pathological variables was performed. Overall survival (OS) and cancer-specific survival (CSS) was calculated using Kaplan-Meier curves. RESULTS: The mean tumor size was 9.7 cm. According to Mayo classification 3/32 (9%) patients had a type I thrombus, 10/32 (31%) had a type II thrombus, 8/32 (25%) had a type III thrombus, and 5/32 (16%) had a type IV thrombus. The mean bleeding was 2000 cc. There was one intraoperative death. Nineteen percent of patients had complications >= 3 according to Clavien-Dindo classification. Reoperations occurred in 9%. Pre and postoperative creatinine levels were 1.17 and 1.91 mg/dl respectively (p < 0.01). Pre and postoperative Hematocrit levels were 47.9 and 31% respectively (p = 0.02). Sixty six percent of tumors were clear cell renal cancer, 9% were papillary and 3% were chromophobic. Mean OS was 10 months. Two-year SCE was 40%. CONCLUSIONS: Our results are similar to those reported elsewhere. Despite being an unusual pathology, the surgical technique has been improving, thanks to the multidisciplinary work of urologists and surgeons.

Initial Experience in Chile with Stent Implantation in the Right Ventricle Outflow Tract in High-Risk Patients with Tetralogy of Fallot.

Tetralogy of Fallot (ToF) treatment is difficult in patients with surgical risk factors or unfavorable anatomy. Stent implantation in the right ventricular outflow tract (RVOT) is an option for these patients. We report our initial experience in Chile with RVOT stenting in patients with ToF. Retrospective and descriptive study conducted in three pediatric cardiovascular centers in Chile between 2012 and 2015, including all ToF patients with stent in the RVOT as first procedure. Clinical records, echocardiographic, interventional, and surgical reports were reviewed for demographics and information of RVOT and pulmonary arteries. 12 newborns with ToF were included (75% female). Median age was 20 days (1-70) and mean weight was 2178 g (1400-3414). Saturations increased after the procedure from 74.3% (55-88) to 88.5% (80-98%), (p < 0.01). No complications or mortality were related to interventions. Follow-up was 11 months (7-36). Median right and left pulmonary arteries Z-score increased from - 4.0 (- 5.2 to - 0.3) and - 1.5 (- 4.8 to - 0.26) to + 0.53 (0.0 to 2.2) and + 1.1 (0.5 to 2.9), (p < 0.05), respectively. Nakata index increased from 63 mm2/mm2 (35 to 143) to 162 mm2/mm2 (107 to 197), (p < 0.05). Surgical repair was performed at a median of 4 months (2-7). Transannular patch repair was necessary in all patients and there was no surgical mortality. RVOT stenting is a safe and useful option for patients with ToF and surgical risk factors or unfavorable anatomy. It increases the pulmonary blood flow, improving saturation and pulmonary artery growth as a bridge for surgical repair.

[Results of a national program of pediatric heart transplantation: strengths and weakness]. / Resultados de un programa nacional de trasplante cardiaco pediátrico: fortalezas y debilidades.

Pediatric heart transplantation is an effective therapy to treat advanced heart failure in children. OBJECTIVES: To analyze the immediate and mid-term results of pediatric patients listed for heart transplantation. PATIENTS AND METHODS: Registration of patients admitted to our transplant protocol between October 2001 and July 2016 were reviewed, analyzing demographic data, diagnosis, status at the time of listing, waiting time until transplantation, donor data, use of ventricular assist device, hemodynamic data, complications and global mortality. RESULTS: Thirthy patients where included with a mean age of 9.4 years (1 month to 15 years). The most frequent diagnosis was dilated cardiomyopathy in 24 patients (80%). The status was I (urgency) in 19 cases and II in 11 cases. Ten patients died on the waiting list (33.3%) at an average of 52 days (13-139 days). Fourteen were transplanted (46.7%), with a waiting time of 199.6 days (4-586 days). Nine patients required mechanical support (30%). All patients received triple association of immunosuppression. One patient died 16 days post transplant due to primary graft failure (7.1%). The average follow-up was 43 months (0.5-159 months). Two patients died later on (82 and 55 months), both due to secondary rejection because of voluntary cessation of immunosuppressive therapy. Survival at 1 and 5 years was 93% and 74%, respectively. CONCLUSIONS: Our program has successfully transplanted 50% of patients enrolled, with good medium-term survival. A significant proportion of patients were listed as a medical emergency and 34.5% died on the waiting list.

[Hypoplastic left heart syndrome: 10 year experience with staged surgical management]. / Síndrome de hipoplasia de corazón izquierdo: experiencia de 10 años de un programa de etapificación quirúrgica.

UNLABELLED: Hypoplastic left heart syndrome (HLHS) is a lethal congenital heart disease in 95% of non-treated patients. Surgical staging is the main form of treatment, consisting of a 3-stage approach, beginning with the Norwood operation. Long term survival of treated patients is unknown in our country. OBJECTIVES: 1) To review our experience in the management of all patients seen with HLHS between January 2000 and June 2012. 2) Identify risk factors for mortality. PATIENTS AND METHOD: Retrospective analysis of a single institution experience with a cohort of patients with HLHS. Clinical, surgical, and follow-up records were reviewed. RESULTS: Of the 76 patients with HLHS, 9 had a restrictive atrial septal defect (ASD), and 8 had an ascending aorta ≤2mm. Of the 65 out of 76 patients that were treated, 77% had a Norwood operation with pulmonary blood flow supplied by a right ventricle to pulmonary artery conduit, 17% had a Norwood with a Blalock-Taussig shunt, and 6% other surgical procedure. Surgical mortality at the first stage was 23%, and for Norwood operation 21.3%. For the period between 2000-2005, surgical mortality at the first stage was 36%, and between 2005-2010, 15% (P=.05). Actuarial survival was 64% at one year, and 57% at 5years. Using a multivariate analysis, a restrictive ASD and a diminutive aorta were high risk factors for mortality. CONCLUSIONS: Our immediate and long term outcome for staged surgical management of HLHS is similar to that reported by large centres. There is an improvement in surgical mortality in the second half of our experience. Risk factors for mortality are also identified.

Survival of newborn infants with severe respiratory failure before and after establishing an extracorporeal membrane oxygenation program.

BACKGROUND: Severe hypoxic respiratory failure is a leading cause of neonatal mortality in Chile. Extracorporeal membrane oxygenation improves survival in neonates with hypoxic respiratory failure. OBJECTIVE: To determine the impact of the establishment of a Neonatal Extracorporeal Membrane Oxygenation Program on the outcome of newborns with severe hypoxic respiratory failure in a developing country. DESIGN/PATIENTS: Data of newborns (birthweight > 2,000 g and gestational age ≥ 35 wk) with hypoxic respiratory failure and oxygenation index greater than 25 were compared before and after extracorporeal membrane oxygenation was available. Extracorporeal membrane oxygenation was initiated in infants with refractory hypoxic respiratory failure who failed to respond to inhaled nitric oxide/high-frequency oscillatory ventilation. MAIN RESULTS: Data from 259 infants were analyzed; 100 born in the pre-extracorporeal membrane oxygenation period and 159 born after the extracorporeal membrane oxygenation program was established. Patients were similar in terms of risk factors for death for both periods except for a higher oxygenation index and a greater proportion of outborn infants during the extracorporeal membrane oxygenation period. Survival significantly increased from 72% before extracorporeal membrane oxygenation to 89% during the extracorporeal membrane oxygenation period (p < 0.01). During the extracorporeal membrane oxygenation period, 98 of 159 patients (62%) with hypoxic respiratory failure were rescued using inhaled nitric oxide/high-frequency oscillatory ventilation, whereas 61 (38%) did not improve; 52 of these 61 neonates were placed on extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survival rate to discharge was 85%. After adjusting for potential confounders, the severity of the pretreatment oxygenation index, a late arrival to the referral center, the presence of a pneumothorax, and the diagnosis of a diaphragmatic hernia were significantly associated with the need for extracorporeal membrane oxygenation or death. CONCLUSIONS: The establishment of an extracorporeal membrane oxygenation program was associated with a significant increase in the survival of newborns more than or equal to 35 weeks old with severe hypoxic respiratory failure.

[Influence of the referring health care systems and other factors on the results of mitral valve replacement]. / Influencia del sistema de salud de procedencia y otros factores en el resultado del reemplazo valvular mitral.

BACKGROUND: There is no consensus regarding which risk factors influence the outcome of mitral valve replacement. AIM: To study the effects of the referring health care system and other factors on the results of mitral replacement. PATIENTS AND METHODS: We included 632 patients operated between 1990 and 2010 receiving the St Jude prosthesis. Patients were divided into three groups, group 1 composed by 180 patients coming from the Public System, group 2 composed by 182 patients coming from the University System and group 3 composed by 270 patients coming from the Private System. RESULTS: Overall operative mortality was 4.3%. There was no difference between groups in mortality. Factors responsible for operative mortality were: emergency operation (Odds Patio (OR): 5.6 P < 0.01) and left ventricular function (according to ejection fraction) grade III to IV (OR: 2.5 p = 0.048). Actuarial survival rates at 1, 5, 10, 15 and 20 years were 95%, 87%, 76%, 61% and 41%, respectively. Risk factors for long-term mortality were diabetes (OR: 3.3 p < 0.01), left ventricular function grades III-IV (OR: 2.6 p < 0.01), New York Heart Association functional class III to PV (OR: 2.1 p < 0.005) and male sex (OR: 1.5 p < 0.032). CONCLUSIONS: Referring health care system and type of surgery do not constitute a risk factor for mitral replacement. Risk factors were: emergency surgery, ventricular function grades III-IV, diabetes, functional capacity class III-IV and male sex. Integration of public and private health care systems in a university hospital setting achieves excellent outcomes for complex pathology.

Case report: Multi-site perfusion strategy for type A acute aortic dissection complicated with cerebral malperfusion.

Acute type A dissection presenting with cerebral malperfusion has high morbidity and mortality. Given the complexity of underlying vascular involvement, it is a challenging clinical scenario. Many of these patients are not deemed surgical candidates. If surgery is considered, it often requires complex aortic arch and neck vessel reconstruction. We present a 48-year-old male with an acute type A aortic dissection that presented with paraplegia and decreased level of consciousness. A Computed Tomography showed occlusion of both common carotid arteries. He was successfully treated with a multi-site perfusion strategy and a Hybrid Frozen Elephant Trunk graft to achieve fast restoration of the cerebral circulation and minimize brain ischemia and permanent neurological damage. From this case, we learn that aggressive arch and neck vessel reconstruction supported by multi-site perfusion could help improve mortality and neurological outcomes in selected patients.

[Aortic valve replacement with bioprosthesis in patients 70 years old or older with aortic stenosis]. / Reemplazo valvular aórtico con prótesis biológica en pacientes mayores de 70 años con estenosis aórtica.

BACKGROUND: Aortic valve stenosis is the most prevalent valvulopathy in the elderly, but it is frequently undertreated. AIM: To assess early and long term results of valve replacement with bioprostheses in patients 70 years old or older with aortic stenosis. PATIENTS AND METHODS: A review of the database of the Cardiovascular Surgery Service of our hospital, for the period 1990-2007, identified 156 patients with aortic valve stenosis, aged 76.7 ± 4.5 years (67% males), that were subjected to an aortic valve replacement with bioprosthesis. Seventy eight (50%) were in functional class III-IV. Six patients had emergency surgery. In 67 patients (43%) coronary artery bypass graft were performed. Long term mortality was ascertained obtaining death records from Chilean death registry. RESULTS: Operative mortality was 3.2% (5 patients). Four patients (2.6%) required a reoperation due to bleeding. The mean follow up was 66 ± 41 months. The survival rate at 1, 3 and 5 years was 94%, 88% and 80%, respectively. Forty two patients (27%) were 80 years old or older. In this sub-group, 1 patient (2.3%) died during the peri operative period and the estimated survival rate at 1, 3 and 5 years was 97%, 92%, and 80%, respectively. Multivariate risk analysis, for the whole group, identified low ejection fraction and concomitant coronary artery bypass graft surgery as predictors of late mortality. CONCLUSIONS: Aortic valve replacement for aortic stenosis with bioprostheses in patients 70 years old or older had low perioperative mortality and morbidity and a good long term survival.

Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery.

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Improvement of survival in infants with congenital diaphragmatic hernia in recent years: effect of ECMO availability and associated factors.

BACKGROUND/PURPOSE: Survival of patients with congenital diaphragmatic hernia (CDH) depends both on non-modifiable congenital conditions and on modifiable pre and postnatal management. ECMO improves survival up to 80% in neonates with CDH in the best ECMO centers worldwide. The first Neonatal ECMO Program in Chile was started in our University in 2003. Our objective is to determine the impact of a Neonatal ECMO Program in a level III NICU on newborns with CDH. METHODS: Data of all newborns with CDH admitted to our NICU was separated into two groups: pre ECMO (1996-2003) and ECMO (2003-2007). Crude and adjusted odds ratios for 24 months survival were estimated by logistic regression. RESULTS: Data of 46 newborns with CDH was analysed, 20 in the pre ECMO and 26 in the ECMO period. Patient characteristics were similar in both groups; however, 24-month survival increased significantly from 25% (5/20) in the pre ECMO period to 77% (20/26) in the ECMO period (P = 0.001). Adjusted odds ratios for 24-month survival were 26.98 for OI or= 7 and 17.5 for ECMO availability. CONCLUSIONS: The establishment of an ECMO program was associated with a significant increase in long-term survival for infants with CDH.

Epithelioid pituicytoma: An unusual case report.

BACKGROUND: Pituicytomas are considered World Health Organization Grade I malignancies. Until September 2017, a total of 81 cases of pituicytomas were diagnosed and described in literature. We present such a case in which histopathology shows an epithelioid pattern, a rare variant of pituicytoma. As far as we know, this is only the second such case described in the literature. CASE DESCRIPTION: A 61-year-old male patient presented with complaints of progressive decrease in visual acuity for about 7 months, worse on the left side. Laboratory and endocrinological investigation returned normal values. Magnetic resonance imaging revealed a mixed solid-cystic lesion, measuring about 3.1 × 2.2 × 2.9 cm. The lesion presented with intermediate signal intensity in T1 and T2 sequences and showed avid postcontrast enhancement. The patient underwent resection through a left pterional approach. Pathology revealed a glial neoplasm with an epithelioid pattern and moderate cellularity with rounded-elongated cell nuclei and with a broad eosinophilic cytoplasm. Absence of cellular pleomorphism, any mitotic figures, or areas of necrosis was noted. CONCLUSION: The epithelioid variant of pituicytomas differs from the commonly encountered forms of this tumor which typically present in a fascicular pattern. Microsurgical resection is the treatment of choice. However, in many cases, subtotal resection was performed because of a considerable risk for neurovascular injuries.

Nefrectomía radical con trombectomía de vena cava: 20 años de cirugías por tumor renal / Vena cava thrombectomy in kidney cancer. Report of 32 nephrectomies

BACKGROUND: Vena cava (VC) involvement in kidney tumors occurs in 4 to 10% of cases, and is associated with a higher mortality. Nephrectomy with thrombectomy of the VC, performed by a multidisciplinary team, improves survival. Aim: To report a series of consecutive nephrectomies with caval thrombectomy performed in an academic center. PATIENTS AND METHODS: We report 32 patients with cT3b and 3c renal tumors, who underwent radical nephrectomy with VC thrombectomy between 2001 and 2021. A descriptive analysis of clinical, surgical and pathological variables was performed. Overall survival (OS) and cancer-specific survival (CSS) was calculated using Kaplan-Meier curves. Results: The mean tumor size was 9.7 cm. According to Mayo classification 3/32 (9%) patients had a type I thrombus, 10/32 (31%) had a type II thrombus, 8/32 (25%) had a type III thrombus, and 5/32 (16%) had a type IV thrombus. The mean bleeding was 2000 cc. There was one intraoperative death. Nineteen percent of patients had complications >= 3 according to Clavien-Dindo classification. Reoperations occurred in 9%. Pre and postoperative creatinine levels were 1.17 and 1.91 mg/dl respectively (p < 0.01). Pre and postoperative Hematocrit levels were 47.9 and 31% respectively (p = 0.02). Sixty six percent of tumors were clear cell renal cancer, 9% were papillary and 3% were chromophobic. Mean OS was 10 months. Two-year SCE was 40%. CONCLUSIONS: Our results are similar to those reported elsewhere. Despite being an unusual pathology, the surgical technique has been improving, thanks to the multidisciplinary work of urologists and surgeons.

[Surgical site infections in children undergoing cardiac surgery with delayed sternal closure: Case-control study]. / Infección del sitio quirúrgico en niños sometidos a cirugía cardíaca con cierre esternal diferido: Estudio de casos y controles.

INTRODUCTION: Surgical site infections (SSI) are an important cause of morbidity in pediatric cardiac surgery. Risk factors in patients requiring delayed sternal closure (DSC) are unknown. AIM: To report the rate of SSI in children undergoing cardiac surgery with DSC and determine the risk factors. METHODOLOGY: A retrospective case-control study, in patients younger than 15 years old undergoing cardiac surgery with DSC in our center between 2009 and 2010. SSI was diagnosed according to the criteria of the nosocomial infections committee of our institution, based on international recommendations. Univariate and multivariate analysis of variables was performed. A p < 0.05 was considered significant. RESULTS: 58 patients were included; the average age was 9.5 days. The most frequent diagnosis were transposition of the great arteries (36%) and hypoplastic left heart syndrome (27%). 13 patients had SSI (22%); 11 incisional and 2 mediastinitis. It was independently associated to SSI by-pass (BP) time longer than 200 min (OR adjusted = 9,53; IC 95% 1,37-66,35) and mechanical ventilation (MV) more than 5 days (OR adjusted = 8,98; IC 95% 1,16-69,40). CONCLUSION: The duration of BP and MV are risk factors of SSI in children undergoing cardiac surgery with DSC.

Reemplazo valvular tricuspídeo: prótesis mecánica versus prótesis biológica: trabajo observacional-descriptivo / Tricuspide valve replacement: comparison of biological versus mechanical valve: a descriptive observational study

ANTECEDENTES: El reemplazo protésico de la válvula tricúspide es un procedimiento infrecuente, con elevada mortalidad y morbilidad operatoria, independientemente de la etiología de la insuficiencia tricuspídea. Persiste aún una discusión respecto al tipo de prótesis a utilizar, mecánica o biológica. OBJETIVO: Analizar nuestros resultados perioperatorios y alejados en el reemplazo valvular tricuspídeo, comparando ambos tipos de prótesis. MÉTODO: Revisión de la Base de Datos de nuestro Servicio de Cirugía Cardiovascular para el periodo enero 1991 - diciembre 2017. Identificados los pacientes con reemplazo valvular tricuspídeo (RVT); se revisaron los protocolos operatorios y los ecocardiogramas. La supervivencia se certificó a través del Registro Civil e Identificación de Chile. RESULTADOS: Se identificaron 83 pacientes con RVT (76% mujeres), los que representaron el 0,7% del total de las cirugías con circulación extracorpórea y el 2,1% de las cirugías valvulares para el periodo en estudio. La edad promedio fue 49±16,5 años. Cuarenta y nueve casos (59%) correspondieron a reoperaciones y otros 49 tuvieron un procedimiento asociado. En 40 pacientes (48%) se utilizó una prótesis mecánica y en 43 (52%) una biológica. La mortalidad operatoria global fue 9,6% (8 pacientes, 4 con una prótesis mecánica y 4 con una biológica). El seguimiento se completó en el 100%, con un promedio de 7,1 años. Veintiocho pacientes fallecieron durante el seguimiento; la principal causa fue insuficiencia cardiaca. Así, la supervivencia a 5 años fue 70,3 ± 5,3% y a 10 años 58 ± 6,3%, sin diferencia significativa entre ambos tipos de prótesis. Siete pacientes se reoperaron durante el seguimiento (5 casos con prótesis biológica y 2 mecánica). CONCLUSIÓN: El RVT continúa siendo un procedimiento infrecuente, con mayor incidencia en mujeres, en la quinta década de la vida. La mayoría de los pacientes presentaba comorbilidad y había tenido cirugía cardiovascular previa. La mitad de estos recibió una prótesis mecánica y la otra, biológica. No hubo diferencias significativas entre ambos tipos de prótesis en cuanto a mortalidad operatoria, supervivencia alejada o reoperación.

BACKGROUND: Tricuspid valve replacement (TVR) is an uncommon surgical procedure, associated with high mortality and morbidity. The use of biological or mechanical prostheses in TVR has advantages and disadvantages and, therefore, there persists a debate regarding the choice of one or other type of prostheses. AIM: To analyze our operative and long-term surgical results, comparing both types of prosthetic valves. METHODS: The Data Base of the Cardiovascular Surgery Service was reviewed for the period between January 1991 and December 2017. 83 patients with TVR were identified, the operative notes and echocardiogram reports were analyzed. Survival was obtained from the Chilean Civil Identification Service. RESULTS: 83 patients (76% women) had TVR. They represented 0.7% of the total cases operated on with extracorporeal circulation and 2.1% of all valve disease cases, for the study period. Mean age was 49±16.5 years. 49 cases (59%) were reoperations and another 49 had an associated procedure. In 40 patients (48%) a mechanical prosthesis was used and in 43 (52%) a biological one was implanted. Operative mortality rate was 9.6% (8 patients, had a mechanical valve and the other 8, a biological one). Follow-up was 100% completed, with an average of 7.1 years. 28 patients died during follow-up; the main cause of death was heart failure. Five-year survival rate was 70.3 ± 5.3% and at 10 years it was 58 ± 6.3%, without significant difference the type of prostheses. Seven patients were re-operated during follow-up (5 cases corresponded to a biological prostheses and 2 to a mechanical one). CONCLUSION: TVR is still an infrequent surgical procedure, more commonly performed in women, on the fifth decade of life. Most patients presented comorbidities and had a previous cardiovascular surgical operation. Half of them received a mechanical prosthesis and half a biological one. There was no significant difference between both types of prostheses related to surgical mortality, long-term survival or reoperation.

[New surgical approach to device closure of multiple apical ventricular septal defects]. / Cierre perventricular de la comunicación interventricular múltiple con dispositivo Amplatzer.

We present an alternative technique for closing multiple ventricular septal defects difficult to access during surgery. A guidewire is advanced through the right ventricular free wall and through the main apical defect to the left ventricle, and this approach is used to place an Amplatzer device to occlude the ventricular septal defects. The procedure is performed in the beating heart, under intraoperative transesophageal echocardiographic guidance, and without extracorporeal circulation. It appears to be a simple and reproducible procedure with excellent short-term results.

[Persistence of oxidative stress after heart transplantation: a comparative study of patients with heart transplant versus chronic stable heart failure]. / Persistencia del estrés oxidativo postrasplante cardíaco: estudio comparativo entre pacientes con trasplante cardíaco y con insuficiencia cardíaca crónica estable.

INTRODUCTION AND OBJECTIVE: Chronic heart failure (CHF) is associated with oxidative stress. Heart transplantation, an important therapeutic alternative in these patients, could reduce oxidative stress by improving cardiac function. Our aim was to evaluate post-heart transplantation oxidative stress. PATIENTS AND METHOD: We studied three experimental groups: a) heart transplant recipients without evidence of rejection (n = 11); b) NYHA class III CHF patients (n = 19), and c) healthy control subjects (n = 14). Oxidative stress was assessed by measuring plasma malondialdehyde levels (MDA), and determining the enzymatic activities of glutathione peroxidase (GSH-Px), catalase (CAT), and superoxide dismutase (SOD). RESULTS: The demographic characteristics of the three groups were similar. Mean time from transplantation was 20.0 4.8 months. Mean MDA plasma levels in heart transplantation and CHF patients were significantly higher than in normal subjects (3.35 0.8; 3.27 1.7 y 0.9 0.3 microM, respectively). GSH-Px activity increased after transplantation compared to control subjects (0.40 0.06 and 0.33 0.05 U/g Hb, respectively), but not the CHF group. A significant decrease in SOD activity was found in the heart transplant vs. CHF group (0.44 0.1 vs. 0.87 0.6 U/mg Hb). There were no differences in CAT values between heart transplant and CHF patients. CONCLUSION: These findings demonstrated the presence of permanent oxidative stress in patients who have undergone heart transplantation, characterized by an increase in MDA and a decrease in SOD activity, despite an increase in GSH-Px activity.

[Coronary artery surgery in the first 24 hours after myocardial infarction]. / Cirugía coronaria en el infarto de miocardio de menos de 24 horas de evolución.

BACKGROUND: Thrombolysis and angioplasty in the first hours after myocardial infarction minimize necrosis, leading to better early and late survival, but these therapies have limited effect in patients with three-vessel disease and cardiogenic shock. Emergency coronary surgery is an alternative treatment in some cases. AIM: To assess perioperative complications, mortality and long-term survival in patients undergoing coronary surgery within 24 h of myocardial infarction. PATIENTS AND METHODS: We retrospectively studied 57 patients undergoing surgery within 24 h of the onset of symptoms of myocardial infarction between 1982 and 1998. Multiple vessel disease was present in 31 patients (54%), shock or cardiac arrest in 19 (33%) and coronary angiography complications in 7 (12%). The mean time between onset of symptoms and surgery was 6.32 h. At the beginning of surgery 32 patients (56%) were hemodynamically stable, 15 (26%) were in shock and 10 (17%) were in cardiac arrest. RESULTS: The operative mortality was 0% for those who were hemodynamically stable at the start of surgery and 44% (11 of 25 patients) for those in shock or cardiac arrest. Shock or prior cardiac arrest were associated with higher rates of sternal infection and heart failure and longer hospital stays.Follow-up (mean 67 months) was possible for all remaining patients. The 5- and 10-year survival rates were 89 and 82%, respectively, for patients who were hemodynamically stable at the time of surgery. Five-year survival was 55%, however, for those who underwent surgery in shock or cardiac arrest. The overall rate of freedom from myocardial infarction, angioplasty or reoperation was over 95% at 5 years and over 85% at 10 years of follow-up. Age and shock or cardiac arrest were risk factors for a poor long-term outcome. CONCLUSION: The early and long-term outcome of coronary surgery within 24 h of myocardial infarction is good for patients who are hemodynamically stable when surgery begins. Shock and cardiac arrest are important risk factors for complication and death. Coronary artery bypass grafting is a good treatment option in the first hours after myocardial infarction.

Resultados de un programa nacional de trasplante cardiaco pediátrico: fortalezas y debilidades / Results of a national program of pediatric heart transplantation: strengths and weakness

El trasplante cardiaco pediátrico es una terapia efectiva para tratar la insuficiencia cardiaca avanzada. Objetivos: Analizar los resultados inmediatos y a mediano plazo de niños enlistados para trasplante cardiaco. Pacientes y Método: Se analizó el registro de pacientes enlistados para trasplante, entre octubre de 2001 y julio de 2016, analizando datos demográficos, diagnósticos, status de enlistamiento, tiempo de espera, datos de donantes, uso de asistencia ventricular, complicaciones y mortalidad. Resultados: La serie abarca 30 pacientes con edad promedio de 9,4 años (1 mes a 15 años). El diagnóstico principal fue miocardiopatía dilatada en 24 pacientes (80%). El status de ingreso fue I (urgencia) en 19 casos y II (no urgencia) en 11. Fallecieron 10 en la lista de espera (33,3%) en un promedio de 52 días (13 a 139 días). Catorce pacientes fueron trasplantados (46.7%), con un tiempo de espera de 199,6 días (4 a 586 días). Requirieron asistencia ventricular 9 pacientes (30%). Todos recibieron inmunosupresión tri asociada. Un paciente falleció a los 16 días por falla primaria del injerto (7,1%). El seguimiento promedio fue de 43 meses (0,5 a 159 meses). Dos pacientes fallecieron alejadamente (55 y 82 meses) por rechazo secundario al abandono de tratamiento inmunosupresor. La supervivencia a 1 y 5 años fue 93% y 74%, respectivamente. Conclusiones: Nuestro programa ha trasplantado al 50% de los pacientes enlistados con buena supervivencia a mediano plazo. Una proporción significativa de pacientes se enlistó con carácter de urgencia y un 34.5% de los pacientes fallecieron en la lista de espera.

Pediatric heart transplantation is an effective therapy to treat advanced heart failure in children. Objectives: To analyze the immediate and mid-term results of pediatric patients listed for heart transplantation. Patients and Methods: Registration of patients admitted to our transplant protocol between October 2001 and July 2016 were reviewed, analyzing demographic data, diagnosis, status at the time of listing, waiting time until transplantation, donor data, use of ventricular assist device, hemodynamic data, complications and global mortality. Results: Thirthy patients where included with a mean age of 9.4 years (1 month to 15 years). The most frequent diagnosis was dilated cardiomyopathy in 24 patients (80%). The status was I (urgency) in 19 cases and II in 11 cases. Ten patients died on the waiting list (33.3%) at an average of 52 days (13-139 days). Fourteen were transplanted (46.7%), with a waiting time of 199.6 days (4-586 days). Nine patients required mechanical support (30%). All patients received triple association of immunosuppression. One patient died 16 days post transplant due to primary graft failure (7.1%). The average follow-up was 43 months (0.5-159 months). Two patients died later on (82 and 55 months), both due to secondary rejection because of voluntary cessation of immunosuppressive therapy. Survival at 1 and 5 years was 93% and 74%, respectively. Conclusions: Our program has successfully transplanted 50% of patients enrolled, with good medium-term survival. A significant proportion of patients were listed as a medical emergency and 34.5% died on the waiting list.

Infección del sitio quirúrgico en niños sometidos a cirugía cardíaca con cierre esternal diferido: estudio de casos y controles / Surgical site infections in children undergoing cardiac surgery with delayed sternal closure: case-control study

Introduction: Surgical site infections (SSI) are an important cause of morbidity in pediatric cardiac surgery. Risk factors in patients requiring delayed sternal closure (DSC) are unknown. Aim: To report the rate of SSI in children undergoing cardiac surgery with DSC and determine the risk factors. Methodology: A retrospective case-control study, in patients younger than 15 years old undergoing cardiac surgery with DSC in our center between 2009 and 2010. SSI was diagnosed according to the criteria of the nosocomial infections committee of our institution, based on international recommendations. Univariate and multivariate analysis of variables was performed. A p < 0.05 was considered significant. Results: 58 patients were included; the average age was 9.5 days. The most frequent diagnosis were transposition of the great arteries (36%) and hypoplastic left heart syndrome (27%). 13 patients had SSI (22%); 11 incisional and 2 mediastinitis. It was independently associated to SSI by-pass (BP) time longer than 200 min (OR adjusted = 9,53; IC 95% 1,37-66,35) and mechanical ventilation (MV) more than 5 days (OR adjusted = 8,98; IC 95% 1,16-69,40). Conclusion: The duration of BP and MV are risk factors of SSI in children undergoing cardiac surgery with DSC.

Introducción: Las infecciones del sitio quirúrgico (ISQ) son importante causa de morbilidad en cirugía cardíaca pediátrica. Los factores de riesgo en pacientes que requieren cierre esternal diferido (CED) se desconocen. Objetivos: Reportar la tasa de ISQ en niños sometidos a cirugía cardíaca con CED y determinar factores de riesgo de ISQ. Metodología: Estudio retrospectivo de casos y controles en pacientes bajo 15 años de edad, sometidos a cirugía cardíaca con CED, en los años 2009 y 2010. Se consideró casos aquellos con ISQ diagnosticada según criterios del comité de IAAS local. Se realizó análisis uni y multivariado de las variables. Se consideró significativo un p < 0,05. Resultados: Se incluyeron 58 pacientes; la mediana de edad fue 9,5 días. Diagnósticos más frecuentes fueron transposición de grandes arterias (36%) e hipoplasia de ventrículo izquierdo (27%). Trece pacientes presentaron ISQ (22%); 11 incisionales y 2 me-diastinitis. Se asociaron de manera independiente a ISQ: circulación extracorpórea (CEC) mayor a 200 min (OR ajustado = 9,53; IC 95% 1,37-66,35) y ventilación mecánica invasora (VMI) más de 5 días (OR ajustado = 8,98; IC 95% 1,16-69,40). Conclusión: La duración de CEC y VMI son factores de riesgo de ISQ en niños sometidos a cirugía cardíaca con CED.

Metástase hipofisária de adenocarcinoma mamário: relato de caso / Pituitary Metastasis of Mammary Adenocarcinoma: A Case Report

Somente 1% de todas as cirurgias hipofisárias são realizadas para tratar tumores metastáticos desta região. Os focos primários mais comuns são respectivamente mama e pulmão. Neste artigo, descrevemos uma paciente com antecedente de adenocarcinoma mamário, que se apresenta com paralisia oculomotora súbita à direita. O objetivo do trabalho é descrever um caso de metástase mamária para a região selar, evidenciando dados clínicos e radiológicos que tornam tal diagnóstico plausível.

Only 1% of all pituitary surgeries are performed to treat metastatic tumors in this region. The most common primary sites are breast and lung respectively. In this article we describe a patient with previous breast adenocarcinoma presenting with oculomotor palsy sudden right. The objective is to describe a case of breast metastasis to the sellar region, showing clinical and radiological findings that make this plausible diagnosis.