Extracorporeal Mechanical Circulatory Support after Pulmonary Thromboendarterectomy: Experience of One Center.

PURPOSE: Pulmonary thromboendarterectomy (PTE) is the treatment for patients with chronic thromboembolic disease. In the immediate postoperative period, some patients may still experience life-threatening complications such as reperfusion lung injury, airway bleeding, and persistent pulmonary hypertension with consequent right ventricular dysfunction. These issues may require support with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or lung transplantation. This study aims to analyze our series of PTEs that require ECMO. METHODS: A descriptive and retrospective analysis of all PTE performed at the Favaloro Foundation University Hospital was conducted between March 2013 and December 2023. RESULTS: A total of 42 patients underwent PTE with a median age of 47 years (interquartile range: 26-76). The incidence of patients with ECMO was 26.6%, of which 53.6% were veno-venous (VV) ECMO. Preoperatively, a low cardiac index (CI), high right and left filling pressures, and high total pulmonary vascular resistances (PVRs) were associated with ECMO with a statistically significant relationship. The hospital mortality was 11.9%, and the mortality in the ECMO group was 45.5%, with a statistically significant relationship. Veno-arterial ECMO has a worse prognosis than VV ECMO. CONCLUSIONS: Preoperatively, a low CI, high right and left filling pressures, and high total PVRs were associated with ECMO after PTE.

Tromboendarterectomía pulmonar en hipertensión pulmonar tromboembólica crónica. Experiencia binacional Uruguay-Argentina / Pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension. Binational experience Uruguay-Argentina / Tromboendarterectomia pulmonar na hipertensão pulmonar tromboembólica crônica. Experiência binacional Uruguai-Argentina

Introducción: La tromboendarterectomía pulmonar (TEA) es la principal herramienta terapéutica en hipertensión pulmonar tromboembólica crónica (HPTEC), potencialmente curativa. Se analiza la experiencia de 13 años de TEAs de pacientes uruguayos en el marco del convenio con el Hospital Universitario Fundación Favaloro (HUFF-Argentina). Metodología: Estudio analítico, observacional y retrospectivo de todas las TEAs realizadas entre 2011 y 2023. Resultados: Se realizaron 15 TEAs. 46 ± 17 años, 67% hombres. Diez pacientes tenían antecedentes de enfermedad tromboembólica previa y 8 hipercoagulabilidad. El tiempo desde el inicio de los síntomas al diagnóstico fue de 36 (22-78) meses. Ochenta por ciento se encontraba en CF III, con una distancia total recorrida en la prueba de la marcha de 6 minutos de 375 (272-458) metros, severidad ecocardiográfica (TAPSE/PAPs 0,22 ± 0,08 mm/mmHg) y hemodinámica (RVP 11 ± 5 UW) que mejoraron significativamente en el posoperatorio temprano. La mortalidad intrahospitalaria fue del 20% que se mantuvo en el seguimiento de 34 (7-97) meses excepto un paciente que murió por una nueva embolia de pulmón a los 3 años. Todos los fallecidos tenían una hemodinamia preoperatoria significativamente más grave (RVP 19 ± 6 UW, índice cardíaco 1,5 ± 0,4 L/min/m2). Seis sobrevivientes (50%) presentaron HP residual asociada a una mayor PAPm y RVP preoperatorias y menor recuperación funcional y ecocardiográfica a corto plazo (P <0,05), dos de los cuales recibieron terapia específica posterior al procedimiento. Conclusiones: La TEA determinó mejoría clínica, ecocardiográfica y hemodinámica. Seis supervivientes (50%) normalizaron la hemodinamia de reposo. La severidad hemodinámica preoperatoria dado por las lesiones obstructivas y microangiopatía distales se asoció con una alta tasa de complicaciones y mortalidad perioperatorias. La reducción del retardo en el diagnóstico y tratamiento junto con una mayor tasa de TEAs/año podrían reducir las complicaciones y mejorar el pronóstico.

Summary Introduction: Pulmonary thromboendarterectomy (PTE) is the main therapeutic tool for chronic thromboembolic pulmonary hypertension (CTEPH), and is potentially curative. The experience of 13 years of PTEs on Uruguayan patients under the agreement with the University Hospital Fundación Favaloro (HUFF-Argentina) is analyzed. Methodology: Analytical, observational, and retrospective study of all PTEs performed between 2011 and 2023. Results: Fifteen PTEs were performed. Age was 46 ± 17 years, 67% male. Ten patients had a history of prior thromboembolic disease, and 8 had hypercoagulability. The time from symptom onset to diagnosis was 36 (22-78) months. Eighty percent were in NYHA Functional Class III, with a total distance walked in the 6-minute walk test of 375 (272-458) meters, echocardiographic severity (TAPSE/sPAP 0,22 ± 0,08 mm/mmHg), and hemodynamic severity (PVR 11 ± 5 WU) which significantly improved in the early postoperative period. In-hospital mortality was 20% and remained at a follow-up of 34 (7-97) months, except for one patient who died from a new pulmonary embolism at 3 years. All deceased patients had significantly more severe preoperative hemodynamics (PVR 19 ± 6 WU, cardiac index 1,5 ± 0,4 L/min/m²). Six survivors (50%) presented with residual PH associated with higher preoperative mPAP and PVR and lower short-term functional and echocardiographic recovery (P <0,05), two of whom received specific therapy post-procedure. Conclusions: PTE resulted in clinical, echocardiographic, and hemodynamic improvement. Six survivors (50%) normalized resting hemodynamics. Preoperative hemodynamic severity due to distal obstructive lesions and microangiopathy was associated with a high rate of perioperative complications and mortality. Reducing the delay in diagnosis and treatment and a higher rate of PTEs/year could reduce complications and improve prognosis.

Introdução: A tromboendarterectomia pulmonar (TEP) é a principal ferramenta terapêutica na hipertensão pulmonar tromboembólica crônica (HPTEC), potencialmente curativa. Analisa-se a experiência de 13 anos de TEPs em pacientes uruguaios no âmbito do convênio com o Hospital Universitário Fundação Favaloro (HUFF-Argentina). Metodologia: Estudo analítico, observacional e retrospectivo de todas as TEPs realizadas entre 2011 e 2023. Resultados: Foram realizadas 15 TEPs. Idade de 46 ± 17 anos, 67% homens. Dez pacientes tinham antecedentes de doença tromboembólica prévia e 8 hipercoagulabilidade. O tempo desde o início dos sintomas até o diagnóstico foi de 36 (22-78) meses. Oitenta por cento encontravam-se em Classe Funcional III, com uma distância total percorrida no teste de caminhada de 6 minutos de 375 (272-458) metros, gravidade ecocardiográfica (TAPSE/sPAP 0,22 ± 0,08 mm/mmHg) e hemodinâmica (RVP 11 ± 5 UW) que melhoraram significativamente no pós-operatório precoce. A mortalidade intra-hospitalar foi de 20% e manteve-se no seguimento de 34 (7-97) meses, exceto um paciente que faleceu por uma nova embolia pulmonar aos 3 anos. Todos os falecidos apresentavam hemodinâmica pré-operatória significativamente mais grave (RVP 19 ± 6 UW, índice cardíaco 1,5 ± 0,4 L/min/m²). Seis sobreviventes (50%) apresentaram HP residual associada a maior PAPm e RVP pré-operatórias e menor recuperação funcional e ecocardiográfica a curto prazo (P <0,05), dois dos quais receberam terapia específica pós-procedimento. Conclusões: A TEP resultou em melhora clínica, ecocardiográfica e hemodinâmica. Seis sobreviventes (50%) normalizaram a hemodinâmica de repouso. A gravidade hemodinâmica pré-operatória devido a lesões obstrutivas e microangiopatia distal foi associada a uma alta taxa de complicações e mortalidade perioperatória. A redução do atraso no diagnóstico e tratamento juntamente com uma maior taxa de TEPs/ano poderia reduzir as complicações e melhorar o prognóstico.

Prevalencia de infecciones asociadas al donante en receptores de trasplante pulmonar

Resumen La complicación infecciosa es la más frecuente posterior a un trasplante. Existe una limitada descripción respecto a la prevalencia de infecciones asociadas al donante (IAD) en receptores de trasplante de pulmón (TxP). Hay reportes de dicha situación de un 7,6%, con documentación de fracaso profiláctico de 5,6%. Objetivo: estimar la frecuencia de infecciones asociadas al donante tras el TxP y su desenlace en términos de supervivencia global (SG). Materiales y métodos: estudio observacional, descriptivo, llevado a cabo en un centro trasplante de Argentina entre los meses de enero 2018 a junio 2020. Se incluyó a todos los pacientes trasplantados en dicho intervalo, y se contabilizaron a todos aquellos con IAD definida/probada. Resultados: en el periodo antedicho se realizaron 65 TxP en 64 individuos (un caso se realizó trasplante y posterior retrasplante en el mismo periodo de estudio). La mediana de edad fue de 39 (12 - 72) años. La fibrosis quística constituyó el principal motivo de TxP (26,2%). En 61/65 (94%) se aislaron gérmenes de muestras biológicas procedentes del donante: en el líquido de conservación 78,6%, secreciones del donante 73,7%, muestras quirúrgicas 21,3% y en hemocultivos 4,9%. Se identificaron IAD en 2/61 casos (prevalencia de 3,1%; IC 95% 0,4-10,7%), con una mediana de SG postrasplante de 12 meses, y una SG del 98,4% (IC 95% 91,7 - 99,9%). Conclusión: la prevalencia de IAD en receptores de TxP en la presente serie fue del 3,1%, superior a lo documentado en trasplantes de órganos sólidos en general (< 1%), aunque menor a la encontrada en los pocos reportes publicados (7,6%).

Prevalence of Donor-Associated Infections in Lung Transplant Recipients

Abstract The infectious complication is the most common condition after a transplantation. There is a limited description regarding the preva lence of donor-associated infections (DAIs) in lung transplant (LTx) recipients. There are reports of DAIs in LTx recipients of 7.6%, with documented prophylactic failure of 5.6%. Objective: to estimate the frequency of donor-associated infections after lung transplantation and their outcome in terms of overall survival (OS). Methodology: an observational, descriptive study, carried out in a transplant center in Argentina between January 2018 and June 2020. The study included all the patients who underwent a transplantation within such period and those with defined/proven DAIs. Results: during the aforementioned period, 65 LTx were performed in 64 individuals (one patient underwent transplantation and subsequent retransplantation in the same study period). The median age was 39 (12-72) years. Cystic fibrosis was the main reason for transplantation (26.2%) In 61/65 cases (94%), germs were isolated from biological samples collected from the donor: 78.6% in the preservation liquid, 73.7% in donor secretions, 21.3% surgical samples, and 4.9% blood cultures. Donor-associated infections were identified in 2/61 cases (prevalence of 3.1%; 95% CI: 0.4-10.7%), with a median posttransplant OS of 12 months, and an OS of 98.4% (95% CI: 91.7-99.9%). Conclusion: the prevalence of DAIs in LTx recipients in the present series was 3.1%: higher than the figures documented for solid organ transplants in general (< 1%), but lower than the numbers found in the few published reports (7.6%).

Terapia de resincronización cardíaca. Incidencia y mecanismos involucrados en la reducción de la insuficiencia mitral funcional / Cardiac Resynchronization Therapy. Incidence and Mechanisms Involved in the Reduction of Functional Mitral Regurgitation

RESUMEN Introducción: La insuficiencia mitral funcional (IMF) es común en pacientes con insuficiencia cardíaca (IC). La IMF moderada/ grave (M/G) se asocia a peor pronóstico. Objetivo: Describir la prevalencia de IMF y los mecanismos involucrados en su reducción en respondedores a la terapia de resincronización cardíaca (TRC) a los 6 meses comparados con 12 y 24 meses. Métodos: Entre 2009 y 2018 fueron tratados 338 pts. Respondedores: reducción de CF NYHA ≥1 grado o aumento de la fracción de eyección ventricular izquierda (FEVI) ≥5% (absoluto). La IMF se graduó en 4 puntos: No-IMF, leve, M y G, y se la relacionó con las mediciones ecocardiográficas. Características Basales: edad 64 ±10 años, hombres 71%, CF-NYHA IIIII 92%, bloqueo de rama izquierda (BRI) 67%, QRS ≥150 ms 75%, diámetro diastólico del VI (DDVI) 68 ± 9 mm, diámetro sistólico del VI (DSVI) 52 ± 12 mm, FEVI 24 ± 7%. Resultados: La prevalencia de IMF fue del 92,6%. A los 6 meses, 86% fueron respondedores y 23% de ellos mejoraron de IMF-M/G a IMF-Leve/No-IMF. Hubo un fuerte remodelado inverso: DDVI 68 ± 10 vs 63 ± 11 mm, (p = 0,0001), DSVI 55 ± 12 vs 50 ± 13 mm, (p = 0,0006) y FEVI 25 ± 11 vs 33 ± 10%, (p = 0,00001). Comparando 6 con 12 meses 89,4% fueron respondedores, 8% mejoraron de IMF-M/G a IMF-Leve/No-IMF. Comparando 6 con 24 meses 88% fueron respondedores, 14,6% mejoraron de IMF-M/G a IMF-Leve/No-IMF. Entre 6 y 12 y 6 y 24 meses no hubo remodelado inverso significativo. Conclusiones: La prevalencia de IMF fue elevada. El mayor remodelado inverso y reducción de la IMF se observaron a los 6 meses, siendo el primero el principal mecanismo en la reducción de la IMF. Esta mejoría se sostuvo a los 12 y 24 meses.

ABSTRACT Background: Functional mitral regurgitation (FMR) is common in heart failure, and moderate/severe (M/S) FMR is associated with worse prognosis. Objective: The aim of this study was to describe the prevalence of FMR and the mechanisms involved in its reduction in responders to cardiac resynchronization therapy (CRT) at 6 months compared with 12 and 24 months. Methods: Between 2009 and 2018, 338 patients received CRT. Patients showing NYHA functional class (FC) reduction ≥1 or left ventricular ejection fraction (LVEF) absolute increase ≥5% were considered responders. Functional mitral regurgitation was graded using a 4-point scale into none-, mild-, M- and S-FMR, and was related to echocardiographic measurements. Baseline patient characteristics were: age 64±10 years, men 71%, NYHA FC II-III 92%, left bundle branch block (LBBB) 67%, QRS ≥150 ms 75%, LV diastolic diameter (LVDD) 68±9 mm, LV systolic diameter (LVSD) 52±12 mm, and LVEF 24±7%. Results: The prevalence of FMR was 92.6%. At 6 months, 86% were responders, 23% improved from M/S-FMR to mild/none-FMR and there was strong reverse remodeling: LVDD 68±10 vs. 63±11 mm, (p=0.0001), LVSD 55±12 vs. 50±13 mm, (p=0.0006) and LVEF 25±11 vs. 33±10%, (p=0.00001). Comparing 6 with 12 months, 89.4% were responders and 8% improved M/S-FMR to mild/none-FMR. Comparing 6 with 24 months, 88% were responders and 14.6% improved M/S-FMR to mild/none-FMR. Between 6 and 12 and 6 and 24 months, there was no significant reverse remodeling. Conclusions: The prevalence of FMR was high. The highest reverse remodeling and FMR reduction was observed at 6 months, the former being the main mechanism of FMR reduction. This improvement persisted at 12 and 24 months.

Trasplante cardíaco en miocardiopatía chagásica: 23 años de experiencia en un centro de referencia / Heart Transplantation in Chagas Cardiomyopathy: 23-Year Follow-Up in a Referral Center

RESUMEN Introducción: La enfermedad de Chagas afecta aproximadamente a 6 millones de personas en América Latina. El 25 a 35% evoluciona hacia la Miocardiopatía Chagásica (MCh). Una opción terapéutica en sus estadios avanzados es el trasplante cardíaco (TxC). Objetivos: Comparar la supervivencia de pacientes con TxC por MCh frente a otras etiologías. Analizar la incidencia de la reactivación (Ra) de enfermedad de Chagas y su impacto en la supervivencia en este subgrupo de pacientes. Material y métodos: Se evaluaron retrospectivamente pacientes con TxC entre agosto 1998 y marzo 2021. Se analizó la supervivencia mediante curvas de Kaplan-Meier y log rank test. El diagnóstico de Ra se realizó mediante métodos moleculares, prueba de Strout en sangre periférica, tejido miocárdico y/o cutáneo. Resultados: De 606 pacientes con TxC, 39 (6,4%) presentaban MCh. Seguimiento medio 4,4 años (Rango Intercuartilo 1,2-8,6). Edad subgrupo MCh 51 años (RIC 45-60). Hombres 28 (72%). Se documentó Ra en el 38,5% de los pacientes. Supervivencia a 1, 5 y 10 años en TxC por MCh con Ra versus no Ra: 85%, 76% y 61% versus 72%, 55% y 44% (p = 0,3). Supervivencia a 1, 5 y 10 años en TxC por MCh versus TxC por otras causas: 79%, 65% y 50% versus 79%, 62% y 47% (p = 0,5). Conclusión: En nuestra serie no se encontró diferencia estadísticamente significativa en la supervivencia de los pacientes trasplantados cardíacos por MCh en comparación con aquellos trasplantados por otras causas; así como tampoco entre los pacientes que reactivaron la enfermedad de Chagas y los que no lo hicieron.

ABSTRACT Background: Chagas disease affects about 6 million people in Latin America, and 25 to 35% progress to Chagas cardiomyopathy (ChCM). Heart transplantation (HTx) is a therapeutic option in advanced stages. Objectives: The aim of this study is to compare survival of patients with HTx due to ChCM versus those transplanted for other etiologies and to analyze the incidence of Chagas disease reactivation (Ra) and its impact on survival in this group of patients. Methods: Patients undergoing HTx between August 1998 and March 2021 were retrospectively evaluated. Survival was analyzed using Kaplan-Meier curves and the log-rank test. The diagnosis of Ra was performed by molecular methods, Strout's test in peripheral blood, myocardial tissue or skin tissue. Results: Of 606 patients with Htx, 39(6,4%) presented ChCM. Median follow up was 4.4 years (interquartile range 1.2-8.6). Median age of the subgroup with ChCM was 51 years (IQR 45-60) and 28 were men (72%). Reactivation was documented in 38.5% of the patients. Survival at 1, 5 and 10 years in HTx recipients due to ChCM and Ra versus no Ra was 85%, 76% and 61% versus 72%, 55% and 44%, respectively (p = 0.3). Survival at 1, 5 and 10 years in HTx recipients due to ChCM versus HTx for other causes was 79%, 65% and 50% versus 79%, 62% and 47%, respectively (p = 0.5). Conclusion: In our series we did not find statistically significant differences in survival of heart transplant recipients due to ChCM versus those transplanted due to other reasons. Survival in patients with Chagas disease reactivation and those without reactivation was also similar.

Arteritis de takayasu. alternativas terapéuticas y pronóstico a largo plazo / Takayasu arteritis Therapeutic alternatives and long term outcomes

Resumen Se analizaron los resultados del tratamiento quirúrgico y endovascular a 7.5 años, rango intercuartilo (RIC) entre 2.6 y 12.5 años de seguimiento en 34 pacientes con arteritis de Takayasu. Se reali zaron en total 5 cirugías cardíacas centrales y 53 procedimientos vasculares,18 cirugías de bypass (33.9%) y 35 angioplastías (66.1%). Entre los 18 procedimientos quirúrgicos realizados, 6 (33.3%) presentaron eventos, mientras que en los 35 con intervención percutánea hubo 16 eventos (45.7%). La supervivencia actuarial y otras complicaciones vasculares (método de Kaplan y Meier) a 1,3,5 y 10 años fue: 80% (IC 95% entre 74 y 89%), 68% (IC 95% entre 58 y 79%), 65% (IC 95% entre 54 y 76%) y 47% (IC 95% entre 41 y 62%).Tanto la revascularización endovascular como la quirúrgica fueron inicialmente exitosas. En el seguimiento del tratamiento endovascular hubo una alta tasa de eventos con necesidad de revascularización repetida a un mismo vaso en el 41% de los casos. La cirugía tuvo mayor mortalidad en pacientes con valvulopatía aórtica, de aorta ascendente y enfermedad coronaria y carotidea combinada. La arteritis de Takayasu requiere frecuentemente revascularización debido a reestenosis y lesiones de novo. En su evolución alejada, el procedimiento quirúrgico ofreció mejores resultados con menor reestenosis.

Abstract The aim of this study was to describe the long term prognosis of 34 patients with Takayasu arteritis and the results of surgi cal and endovascular treatment. A total of 5 central surgeries and 53 endovascular procedures were performed including 18 bypass surgeries (33.8%) and 35 angioplasties (66.2%). The median follow-up was 7.5 years, in terquartile range [IQR] 2.6-12.5. Among the 18 bypass surgeries 6 (33.3%) had events, while in the 35 patients with endovascular treatment there were 16 events (45.7%). The overall 1-, 3-, 5-, and 10-year death and arterial complication-free survival rates were 80% (95% CI between 74 and 89%), 68% (95% CI between 58 and 79%), 65% (95% CI between 54 and 76%) and 47% (95% CI between 41 and 62%). Both revascularization techniques were initially successful. In long term follow-up there was a high restenosis recurrence rate with endovascular treatment requiring repeated revascularization to the same vessel in 41% of the cases. Surgery had higher mor tality in patients with aortic and ascending aortic valve disease, combined coronary artery disease and carotid disease. In long term follow up Takayasu arteritis frequently requires revascularization and restenosis or new lesions are common. Surgical treatment had better results with less restenosis than angioplasty.

[Takayasu arteritis. Therapeutic alternatives and long term outcomes]. / Arteritis de Takayasu. Alternativas terapéuticas y pronóstico a largo plazo.

The aim of this study was to describe the long term prognosis of 34 patients with Takayasu arteritis and the results of surgical and endovascular treatment. A total of 5 central surgeries and 53 endovascular procedures were performed including 18 bypass surgeries (33.8%) and 35 angioplasties (66.2%). The median follow-up was 7.5 years, interquartile range [IQR] 2.6-12.5. Among the 18 bypass surgeries 6 (33.3%) had events, while in the 35 patients with endovascular treatment there were 16 events (45.7%). The overall 1-, 3-, 5-, and 10-year death and arterial complication-free survival rates were 80% (95% CI between 74 and 89%), 68% (95% CI between 58 and 79%), 65% (95% CI between 54 and 76%) and 47% (95% CI between 41 and 62%). Both revascularization techniques were initially successful. In long term follow-up there was a high restenosis recurrence rate with endovascular treatment requiring repeated revascularization to the same vessel in 41% of the cases. Surgery had higher mortality in patients with aortic and ascending aortic valve disease, combined coronary artery disease and carotid disease. In long term follow up Takayasu arteritis frequently requires revascularization and restenosis or new lesions are common. Surgical treatment had better results with less restenosis than angioplasty.

Se analizaron los resultados del tratamiento quirúrgico y endovascular a 7.5 años, rango intercuartilo (RIC) entre 2.6 y 12.5 años de seguimiento en 34 pacientes con arteritis de Takayasu. Se realizaron en total 5 cirugías cardíacas centrales y 53 procedimientos vasculares,18 cirugías de bypass (33.9%) y 35 angioplastías (66.1%). Entre los 18 procedimientos quirúrgicos realizados, 6 (33.3%) presentaron eventos, mientras que en los 35 con intervención percutánea hubo 16 eventos (45.7%). La supervivencia actuarial y otras complicaciones vasculares (método de Kaplan y Meier) a 1,3,5 y 10 años fue: 80% (IC 95% entre 74 y 89%), 68% (IC 95% entre 58 y 79%), 65% (IC 95% entre 54 y 76%) y 47% (IC 95% entre 41 y 62%).Tanto la revascularización endovascular como la quirúrgica fueron inicialmente exitosas. En el seguimiento del tratamiento endovascular hubo una alta tasa de eventos con necesidad de revascularización repetida a un mismo vaso en el 41% de los casos. La cirugía tuvo mayor mortalidad en pacientes con valvulopatía aórtica, de aorta ascendente y enfermedad coronaria y carotidea combinada. La arteritis de Takayasu requiere frecuentemente revascularización debido a reestenosis y lesiones de novo. En su evolución alejada, el procedimiento quirúrgico ofreció mejores resultados con menor reestenosis.

[Ischemic cardiogenic shock and short-term mechanical circulatory support as bridge to transplantation]. / Shock cardiogénico en infarto agudo de miocardio y soporte circulatorio puente al trasplante.

Cardiogenic shock (CS) has a high mortality rate and often requires advanced therapies such as mechanical circulatory support (MCS) and heart transplantation (HT). Those patients who presented an acute myocardial infarction (AMI) with CS and required support through MCS as bridge to HT were retrospectively analyzed in a single Center. Between January 1997 and June 2020, 524 patients received HT, 203 for ischemic-cardiomyopathy, 103 were in emergency waiting list. Eleven patients met the inclusion criteria (mean age 53 ± 11 years old; men 73%). Five primary angioplasties and 2 emergency myocardial revascularization surgeries were performed. Four patients had coronary anatomy not subject to revascularization. All received inotropic and vasopressor treatment and required intra-aortic balloon pump (IABP). Subsequently, two required support with a left univentricular centrifugal pump (BioMedicus®, Medtronic) and two with peripheral veno-arterial extracorporeal membrane oxygenator (VA-ECMO) (Maquet®, Getinge Group). The median between AMI and HT was 15 days (range 7-21) and the mean age of the donors 28 ± 11 years. All had extensive AMI (necrotic amount 35 ± 5%) with histopathological signs of transmural necrosis and reperfusion injury. The median follow-up was 9 years (range 1-15). None died in hospitalization or during the first year after transplantation. Survival at 5 and 10 years was 73% and 55%. Emergency HT may be the best option for selected patients with acute myocardial infarction and cardiogenic shock refractory to conventional therapy.

El shock cardiogénico (SC) presenta una elevada mortalidad y puede requerir de terapéuticas avanzadas como la asistencia circulatoria mecánica (ACM) y el trasplante cardíaco (TC). Se analizaron en forma retrospectiva, en un único centro, aquellos pacientes que presentaron un infarto agudo de miocardio (IAM), SC y requirieron ACM puente al TC. Entre enero 1997 y junio 2020, 524 pacientes recibieron un TC, 203 por cardiopatía isquémica, 103 en lista de emergencia. Se incluyeron once pacientes con los criterios mencionados (edad media 53 ± 11 años; hombres 73%). Se realizaron 5 angioplastias primarias y 2 cirugías de revascularización miocárdica de urgencia. Cuatro pacientes presentaban anatomía coronaria no pasible de revascularización. Todos recibieron tratamiento inotrópico y vasopresor y requirieron soporte con balón de contrapulsación intra aórtico (BCIA). Dos requirieron el implante de bomba centrífuga univentricular izquierda (BioMedicus®, Medtronic) y 2 de oxigenador de membrana extracorpóreo veno-arterial (ECMO-VA) periférico (Maquet®, Getinge Group). La mediana entre IAM y TC fue 15 días (rango 7-21) y la edad de los donantes 28 ± 11 años. Todos presentaron un IAM extenso (monto necrótico 35 ± 5%) con signos histopatológicos de necrosis transmural e injuria de reperfusión. La mediana de seguimiento fue 9 años (rango 1-15). Ninguno falleció en la internación ni durante el primer año post trasplante. La supervivencia a los 5 y 10 años fue 73% y 55%. El TC en situación de emergencia ha demostrado ser, en nuestro medio, la mejor opción en aquellos pacientes con IAM y SC refractario a la terapia convencional.

Shock cardiogénico en infarto agudo de miocardio y soporte circulatorio puente al trasplante / Ischemic cardiogenic shock and short-term mechanical circulatory support as bridge to Transplantation

Resumen El shock cardiogénico (SC) presenta una elevada mortalidad y puede requerir de terapéuticas avanzadas como la asistencia circulatoria mecánica (ACM) y el trasplante cardíaco (TC). Se analizaron en forma retrospectiva, en un único centro, aquellos pacientes que presentaron un infarto agudo de miocardio (IAM), SC y requirieron ACM puente al TC. Entre enero 1997 y junio 2020, 524 pacientes recibieron un TC, 203 por cardiopatía isquémica, 103 en lista de emergencia. Se incluyeron once pacientes con los criterios mencionados (edad media 53 ± 11 años; hombres 73%). Se realizaron 5 angioplastias primarias y 2 cirugías de revascularización miocárdica de urgencia. Cuatro pacientes presentaban anatomía coronaria no pasible de revascularización. Todos recibieron tratamiento inotrópico y vasopresor y requirieron soporte con balón de contrapulsación intra aórtico (BCIA). Dos requirieron el implante de bomba centrífuga univentricular izquierda (BioMedicus®, Medtronic) y 2 de oxigenador de membrana extracorpóreo veno-arterial (ECMO-VA) periférico (Maquet®, Getinge Group). La mediana entre IAM y TC fue 15 días (rango 7-21) y la edad de los donantes 28 ± 11 años. Todos presentaron un IAM extenso (monto necrótico 35 ± 5%) con signos histopatológicos de necrosis transmural e injuria de reperfusión. La mediana de seguimiento fue 9 años (rango 1-15). Ninguno falleció en la internación ni durante el primer año post trasplante. La supervivencia a los 5 y 10 años fue 73% y 55%. El TC en situación de emergencia ha demostrado ser, en nuestro medio, la mejor opción en aquellos pacientes con IAM y SC refractario a la terapia convencional.

Abstract Cardiogenic shock (CS) has a high mortality rate and often requires advanced therapies such as mechanical circulatory support (MCS) and heart transplantation (HT). Those patients who presented an acute myocardial infarction (AMI) with CS and required support through MCS as bridge to HT were retrospectively analyzed in a single Center. Between January 1997 and June 2020, 524 patients received HT, 203 for ischemic-cardiomyopathy, 103 were in emergency waiting list. Eleven patients met the inclusion criteria (mean age 53 ± 11 years old; men 73%). Five primary angioplasties and 2 emergency myocardial revasculariza tion surgeries were performed. Four patients had coronary anatomy not subject to revascularization. All received inotropic and vasopressor treatment and required intra-aortic balloon pump (IABP). Subsequently, two required support with a left univentricular centrifugal pump (BioMedicus®, Medtronic) and two with peripheral veno-arterial extracorporeal membrane oxygenator (VA-ECMO) (Maquet®, Getinge Group). The median between AMI and HT was 15 days (range 7-21) and the mean age of the donors 28 ± 11 years. All had extensive AMI (necrotic amount 35 ± 5%) with histopathological signs of transmural necrosis and reperfusion injury. The median follow-up was 9 years (range 1-15). None died in hospitalization or during the first year after transplantation. Survival at 5 and 10 years was 73% and 55%. Emergency HT may be the best option for selected patients with acute myocardial infarction and cardiogenic shock refractory to conventional therapy.

Primer implante exitoso de asistencia ventricular izquierda HeartMate 3TM como terapia de destino en Argentina. Revisión de la literatura / First successful Heartmate 3TM left ventricular assist device implantation as destination therapy in Argentina

RESUMEN Se presenta el primer implante exitoso de asistencia ventricular izquierda como terapia de destino mediante el dispositivo de flujo continuo centrífugo con levitación magnética intracorpóreo HeartMate 3TM (Abbott) en la Argentina. El dispositivo se implantó en una paciente de 52 años portadora de miocardio no compacto con disfunción ventricular izquierda grave, hipertensión pulmonar, insuficiencia cardíaca avanzada en estadio INTERMACS 3 y contraindicación para trasplante cardíaco debido a títulos elevados de anticuerpos preformados contra el sistema HLA en crossmatch contra panel.

ABSTRACT First case of successful implantation of intracorporeal full magnetically levitated continuous centrifugal flow left ventricular assist device HeartMate 3 Abbott® as destination therapy in Argentina in a female patient, 52-years-old with non compaction cardiomyopathy, severe left ventricular dysfunction, pulmonary hypertension, end-stage heart failure INTERMACS 3 and contraindication for heart transplantation due to high titers of preformed antibodies against the HLA system in panel reactive antibody assay.

HIF-1α and CD73 expression in cardiac leukocytes correlates with the severity of myocarditis in end-stage Chagas disease patients.

Chronic Chagas cardiomyopathy is the main infectious myocarditis worldwide. Almost 30% of Trypanosoma cruzi infected individuals develop slow and progressive myocarditis that leads to ventricular dilation and heart failure. Heart transplantation is an established, valuable therapeutic option for end-stage Chagas disease patients. Although the pathophysiology of Chagas disease has been addressed for decades by numerous groups, the cardiac immunologic mechanisms involved in the progression of clinical manifestation are still unknown. Growing evidence demonstrates that hypoxia-inducible factor (HIF)-1α plays indispensable roles in driving immune response by triggering the expression of CD73 purinergic ecto-enzyme. Purinergic system controls the duration and magnitude of purine signals directed to modulate immune cells through the conversion of extracellular ATP (microbicide/proinflammatory) to the immunoregulatory metabolite adenosine. In the present work, we described that infiltrating leukocytes within cardiac explants from patients with end-stage Chagas cardiomyopathy up-regulated HIF-1α and CD73 expression. Moreover, the number of HIF-1α+ and CD73+ leukocytes positively correlated with the myocarditis severity and the local parasite load. Furthermore, we demonstrated a direct relationship between tissue parasite persistence and the influx of immune cells to the infected hearts, which ultimately determine the severity of the myocarditis. These findings provide evidence that CD73-dependent regulatory pathways are locally triggered in the myocardium of patients with end-stage Chagas disease.

Radiofrequency ablation of supraventricular arrhythmias after orthotopic heart transplantation: Long-term follow-up of a single-center experience.

BACKGROUND: Supraventricular arrhythmias (SVAs), commonly managed with radiofrequency ablation (RFA), may occur after orthotopic heart transplantation (OHT). METHODS: We retrospectively assessed 514 consecutive patients (pts.) undergoing OHT between January 1990 and July 2016 in a single-center. Patients with SVAs managed with RFA were included. Mechanisms of genesis of SVAs, association with surgical techniques and outcomes, were analyzed. RESULTS: Of 514 pts undergoing OHT, 53% (272 pts.) were managed with bicaval (BC) technique and 47% (242 pts.) with biatrial (BA) technique. Mean follow-up 10 ± 8.4 years. Nine pts. (1.7%) developed SVA requiring RFA. The BC technique was performed in 4 pts., 3 pts. presented cavotricuspid isthmus-dependent atrial flutter (CTI AFL), and 1 pt. double loop AFL. Five pts. were managed with BA technique, 4 pts. presented CTI AFL, and 1 pt. atrial tachycardia (AT). Mean time between OHT and SVA occurrence was 6.6 ± 5.5 years. The procedure was successful in 89% (8 pts.). Arrhythmia recurrence was seen in 3 pts (37%), all with BA technique. CONCLUSION: Supraventricular arrhythmias in heart transplantation may be associated with the surgical scar. Identifying the mechanism is vital to choose the appropriate treatment with radiofrequency ablation.

Dynamic neurocognitive changes in interoception after heart transplant.

Heart-brain integration dynamics are critical for interoception (i.e. the sensing of body signals). In this unprecedented longitudinal study, we assessed neurocognitive markers of interoception in patients who underwent orthotopic heart transplants and matched healthy controls. Patients were assessed longitudinally before surgery (T1), a few months later (T2) and a year after (T3). We assessed behavioural (heartbeat detection) and electrophysiological (heartbeat evoked potential) markers of interoception. Heartbeat detection task revealed that pre-surgery (T1) interoception was similar between patients and controls. However, patients were outperformed by controls after heart transplant (T2), but no such differences were observed in the follow-up analysis (T3). Neurophysiologically, although heartbeat evoked potential analyses revealed no differences between groups before the surgery (T1), reduced amplitudes of this event-related potential were found for the patients in the two post-transplant stages (T2, T3). All these significant effects persisted after covariation with different cardiological measures. In sum, this study brings new insights into the adaptive properties of brain-heart pathways.

Short-term mechanical circulatory support devices as bridge to heart transplantation: A prospective single-center experience in Argentina.

BACKGROUND: Patients with cardiogenic shock may require hemodynamic stabilization with short-term mechanical circulatory support devices (ST-MCS) such as extracorporeal membrane oxygenation (ECMO) and centrifugal pump (CP) as bridge to transplantion (BTT). This study aimed to describe ECMO and CP during BTT and after heart transplant. METHODS: A cohort of patients on ECMO or CP as BTT between April 2006 and April 2018 in a single hospital. RESULTS: Thirty-seven consecutive patients with ECMO (n = 14) or CP (n = 23) were included. Acute kidney injury was more prevalent during CP (28.6% vs 69.6%, P = .02). There were no differences in stroke, thrombosis, sepsis, or vasoplegia. Bleeding (0% vs 56.5%, P = .0003) and reoperation (0% vs 47.8%, P = .002) were more frequent in CP group as well as mortality (0 vs 7 [30.4%], P = .03). The remaining 30 patients (81.1%) underwent heart transplantation, without differences in primary graft dysfunction, vasoplegia, reoperation for bleeding, or hospital stay. Mortality was 23.3% at 30 days, similar in both groups, with no further deaths at median follow-up of 44.2 months. CONCLUSIONS: In patients with cardiogenic shock, ST-MCS with ECMO or CP as BTT are a lifesaving approach allowing successful transplantation in the majority of cases, with good short- and long-term survival.

Lobectomía pulmonar: ¿Qué beneficios ofrece la videotoracoscopía? / Pulmonary Lobectomy. What are the Benefits of Video-assisted Thoracoscopy?

Introducción: A pesar del creciente uso de la lobectomía por videotoracoscopía, este abordaje resulta aún controvertido en algunos aspectos. El objetivo del presente trabajo es comparar los resultados quirúrgicos de la lobectomía pulmonar por videotoracoscopía y por toracotomía. Material y métodos: En el Hospital Universitario Fundación Favaloro, entre los años 2008 y 2017, fueron intervenidos quirúrgicamente 153 pacientes (n = 89 masculinos). Resultados: Se realizó lobectomía por videotoracoscopía a 39/89 pacientes. Los pacientes intervenidos por videotoracoscopía y con diagnóstico de cáncer de pulmón, tenían predominantemente tumores en estadío I (25/39 pacientes). La incidencia de complicaciones postoperatorias y mortalidad fueron similares en ambos grupos. En el grupo intervenido por videotoracoscopía la permanencia del drenaje pleural fue significativamente menor (4 versus 3 días, p = 0.004) y, también resultó más breve la estadía hospitalaria (6 versus 4 días de internación, p = 0.03). El número de estaciones ganglionares exploradas durante la cirugía fue mayor en los pacientes operados por toracotomía (4 versus 3.5 estaciones ganglionares, p < 0.001). Conclusión: La lobectomía por videotoracoscopía resultó al menos equivalente a la cirugía por toracotomía en términos de complicaciones postoperatorias. Los principales beneficios del abordaje por videotoracoscopía fueron una menor permanencia del drenaje pleural y menor estadía hospitalaria. Se recomienda tener especial cuidado con el muestreo ganglionar cuando la cirugía se realiza por videotoracoscopía.

Introduction: Despite the widespread adoption of video-assisted thoracoscopic lobectomy, this surgical approach still remains controversial. The objective of this paper is to compare the surgical results of video-assisted thoracoscopic lobectomy to open thoracotomy lobectomy, performed at the Hospital Universitario Fundación Favaloro between 2008 and 2017. Materials and Methods: One-hundred and fifty three patients (n = 89 males) had surgery during the study period; 39/153 had video-assisted thoracoscopic lobectomy. Results: Patients that had video-assisted thoracoscopic lobectomy were more likely to have stage I lung cancer (25/39). Postoperative complications and mortality rates were similar in both groups. Video-assisted thoracoscopic lobectomy patients had a shorter chest tube drainage time (4 vs. 3 days, p = 0.004) and length of hospital stay (6 vs. 4 days of stay, p = 0.03). The median number of lymph node stations sampled at surgery was significantly higher in the patients that had open thoracotomy lobectomy (4 vs. 3.5 lymph node stations, p < 0.001). Conclusion: Video-assisted thoracoscopic lobectomy is at least equivalent to open thoracotomy lobectomy in terms of postoperative complications and mortality. The main benefits of the video-assisted thoracoscopic approach are a shorter chest tube drainage time and length of hospital stay. Special attention should be taken at the time of nodal sampling when the surgery is performed by the video-assisted thoracoscopic approach.

Pulmonary Lobectomy: What are the Benefits of Video-assisted Thoracoscopy?

Introduction: Despite the increasing use of video-assisted thoracoscopic lobectomy, this surgical approach is still controversial in certain aspects. The purpose of this study is to compare the surgical results of video-assisted thoracoscopic pulmonary lobectomy to pulmonary lobectomy via thoracotomy. Materials and Methods: Between 2008 and 2017, 153 patients (n = 89 males) had surgery at the Hospital Universitario Fundación Favaloro. Results: 39/89 patients underwent video-assisted thoracoscopic lobectomy. Patients who had video-assisted thoracoscopy and were diagnosed with lung cancer mostly had stage I tumors (25/39 patients). Postoperative complications and mortality rates were similar in both groups. Video-assisted thoracoscopy patients had a significantly shorter pleural drainage time (4 vs. 3 days, p = 0.004) and a shorter length of hospital stay (6 vs. 4 days of stay, p = 0.03). The number of lymph node stations sampled during surgery was higher in the patients operated via thoracotomy (4 vs. 3.5 lymph node stations, p < 0.001). Conclusion: Video-assisted thoracoscopic lobectomy was at least equivalent to surgery by means of thoracotomy in terms of postoperative complications. The main benefits of the video-assisted thoracoscopy approach were shorter pleural drainage time and length of hospital stay. Special attention should be paid to nodal sampling when the surgery is performed via video-assisted thoracoscopy.

Experiencia preliminar con el uso del soporte vital extracorpóreo como puente al trasplante pulmonar / Preliminary Experience of the Use of Extracorporeal Life Support as a Bridge to Lung Transplantation

Introducción: Diversos estudios han demostrado los beneficios del soporte vital extracorpóreo en pacientes críticos con patologías cardiorrespiratorias. El objetivo del presente trabajo consiste en evaluar la experiencia preliminar con el uso del soporte vital extracorpóreo en pacientes con enfermedad pulmonar avanzada, en lista de espera para trasplante pulmonar. Material y métodos: Se realizó un análisis retrospectivo y descriptivo de los pacientes que recibieron soporte vital extracorpóreo como puente al trasplante o a la candidatura para trasplante, entre agosto 2010 y julio 2015. Se analizaron los resultados según: exclusión de la lista de espera, candidatos a trasplante y trasplantes realizados. Se describen complicaciones y causas de mortalidad, tiempos de soporte vital extracorpóreo, asistencia respiratoria mecánica e internación post-trasplante. Se incluyeron 23 pacientes, edad promedio 36 ± 17 años, 61% mujeres. Los diagnósticos principales fueron fibrosis quística (34.8%), fibrosis pulmonar idiopática (30.4%) y fibrosis pulmonar secundaria (13.0%). Resultados: El tiempo medio con soporte vital extracorpóreo fue 14.4 ± 11.7 días; y se realizó veno-venoso en 14 pacientes, veno-arterial en 4, arterio-venoso 3 casos y veno-arterio-venoso en 2. Ocho pacientes no calificaron como candidatos al trasplante y se excluyeron de la lista de espera. Fueron aceptados como puente al trasplante 15 pacientes; 8 fallecieron bajo soporte vital extracorpóreo y 7 lograron ser trasplantados. Post trasplante, un paciente falleció y 6 fueron externados superando el año de supervivencia. Conclusión: En nuestra serie, el 46.7% de los candidatos lograron acceder al trasplante pulmonar bajo soporte vital extracorpóreo. La implementación de un programa de soporte vital extracorpóreo como puente al trasplante pulmonar efectivo requiere acceso a nuevas tecnologías y desarrollo de experiencia por parte del equipo.

Introduction: Several studies have demonstrated that the use of extracorporeal life support (ECLS) improves the recovery of critically ill patients with cardiorespiratory diseases. The purpose of this study was to evaluate a preliminary experience on the use of ECLS as a bridge to lung transplantation. Methods: We conducted a retrospective and descriptive analysis of patients who received ECLS as a bridge to lung transplantation between August 2010 and July 2015. ECLS results were analyzed according to the final status: excluded from the waiting list, confirmed transplant candidacy and transplanted patients. Complications and cause of mortality were evaluated, as well as the length of ECLS, time on mechanical ventilation, length of stay and survival. Twenty-three patients were included, mean age 36±17 years, 61% were female. The most common diagnoses were cystic fibrosis (34.8%), idiopathic pulmonary fibrosis (30.4%) and secondary pulmonary fibrosis (13.0%). Results: Mean time on ECLS was 14.4±11.7 days; veno-venous support was implemented in 14 patients, veno-arterial support in 4 cases, arterio-venous in 3, and veno-arterio-venous in 2. During ECLS, 8 patients did not qualify as candidates for transplantation. Fifteen patients were accepted as candidates for lung transplant, 8 of them died during ECLS, and 7 were transplanted. After transplant, one patient died and 6 were discharged from the hospital. Conclusion: The use of ECLS provided a successful bridge to lung transplantation in 46.7% of the patients. The implementation of an effective ECLS program requires of the conjunction between the technological advances and the development of the center's experience.