Improving Extracorporeal Membrane Oxygenation Survival in COVID-19. Effect of a Bundle of Care.

Veno-venous extracorporeal membrane oxygenation (ECMO) support surged during the COVID-19 pandemic. Our program changed the model of care pursuing to protect the multidisciplinary team from the risk of infection and to serve as many patients as possible. Patient-healthcare interactions were restricted, and the ECMO bed capacity was increased by reducing the ECMO specialist-patient ratio to 1:4 with non-ECMO trained nurses support. The outcomes worsened and we paused while we evaluated and modified our model of care. The ECMO bed capacity was reduced to allow a nurse ECMO-specialist nurse ratio 2:1 with an ECMO trained nurse assistant's support. Intensivists, general practitioners, nurse assistants, and physical and respiratory therapists were trained on ECMO. Tracheostomy, bronchoscopy, and microbiological molecular diagnosis were done earlier, and family visits and rehabilitation were allowed in the first 48 hours of ECMO cannulation. There were 35 patients in the preintervention cohort and 66 in the postintervention cohort. Ninety days mortality was significantly lower after the intervention (62.9% vs. 31.8%, p = 0.003). Factors associated with increased risk of death were the need for cannulation or conversion to veno arterial or veno arterio venous ECMO, hemorrhagic stroke, and renal replacement therapy during ECMO. The interventions associated with a decrease in the risk of death were the following: early fiberoptic bronchoscopy and microbiological molecular diagnostic tests. Increasing the ECMO multidisciplinary team in relation to the number of patients and the earlier performance of diagnostic and therapeutic interventions, such as tracheostomy, fiberoptic bronchoscopy, molecular microbiological diagnosis of pneumonia, rehabilitation, and family support significantly decreased mortality of patients on ECMO due to COVID-19.

Somatic Support with Veno-venous ECMO in a Pregnant Woman with Brain Death: A Case Report.

Supporting homeostasis in a pregnant woman with brain death to achieve fetal viability is called somatic support. We present a case of young pregnant woman at 21 weeks' gestation who developed acute respiratory distress syndrome secondary to influenza A H2N3 infection requiring veno-venous extracorporeal membrane oxygenation (VV ECMO) support for refractory hypoxemia. The clinical course was complicated by intracranial hemorrhage and subsequent brain death. After multidisciplinary team discussion with her family, consensus was reached to continue somatic support with VV ECMO to enable fetal development to attain extrauterine viability. The challenging clinical, ethical, and legal concerns are discussed.

Survival after heart transplantation for Chagas cardiomyopathy using a conventional protocol: A 10-year experience in a single center.

BACKGROUND: Heart transplant (HT) remains the most frequently indicated therapy for patients with end-stage heart failure that improves prognosis in Chagas cardiomyopathy (CCM). However, the lack of benznidazole therapy and availability of RT-PCR follow-up in many centers is a major limitation to perform this life-saving intervention, as there are concerns related with the risk of reactivation. We aimed to describe the outcomes of a cohort of patients with CCM who underwent HT using a conventional protocol with mycophenolate mofetil, without benznidazole prophylaxis or RT-PCR follow-up. METHODS: Retrospective cohort study. Between 2008 and 2018, 43 patients with CCM underwent HT. A descriptive analysis to characterize outcomes as rejection, infectious and neoplastic complications and a survival analysis was carried out. RESULTS: Median of follow-up was 4.3 (IR 4.28) years. Survival at 1 month, 1 year, and 5 years was 95%, 85%, and 75%, respectively, infections being the main cause of death (60%). Reactivations occurred in only three patients (7.34%) and were not related to mortality. CONCLUSION: This cohort showed a favorable survival and a low reactivation rate without an impact on mortality. Our results suggest that performing HT in patients with CCM following conventional guidelines and recommendations for other etiologies is a safe approach.

Experience with veno-venous ecmo in patients with adult respiratory distress syndrome secondary to viral pneumonia. Case series / Experiencia con ecmo veno-venoso en pacientes con síndrome de dificultad respiratoria del adulto secundario a neumonía viral. Serie de casos

Abstract Introduction The use of extracorporeal membrane oxygenation (ECMO) has increased exponentially in recent years and has shown to be effective in treating adult respiratory distress syndrome (ARDS) secondary to HiNi-related pneumonia. However, evidence remains controversial. This study describes a case series of ECMO in ARDS secondary to viral pneumonia. Methods A search was conducted in the ECMO database of Fundación Cardiovascular de Colombia for the 20132017 period. A case series report was written of patients diagnosed with ARDS secondary to confirmed or suspected viral pneumonia. Results Nineteen patients with ECMO support and ARDS due to viral pneumonia were included in the study. The survival rate upon discharge was 11 patients (58%) and weaning from ECMO support was successful in 13 patients (68%). Hemorrhagic complications were the most frequent: gastrointestinal bleeding, 10 patients (53%); intracranial bleeding, 2 (10%); alveolar hemorrhage, 2 (10%);' hemothorax requiring thoracostomy with chest tube drainage, 2 (10%); cannulation site bleeding, 9 patients (47%); and surgical site bleeding in 3 patients (25%) who required tracheostomy. Other complications were: pneumothorax, 1 patient (5%); sepsis, 6 patients (32%); and growth of microorganisms in bronchial lavage, 6 patients (32%). Conclusions This study supports the use of veno-venous ECMO to achieve a higher survival rate than expected in patients with severe ARDS and refractory hypoxemia secondary to viral pneumonia. Early initiation of the therapy should improve overall results.

Resumen Introducción El uso de la oxigenación por membrana extracorpórea (ECMO) ha tenido un incremento exponencial en los últimos años y ha demostrado ser efectivo en el manejo del síndrome de dificultad respiratoria del adulto (SDRA) secundario a neumonía por H1N1, si bien la evidencia sigue siendo controvertida. En este estudio describimos una serie de casos de ECMO por SDRA secundario a neumonía viral. Métodos Se realizó una búsqueda en la base de datos de ECMO de la Fundación Cardiovascular desde el año 20132017. Reportamos una serie de casos donde se incluyeron pacientes diagnosticados con SDRA secundario a neumonía viral sospechosa o confirmada. Resultados Se incluyeron en el estudio 19 pacientes con soporte de ECMO y SDRA por neumonía viral. La sobrevida al alta fue 11 pacientes (58%) y el destete del ECMO fue exitoso en 13 pacientes (68%). Las complicaciones hemorrágicas presentadas fueron: sangrado digestivo, 10 pacientes (53%), sangrado cerebral, 2 (10%), hemorragia alveolar, 2 (10%), hemotórax con requerimiento de toracostomía a drenaje cerrado, 2 (10%), sangrado activo por sitio de canulación, 9 pacientes (53%), y 3 pacientes traqueostomizados (25%) que sangraron por el sitio quirúrgico. Otras complicaciones presentadas fueron: neumotórax, 1 paciente (5%), septicemia, 6 (32%) y crecimiento de microorganismos en lavados bronquiales 6 (32%). Conclusion El presente estudio permite indicar que el uso de la ECMO VV viabiliza una sobrevida mayor a la esperada en pacientes con SDRA severo e hipoxemia refractaria secundario a neumonía viral. Su inicio tempranamente debe mejorar los resultados globales.

Erector spinae plane block as a rescue analgesia technique in a patient with HeartMate 3 ventricular assist type device: case report / Bloqueo de plano del músculo erector de la espina como técnica analgésica de rescate en un paciente con asistencia ventricular tipo HeartMate 3: reporte de caso

Abstract Introduction: Heart failure represents a public health problem involving high morbidity and mortality. For advanced stages of the disease the use of ventricular assist devices (VADs) has been implemented as destination therapy. The perioperative management of patients with VADs may result in multiple challenges, with optimal pain management being one of those challenges. Objective: To describe the use of erector spinae plain (ESP) block as a rescue analgesia technique in a patient undergoing HeartMate 3 type VAD implantat. Methods: Case report and subject review. Results: The case discussed is a patient with ischemic cardiomyopathy and severe ventricular dysfunction, undergoing a HeartMate 3 type VAD implant as destination therapy, under general anesthesia and postoperative analgesia protocol with fentanyl and acetaminophen. During the postoperative period the patient developed acute pain of severe intensity (visual analogue scale [VAS]: 8-10/10), that led to the use of a regional rescue technique-ESP block-that showed satisfactory results with optimal analgesia control (VAS: 1-3/10). Conclusion: The ESP block was a safe and effective option as part of a postoperative analgesia strategy for a patient with a HeartMate 3 type VAD implant.

Resumen Introducción: la insuficiencia cardiaca representa un problema de salud pública con alta morbimortalidad. En estadios avanzados se ha implementado el uso de dispositivos de asistencia ventricular (DAV) como terapia destino. El manejo perioperatorio de pacientes con DAV puede generar múltiples retos, dentro de los cuales se destaca el manejo óptimo del dolor. Objetivo: describir el uso del bloqueo del plano del musculo erector de la espina (ESP) como técnica analgésica de rescate en un paciente llevado a implante de DAV tipo HeartMate 3. Métodos: reporte de caso y revisión de tema. Resultados: se presenta el caso de un paciente con cardiopatía isquémica y disfunción ventricular severa, que fue llevado a un implante de DAV tipo HeartMate 3 como terapia destino, bajo anestesia general y protocolo de analgesia postoperatoria con fentanil y acetaminofén. Durante el posoperatorio presentó dolor agudo de intensidad severa (Escala Visual Análoga: 8-10/10), por lo que se aplicó una técnica regional de rescate: bloqueo ESP, la cual mostró resultados satisfactorios con control analgésico óptimo (Escala Visual Análoga: 1-3/10). Conclusiones: el bloqueo ESP fue una opción segura y efectiva como parte de una estrategia analgésica postoperatoria para un paciente con implante de un DAV tipo HeartMate 3.

Telemedicine in Pediatric Critical Care: A Retrospective Study in an International Extracorporeal Membrane Oxygenation Program.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is an invaluable rescue technique for critically ill children with imminent or present cardiopulmonary collapse. However, medical team expertise to optimize results and decrease complications is scarce. Telemedicine can be used to enhance the delivery of quality interventions. MATERIALS AND METHODS: This is a retrospective review of pediatric patients assisted with ECMO in the cardiac intensive care unit (CICU) at Fundación Cardiovascular de Colombia from July 2011 to June 2015 (telemedicine) compared with similar patients from a previous period (pretelemedicine). Collected information included demographic data, cardiac diagnosis, risk adjustment for congenital heart surgery (RACHS-1), hospital mortality, CICU and hospital length of stay (LOS), ECMO type, and ECMO run hours as well as specific telemedicine information. RESULTS: Fifty-seven patients in the pretelemedicine and 109 in the telemedicine periods were included in the analysis. Forty-nine teleconsulted patients received 218 teleconsultations, with a recommendation for diagnostic or interventional catheterization in 38 patients (77.5%). A surgical procedure for significant residual lesions was recommended in 30 patients (61.2%). Patients in the telemedicine period were older (4.7 months vs. 1.6 months, p = 0.006), more likely to receive operating room ECMO (43.1% vs. 24.6%, p = 0.02), and had a higher proportion of patients with two-ventricle physiology (73.4% vs. 54.4%, p = 0.013). Hospital survival was higher during the telemedicine period (54.1% vs. 29.8%, p = 0.002), with a longer hospital LOS (67 days vs. 28 days, p < 0.001). CONCLUSION: The implementation of telemedicine-assisted interventions in a pediatric ECMO program delivered valuable diagnostic and therapeutic advice, was associated with significant changes in selection criteria and model of care, and an increased hospital survival.

Reporte del primer caso de implante exitoso de asistencia ventricular izquierda HeartMate II como terapia de destino en Suramérica / Report of the first successful case of HeartMate II Left Ventricular Assist Device placement as a destination therapy in South America

Resumen Se describe el caso de una paciente de sexo femenino de 55 años de edad, con insuficiencia cardiaca congestiva descompensada secundaria a cardiopatía dilatada idiopática y con contraindicación para trasplante cardiaco, en quien se implanta de manera exitosa el primer dispositivo de asistencia ventricular izquierda HeartMate II en Suramérica.

Abstract The case of a 55 year-old woman with decompensated congestive heart failure secondary to idiopathic dilated cardiomyopathy is described. Cardiac transplantation was contraindicated, and the first HeartMate II Left Ventricular Assist Device was placed in South America.

Clinical validation study of the SignCare Vital Signs Monitor of Fundación Cardiovascular de Colombia / Estudio de validación clínica del monitor de signos vitales SignCare de la Fundación Cardiovascular de Colombia

Abstract Introduction: In Colombia, due to the difficult access to health services and to geographic conditions, the implementation and innovation of telemedicine technological tools is a priority. Having a validated vital signs monitor (VSM) improves proper medical treatment and diagnosis. Objective: To design and perform clinical trials for the SignCare VSM. Materials and methods: A device for continuous monitoring of electrocardiography, respiration, oxygen saturation, temperature and noninvasive blood pressure (NIBP) was designed. This device was validated in a laboratory in order to ensure a robust prototype, close to the level of commercial medical devices. Clinical trials were performed through a cross -section study with 98 patients, whose vital signs were measured using the SignCare monitor and a commercial monitor. These two measurements were compared using Pearson's correlation coefficients. Results: There were no statistically significant differences between the results obtained with the SignCare VSM and the commercial monitor. The highest correlations were found for the following items: heart rate by electrocardiogram (r=0.844), heart rate by oxymetry (r=0.821), body temperature (r=0.895), systolic blood pressure (r=0.780), and diastolic blood pressure (r=0.811). Conclusions: The SignCare device is as reliable as the commercial monitor in the qualitative detection of morphologic alterations of electrocardiogram records, as well as in breathing, temperature, oxygen saturation and blood pressure parameters, which makes it recommendable for clinical use in adult population.

Resumen Introducción. Debido a las dificultades geográficas y de acceso a los servicios de salud en Colombia, la implementación e innovación con herramientas de telemedicina se convierte en un tema prioritario; contar con un monitor de signos vitales validado favorece el tratamiento médico oportuno. Objetivos Diseñar y realizar la validación clínica del monitor de signos vitales SignCare. Materiales y métodos. Se diseñó un equipo para el monitoreo constante de las señales de electrocardiografía, respiración, saturación de oxígeno, temperatura y presión arterial no invasiva. El dispositivo fue validado en el laboratorio para asegurar un prototipo robusto a nivel de dispositivos médicos comerciales. La validación clínica se hizo mediante un estudio de corte transversal en 98 pacientes a los que se les realizaron mediciones con el monitor SignCare y con un monitor comercial. Se compararon estas dos mediciones mediante coeficientes de correlación de Pearson. Resultados. No hubo diferencias estadísticamente significativas en cuanto a los resultados obtenidos con el monitor SignCare y con el monitor comercial. Las mayores correlaciones se presentaron en la frecuencia cardíaca por electrocardiograma (r=0.844), frecuencia cardíaca por oximetría (r=0.821), temperatura corporal (r=0.895), tensión arterial sistólica (r=0.780) y tensión arterial diastólica (0.811). Conclusiones. El monitor SignCare es tan confiable como el monitor comercial para la detección cualitativa de alteraciones morfológicas del registro electrocardiográfico, lo que hace posible su recomendación para uso clínico en población adulta.

Setting Up an ECMO Program in a South American Country: Outcomes of the First 104 Pediatric Patients.

BACKGROUND: Less than 1% of the extracorporeal life support organization (ELSO) registry patients are from South America. Extracorporeal membrane oxygenation (ECMO) is an expensive therapy not only in terms of direct financial cost but also with respect to technical and human resources. Finding a successful ECMO model that developing countries can afford is critical to the expansion of therapy to include the availability of this technology for patients in the developing world. METHODS: We retrospectively studied the first 104 pediatric ECMO patients in the Fundacion Cardiovascular de Colombia between May 2007 and May 2013. We collected the ELSO registry data from electronic medical records to determine the survival rate, mortality risk factors, and complications in pediatric patients who received ECMO support for cardiac failure, respiratory failure, or ECMO for extracorporeal cardiopulmonary resuscitation in the setting of refractory cardiopulmonary resuscitation. We describe our model of ECMO care regarding staff, training process, care protocol, ECMO circuit, and costs. RESULTS: Of 104 patients, 82 were diagnosed with congenital heart disease. Of those, 50 had biventricular and 32 had univentricular physiology, with a significantly higher survival rate at discharge in the biventricular group (44% vs 18.7%, odds ratio [OR] 3.6, 95% confidence interval [CI] = 1.28-10.52, P = .01). Pediatric patients with a cardiac indication had survival rates of 76.3% at weaning and 52.6% at discharge, which is roughly comparable to those reported by the ELSO in 2013. Univentricular physiology, ECPR, severe pre-ECMO acidosis, ECMO-associated renal failure, and duration of ECMO support were factors associated with increased mortality. CONCLUSION: Despite limited availability of technical and economic resources, ECMO therapy can be done successfully in a developing country. A model of care based on nurses as ECMO specialists, supported by a multidisciplinary team, is cost-effective.

Endocarditis infecciosa de alto riesgo embolígeno durante el embarazo: ¿manejo conservador o quirúrgico? / High risk infective endocarditis embolism during pregnancy: Medical or surgical management?

Presentamos el caso de una paciente de 22 años de edad con embarazo de 14 semanas y endocarditis infecciosa de válvula mitral nativa con una vegetación de 15 mm con amplia movilidad, acompañada de insuficiencia valvular severa. Inicialmente, y pese al riesgo embolígeno, se dio tratamiento antibiótico durante 4 semanas. Por persistencia del tamaño de la vegetación se decide llevar a cirugía para reparación mitral y remoción de la lesión en la semana 18 de gestación, considerando que el balance entre el riesgo fetal y materno estaba a favor del procedimiento quirúrgico. Se usaron técnicas de protección fetal intraoperatoria y se colocó una prótesis biológica previo intento de reparación. La evolución postintervención fue satisfactoria, lográndose parto por cesárea a las 30 semanas.

A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.

[High risk infective endocarditis embolism during pregnancy: Medical or surgical management?]. / Endocarditis infecciosa de alto riesgo embolígeno durante el embarazo: ¿manejo conservador o quirúrgico?

A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.

Tratamiento endovascular del aneurisma de aorta descendente en el adolescente con síndrome de Marfan: reporte de un caso / Endovascular treatment of an aneurysm of the descending aorta in an adolescent with Marfan syndrome

Se expone el caso de un adolescente de 14 años de edad, con síndrome de Marfan y antecedente de tres cirugías cardiovasculares previas: valvuloplastia aórtica y mitral a los cinco años y valvuloplastia aórtica y reconstrucción de la aorta torácica con tubo de pericardio bovino a sus diez años. En primer tiempo quirúrgico se realizó reemplazo valvular aórtico por válvula mecánica y valvuloplastia mitral y tricuspidea, y en segundo tiempo quirúrgico, durante la misma hospitalización, exclusión endovascular de aneurisma de aorta descendente asintomático sin complicaciones. Antes del egreso se diagnosticó una endofuga tipo II que se manejó con observación clínica. Luego de un año del procedimiento, los controles clínico y tomográfico son satisfactorios.

We describe the case of a 14-year-old adolescent with Marfan syndrome and a history of three previous cardiovascular surgeries: aortic and mitral valve replacement at the age of 5 and aortic valve replacement and reconstruction of the thoracic aorta with a tube of bovine pericardium at the age of ten. In the first surgical procedure the aortic valve was replaced by a mechanical valve, and mitral and tricuspid valvuloplasty was performed. In a second surgical procedure during the same hospitalization, endovascular exclusion of the asymptomatic descending aortic aneurysm was realized without complications. Before discharge, a type II endoleak was diagnosed and managed through clinical observation. After a year of the procedure, clinical and tomographic controls are satisfactory.

Manejo endovascular de la aorta torácica / Endovascular treatment of thoracic aorta

En comparación con el tratamiento convencional, la terapia endovascular en aneurisma de aorta torácica, presenta los mejores resultados, por lo que se convierte en el tratamiento de elección para la patología de aorta torácica descendente endovascular, por su baja morbimortalidad perioperatoria. El tratamiento quirúrgico por vía retroperitoneal y/o endovascular para aneurisma de aorta abdominal infrarrenal, resulta ser especialmente seguro en pacientes octogenarios o con alta morbilidad. Esta cohorte institucional presenta resultados perioperatorios y en el seguimiento, similares a los reportados en la literatura mundial.

Compared with the conventional treatment, endovascular therapy in thoracic aortic aneurysm shows the best results, being the election treatment for the pathology of the descending thoracic aorta, due to its low peri-operative morbid-mortality. Surgical treatment by retro-peritoneal route and/or endovascular for infra-renal abdominal aortic aneurysm is especially safe in octogenarian patients or in those with a high mortality rate. This institutional cohort show peri-operative and follow-up results similar to those reported in the world literature.

Arteria carótida y placa carótida un órgano / Carotid artery and plaque. Carotid: an organ

En estos momentos es posible hacer recomendaciones sobre las indicaciones de la endarterectomía carotídea, basadas en los ensayos clínicos publicados y en la revisión de grandes series quirúrgicas. Las indicaciones para la cirugía dependerán del grado de estenosis y de la morfología de la placa, así como del estado clínico del paciente y de la morbi-mortalidad del equipo quirúrgico. Este al igual que otros estudios con grandes series de casos, evidencia que la endarterectomía carotídea y/o el manejo endovascular, realizado por equipos expertos, es un procedimiento seguro en pacientes con indicación quirúrgica.

It is now possible to recommend indications for aortic endarterectomy, based on published clinical essays and revision of large surgical series. Surgery indications will depend on the stenosis degree and the plaque morphology, as well as on the patient's clinical state and the morbid-mortality in this surgical team. As other studies with large case series, evidences that carotid endarterectomy and/or endovascular management, when realized by expert teams, is a safe procedure in patients with surgical indication.

Transplante cardiaco en niños: reporte del primer caso atendido en la Fundación Cardiovascular de Colombia / Cardiac transplantation in children: report of the first case treated in the Colombian Cardiovascular Foundation

En los últimos años, el trasplante cardiaco ha mejorado sustancialmente la calidad de vida y la sobrevida de los niños con enfermedad cardiaca terminal. En la actualidad, es un procedimiento rutinario en centros especializados; sin embargo, pese a los numerosos avances, existen complicaciones a largo plazo, como el rechazo tardío, la enfermedad vascular del injerto y los desórdenes linfoproliferativos que limitan la sobrevida y la calidad de vida (2). Estas limitaciones podrían disminuirse con la identificación oportuna de los donantes potenciales, lo cual permite disponer de órganos de mejor calidad, el mejoramiento del soporte al donante, un adecuado sistema de transporte y de preservación de los órganos, la actualización y el mejoramiento de los protocolos de manejo, y la utilización de nuevos fármacos.

During the last years, cardiac transplantation has substantially improved survival and life quality in children with terminal heart disease. It is actually a routine procedure in specialized centers. Nevertheless, in spite of the numerous advances, there are long-term complications, such as late rejection, implant vascular disease and lymphoproliferative disorders that limit survival and life quality (2). These limitations could be diminished by an opportune identification of the potential donors, allowing best quality organs disposal, improvement of donor support, adequate transport and preservation system, updating and improvement of treatment protocols and new medicines utilization. The scarce donors’ availability obliges the implement of strategies tending to sensitize the community on the need of adopting a culture of organs’ donation. In order to achieve the treatment’s goals, to offer an integral rehabilitation and to have a prompt reincorporation to society of the transplanted patient, educational programs and multidisciplinary support are required, not only for the patients, but also for their families.

Mortalidad quirúrgica de la corrección de cardiopatías congénitas en la Fundación Cardiovascular de Colombia: 2000-2005 / Surgical mortality in the correction of congenital heart disease at the Colombian Cardiovascular Foundation: 2000-2005

Antecedentes: la cirugía cardiaca se reconoce como uno de los mayores logros de la medicina. En las últimas décadas, ha experimentado enormes progresos en relación con el perfeccionamiento de las técnicas quirúrgicas, anestésicas y de cuidado crítico, técnicas que en conjunto han permitido corregir de manera oportuna y definitiva la mayoría de cardiopatías congénitas.Objetivo: describir el porcentaje de mortalidad quirúrgica institucional de los pacientes intervenidos por cardiopatías congénitas según su nivel de complejidad (Pediatric Cardiac Care Consortium RACHS-1 - based method for Risk Adjusment for Surgery congenital Heart disease).Métodos: estudio descriptivo de corte transversal. Se revisaron las historias clínicas de los pacientes intervenidos mediante cirugía para corrección de cardiopatías congénitas de enero de 2000 a octubre de 2005. Se contemplaron las siguientes variables: grupo etáreo, clasificación del riesgo del procedimiento y número de muertes operatorias.

Background: Cardiac surgery is recognized as one of the biggest achievements in medicine. In the last decades, it has experienced enormous progresses through the improvement of the surgical, anesthetic and critical care techniques that have allowed the correction of most of the congenital cardiac defects opportunely and definitively. Method: To describe the percentage of institutional surgical mortality of patients operated for cardiac congenital defects according to the complexity level (Pediatric Cardiac Care Consortium RACHS-1 - based method for Risk Adjusment for Surgery congenital Heart disease). Results: Between January 2000 and October 2005, 1132 patients were operated. The surgical mortality accumulated in the described period was 7.2%, 7.8% in 2000, 13.8% in 2001, 6.5% in 2002, 7.9% in 2003, 5.1% in 2004 and 3.9% in 2005. The mortality by category of risk was 1.8% in the category 1, 4.8% in the category 2, 11.8% in the category 3, 11.5% in the category 4, 0% in the category 5 and 50% in the category 6. Conclusions: In the last six years, an important decrease in pediatric mortality due to cardiovascular surgical procedures has been observed. Maintaining an adequate register in the long term will allow the systematic analysis of the survival performance (tendencies) which will permit to establish comparisons with the main reference centers worldwide.

Comparacion de las estrategias tradicionales y la teoria de Stewart en la interpretacion de las alteraciones acido-basicas en pacientes pediatricos con disfuncion multiorganica en el postoperatorio de cirugia cardiaca / Comparison of the traditional strategy of acid-basic analysis with the novel Steward's theory in pediatric patients with multiorganic dysfunction undergoing cardiac surgery

Objetivo: Comparar las estrategias tradicionales del análisis ácido-básico con la teoría de Stewart en pacientes pediátricos con disfunción multiorgánica en postoperatorio de cirugía cardiaca. Materiales y métodos: Estudio observacional analítico de cohorte concurrente, realizado en 66 pacientes pediátricos sometidos a circulación extracorporea (CEC) con una técnica estándar. En el postoperatorio inmediato se tomo muestra arterial para realizar el análisis ácido-básico tradicional y según Stewart; se aplicó diariamente la escala SOFA de disfunción orgánica durante tres días y se obtuvieron los valores mas altos. Los pacientes se dividieron en dos grupos de acuerdo a quienes presentaron falla orgánica (SOFA > 7; 20 pacientes) y sin falla orgánica (SOFA < 7; 46 pacientes). Resultados y conclusiones: El análisis tradicional en los pacientes que no desarrollaron falla mostró acidosis metabólica (pH 7.36 +/- 0.08, HCO3 16.6 +/- 2.6, BE -6.03 +/- 3.5). Los pacientes que desarrollaron falla mostraron resultados normales (pH 7.39 +/-0.08, HCO3 17.9+/-2.1, BE-4.8+/-2.6). El análisis de Stewart evidenció una mayor aparición de aniones anormales en los pacientes que desarrollaron falla (-4.2 vs -2.6), además sugiere que la acidosis evidenciada en los pacientes sin falla se explica por los cambios en la concentración de cloro y sodio producidos por la CEC