Avulsión del tronco arterial innominado por aplastamiento torácico / Avulsion of the innominate artery due to a crushed chest injury

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Can the opportunity of cardio-pulmonary bypass be useful in complex general thoracic surgery problems? A report of nine cases.

AIM: We report on nine highly selected patients in whom the resection of the tumor was only possible with cardiopulmonary bypass (CPB). METHODS: Between November 1996 and November 2009, nine patients with non-cardiac tumors underwent surgery under CPB. Indications were: infiltration of the pulmonary vein in the left atrium (four cases), one case where the tumor (a paraganglioma apparently located in the subcarinal space) was actually in the atrium wall, one mediastinal liposarcoma with massive infiltration of the pericardium and the main pulmonary artery, and three tracheal tumors (2 cylindromas and 1 carcinoid). RESULTS: Indication for CPB was decided preoperatively in 7 cases and intraoperatively in the other 2 patients. Cardiac infiltration was confirmed with intraoperative transesophageal cardiac echography in 2 patients, which proved to be very useful. Concerning postoperative complications, one patient died intraoperatively because it was impossible to stop the CPB after reconstruction of the bifurcation of the main pulmonary artery. Although the duration of the operation was significantly increased by the use of cardiopulmonary by-pass, it did not influence postoperative recovery in any of the other eight patients, as far as bleeding or infection was concerned. In one patient, a thoracic drain had to be replaced due to a partial pneumothorax. In another patient a partial dehiscence of the neo-carina was conservatively treated. Long-term results were influenced by the initial pathology of the patient. CONCLUSION: CPB provides the possibility of safely resecting intrathoracic tumors invading cardiac structures that were previously inoperable. This can be achieved with an acceptable level of risk and - in very selected cases - may achieve long-term survival.

Cryopreserved aortic allograft for the treatment of a thoracic stent graft infection.

Arterial prosthetic graft infection is one of the most challenging issues in vascular surgery. We report a case of an infected descending thoracic aorta endograft, presenting itself several years after placement, with hemoptysis and back pain as referred symptoms. The patient was successfully treated by removing the thoracic aorta and replacing the infected endografts with a cryopreserved aortic allograft, running from the left subclavian artery to the aortic diaphragmatic hiatus.

[Atrial fibrillation surgery]. / Cirugía de la fibrilación auricular.

Atrial fibrillation surgery is based on creating scars in the atrium, in order to avoid re-entry phenomena that may initiate and perpetuate arrhythmia, and driving the normal stimuli from the sinus node to the atrio-ventricular node. The complexity and increased risk of the initial surgical technique, based on a "cut-and-sew" procedure, have enhanced other current procedures, in which different energies are used making it possible to perform scars in a safer and less invasive way. At present, atrial fibrillation surgery is not performed routinely in all cardiothoracic surgical centers, and there is no consensus in which is the best type of technique. Even if the results are good, they depend on multiples factors such as duration of arrhythmia, atrial size and type of technique employed. In addition, there is some variability in the description within the scientific community of the results and procedures used, which makes its analysis confusing. In this paper we review the different techniques described, the results and their application in minimally invasive surgery.

Cirugía de la fibrilación auricular / Atrial fibrillation surgery

La cirugía de la fibrilación auricular se basa en la creación de cicatrices de aislamiento en la aurícula con el propósito de evitar los fenómenos de reentrada que inician y perpetúan la arritmia, permitiendo la reconducción del estímulo normal desde el nodo sinusal hasta el nodo auriculo-ventricular. La técnica quirúrgica inicialmente descrita (basada en incisiones y sutura), compleja y poco utilizada por el riesgo de complicaciones, potenció el desarrollo de otros procedimientos actuales, en los que se utilizan diversas energías que permiten realizar cicatrices de manera segura y menos invasiva. En la actualidad, la cirugía de fibrilación auricular no se realiza rutinariamente en todos los centros quirúrgicos; tampoco existe un consenso en relación con los tipos de técnicas utilizadas. Aunque, en general, los resultados son buenos, dependen de diversos factores como la duración de la arritmia, el tamaño de la aurícula y el tipo de cirugía realizada. Además, existe cierta variabilidad en la descripción de la comunidad científica de los resultados y los procedimientos utilizados, lo que hace que su análisis sea confuso. Proponemos una revisión de las diferentes técnicas descritas, los resultados y su aplicación en técnicas mínimamente invasivas(AU)

Atrial fibrillation surgery is based on creating scars in the atrium, in order to avoid re-entry phenomena that may initiate and perpetuate arrhythmia, and driving the normal stimuli from the sinus node to the atrio-ventricular node. The complexity and increased risk of the initial surgical technique, based on a “cut-and-sew” procedure, have enhanced other current procedures, in which different energies are used making it possible to perform scars in a safer and less invasive way. At present, atrial fibrillation surgery is not performed routinely in all cardiothoracic surgical centers, and there is no consensus in which is the best type of technique. Even if the results are good, they depend on multiples factors such as duration of arrhythmia, atrial size and type of technique employed. In addition, there is some variability in the description within the scientific community of the results and procedures used, which makes its analysis confusing. In this paper we review the different techniques described, the results and their application in minimally invasive surgery(AU)

Progresos en cirugía cardiaca / Advances in cardiac surgery

El desarrollo de la cirugía cardiovascular se ha acompañado de unaserie de progresos en la tecnología complementaria que la han convertidoen una cirugía mas segura y menos agresiva. En este artículose revisan los progresos recientes de la cirugía coronaria, valvular,insuficiencia cardiaca, arrítmias y la aplicación de la circulaciónextracorpórea en enfermedades no cardiacas. Estos progresos debenser el punto de partida para desarrollar el futuro adaptado a lasnecesidades generadas por el paciente y la enfermedad

The development of cardiovascular surgery has been accompanied by a series of advances in complementary technology, which has made it possible to carry out safer and less aggressive surgery. In this article there is a review of the latest progress in coronary and valvular surgery, cardiac insufficiency, arrhythmia and the application of extracorporeal circulation in non-cardiac diseases. These advances can serve as the starting point in order to build a future adapted to the needs generated by both patient and disease (AU)

Traumatismos vasculares periféricos / No disponible

Los traumatismos vasculares en la vida civil han aumentado de forma importante. Esto se debe al incremento de los accidentes de circulación, laborales y domésticos, al aumento de la violencia en nuestra sociedad y al creciente número de complicaciones vasculares iatrogénicas. Este estudio tiene como objetivos el revisar el diagnóstico y el tratamiento de los traumatismos vasculares periféricos. Los pasos más importantes en el manejo de las heridas vascularesson: 1. Control de la hemorragia y tratamiento del shock. 2. Diagnóstico precoz y tratamiento rápido. 3. Restauración completa del flujo arterial en la operación inicial. 4. Resección del tejido arterial dañado y anastomosis término-terminal o con injerto de safena. 5. Utilización liberal de la heparina. 6. Trombectomía con catéter de Fogarty. 7. Reparación de las heridas venosas asociadas. 8. Recubrimiento con tejidos blandos de la reparación arterial. 9. Utilización de la arteriografía peroperatoria. 10. Fasciotomías utilizadas de formaliberal pero selectiva. 11. Tratamiento de las lesiones asociadas. En las heridas contaminadas los principios más importantes para prevenir la infección son: desbridamiento adecuado, irrigación abundante y cierre retrasado de la herida

The frequency of vascular injuries in civilian life has increased greatly. This is due to more traffic, labour and domestic accidents, the increase of violence in our society and the increasing number of iatrogenicvascular complications. The objective is of this study were to review the diagnosis and treatment of patients who sustained vascular injuries in the extremities.The most important steps in the management of vascular injuries are: 1. Control of haemorrhage and treatment of shock. 2. Early recognition and prompt treatment. 3. Complete restoration of arterial flow during the initial procedure. 4. Resection of damaged tissue with endto-end anastomosis or saphenous vein grafting. 5. Liberal employment of heparin. 6. Fogarty catheter thrombectomy. 7. Repair of associate venous injuries. 8. Soft tissue coverage of the site of arterial repair. 9. Use of completion arteriography. 10. Fasciotomy used liberallybut selectively. 11. Management of associated injuries.In contaminated wound the most important principles in prevention of infections are: adequate debridement, copious irrigation and delayed closure of the wound (AU)

[Advances in cardiac surgery]. / Progresos en cirugía cardiaca.

The development of cardiovascular surgery has been accompanied by a series of advances in complementary technology, which has made it possible to carry out safer and less aggressive surgery. In this article there is a review of the latest progress in coronary and valvular surgery, cardiac insufficiency, arrhythmia and the application of extracorporeal circulation in non-cardiac diseases. These advances can serve as the starting point in order to build a future adapted to the needs generated by both patient and disease.

[Large false aortic aneurysm after 30 years of a coarctation repair]. / Falso aneurisma aórtico 30 años después de la corrección de una coartación: tratamiento quirúrgico bajo hipotermia profunda.

We report a case of a large false aortic aneurysm that had developed in a 43-year-old man who had had coarctation repair 30 years previously. The coarctation repair had been done by inserting an end-to-end Dacron tubular graft which was sutured with silk. The re-operation was successfully performed under deep hypothermic arrest and it was noted that there was complete separation of the graft from both ends and no sutures were visualised. The deep hypothermic technique has considerably improved the ease and safety of this operation. We attribute this complication to the reabsorption of the silk sutures. Patients after coarctectomy with graft material should have regular chest X-rays for life in order to detect false aneurysms.

Reoperación coronaria por toracotomía izquierda sin circulación extracorpórea después de laringuectomía: seguimiento a nueve años / No disponible

La toracotomía izquierda es una vía de acceso alternativa en las reoperaciones coronarias en algunos enfermos en los cuales la reesternotomía puede ser peligrosa. Presentamos un enfermo en quien realizamos una reoperación coronaria sin circulación extracorpórea a través de una toracotomía izquierda para evitar una incisión quirúrgica en las proximidades de una traqueotomía permanente. Nueve años después el enfermo permanece asintomático. En casos seleccionados se pueden realizar reoperaciones coronarias sin circulación extracorpórea a través de una toracotomía izquierda con morbilidad y mortalidad bajas y con buenos resultados a largo plazo (AU)

The use of left thoracotomy is an alternative approach in redo coronary surgery in selected patients for whom median sternotomy is potentially hazardous. We present a patient in whom a redo reoperative coronary revascularization was performed off-pump via left thoracotomy to avoid a tracheal stoma. Nine years after reoperation the patient remains free of cardiac symptoms. In selected patients, redo coronary bypass grafting can be performed without cardiopulmonary bypass through a left thoracotomy, with a low perioperative morbidity and mortality rate and good long-term symptomatic improvement (AU)

Chronic aneurysm of the descending thoracic aorta presenting with right pleural effusion and left phrenic paralysis.

A 62-year-old man was admitted to the emergency department with chronic dysphagia and lower back pain. Chest radiography revealed a wide mediastinal shadow and an elevated left diaphragm, which proved to be secondary to left phrenic paralysis. The patient was diagnosed with an aneurysm of the descending thoracic aorta and was admitted to the hospital. After the patient was admitted, the aneurysm ruptured into the right chest. The patient underwent an emergency operation to replace the ruptured segment with a synthetic graft. Postoperative recovery and follow-up were uneventful. This report describes an unusual presentation of a thoracic aortic aneurysm. Hemidiaphragmatic paralysis caused by compression of the phrenic nerve is an unusual complication that, to our knowledge, has not been previously reported.

Eighteen-year follow up after Hancock II bioprosthesis insertion.

BACKGROUND AND AIM OF THE STUDY: The long-term (18 years) results after aortic (AVR), mitral (MVR) and double (aortic/mitral, DVR) valve replacement with Hancock II bioprosthesis were investigated. METHODS: Between 1978 and 1996, 279 Hancock II bioprostheses were implanted in 269 patients (166 males, 113 females; mean age 61.8+/-13.3 years). There were 135 AVR (48.4%), 122 MVR (43.8%) and 22 DVR (7.8%). Preoperatively, 208 patients (77.3%) were in NYHA functional class III/IV, 53 (19.7%) had previous cardiac surgery, and 19 (7.1%) underwent concomitant coronary artery bypass. Follow up (mean seven years) was 96% complete, with a total of 1,857 patient-years. RESULTS: There were 20 early (7.3%), and 78 (29.0%) late deaths. At the last follow up, 68.3% of patients were in NYHA functional class I/II. The actuarial survival rate of patients at 10 and 18 years after discharge was 67.7+/-5.0% and 44.7+/-8.8% after AVR and 64.5+/-5.6% and 32.7+/-11.5% after MVR, respectively; survival after DVR was 74.0+/-11.2% at 12 years. At 10 and 18 years, actuarial freedom from thromboembolism was 83.5+/-4.5% and 73.1+/-10.5% after AVR and 82.1+/-4.3% and 73.2+/-7.3% after MVR; it was 78.4+/-15.0% after DVR at 12 years. At these times, actuarial freedom from hemorrhage was 88.7+/-3.8% and 83.5+/-6.2% after AVR and 79.0+/-4.9% and 32.6+/-23.3% after MVR; freedom after DVR was 36.2+/-26.6%. Probability of freedom from endocarditis at 10 and >15 years was 93.4+/-3.5% and 85.9+/-7.8% after AVR and 97.0+/-2.1% and 97.0+/-2.1% for MVR, respectively; freedom at 10 years after DVR was 75.0+/-21.6%. Freedom from structural deterioration at 10 and 18 years was 77.9+/-5.3% and 18.7+/-14.6% after AVR and 78.3+/-6.0% and 32.1+/-10.2% after MVR; freedom at 10 and 12 years after DVR was 64.0+/-17.5% and 32.0+/-24.2%. A low incidence of structural valve deterioration was found in AVR patients aged >65 years (p = 0.0478). Hemorrhage and paravalvular leak were more frequent in MVR (p = 0.0296 and 0.0309, respectively). No difference was seen in thromboembolism after anticoagulation for one or three months after AVR. Actuarial freedom from explantation at 10 and 18 years was 73.1+/-5.9% and 15.9+/-13.5% after AVR and 77.1+/-6.1% and 37.3+/-9.7% after MVR; freedom at 10 and 12 years after DVR was 72.0+/-17.8% and 24.0+/-20.4%. CONCLUSION: Over an 18-year follow up, the Hancock II bioprosthesis has shown satisfactory results, with a low incidence of valve-related complications, especially in elderly patients in the aortic position.

Surgical approach for cardiac surgery in a patient with tracheostoma.

The thoracic approach for cardiac surgery in a patient with a tracheostoma can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a distinct approach consisting of an incision at the second intercostal space, transverse sternum transection and longitudinal median sternotomy to the xiphoid process, performed for coronary artery bypass grafting and aortic valve replacement, in a patient with previous tracheotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass, aortic valve replacement and coronary revascularization procedures.

Coronary angioplasty and stenting following heart transplantation with older donors. Is this a rational approach?

The shortage of ideal donor hearts has led to an extension of the classical donor criteria of age. Higher incidence of focal coronary artery disease has been found in this older donor population requiring conventional angioplasty therapy. The authors present two patients with early coronary angiogram post transplantation, requiring angioplasty and stent in the lesions found.

[Aneurysm of the ascending aorta in patients with a prior aortic valve replacement]. / Aneurisma de aorta ascendente en pacientes con sustitución valvular aórtica previa.

INTRODUCTION AND OBJECTIVES: The purpose of this study is to show our experience in the treatment of aneurysms of the ascending aorta in patients with previous aortic valve surgery. METHODS: We studied retrospectively the clinical characteristics and operative methods of 9 patients who underwent surgery for aneurysm of the ascending aorta after previous aortic valve replacement. RESULTS: Time interval between the first and subsequent reoperation was 8.4 +/- 3.5 years (range 4-15 years). During the first operation there were 5 cases who presented with aortic regurgitation and dilatation of the ascending aorta. Isolated valvular aortic replacement was performed in these patients. Two patients underwent valvular replacement and implantation of supracoronary aortic graft. In two other cases valvular replacement was done with wedge resection of the aortic sinuses. Reoperation was performed because to the following reasons: valvular prosthesis disfunction and aneurysm of the ascending aorta (3), valvular prosthesis disfunction and aneurysm of the aortic remnant located between the prosthesis and the supracoronary aortic graft (2), thrombosis of the prosthesis (1), dissection of the ascending aorta (2) and superior vena cava syndrome (1). There was one hospital death. Another patient died after 26 months because of graft infection. The other 7 patients are in functional class I. CONCLUSIONS: We conclude that an aggressive surgical approach should be adopted in patients with degenerative aortic regurgitation and moderate dilatation of the ascending aorta because of the rapid progression of the aortic disease. We advise complete replacement of the aortic root.

Does desmopressin acetate reduce blood loss after surgery in patients on cardiopulmonary bypass?

It has been suggested that desmopressin acetate (DDAVP) administration reduces blood loss after cardiac surgery. We have investigated the effect of DDAVP administration in a double-blind, randomized, prospective trial including 100 patients placed on cardiopulmonary bypass during surgery. Fifty patients received 0.3 micrograms/kg DDAVP and 50 patients received a placebo administered in a 50 ml saline solution over 15 min when cardiopulmonary bypass had been concluded. Results showed no significant differences either in total blood loss per square meter (458 +/- 206 ml in the DDAVP group vs 536 +/- 304 ml in the placebo group) or in necessity for red cell transfusions (1642 +/- 705 ml in the DDAVP group vs 1574 +/- 645 ml in the placebo group) in the first 72 hr after surgery. Only intraoperative blood loss per square meter was significantly lower (p less than .02) in the DDAVP group (131 +/- 106 ml) as compared with the placebo group (193 +/- 137 ml). The prolongation of bleeding time and the decrease of factor VIII:C and factor VIII:von Willebrand factor 90 min after treatment were significantly lower (p less than .001) in the DDAVP group as compared with the placebo group. We conclude that the administration of DDAVP in patients placed on cardiopulmonary bypass during surgery does not reduce total blood loss and is only effective in reducing intraoperative bleeding.