Tetralogy of Fallot Repair in Developing Countries: International Quality Improvement Collaborative.

BACKGROUND: Isolated reports from low- and middle-income countries (LMICs) for surgical results in tetralogy of Fallot (TOF) are available. The International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) seeks to improve surgical results promoting reductions in infection and mortality in LMICs. METHODS: All cases of TOF in the IQIC database performed between 2010 and 2014 at 32 centers in 20 LMICs were included. Excluded from the analysis were TOF with any associated lesions. A logistic regression analysis was performed to identify risk factors for in-hospital mortality after surgery for TOF. RESULTS: A total of 2,164 patients were identified. There were 1,839 initial primary repairs, 200 with initial systemic-to-pulmonary artery shunt, and 125 underwent secondary repair after initial palliation. Overall mortality was 3.6% (78 of 2,164), initial primary repair was 3.3% (60 of 1,839), initial systemic-to-pulmonary artery shunt was 8.0% (16 of 200), and secondary repair was 1.6% (2 of 125; p = 0.003). Major infections occurred in 5.9% (128 of 2,164) of the entire cohort. Risk factors for death after the initial primary repair were oxygen saturation less than 90% and weight/body mass index for age below the fifth percentile (p < 0.001). The initial primary repair occurred after age 1 year in 54% (991 of 1,839). Older age at initial primary repair was not a risk factor for death (p = 0.21). CONCLUSIONS: TOF patients are often operated on after age 1 year in LMICs. Unlike in developed countries, older age is not a risk factor for death. Nutritional and hypoxemic status were associated with higher mortality and infection. This information fills a critical knowledge gap for surgery in LMIC.

Histidine-Tryptophan-Ketoglutarate Solution versus Blood Cardioplegia in Cardiac Surgery: A Propensity-Score Matched Analysis.

BACKGROUND: Choosing a cardioplegic solution is a significant issue in modern cardiac surgery. Although different options are available, the optimal strategy for myocardial protection has not been established. The aim of this study was to compare intraoperative and postoperative effects of histidine-tryptophan-ketoglutarate (HTK) solution with those of standard blood cardioplegia with St Thomas No 2 solution. The study was conducted using a large cohort of adult patients undergoing complex cardiac surgery. METHODS: This study was a single center retrospective review of prospectively collected data. Between January 2008 and December 2015, 4480 patients underwent cardiac surgery using cardiopulmonary bypass (CPB) and cardioplegic arrest. Patients were divided into a blood cardioplegia group (n = 3852) and an HTK solution group (n = 628). Propensity score matching was used to adjust for differences between the two groups, and 292 matched pairs were identified. The primary end point was Intensive Care Unit (ICU) length of stay (LOS). Secondary end points included intraoperative changes in serum sodium concentration, readmission to ICU, transfusion of blood products, 30-day hospital readmission, 30-day mortality, and the incidence of major postoperative complications. Results: No significant differences were found between the matched groups with regard to baseline characteristics. Aortic cross-clamp and CPB times were longer for the blood cardioplegia (147.4 versus 132.8 min; P < .001). Administration of HTK solution was associated with acute and transient hyponatremia (141 versus 130 mmol/L; P < .001). ICU LOS was comparable between the groups (5.4 versus 5.4 days; P = .585). No significant differences were noted in any other secondary end point. CONCLUSIONS: During complex cardiac surgery, both cardioplegia techniques were equivalent in terms of early clinical outcomes.

Factors associated with delayed cardiac tamponade after cardiac surgery.

CONTEXT: Cardiac tamponade (CT) following cardiac surgery is a potentially fatal complication and the cause of surgical reintervention in 0.1%-6% of cases. There are two types of CT: acute, occurring within the first 48 h postoperatively, and subacute or delayed, which occurs more than 48 h postoperatively. The latter does not show specific clinical signs, which makes it more difficult to diagnose. The factors associated with acute CT (aCT) are related to coagulopathy or surgical bleeding, while the variables associated with subacute tamponade have not been well defined. AIMS: The primary objective of this study was to identify the factors associated with the development of subacute CT (sCT). SETTINGS AND DESIGN: This report describes a case (n = 80) and control (n = 160) study nested in a historic cohort made up of adult patients who underwent any type of urgent or elective cardiac surgery in a tertiary cardiovascular hospital. Methods: The occurrence of sCT was defined as the presence of a compatible clinical picture, pericardial effusion and confirmation of cardiac tamponade during the required emergency intervention at any point between 48 hours and 30 days after surgery. All factors potentially related to the development of sCT were taken into account. STATISTICAL ANALYSIS USED: For the adjusted analysis, a logistical regression was constructed with 55 variables, including pre-, intra-, and post-operative data. RESULTS: The mortality of patients with sCT was 11% versus 0% in the controls. Five variables were identified as independently and significantly associated with the outcome: pre- or post-operative anticoagulation, reintervention in the first 48 h, surgery other than coronary artery bypass graft, and red blood cell transfusion. CONCLUSIONS: Our study identified five variables associated with sCT and established that this complication has a high mortality rate. These findings may allow the implementation of standardized follow-up measures for patients identified as higher risk, leading to either early detection or prevention.

Identification of clinically relevant phenotypes in patients with Ebstein anomaly.

BACKGROUND: Ebstein anomaly (EA) is a heterogeneous congenital heart defect (CHD), frequently accompanied by diverse cardiac and extracardiac comorbidities, resulting in a wide range of clinical outcomes. HYPOTHESIS: Phenotypic characterization of EA patients has the potential to identify variables that influence prognosis and subgroups with distinct contributing factors. METHODS: A comprehensive cross-sectional phenotypic characterization of 147 EA patients from one of the main referral institutions for CHD in Colombia was carried out. The most prevalent comorbidities and distinct subgroups within the patient cohort were identified through cluster analysis. RESULTS: The most prevalent cardiac comorbidities identified were atrial septal defect (61%), Wolff-Parkinson-White syndrome (WPW; 27%), and right ventricular outflow tract obstruction (25%). Cluster analysis showed that patients can be classified into 2 distinct subgroups with defined phenotypes that determine disease severity and survival. Patients in cluster 1 represented a particularly homogeneous subgroup with a milder spectrum of disease, including only patients with WPW and/or supraventricular tachycardia (SVT). Cluster 2 included patients with more diverse cardiovascular comorbidities. CONCLUSIONS: This study represents one of the largest phenotypic characterizations of EA patients reported. The data show that EA is a heterogeneous disease, very frequently associated with cardiovascular and noncardiovascular comorbidities. Patients with WPW and SVT represent a homogeneous subgroup that presents with a less severe spectrum of disease and better survival when adequately managed. This should be considered when searching for genetic causes of EA and in the clinical setting.

Thermogenic capacity of human periaortic adipose tissue is transformed by body weight.

The anatomical location of adipose tissue might have direct implications for its functionality and risk of cardiovascular disease. Adipose tissue surrounding blood vessels may be thermogenically more active in specific areas of the body, releasing substances that regulate vascular metabolism. In humans, the phenotypic characteristics of adipose tissue surrounding the aorta and the cardiovascular disease risk that it might entail remain largely unknown. Here, we compared thermogenesis-related molecular features of human periaortic adipose tissue samples with those of subcutaneous adipose tissue, obtained by sternotomy from 42 patients undergoing cardiovascular surgery. To determine the expression of genes related to energy expenditure and the levels of some adipokines, histological examinations, quantitative PCR, and protein expression measurements in adipocyte precursor cells were performed. Periaortic adipocytes were smaller than those from subcutaneous tissue. Moreover, weight gain induced periaortic adipocyte hypertrophy (r = -0.91, p<0.01). Compared to subcutaneous tissue, adiponectin, FABP4, IL-4 and IL-6 was decreased in periaortic adipocytes, whereas FGF21, UCP-1, PGC-1a, CITED1, Omentin and TFAM (Mitochondrial protein) increased. Upon analyzing patients' clinical conditions, it emerged that the levels of PGC-1a both in male (r = -0.48 p<0.04) and female (r = -0.61, p<0.05) and TFAM in male (r = -0.72, p<0.0008) and female (r = -0.86, p<0.002) decreased significantly with progressive weight gain. However, no differences were observed in patients with diabetes mellitus 2 or Hyperlipidemia. Adipocytes surrounding the ascending aorta present markers of major thermogenic activity than those in subcutaneous tissue. Nevertheless, this characteristic might change, due to unfavorable metabolic conditions such as obesity, which is a risk factor for cardiovascular disease.

Functional Characterization of Preadipocytes Derived from Human Periaortic Adipose Tissue.

Adipose tissue can affect the metabolic control of the cardiovascular system, and its anatomic location can affect the vascular function differently. In this study, biochemical and phenotypical characteristics of adipose tissue from periaortic fat were evaluated. Periaortic and subcutaneous adipose tissues were obtained from areas surrounding the ascending aorta and sternotomy incision, respectively. Adipose tissues were collected from patients undergoing myocardial revascularization or mitral valve replacement surgery. Morphological studies with hematoxylin/eosin and immunohistochemical assay were performed in situ to quantify adipokine expression. To analyze adipogenic capacity, adipokine expression, and the levels of thermogenic proteins, adipocyte precursor cells were isolated from periaortic and subcutaneous adipose tissues and induced to differentiation. The precursors of adipocytes from the periaortic tissue accumulated less triglycerides than those from the subcutaneous tissue after differentiation and were smaller than those from subcutaneous adipose tissue. The levels of proteins involved in thermogenesis and energy expenditure increased significantly in periaortic adipose tissue. Additionally, the expression levels of adipokines that affect carbohydrate metabolism, such as FGF21, increased significantly in mature adipocytes induced from periaortic adipose tissue. These results demonstrate that precursors of periaortic adipose tissue in humans may affect cardiovascular events and might serve as a target for preventing vascular diseases.

Fibroelastoma papilar incidental o sintomático ¿Debeintervenirse? / Incidental or symptomatic papillary fibroelastoma: Should it be treated?

Resumen El fibroelastoma papilar, también conocido como papiloma fibroelástico, es un tumor benigno poco común, que se puede observar en las válvulas cardíacas o, en algunas ocasiones, en el endocardio ventricular. Se describen dos casos; el primero corresponde a un paciente de 72 años con fibrilación auricular paroxística, asintomático por lo demás, en quien en estudio de su fibrilación auricular se evidenció masa pediculada de 1 y 1 cm dependiente de la válvula pulmonar y por riesgo de embolia se llevó a cirugía en la que se resecó masa, sin complicaciones. El reporte de histopatología fue positivo para fibroelastoma papilar. El segundo caso es una paciente de 67 años, sintomática, con angina de esfuerzo en quien, mediante ecocardiograma transtorácico, se documentó masa de 1,5 y 1,5 cm dependiente de la valva coronariana derecha, se consideraron síntomas secundarios a la masa. Se llevó a cirugía por técnica mínimamente invasiva y se resecó la masa. El reporte de histopatología fue positivo para fibroelastoma papilar. Conclusión: el fibroelastoma papilar es una causa poco frecuente pero cada vez más reconocida de fenómenos embólicos. Su identificación oportuna permite la extirpación de la lesión, que es aparentemente curativa, segura y bien tolerada.

Abstract The papillary fibroelastoma, also known as fibroelastic papilloma, is a fairly uncommon benign tumour that can be found in cardiac valves or, in some occasions in the ventricular endocardium. Two cases are presented, with the first corresponding to a 72 year-old patient with intermittent atrial fibrillation, with no other symptoms. During the study of the atrial fibrillation, a pedunculated mass of 1 × 1 cm was observed hanging from the pulmonary valve. Due to the risk of emboli, the patient was taken to surgery where the mass was resected with no complications. The histopathology reported positive for a papillary fibroelastoma. The second case was a 67 year-old patient with symptoms of with angina of effort, which on observing a mass of 1.5 × 1.5 cm hanging from the right coronary valve, they were considered as symptoms secondary induced by the mass. He was taken to surgery, and the mass was resected using a minimally invasive technique. The histopathology reported positive for a papillary fibroelastoma. Conclusion: Papillary fibroelastoma is a rare cause, but increasingly recognised due to its embolic phenomena. Their timely identification allows the lesion to be extirpated, which is apparently curative, safe and well tolerated.

Factores asociados a insuficiencia renal postoperatoria en cirugía de revascularización miocárdica / Factors associated to postoperative kidney failure following myocardial revascularisation

Objetivos: Determinar qué antecedentes clínicos del paciente y factores del procedimiento quirúrgico se asocian con la aparición de insuficiencia renal postoperatoria en pacientes sometidos a cirugía de revascularización miocárdica. Métodos: estudio llevado a cabo entre enero de 2005 y diciembre de 2013, de casos y controles anidado en una cohorte, en la que se incluyeron pacientes sometidos a cirugía de revascularización miocárdica electiva que presentaron insuficiencia renal postoperatoria durante el postoperatorio inmediato hasta el egreso. Los controles estuvieron conformados por pacientes sometidos a cirugía de revascularización miocárdica electiva que no desarrollaron insuficiencia renal postoperatoria inmediata hasta el egreso. Se realizó un modelo de regresión logística para determinar los factores asociados a insuficiencia renal postoperatoria. Las asociaciones se expresaron en razones de disparidad con sus respectivos intervalos de confianza. Resultados: la edad avanzada {OR 1,03 IC95% (1,01-1,04){, la presencia preoperatoria de diabetes mellitus {OR 1,8 IC95% (1,9-3,4){, la insuficiencia cardiaca {OR 2,7 IC 95% (1,1-6,7){ y el mayor tiempo de perfusión {OR 1,02 IC 95% (1,01-1,03){ se asociaron con mayor riesgo de insuficiencia renal postoperatoria, en tanto que el mayor hematocrito {OR 0,86 IC95% (0,82-0,91){ y la mayor fracción de eyección {OR 0,94 IC95% (0,92-0,96){ se relacionaron con disminución del riesgo de insuficiencia renal postoperatoria. Conclusiones: En quienes se realizó revascularización miocárdica los factores asociados a la presentación de insuficiencia renal postoperatoria fueron comorbilidades que se relacionaron con daño renal progresivo dentro y fuera del contexto de la cirugía. Esto implica que las estrategias para minimizar este evento estarán enfocadas a identificar de manera oportuna a estos pacientes y proporcionarles nefroprotección adecuada.

Motivation: To determine which medical history and surgical procedure factors are associated to the onset of postoperative kidney failure in patients undergoing myocardial revascularisation. Methods: Case-control cohort study carried out between January 2005 and December 2013 which included patients who had undergone elective myocardial revascularisation and showed postoperative kidney failure immediately after surgery and until discharge. Controls consisted of patients who had undergone elective myocardial revascularisation and did not develop postoperative kidney failure immediately after surgery. A logistic regression model was used to determine the factors associated to postoperative kidney failure. Associations were expressed as grounds of disparity with their corresponding confidence intervals. Results: old age {OR 1.03 CI 95% (1.01-1.04){, preoperative presence of diabetes mellitus {OR 1.8 CI 95% (1.9-3.4)}, cardiac insufficiency {OR 2.7 CI 95% (1.1-6.7)} and a longer perfusion time {OR 1.02 CI 95% (1.01-1.03)} were associated to a higher risk of postoperative kidney failure, while higher hematocrit {OR 0.86 CI 95% (0.82-0.91)} and higher ejection fraction {OR 0.94 CI 95% (0.92-0.96)} were associated with a decrease of the risk of postoperative kidney failure. Conclusions: In patients who had undergone myocardial revascularisation, risk factors associated to postoperative kidney failure where comorbidities related to internal and external gradual kidney damage outside the context of the surgery. This implies that strategies to minimise this event should be focused on identifying these patients in a timely manner and offering appropriate nephroprotection.

Resultados del tratamiento quirúrgico de los aneurismas de aorta abdominal infrarrenal / Results of surgical treatment of infrarenal abdominal aortic aneurysms

Introducción: Los resultados del tratamiento quirúrgico de los aneurismas de aorta abdominal dependen de múltiples factores asociados al paciente y a la experiencia del grupo tratante. Objetivos: Describir los resultados obtenidos en el tratamiento quirúrgico de aneurismas de aorta abdominal por un grupo multidisciplinario y evaluar el impacto del volumen de casos año y de la experiencia adquirida. Métodos: Cohorte histórica de pacientes con diagnóstico de aneurisma de aorta abdominal sometidos a tratamiento quirúrgico desde junio de 1994 a junio de 2013, en la que se establecieron tres grupos: Grupo 1, aneurisma roto reparo abierto; Grupo 2, pacientes electivos reparo abierto; Grupo 3, pacientes electivos reparo endovascular. El desenlace primario a evaluar fue mortalidad hospitalaria, y el secundario, morbilidad asociada con el procedimiento. Para el análisis, la cohorte se dividió en dos: casos intervenidos de 1994 a 2002 y casos de 2002 a 2013, fundamentado en la implementación del programa endovascular en la institución en 2002. Resultados: Se intervinieron 573 pacientes en total. En el Grupo 1, 65; en el 2, 433, y en el 3, 75. La mortalidad global fue de 28,6, 2,8 y 1,3% respectivamente. Se demostró un incremento significativo en el volumen de casos (233%) y una reducción importante en la mortalidad de los casos abiertos después de 2002 (4,8 vs. 2,0%, p = 0,19). Conclusiones: La implemetación de la terapia endovascular ha contribuido a aumentar el número de pacientes tratados con aneurisma de aorta abdominal en nuestra institución. El aumento del volumen se tradujo en disminución efectiva de la mortalidad.

Introduction: Surgical treatment outcomes for infrarenal abdominal aortic aneurysm repair depend on patient factors and attending vascular team expertise. Objetives: To describe the outcomes of surgical treatment of abdominal aortic aneurysm performed by an interdisciplinary team and to evaluate the effects of annual caseload and acquired expertise. Methods: Historic cohort of patients with abdominal aortic aneurysm diagnosis surgically treated from January 1994 to June 2013. Three groups were established: Group 1 was for open ruptured abdominal aortic aneurysm repair, Group 2 was for open elective repair and Group 3 was for elective endovascular aneurysm repairs. Primary outcome was in-hospital mortality, and secondary outcomes were peri-procedural morbidity. For analysis the cohort was divided in two: cases repaired from 1994 to 2002 and from 2002 to 2013. This was based in the implementation of endovascular therapy from 2002 at the institution. Results: 573 patients were treated; Group 1: 65 patients; Group 2: 433 patients; Group 3: 75 patients. Mortality was 28.6%, 2.8% and 1.3% respectively. A significant rise in annual caseload (233%) was demonstrated and a trend toward lowering in surgical mortality (4.8 vs. 2.0%, p = 0.19) after 2002. Conclusions: Implementation of endovascular repair has contributed to rising annual caseload of patients with abdominal aortic aneurysm at our institution. This rising in volume correlates with effective lowering in mortality.

Factores asociados a la aparición de mediastinitis en 2073 revascularizaciones miocárdicas / Factors associated with the onset of mediastinitis in 2073 myocardial revascularizations

Introducción: La mediastinitis, entidad de etiología multifactorial, ocurre hasta en 4% de los pacientes sometidos a revascularización miocárdica, y se reporta una mortalidad hospitalaria de 14% a 47%, que genera aumento en los costos de atención y deterioro de la calidad de vida así como de la sobrevida del paciente a largo plazo. Objetivo: Determinar cuáles antecedentes clínicos del paciente y factores relacionados con el procedimiento quirúrgico se asocian con la aparición de mediastinitis. Materiales y métodos: Diseño de casos y controles anidado en una cohorte histórica de pacientes sometidos a revascularización miocárdica en el periodo de enero de 2005 a julio de 2011. Los pacientes con mediastinitis se compararon con un grupo control sin mediastinitis tomados del mismo grupo de riesgo en una relación 1:4, y pareados por fecha de cirugía. El diagnóstico de mediastinitis se hizo con criterios clínicos, de laboratorio y hallazgos quirúrgicos. Resultados: Se identificaron treinta casos en el periodo relacionado. Los factores asociados a la aparición del evento fueron: diabetes mellitus OR 2,3 (1,1-4,9), uso de circulación extracorpórea OR 2,4 (1,1-5,5), tiempo de perfusión OR 1,1 (1,1-1,3) y pacientes mayores de 70 años OR 1,1 (1,2-1,4). Conclusiones: La mediastinitis sigue siendo una complicación de baja prevalencia con consecuencias devastadoras. El impacto clínico y económico de esta complicación debe obligar a los grupos quirúrgicos a crear estrategias de prevención con base en el conocimiento de los factores de riesgo de su población.

Introduction: Mediastinitis is a multifactorial entity which occurs in up to 4% of patients undergoing coronary artery bypass graft (CABG). It has a hospital mortality of 14% to 47%, which generates increased costs of care and deterioration of the quality of life and patient survival in the long term. Objective: To determine which clinical antecedents and factors related to the surgical procedure are associated with the occurrence of mediastinitis. Materials and methods: A nested case control study in a historical cohort of patients undergoing CABG in the period January 2005 to July 2011. Patients with mediastinitis were compared with a control group without mediastinitis taken from the same risk group in a 1:4 ratio and matched for date of surgery. The diagnosis of mediastinitis was made on clinical and laboratory criteria and surgical findings. Results: Thirty cases were identified in the related period. Factors associated with the occurrence of the event were: diabetes mellitus OR 2.3 (1.1 to 4.9), use of extracorporeal circulation OR 2.4 (1.1-5.5), OR 1 perfusion time, 1 (1.1 to 1.3) and patients older than 70 years OR 1.1 (1.2-1.4). Conclusions: Mediastinitis remains complications of low prevalence with devastating consequences. The clinical and economic impact of this complication should compel surgical groups to create prevention strategies based on knowledge of the risk factors of the population.

La enfermera y su papel en el cuidado del paciente de cirugía cardiovascular / The nurse and its role in the care of the patient with cardiovascular surgery

El cuidado postoperatorio del paciente de cirugía cardiovascular requiere de un trabajo en equipo coordinado, que busque el cumplimiento de objetivos de atención integral y que asegure una gran experiencia al enfermo y su familia, con los mejores estándares de atención. Parte fundamental de este equipo es el grupo de enfermería, el cual, en gran número de instituciones, está compuesto por personal especializado en cuidado crítico o tiene amplia experiencia en el cuidado de pacientes cardiovasculares. El grupo de enfermería aborda la atención del paciente desde todas las esferas del cuidado, como bien lo expone el artículo de Ariza (1), y logra una compresión integral del paciente más allá de los parámetros biológicos que en general direccionan el cuidado médico tradicional. Así mismo, da a conocer uno de los múltiples enfoques o teorías desarrolladas por los grupos de enfermería para el abordaje de cuidado de los pacientes. Adicionalmente, los conceptos expuestos en este documento reflejan la delicada integración entre la evaluación cualitativa y cuantitativa de un paciente en el postoperatorio. Si bien los resultados del estudio se centran en los resultados cualitativos, permiten entrever que una evaluación sistemática enfocada en objetivos conducirá a intervenciones tempranas que prevengan o minimicen la severidad de eventos fisiopatológicos adversos.

Escalas de riesgo en cirugía cardiaca: ¿qué predicen, para quién y para qué? / Risk Scales in Cardiac Surgery: what do they predict, for whom and for what?

El "riesgo" inherente a todos los procedimientos médicos y quirúrgicos ha generado esfuerzos multidisciplinarios para prevenirlo, controlarlo y minimizar sus implicaciones; ejemplo de esto son las escalas de predicción de riesgo de mortalidad y morbilidad en cirugía cardiaca. La literatura ha demostrado que hay muchas razones para predecir el riesgo de mortalidad en pacientes de cirugía cardiaca: planear el cuidado intra y postoperatorio, calcular el riesgo preciso y realista de un paciente de muy alto riesgo especialmente cuando las indicaciones de cirugía no son absolutamente claras, monitorizar la calidad del cuidado de las instituciones donde se atiende una proporción importante de pacientes de alto riesgo, evaluar mortalidad secundaria al factor humano, rotación de residentes, ajuste del riesgo de mortalidad en cirugías complejas, entre otras. De otro lado, los grupos quirúrgicos aquejan la necesidad de una evaluación de riesgo preoperatoria que permita avalar la decisión quirúrgica sobre determinado paciente, plenamente justificada según los riesgos y beneficios, aunado a la percepción generalizada que en la última década los pacientes son de mayor de riesgo y que por lo tanto han contribuido al cambio en la mortalidad, situación que, según se ha observado, ocurre hacia ambos extremos: aumento en la cantidad de pacientes de alto y bajo riesgo. Uno de los puntos más importantes para la evaluación del riesgo es la selección de un modelo que se ajuste mejor a la población objeto del grupo quirúrgico; si se tiene en cuenta que estos modelos varían con la población y el tiempo, su selección inadecuada podría beneficiar o perjudicar la evaluación objetiva de los pacientes, mientras que un modelo adecuado para un grupo, en un momento podría sobre o subvalorar el riesgo en otros grupos en el futuro, cuando los estándares del momento exijan mejores resultados .

Risk factors associated with postoperative seizures in patients undergoing cardiac surgery who received tranexamic acid: a case-control study.

Antifibrinolytic agents are used during cardiac surgery to minimize bleeding and reduce exposure to blood products. Several reports suggest that tranexamic acid (TA) can induce seizure activity in the postoperative period. To examine factors associated with postoperative seizures in patients undergoing cardiac surgery who received TA. University-affiliated hospital. Case-control study. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) between January 2008 and December 2009 were identified. During this time, all patients undergoing heart surgery with CPB received TA. Cases were defined as patients who developed seizures that required initiation of anticonvulsive therapy within 48 h of surgery. Exclusion criteria included subjects with preexisting epilepsy and patients in whom the convulsive episode was secondary to a new ischemic lesion on brain imaging. Controls who did not develop seizures were randomly selected from the initial cohort. From an initial cohort of 903 patients, we identified 32 patients with postoperative seizures. Four patients were excluded. Twenty-eight cases and 112 controls were analyzed. Cases were more likely to have a history of renal impairment and higher preoperative creatinine values compared with controls (1.39 ± 1.1 vs. 0.98 ± 0.02 mg/dL, P = 0.02). Significant differences in the intensive care unit, postoperative and total lengths of stay were observed. An association between high preoperative creatinine value and postoperative seizure was identified. TA may be associated with the development of postoperative seizures in patients with renal dysfunction. Doses of TA should be reduced or even avoided in this population.

The presence of abdominal obesity is associated with changes in vascular function independently of other cardiovascular risk factors.

BACKGROUND: Because of the strong association between abdominal obesity (AO) and other cardiovascular risk factors, it has been difficult to determine which changes in vascular function are directly related to this condition. Our objective was to evaluate the changes in ex-vivo vascular reactivity, circulating levels of adipokines and inflammatory markers associated with the presence of AO in subjects who underwent coronary artery bypass graft (CABG) controlling by the presence of other cardiovascular risk factors. METHODS: Subjects scheduled for a CABG with (n=17) and without (n=17) AO (defined as a waist circumference > or =90 cm for male or > or =80 cm for female) whom were matched by several cardiovascular risk factors, were included in the study. Lipid profile and plasma levels of glucose, insulin, leptin, adiponectin and inflammatory markers were measured. Internal mammary artery segments were used for ex-vivo vascular reactivity experiments and morphometry. RESULTS: Leptin concentrations were higher and adiponectin concentrations were lower in subjects with AO. No differences were observed in other biochemical or clinical parameters between the groups. No correlation between waist circumference, HOMA index and inflammatory markers were observed. Endothelium-dependent relaxation to acetylcholine was lower, and contractile responses to angiotensin-II were higher in subjects with AO. These changes were not related to differences in vascular morphometry. CONCLUSION: In subjects with severe coronary disease, the presence of AO was associated with leptin/adiponectin imbalance, decreased endothelium-dependent relaxation and an enhanced response to angiotensin-II. These changes occurred independently of other cardiovascular risk factors including insulin resistance and levels of inflammatory markers.

Experiencia en el manejo endovascular para el tratamiento de la aorta torácica / Experience in endovascular management for thoracic aorta treatment

Antecedentes: el tratamiento endovascular ofrece la posibilidad de cubrir el origen de la disección y evitar que progrese hasta aneurisma de la aorta, y con ello demuestra una reducción en la mortalidad hasta del 16 porciento.Objetivo: evaluar los resultados quirúrgicos en términos de morbi-mortalidad de los pacientes sometidos a manejo endovascular de las lesiones de la aorta torácica en la Fundación Cardiovascular de Colombia desde 2003 hasta 2005. Diseño–método: estudio longitudinal tipo descriptivo retrospectivo, en el que se evaluaron las historias clínicas de todos los pacientes sometidos a manejo endovascular de patología toracoabdominal; en éste sólo se incluyeron los pacientes con procedimientos de la aorta torácica, desde 2003 hasta 2005. El análisis de los datos se realizó en Stata/SE 8,0...

Endarterectomía carotídea en pacientes sintomáticos y asintomáticos: resultados de morbi-mortalidad desde 1998 hasta 2005 / Carotid endarterectomy in symptomatic and asymptomatic patients: morbid-mortality results from 1998 to 2005

Antecedentes: el accidente cerebrovascular es la tercera causa de muerte y probablemente la causa más importante de discapacidad a largo plazo. La tasa de mortalidad está entre 15% y 35% con el primer ataque y se eleva a 65% para los accidentes cerebrovasculares subsiguientes. Los resultados a largo y mediano plazo avalan esta técnica quirúrgica para el tratamiento de la enfermedad carotídea, al demostrar altos perfiles de seguridad. Objetivo: determinar los resultados de morbilidad y mortalidad quirúrgica y a 3, 6 y 12 meses de seguimiento, en los pacientes sometidos a endarterectomía carotídea desde 1998 hasta septiembre de 2005. Diseño-método: se evaluaron las historias clínicas de los pacientes sometidos a endarterectomía carotídea, desde 1998 hasta septiembre de 2005. Resultados: se realizaron 42 procedimientos desde 1998 hasta septiembre de 2005; el 57% de los pacientes eran hombres, con edad promedio de 68,8 ± 9,9 años. Los antecedentes de importancia fueron: hipertensión arterial (82%), tabaquismo (61%) y dislipidemia (50%). El 82% de los pacientes mostraban síntomas de enfermedad carotídea. Once pacientes tuvieron lesión de carótida derecha, 16 de carótida izquierda y 15 lesión bilateral, con un promedio de obstrucción de 85 ± 11,4%. La mortalidad fue de 4,7% y no estaba relacionada con el procedimiento quirúrgico. A septiembre de 2005 el 57% de los pacientes egresados estaban libres de síntomas. Conclusiones: la mortalidad para este grupo de pacientes es comparable con los resultados publicados en todo el mundo. La seguridad del procedimiento avala esta técnica quirúrgica como la primera opción en el manejo de la patología carotídea.

Antecedents: cerebrovascular disease is the third cause of death and probably the most common cause of significant long term disability. Mortality rate with first stroke is between 15% and 35% and goes up to 65% with subsequent strokes. Results at long and middle term endorse carotid endarterectomy for carotid artery disease treatment by demonstrating high safety profiles. Objective: to determine the surgical morbidity and mortality results at 3, 6 and 12 months of follow-up in patients submitted to carotid endarterectomy from 1998 to 2005. Design-Method: clinical histories of patients submitted to carotid endarterectomy from 1998 to September 2005 were evaluated. Results: 42 procedures were realized since 1998 until September 2005. 57% of the patients were men with mean age 68.8 ± 9.9 years. Important antecedents were arterial hypertension (82%), cigarette smoking (61) and dyslipidemia (50%). 82% showed symptoms of carotid disease. 11 patients had right carotid lesion and in 15 the lesion was bilateral, with mean obstruction of 85 ± 11.4%. Mortality was 4.7% and was not related to the surgical procedure. At September 2005, 57% of the discharged patients were asymptomatic. Conclusions: mortality for this group of patients is comparable to the worldwide published results. Procedure safety guarantees this surgical technique as the first option in this carotid pathology management.

Tratamiento de aorta abdominal e ilíacas con técnica endovascular / Treatment of abdominal aorta and iliac arteries with endovascular technique

Antecedentes: desde 1991 la técnica endovascular se ha aplicado con éxito en el manejo de los aneurismas de aorta infrarrenal, y se ha perfeccionado de manera tal que rápidamente se ha convertido en una alternativa para pacientes de alto riesgo para la cirugía convencional. Objetivo: describir los resultados institucionales en el manejo de las patologías de aorta abdominal e ilíacas mediante técnica endovascular desde 2003 a 2005.Diseño-Método: estudio descriptivo, longitudinal, retrospectivo, en el que se analizaron las historias clínicas de los pacientes sometidos a procedimiento endovascular de aorta abdominal e ilíacas. El análisis se realizó en Stata 8,0 S/E...

Antecedents: since 1991 endovascular technique has been successfully used in the management of infra-renal aortic aneurysms and it has been improved in such a way that it has quickly turned into an alternative for patients considered having high risk for conventional surgery. Objective: describe the institutional results in the management of abdominal aortic pathologies through endovascular technique from 2003 to 2005. Design-Method: descriptive, longitudinal, retrospective study in which clinical histories of patients that underwent an endovascular procedure of abdominal aorta and iliac arteries were analyzed. The analysis was performed in Stata 8,0 S/E. Results: 9 patients received exclusively treatment for abdominal aortic and iliac lesions. All were male individuals with mean age 68.9 ± 8.1 years. 6 patients had diagnosis of infra-renal aortic aneurysm and the other 3 had anastomotic aneurysms. Requirement of endoprosthesis was evidenced in an average of 1.9 ± 0.8. Femoro-femoral bypass surgery was performed as simultaneous procedure in 4 of the 9 patients. 77.8% of patients had no complications. Mortality due to the procedure was 22% (2 patients) and it is important to notice that only these 2 patients had complications. Conclusions: exclusion of aortic and iliac aneurysms with modular endoprosthesis is being widely implemented as a valid treatment option, with excellent results that avoid the risks of conventional surgery and its associated morbidity.

Papel del tejido perivascular en la regulación del tono vascular: repercusión en el uso de puentes aorto-coronarios para revascularización miocárdica / Role of perivascular tissue in vascular tone regulation: repercussion in the use of aortocoronary bypass for myocardial revascularization

Desde hace más de treinta años, la inserción quirúrgica de puentes aorto-coronarios autólogos de vena safena y de arteria mamaria, constituye el tratamiento de elección para pacientes con enfermedad coronaria severa. La vida útil de estos injertos ha demostrado ser mayor en los colgajos de tipo arterial, aunque su uso está limitado por la restringida disponibilidad de los mismos. Por esta razón, y a pesar de que tienen mayor riesgo de presentar oclusión, los injertos de vena safena son los que más se usan en estos procedimientos de reperfusión miocárdica. Aún no se han esclarecido del todo las razones por las cuales los injertos venosos se ocluyen luego de su inserción en los lechos arteriales; no obstante, se ha propuesto que podría deberse a diferentes factores como: trauma mecánico quirúrgico, aumento de la presión arterial y disminuido estrés de fricción.En 1996 se describió la técnica no-touch de preparación de los injertos venosos, en la cual se implantaron los puentes venosos en los lechos coronarios junto con el tejido peri-vascular que los circunda, y demostró mejorar la vida útil de este tipo de injertos. Recientemente se ha propuesto que el tejido adiposo peri-vascular podría desempeñar un papel en la regulación del tono vascular, e incluso se ha descrito la existencia de un factor relajante derivado del adipocito (ADRF), cuya naturaleza no se ha esclarecido completamente.El objetivo de este articulo es revisar los diferentes factores vinculados con la oclusión de los injertos aorto-coronarios, las posibles vías fisiopatológicas que configuran este fenómeno, las nuevas alternativas quirúrgicas utilizadas para la preparación de los injertos venosos y los avances en la descripción del ADRF y su papel en la regulación del tono vascular.

Since more than thirty years, surgical insertion of autologous aortocoronary bypasses from saphenous vein and mammary artery constitute the election treatment for patients with severe coronary disease. The lifespan of these grafts has shown to be longer with arterial tissue even though its use is limited by its restricted availability. This is why the saphenous vein bypasses, although having a greater risk of presenting occlusion, are the most used in these procedures of myocardial reperfusion. The reasons by which the venous grafts are occluded after its insertion in the arterial site are still not clear; nevertheless, it has been proposed that it could be due to different factors such as: surgical mechanical trauma, increment of arterial pressure and diminished friction stress. In 1996 the «no-touch¼ preparation technique of venous grafts was described, in which the venous bypasses were implanted in the coronary site along with the surrounding perivascular tissue and demonstrated to improve the lifespan of this type of grafts. Recently it has been proposed that the perivascular fat tissue could play a role in the vascular tone regulation and it has been even described the existence of an adipose cell derived relaxing factor (ADRF), whose nature has not been completely cleared yet. The objective of this article is to review the different factors related to the aortocoronary grafts’ occlusion, the possible physiopathologic channels that form this phenomenon, the new surgical alternatives used for vein grafts preparation and the advances in the description of ADRF and its role in vascular tone regulation.

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.

Cambio valvular mitral, aórtico o mitro-aórtico en pacientes con baja fracción de eyección / Mitral, aortic or mitral-aortic valvular replacement in patients with low ejection fraction

La decisión de someter a cambio valvular a un paciente con disfunción ventricular moderada a severa, es motivo de controversia debido a las complicaciones y los malos resultados a corto y largo plazo. El objetivo de este estudio fue evaluar los resultados quirúrgicos en los pacientes con baja fracción de eyección pre-quirúrgica sometidos a cambio valvular mitral aórtico o mitro-aórtico. En este tipo de pacientes se puede obtener una aceptable sobrevida libre de sintomas. La clase funcional IV de la New York Heart Association incrementa la mortalidad temprana y tardía. La marcada reducción de la fracción de eyección preoperatoria, no debe considerse como una contraindicación para cambio valvular.

The decision to submit patients with moderate to severe ventricular dysfunction to valvular replacements is subject to controversy because complications and the adverse outcomes in short and long-term. The aim of this study was to evaluate the outcomes in mitral or aortic valve replacements or combined aortic and mitral valve replacements in patients with preoperative low left ventricular ejection fraction. Good symptomatic relief and acceptable overall survival can be obtained in patients with systolic dysfunction and valvular disease. Preoperative NYHA class IV increases early and late mortality. A marked ejection fraction reduction should not be considered a contraindication for valvular replacement.