Clinical and hemodynamic outcomes and mortality risk factors in patients undergoing pulmonary thromboendarterectomy / Resultados clínicos y hemodinámicos y factores de riesgo de mortalidad en pacientes sometidos a tromboendarterectomía pulmonar

Abstract Background: Pulmonary thromboendarterectomy is the current treatment of choice in patients with chronic thromboembolic pulmonary hypertension. The objective of the present study was to analyze the clinical and hemodynamic outcomes and the risk factors for mortality in a cardiovascular center in Colombia. Methods: Cohort study, conducted between 2001 and 2019. All operated patients were included in the study. Risk factors associated with mortality were established by means of a multivariate regression using the COX method and survival was established using the Kaplan-Meier method. p < 0.05 was considered statistically significant. Results: Seventy-three patients were operated. Median age was 51 years, 55% of females, 79% had functional Class III and IV. The mean pulmonary arterial pressure was 50 mmHg and 640 dyn.s.cm−5 for pulmonary vascular resistance (PVR). After the intervention, there was a decrease in mean pulmonary artery pressure (p ≤ 0.001) and in PVR (p = 0.357); 21% had evidence of residual pulmonary hypertension. Only 8% and 6% continued with functional Class III and IV at 6 and 12 months, respectively. There were 15 deaths (19.1%; 12% at 30 days). The factors associated with mortality were the diastolic diameter of the right ventricle measured postoperatively (hazard ratio [HR] 10.88 95% confidence interval [CI] 1.97-62, p = 0.007), time of invasive mechanical ventilation (HR 1.06 95% CI 1.02-1.09 p = 0.004), and the presence of complications during the surgical procedure (HR 5.62 95% CI 1.94-16.22 p = 0.001). Conclusions: Pulmonary thromboendarterectomy is associated with excellent clinical and hemodynamic outcomes. The mortality risk factors found are not those usually described in the literature.

Resumen Antecedentes: La tromboendarterectomía pulmonar es el tratamiento de elección actual en pacientes con hipertensión pulmonar tromboembólica crónica. El objetivo del presente estudio fue analizar los resultados clínicos y hemodinámicos y los factores de riesgo de mortalidad en un centro cardiovascular de Colombia. Métodos: Estudio de cohorte entre 2001 y 2019. Se incluyeron todos los pacientes operados. Los factores de riesgo asociados a la mortalidad se establecieron mediante una regresión multivariante mediante el método COX y la supervivencia se estableció mediante el método de Kaplan-Meier. Los valores de p < 0.05 se consideraron estadísticamente significativos. Resultados: se operaron 73 pacientes. La mediana de edad fue de 51 años, 55% mujeres, 79% tenían clase funcional III y IV. La presión arterial pulmonar media fue de 50 mmHg y 640 dyn.s.cm−5 para la resistencia vascular pulmonar. Después de la intervención, hubo una disminución en la presión arterial pulmonar media (p ≤ 0.001) y en la resistencia vascular pulmonar (p = 0.357). El 21% tenía evidencia de hipertensión pulmonar residual. Solo el 8% y el 6% continuaron con clase funcional III y IV a los 6 y 12 meses respectivamente. Hubo 15 muertes (19.1%; 12% a los 30 días). Los factores asociados con la mortalidad fueron el diámetro diastólico del ventrículo derecho medido en el postoperatorio (HR 10.88 IC 95% 1.97-62, p = 0.007), el tiempo de ventilación mecánica invasiva (HR 1.06 IC 95% 1.02-1.09 p = 0.004) y el presencia de complicaciones durante el procedimiento quirúrgico (HR 5.62 IC 95% 1.94-16.22 p = 0.001). Conclusiones: La tromboendartectomía pulmonar se asocia con excelentes resultados clínicos y hemodinámicos. Los factores de riesgo de mortalidad encontrados no son los habitualmente descritos en la literatura.

Clinical and hemodynamic outcomes and mortality risk factors in patients undergoing pulmonary thromboendarterectomy.

BACKGROUND: Pulmonary thromboendarterectomy is the current treatment of choice in patients with chronic thromboembolic pulmonary hypertension. The objective of the present study was to analyze the clinical and hemodynamic outcomes and the risk factors for mortality in a cardiovascular center in Colombia. METHODS: Cohort study, conducted between 2001 and 2019. All operated patients were included in the study. Risk factors associated with mortality were established by means of a multivariate regression using the COX method and survival was established using the Kaplan-Meier method. p < 0.05 was considered statistically significant. RESULTS: Seventy-three patients were operated. Median age was 51 years, 55% of females, 79% had functional Class III and IV. The mean pulmonary arterial pressure was 50 mmHg and 640 dyn.s.cm-5 for pulmonary vascular resistance (PVR). After the intervention, there was a decrease in mean pulmonary artery pressure (p ≤ 0.001) and in PVR (p = 0.357); 21% had evidence of residual pulmonary hypertension. Only 8% and 6% continued with functional Class III and IV at 6 and 12 months, respectively. There were 15 deaths (19.1%; 12% at 30 days). The factors associated with mortality were the diastolic diameter of the right ventricle measured postoperatively (hazard ratio [HR] 10.88 95% confidence interval [CI] 1.97-62, p = 0.007), time of invasive mechanical ventilation (HR 1.06 95% CI 1.02-1.09 p = 0.004), and the presence of complications during the surgical procedure (HR 5.62 95% CI 1.94-16.22 p = 0.001). CONCLUSIONS: Pulmonary thromboendarterectomy is associated with excellent clinical and hemodynamic outcomes. The mortality risk factors found are not those usually described in the literature.

[Outcomes the Mitrofanoff technique in the management of patients with neurogenic bladder: the experience in the San Vicente de Paul Universitary Hospital]. / Resultados del uso de la técnica de Mitrofanoff en pacientes con disfunción neurógena de la vejiga: análisis de la experiencia en el Hospital Universitario San Vicente de Paul.

INTRODUCTION: The care for children with neurogenic bladder, should be integral, multidisciplinary look to preserve renal function and to accomplish urinary and fecal continence, achieving that the patient becomes self-sufficient and useful to society. METHODS: The result of the use of the Mitrofanoff technique for the treatment of patients with neurogenic dysfunction bladder used in the HUSVP 1998-2003, and the current condition of the patients with respect to their illness and treatment are described in this article. A descriptive retrospective study 1998-2002 and a prospective study during 2003 were done, in which a series of cases were analyzed. RESULTS: 41 patients had surgery. Average age 10.2 years; average follow-up time 27.2 months; the most frequent illness was myelomeningocele (46.3%) and 46.3% had dysinergic bladder. Bladder augmentation was performed on 63.3%, of which 71.4% were constructed with ileum. A surgical intervention of the bladder neck was done on 51.2%. A continent conduct (Mitrofanoff) was performed on 95.1% of the patients with complete continence 70.4%, complete incontinence 14.6% and occasional incontinence 14.6%. 31.7% had Malone surgery with adequate fecal management on 90.2%. 19% of the stomas presented stenosis and 21.9% presented urine leakage. 80% reached appropriate social adaptation. CONCLUSIONS: The continent catheterizable stomas are useful for the treatment of urinary and fecal incontinence. The conducts constructed with ileum had more complications than the conducts done with cecal appendix, which is why the appendix is the choice tissue to perform the continent catheterizable stomas, as long as it is available.

Resultados del uso de la técnica de Mitrofanoff en pacientes con disfunción neurógena de la vejiga: Análisis de la experiencia en el Hospital Universitario San Vicente de Paul / Outcomes the Mitrofanoff technique in the management of patients with neurogenic bladder: the experience in the San Vicente de Paul Universitary Hospital

Introducción: El cuidado de los niños con vejiga neurogénica, debe ser integral, multidisciplinario y busca preservar la función renal, alcanzar continencia urinaria y fecal, logrando que el paciente sea una persona autosuficiente y útil a la sociedad. Métodos: Describimos el resultado del uso de la técnica de Mitrofanoff en el manejo de pacientes con disfunción vesical neurógena, utilizada en el HUSVP desde 1998 al 2003, y las condiciones actuales de los pacientes con respecto a su enfermedad y tratamiento. Se realizó un estudio observacional descriptivo, retrospectivo 1998-2002 y prospectivo durante el 2003, analizando una serie de casos. Resultados: Fueron intervenidos 41 pacientes con vejiga neurogénica. Edad promedio 10.2 años; seguimiento promedio 27,2 meses; enfermedad de base más frecuente mielomeningocele (46,3%); vejiga disinérgica en 46,3%, esfínter hipotónico en 41,5%. Se realizo aumento vesical al 68,3%, utilizándose ileon en 71,4%, y alguna intervención sobre el cuello vesical al 51,2%. Se hizo una derivación tipo Mitrofanoff al 95,1% con continencia completa en 70,8%, incontinencia completa en 14.6% e incontinencia ocasional en 14,6%. En 31,7% se realizó un Malone con adecuada continencia fecal en 90,2%. De los estomas el 19% presentaron estenosis y el 21,9% presentaron escape de orina. Se encuentran socialmente adaptados 80% de los pacientes. Conclusiones: Los estomas continentes cateterizables son útiles para tratar la incontinencia urinaria y fecal. Los conductos realizados con ileon tuvieron mayores complicaciones que los elaborados con apéndice, por lo cual el apéndice debe ser el tejido de elección para realizar las derivaciones, cuando esté disponible (AU)

Introduction: The care for children with neurogenic bladder, should be integral, multidisciplinary look to preserve renal function and to accomplish urinary and fecal continence, achieving that the patient becomes self-sufficient and useful to society. Methods: The result of the use of the Mitrofanoff technique for the treatment of patients with neurogenic dysfunction bladder used in the HUSVP 1998- 2003, and the current condition of the patients with respect to their illness and treatment are described in this article. A descriptive retrospective study 1998- 2002 and a prospective study during 2003 were done, in which a series of cases were analyzed. Results: 41 patients had surgery. Average age 10.2 years; average follow–up time 27.2 months; the most frequent illness was myelomeningocele (46.3%) and 46.3% had dysinergic bladder. Bladder augmentation was performed on 63.3%, of which 71.4% were constructed with ileum. A surgical intervention of the bladder neck was done on 51.2%. A continent conduct (Mitrofanoff) was performed on 95.1% of the patients with complete continence 70.4%, complete incontinence 14.6% and occasional incontinence 14.6%. 31.7% had Malone surgery with adequate fecal management on 90.2%. 19% of the stomas presented stenosis and 21.9% presented urine leakage. 80% reached appropriate social adaptation. Conclusions: The continent catheterizable stomas are useful for the treatment of urinary and fecal incontinence. The conducts constructed with ileum had more complications than the conducts done with cecal appendix, which is why the appendix is the choice tissue to perform the continent catheterizable stomas, as long as it is available (AU)