Tricuspid valve surgery.

INTRODUCTION: The tricuspid valve has been taken as a non-critical valve in terms of acute or late mortality in a number of conditions. Tricuspid functional regurgitation is a cause of late operations with an increased morbidity. A number of techniques have been described and used in clinical practice in the past forty years and include simple suture techniques and the use of support for annuloplasty with the use of different types of prosthetic rings. The experience accumulated over the years indicates that tricuspid annuloplasty is mandatory to improve late results, which are superior, in general, to replacement of the valve. METHODS: The role of echocardiography in defining surgical planning, intraoperative results and follow-up is reviewed as echocardiography is a fundamental tool in cardiac surgery. Surgery for isolated lesions of the tricuspid valve has not received much attention and herein we report the results of the follow-up of a limited series of patients undergoing isolated tricuspid surgery. RESULTS: The correlation between echocardiographic measurements and surgical measurements was confirmed and was helpful at the time of the confirmation of repair (r=0.53). Forty-seven patients (18 repair, 29 replacement) underwent isolated surgery. Results of isolated tricuspid repair seemed to be superior when compared to those of tricuspid replacement. Survival was 20.7% for tricuspid valve replacement (N=18) and 50% for tricuspid valve repair (N=29) (p=0.04). Freedom from reoperation was 94.4±5.4% for repair and 67.3±12.1% for replacement (p= 0.0011). CONCLUSIONS: The tricuspid valve continues to be a surgical challenge.

Mechanical properties of human coronary arteries.

The lack of reliable mechanical data on coronary arteries and, more specifically, on their wall strength hampers the application of numerical models and simulations to vascular problems, and precludes physicians from knowing in advance the response of coronary arteries to the different interventions. Studies of the mechanical properties of coronary arteries have been carried out almost exclusively on animals. Only a few studies have tried to characterize the in vivo behavior of human coronaries through tests under physiological conditions. In this work, the mechanical properties of human coronary arteries have been characterized. Whole samples from human right (RC) and left anterior descending (LAD) coronary arteries aged between 23 and 83 years have been studied by means of in-vitro tensile testing up to failure.

Surgical treatment of arterial ischemia associated with the use of the angioseal vascular closure device.

BACKGROUND: Despite the theoretical effectiveness of the Angio-Seal closure device to control bleeding after arterial puncture it can increase the risk of ischemia. OBJECTIVES: To describe arterial lesions caused by the device, surgical techniques needed to repair those lesions and surgical outcome in patients who underwent surgery for arterial ischemia after heart catheterization. PATIENTS AND METHODS: Seven patients underwent surgery over a period of 12 months at our institution. Five patients underwent emergency surgery and two a delayed procedure. The cause of ischemia was dissection of an atheroma plaque at the puncture site in four cases, dissection of the superficial femoral artery in one case, thrombosis of the common femoral artery in one case, and plication of the posterior arterial wall in one case. Arterial repair in these patients required the insertion of a vascular graft in three cases, endarterectomy plus angioplasty in two cases, endarterectomy plus graft interposition plus thrombectomy of the superficial femoral artery in one case and endarterectomy plus femoropopliteal bypass in one case. RESULTS: Treatment was successful in all patients. Mean follow up was 7.6 months (range 5-11 months). During the study period one patient died due to cardiopathy. No patients had to be re-operated and no limb losses were recorded. All the patients were asymptomatic from a vascular point of view with normal active lives for their age. CONCLUSIONS: Surgical repair is effective, although, generally, it is not restricted to a simple thrombectomy, requiring the use of different arterial repair techniques.

Endovascular repair of a ruptured giant popliteal artery aneurysm.

An 88-year-old woman with hypertension, chronic vein insufficiency, and repeated cellulites in the right lower extremity was admitted to our hospital with a new episode of right leg inflammation and edema associated with fever and leukocytosis. Due to unilateral enlargement of the leg and D-simer levels of 1000 microg/mL, a concomitant deep venous thrombosis was suspected and ultrasonography was performed. Color duplex-scanning found normal flow in the right deep leg veins but revealed an 11-cm-diameter popliteal artery aneurysm. A computed tomography scan confirmed the diagnosis and revealed a large perianeurysmal hematoma, and angiography provided evidence of perianeurysmal bleeding. The patient was unfit for open surgery, so an endovascular approach under local anesthesia was elected. The aneurysm was successfully excluded with an endograft, and 15 months after surgery, the patient is alive and had an uneventful postoperative course.

Assessment of the diagnostic capacity of planar scintigraphy and SPECT with 99mTc-HMPAO-labelled leukocytes in superficial and deep sternal infections after median sternotomy.

Sternal infection is a rare complication of median sternotomy but is associated with considerable morbidity and mortality, particularly in the case of deep sternal infection (mediastinitis). Successful treatment depends on early diagnosis and on the location (deep or superficial) of the infection. Radiological techniques have many limitations, and although 67Ga scintigraphy is effective, it delays diagnosis by 48 h. We assessed the diagnostic capacity of planar scintigraphy and single photon emission computed tomography (SPECT) with 99mTc-hexamethylpropylene amine oxime (HMPAO)-labelled leukocytes in deep sternal infections after median sternotomy. We prospectively studied 41 patients with clinical suspicion of deep sternal infection 4 and 20 h after administration of the tracer. The final diagnosis was deep sternal infection in nine patients and superficial sternal infection in 10, with infection being ruled out in 22 patients. Planar scintigraphy did not detect any of the deep sternal infections at either 4 h or 20 h. SPECT correctly identified eight of the nine deep sternal infections at 4 h and all seven at 20 h, with no false positive results. Planar scintigraphy identified 16 of the 18 superficial sternal infections at 4 h and all of them at 20 h. SPECT identified 17 of these 18 infections at 4 h and all of them at 20 h. Other infections unrelated to the sternotomy were identified in seven patients. Leukocytes labelled with 99mTc-HMPAO are a highly reliable method for the early diagnosis of sternal infections after median sternotomy. Use of SPECT allows determination of the depth of the infection and differentiation of superficial from deep sternal infections. It is also possible to detect other sites of infection, thus providing alternative diagnoses.

[Traumatic maculopathies]. / Maculopatías traumáticas.

PURPOSE/METHODS: We reviewed all patients seen urgently on our Hospital and we studied those that present contusive pathology of the anterior pole with macular repercusion. RESULTS/CONCLUSIONS: Post-traumatic maculopathies are usually produced by contusion, namely: rupture of the choroid, chorioretinitis sclopetaria, postraumatic macular hole, commotio retinae (Berlin's oedema) and Purtscher's retinopathy was reported. With the presentation of these clinical cases, some of which are very typical, we aim to show the functional sequelae some patients suffer.

[Pre and perioperative factors determining early in-hospital mortality in patients over 75 years of age undergoing cardiac surgery]. / Factores pre y perioperatorios determinantes de la mortalidad precoz en pacientes mayores de 75 años sometidos a circulación extracorpórea.

INTRODUCTION AND OBJECTIVES: To know the in-hospital morbidity and mortality and the related factors in patients over 75 years old undergoing cardiac surgery. PATIENTS AND METHODS: A retrospective analysis was carried out in 252 out of 2043 consecutive patients (129 female, 123 male) over 75 years of age (mean age 77.8 years; range 75 to 89 years) undergoing open heart surgery from january 1, 1994 to november 30, 1997. Isolated aortic valve replacement was performed in 128 patients, 78 underwent isolated coronary artery bypass grafting and 46 combined surgery. Preoperative determinants of morbidity and mortality were analyzed. RESULTS: The overall hospital mortality was 15.1%, 13.2% in the aortic group, 12.8% in the coronary group and 23.9% in the combined surgery group. The overall morbidity rate was 38.6% and 25.8%, 34.2% in the aortic and coronary groups, respectively. Preoperative risk factors were prior surgery (p < 0.0004) and emergency operation (p < 0.04). In aortic valve replacement, NYHA class IV (p < 0.05), prior operation (p < 0. 01) and emergency surgery (p < 0.01) were determinant. Perioperative factors of early mortality were: prolonged cross-clamping > 60 min (p < 0.02), cardiopulmonary bypass time > 90 min (p < 0.002), need for inotropic drugs (p < 0.005) and postoperative complications (p < 0.00001). Mean postoperative length of hospital stay was 12.8 +/- 8. 5 days. CONCLUSIONS: Despite the greater rate of early morbimortality in patients over 75 years of age, cardiac surgery may be performed avoiding emergency surgery, functional grade IV and prolonged length of surgery.

Evaluation of the Duke criteria in 93 episodes of prosthetic valve endocarditis: could sensitivity be improved?

BACKGROUND: Since publication of the Duke criteria for diagnosing endocarditis, several articles have confirmed their sensitivity when native and prosthetic valves are considered together. OBJECTIVES: To compare the differences between the older von Reyn criteria and the Duke criteria in prosthetic valve endocarditis only, and to determine if the latter's sensitivity could be improved by adding 2 minor criteria: new-onset heart failure and presence of conduction disturbances. METHODS: We retrospectively evaluated 93 episodes of prosthetic valve endocarditis from January 1986 to January 1998 in a teaching hospital, and then analyzed the 76 surgically confirmed episodes to compare the differences between the von Reyn and Duke diagnostic criteria. RESULTS: The von Reyn criteria rejected the diagnosis in 16 of the confirmed episodes, compared with 1 diagnosis missed by the Duke criteria and 1 missed using our suggested modifications. Definite diagnosis (Duke) was established in 60 episodes, compared with a diagnosis of probable (von Reyn) in 36 episodes (P<.001). Our modifications improved the sensitivity of the Duke criteria, diagnosing 70 episodes as definite (P = .02). CONCLUSIONS: As was the case with native valve endocarditis, the Duke criteria proved to be more sensitive than the von Reyn criteria in prosthetic valve endocarditis. The addition of 2 minor criteria (new-onset heart failure and presence of conduction disturbances) could improve the diagnostic sensitivity of the Duke criteria.

Planar scintigraphy and SPET with 99Tcm-HMPAO-labelled leukocytes in patients with median sternotomy: normal patterns.

The aim of this study was to determine the normal planar and SPET patterns of the thoracic distribution of 99Tcm-hexamethylpropylene amine oxime (99Tcm-HMPAO) in 20 patients who had undergone a previous median sternotomy and without infectious complications at follow-up. The study included anterior and oblique anterior planar views at 4 and 20 h. SPET of the chest was also carried out at 4 and 20 h. At 4 h, the planar views showed low background vascular activity in the lungs and cardiac region in addition to the sternal uptake, which showed two patterns: homogeneous in five patients and heterogeneous in 15. A long and narrow defect of uptake along the sternal midline was the most characteristic finding. At 4 h, in addition to the background vascular activity in the lungs and cardiac region, the greatest uptake on SPET was in the sternum anteriorly and the marrow spine posteriorly without any focal uptake, allowing visualization of the mediastinum free of focal activity. At 20 h, both the planar and SPET images showed a higher organ-to-background ratio. Knowledge of these post-surgical patterns will make it easier to interpret planar and SPET images when 99Tcm-HMPAO-labelled leukocytes are used in the diagnosis of mediastinitis and sternal infections in patients who had previously undergone median sternotomy. Planar views were better for the assessment of sternal uptake, but SPET views were better for the direct visualization of the mediastinum by eliminating overlapping sternal uptake.

The CarboMedics "Top-Hat" supraannular prosthesis.

BACKGROUND: The CarboMedics "Top-Hat" supraannular prosthesis was designed to permit the implantation of a larger prosthesis. METHODS: Between June 1993 and November 1996, 127 patients (average age, 61.8+/-10.2 years) received a CarboMedics "Top-Hat" supraannular aortic prosthesis. The average follow-up was 15.7 months, and all surviving patients underwent echocardiographic study. This group is compared with 656 patients in whom a standard CarboMedics prosthesis was implanted and also with 2,927 patients who received other aortic prostheses. RESULTS: Using the standard and the supraannular sizers, there was an average increase of one size in favor of the supraannular prosthesis: 18.9+/-2.8 mm standard versus 20.8+/-2.6 mm supraannular (p < 0.005). For each prosthesis size (19 to 23 mm), the body surface area of the patients in whom a CarboMedics supraannular prosthesis was implanted was significantly smaller than that in those who received a CarboMedics standard prosthesis or any other model. Hospital mortality was 3.9%, and late mortality was 5.5%. The actuarial survival was 86.5%+/-3.9% at 42 months. CONCLUSIONS: Using the CarboMedics supraannular prosthesis allows implantation of a larger prosthesis compared with the standard CarboMedics prosthesis or other models. This advantage is especially important in patients with a small aortic root.

[Contribution of planar scintigraphy and SPECT with Ga-67 in the diagnosis of infectious complications after median sternotomy]. / Aportación de la gammagrafía planar y del SPECT con 67Ga al diagnóstico de las complicaciones infecciosas tras esternotomía media.

The prognosis of infections complications after median sternotomy depends of precocious diagnoses and depth extension of infection. We wanted to analyze the use of 67Ga scintigraphy in this pathology, comparing planar studies an SPECT. We studied 22 patients with suspect of infection complication after median sternotomy, the final diagnoses were 5 mediastinitis, 10 osteomyelitis and 7 patients with other pathology. 67Ga scintigraphy diagnosed correctly the 5 mediastinitis, 9 of 10 osteomyelitis and descarted both pathology in the other 7 patients. Planar studies only were able to diagnose correctly 3 of 5 mediastinitis and the another 2 were correctly diagnosed by SPECT. 67Ga scintigraphy is useful in the diagnosis of infection complication after median sternotomy and SPECT is better than planar studies in the diagnosis of mediastinitis.

[Coronary surgery associated with vascular disease]. / Cirugía coronaria asociada a enfermedad vascular.

Given the characteristics of ischemic heart disease, this condition is frequently associated with carotid and peripheral artery disease. Cardiac complications of vascular surgery and vascular complications of myocardial revascularization operations are common and severe. However, carotid artery endarterectomy or revascularization procedures for the lower extremities can be combined simultaneously with coronary artery bypass operations with acceptable results. It is difficult to determine whether or not both disorders should be treated surgically in a single stage or in two stages. This decision should be individualized according to the severity of the lesions and the risk of complications if one of these procedures is delayed.

Repair of nonsevere rheumatic aortic valve disease during other valvular procedures: is it safe?

OBJECTIVE: To investigate the long-term performance of aortic valve repair, we analyzed the results obtained in a 22-year period in patients who underwent repair of nonsevere rheumatic aortic valve disease during other valvular procedures. METHODS: Fifty-three patients (mean 40 +/- 11.6 years of age) with predominant rheumatic mitral valve disease had concomitant aortic valve disease in association with serious tricuspid valve disease in 25 of them. Preoperatively, aortic valve disease was considered moderate in 47.2% of the patients and mild in 52.8%. All patients underwent reparative techniques of the aortic valve (free edge unrolling, 44; subcommissural annuloplasty, 40; commissurotomy, 36) at the time of mitral or mitrotricuspid valve surgery. The completeness of follow-up during the closing interval was 100%, with a mean follow-up of 18.8 years (range 8 to 22.5 years). RESULTS: Hospital mortality rate was 7.5%. Of 49 surviving patients, 26 (53.1%) died during late follow-up. The actuarial survival curve including hospital mortality was 35.4% +/- 8.7% at 22 years. For patients who underwent mitral and aortic valve surgery, the actuarial survival curve at 22 years was 32.3% +/- 13%, whereas for patients who had a triple-valve operation the survival was 37.0% +/- 10.1% (p = 0.07). Twenty-five patients underwent an aortic prosthetic valve replacement. Actuarial free from aortic structural deterioration and valve-related complications at 22 years was 25.3% +/- 9.3% and 12.7% +/- 4.8%, respectively. CONCLUSIONS: Long-term functional results of reparative procedures of nonsevere aortic valve disease in patients with predominant rheumatic mitral valve disease have been inadequate at 22 years of follow-up. According to these data, conservative operations for rheumatic aortic valve disease do not seem appropriate.

Behavior of mitral allografts in the tricuspid position in the growing sheep model.

BACKGROUND: On the basis of a previous experience in a chronic sheep model in which partial mitral allografts remained viable and properly functioning 12 months after operation, we assessed the results obtained by replacing the tricuspid valve with fresh antibiotic-preserved mitral allografts. METHODS: Twenty 3-month-old sheep with a mean weight of 23.7 +/- 2.3 kg underwent cardiopulmonary bypass and had a fresh antibiotic-preserved mitral allograft implanted in the tricuspid position with the heart beating under normothermic conditions. The tricuspid valve apparatus was not excised. After a mean follow-up of 13.2 months, the allograft was evaluated by gross inspection and light and electron microscopy. RESULTS: Nine sheep died of technical causes within the first week after operation and 2 at 4 and 6 months of infective endocarditis of the allograft. The hemodynamic study before heart explantation revealed residual tricuspid incompetence in 3 of the 9 survivors. Macroscopic examination showed flexible valves with no signs of structural deterioration, calcification, or thrombosis. Under light and scanning electron microscopic examination, allografts were almost completely denuded of endothelial cells and showed loosely arranged connective tissue with scarce signs of inflammatory reaction. Despite these findings, allografts were free from major structural damage. CONCLUSIONS: The mitral homograft could be an alternative to replacement of the tricuspid valve with a bioprosthesis or a mechanical prosthesis.

The CarboMedics valve: experience with 1,049 implants.

BACKGROUND: The lack of valve rotatability, the structural deterioration, and the rate of valve-related complications with the standard mechanical bileaflet prosthesis led to the development of a new second-generation bileaflet valve in 1986. METHODS: Between January 1989 and March 1994, 1,049 CarboMedics valves were implanted in 859 patients. The rotatability was used in 109 mitral prostheses (21.5%) and in 61 aortic prostheses (11.6%). Follow-up was 97.1% complete, with 3,049 patient-years. RESULTS: The hospital mortality was 6.9% for the mitral group, 3.4% for the aortic group, and 10.7% for the double-valve group (p < 0.005). The actuarial survival curve at 5 years was 77.3% +/- 3.6%, 90.1% +/- 2.5%, and 79.2% +/- 3.7% (p = 0.0003), freedom from thromboembolism was 89.1% +/- 3.6%, 87.1% +/- 3.8%, and 68.8% +/- 8.2%, freedom from reoperation was 95.9% +/- 1.4%, 98.9% +/- 0.6%, and 94.9% +/- 2.4%, and freedom from valve-related complications was 68.8% +/- 4.1%, 79.5% +/- 3.5%, and 55.3% +/- 5.9% after mitral, aortic, and mitral and aortic valve replacement, respectively. There were five episodes of valve thrombosis, but no structural deterioration occurred. CONCLUSIONS: The clinical performance of the CarboMedics valve is quite satisfactory, with a low incidence of valve-related mortality and morbidity. The rotatability feature was useful when the native valve was preserved or for repeat valve replacement.

Nosocomial infections in patients having cardiovascular operations: a multivariate analysis of risk factors.

A total of 970 adult patients undergoing cardiovascular operations during a 1-year period were eligible for a case-control study on the risk factors for nosocomial infection. Cases were defined as patients in whom a postoperative infection developed. Every case was paired with one uninfected subject. Nosocomial infection occurred in 89 (9.2%) patients. A total of 120 episodes of infection were diagnosed (1.3 episodes per patient). The infection ratio was 12.4%. Surgical site infection was the most common (5.6%), followed by pneumonia (3.2%), urinary tract infection requiring the use of intravenous antibiotics (1.8%), deep surgical site (0.9%), and bacteremia (0.7%). Advanced age, urgent intervention, duration of surgical procedure, blood transfusion, and use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage) were significantly associated with infection in the bivariate analysis. Nosocomial infection resulted in a significant increase in the length of hospital stay. Cases showed an almost fivefold greater risk of death than controls (odds ratio, 4.73; 95% confidence interval, 1.11 to 6.83; p = 0.009). Age older than 65 years, female sex, and mode of surgical intervention were selected in the multivariate analysis for patients undergoing cardiac operations, whereas general anesthesia or assisted ventilation, central venous catheter, and blood transfusion were the variables selected for patients undergoing operation for vascular disorders. In summary, the recognition of risk factors for postoperative infection in patients undergoing cardiovascular surgical procedures may contribute to improve their prognosis and to more organized surveillance and control activities in the hospital environment.