[Papillary fibroelastoma: retrospective analysis. Clinical presentation and surgical results]. / Fibroelastoma papilar cardíaco: estudio retrospectivo. Presentación clínica y resultados quirúrgicos.

Papillary ibroelastomas are small benign intracardiac tumors known for their embolic potential. Since the introduction of echocardiography with improved resolution and transesophageal imaging techniques, they are being increasingly detected in clinical practice. In recent series, papillary fibroelastoma is considered the most frequent benign tumor of the heart. Our objective was to analyze characteristics and midterm surgical outcome of histologically-confirmed cases of papillary fibroelastoma. We conducted a retrospective study on patients with cardiac tumors submitted to surgical excision between June 1992 and February 2017. Out of 108 patients, 18 had papillary fibroelastomas. Their mean age was 58 years (22-77); 10 were men. The most frequent localizations were the aortic valve (7) and the mitral valve (5). None had significant valvular dysfunction. By transesophageal echocardiography, the tumor size (larger diameter) was 13.33 ± 5.55 mm (6.6-28.0). Two patients, both with tumor in the aortic valve, had suffered a stroke; other two had dyspnoea and atrial flutter, respectively. The remaining 14 patients were asymptomatic and their tumors were incidental findings. In 15 patients the valve was preserved. There was neither surgical mortality nor recurrence after 2.6 years of follow-up. In conclusion, most papillary fibroelastomas can be surgically removed with valve preservation and favorable clinical outcome. However, until the results of randomized trials support the decision, an aggressive surgical approach in asymptomatic patients needs to be defined in the context of surgical expertise.

Fibroelastoma papilar cardíaco: estudio retrospectivo: Presentación clínica y resultados quirúrgicos / Fibroelastoma papilar cardíaco: estudio retrospectivo: Presentación clínica y resultados quirúrgicos

Los fibroelastomas papilares cardíacos son pequeños tumores benignos con potencial embolígeno. Con la incorporación de la ecocardiografía y la mejoría en la resolución de las imágenes, el diagnóstico clínico es cada vez más frecuente, y en series recientes su frecuencia supera a la del mixoma cardíaco. Nuestro objetivo fue analizar las características de una serie de casos de fibroelastoma papilar cardíaco con confirmación histológica operados en nuestro hospital. Analizamos retrospectivamente los tumores cardíacos y las características clínicas de los pacientes operados desde junio de 1992 a febrero de 2017. De 108 operados, 18 presentaron fibroelastoma papilar. La edad media del grupo con fibroelastoma papilar fue 58 años (22-77); 10 eran varones. Las localizaciones más frecuentes fueron la válvula aórtica (7) y la válvula mitral (5). Ninguno presentó disfunción valvular significativa. Por ecografía transesofágica, el tamaño (diámetro mayor) fue 13.33 ± 5.55 mm (6.6-28.0). Cuatro pacientes eran sintomáticos; uno presentaba disnea, otro aleteo auricular, dos con fibroelastoma en válvula aórtica habían sufrido un accidente cerebrovascular. Los restantes, asintomáticos, fueron intervenidos preventivamente. En 15 pacientes el tumor se extirpó sin necesidad de reemplazo valvular. No hubo mortalidad quirúrgica ni recidiva tumoral en el seguimiento de 2.6 años. Se concluye que los fibroelastomas papilares cardíacos pueden ser extirpados con buenos resultados a mediano plazo y, en su mayoría, con preservación valvular. Sin embargo, no existen aún estudios aleatorizados que avalen la escisión quirúrgica en pacientes asintomáticos. Por el momento, esta última depende de la experiencia del grupo quirúrgico tratante.

Papillary ibroelastomas are small benign intracardiac tumors known for their embolic potential. Since the introduction of echocardiography with improved resolution and transesophageal imaging techniques, they are being increasingly detected in clinical practice. In recent series, papillary fibroelastoma is considered the most frequent benign tumor of the heart. Our objective was to analyze characteristics and midterm surgical outcome of histologically-confirmed cases of papillary fibroelastoma. We conducted a retrospective study on patients with cardiac tumors submitted to surgical excision between June 1992 and February 2017. Out of 108 patients, 18 had papillary fibroelastomas. Their mean age was 58 years (22-77); 10 were men. The most frequent localizations were the aortic valve (7) and the mitral valve (5). None had significant valvular dysfunction. By transesophageal echocardiography, the tumor size (larger diameter) was 13.33 ± 5.55 mm (6.6-28.0). Two patients, both with tumor in the aortic valve, had suffered a stroke; other two had dyspnoea and atrial flutter, respectively. The remaining 14 patients were asymptomatic and their tumors were incidental findings. In 15 patients the valve was preserved. There was neither surgical mortality nor recurrence after 2.6 years of follow-up. In conclusion, most papillary fibroelastomas can be surgically removed with valve preservation and favorable clinical outcome. However, until the results of randomized trials support the decision, an aggressive surgical approach in asymptomatic patients needs to be defined in the context of surgical expertise.

[Acute aortic regurgitation due to infective endocarditis]. / Insuficiencia aórtica aguda por endocarditis infecciosa.

Acute aortic regurgitation (AAR) due to infective endocarditis (IE) is a serious disease and usually requires surgical treatment. Our study aims to compare the clinical, echocardiographic, and microbiological characteristics as well as in-hospital outcome of patients with AAR according to the severity of heart failure (HF) and to evaluate predictors of in-hospital mortality in a tertiary centre. In a prospective analysis, we compared patients with NYHA functional class I-II HF (G1) vs. functional class III-IV HF (G2). From 06/92 to 07/16, 439 patients with IE were hospitalized; 86 presented AAR: (G1, 39: 45.4% y G2, 47: 54.7%). The G1 had higher prosthetic IE (43.6% vs. 17%, p 0.01). All G2 patients had dyspnoea vs. 30.8% of the G1 (p < 0.0001). There were no differences in clinical, echocardiographic and microbiological characteristics. Surgical treatment was indicated mainly due to infection extension or valvular dysfunction in G1 and HF in G2. In-hospital mortality was 15.4% vs. 27.7% (G1 and G2 respectively p NS). In multivariate analysis, health care-associated acquisition (p 0.001), negative blood cultures (p 0.004), and functional class III-IV HF (p 0.039) were in-hospital mortality predictors. One-fifth of the patients with EI had AAR. Half of them had severe HF which needed emergency surgery and the remaining needed surgery for extension of the infection and / or valvular dysfunction. Both groups remain to have high surgical and in-hospital mortality. Health care-associated acquisition, negative blood cultures and advanced HF were predictors of in-hospital mortality.

Insuficiencia aórtica aguda por endocarditis infecciosa / Acute aortic regurgitation due to infective endocarditis

La insuficiencia aórtica aguda (IAOA) por endocarditis infecciosa (EI) es grave y generalmente requiere tratamiento quirúrgico. Se compararon los pacientes con IAOA grave por EI e insuficiencia cardíaca (IC) en clase funcional I-II NYHA (G1) con los pacientes en clase funcional III-IV (G2) en relación a características clínicas, ecocardiográficas, microbiológicas y evolución hospitalaria y se evaluaron los predictores de mortalidad, en un centro de alta complejidad. Desde 06/92 a 07/16, de 439 pacientes con EI, 86 presentaron IAOA: (G1, 39: 45.4% y G2, 47: 54.7%). El G1 presentó mayor EI protésica (43.6% vs. 17.0%; p < 0.01). Los 47 casos G2 presentaban disnea vs. 12 (30.8%) G1 (p < 0.0001). No hubo diferencias en cuanto a las características clínicas, ecocardiográficas y microbiológicas. El tratamiento quirúrgico fue principalmente por extensión de la infección y/disfunción valvular en el G1 y por IC en el G2. La mortalidad hospitalaria fue del 15.4% vs. 27.7% (G1 y G2 respectivamente, p NS). Fueron predictores en el análisis multivariado: la infección intrahospitalaria (p 0.001), los hemocultivos negativos (p 0.004) y la presencia de IC clase funcional III-IV (p 0.039).Una quinta parte de los pacientes con EI presentaron IAOA. Aquellos con IC grave requirieron tratamiento quirúrgico de emergencia y con IC con clase funcional I-II requirieron cirugía por extensión de la infección y/o disfunción valvular. La mortalidad quirúrgica y hospitalaria continúan siendo elevadas en ambos grupos y fueron predictores de mortalidad hospitalaria: la infección intrahospitalaria, los hemocultivos negativos y la IC avanzada.

Acute aortic regurgitation (AAR) due to infective endocarditis (IE) is a serious disease and usually requires surgical treatment. Our study aims to compare the clinical, echocardiographic, and microbiological characteristics as well as in-hospital outcome of patients with AAR according to the severity of heart failure (HF) and to evaluate predictors of in-hospital mortality in a tertiary centre. In a prospective analysis, we compared patients with NYHA functional class I-II HF (G1) vs. functional class III-IV HF (G2). From 06/92 to 07/16, 439 patients with IE were hospitalized; 86 presented AAR: (G1, 39: 45.4% y G2, 47: 54.7%). The G1 had higher prosthetic IE (43.6% vs. 17%, p 0.01). All G2 patients had dyspnoea vs. 30.8% of the G1 (p < 0.0001). There were no differences in clinical, echocardiographic and microbiological characteristics. Surgical treatment was indicated mainly due to infection extension or valvular dysfunction in G1 and HF in G2. In-hospital mortality was 15.4% vs. 27.7% (G1 and G2 respectively p NS). In multivariate analysis, health care-associated acquisition (p 0.001), negative blood cultures (p 0.004), and functional class III-IV HF (p 0.039) were in-hospital mortality predictors. One-fifth of the patients with EI had AAR. Half of them had severe HF which needed emergency surgery and the remaining needed surgery for extension of the infection and / or valvular dysfunction. Both groups remain to have high surgical and in-hospital mortality. Health care-associated acquisition, negative blood cultures and advanced HF were predictors of in-hospital mortality.

SIFamide Translates Hunger Signals into Appetitive and Feeding Behavior in Drosophila.

Animal behavior is, on the one hand, controlled by neuronal circuits that integrate external sensory stimuli and induce appropriate motor responses. On the other hand, stimulus-evoked or internally generated behavior can be influenced by motivational conditions, e.g., the metabolic state. Motivational states are determined by physiological parameters whose homeostatic imbalances are signaled to and processed within the brain, often mediated by modulatory peptides. Here, we investigate the regulation of appetitive and feeding behavior in the fruit fly, Drosophila melanogaster. We report that four neurons in the fly brain that release SIFamide are integral elements of a complex neuropeptide network that regulates feeding. We show that SIFamidergic cells integrate feeding stimulating (orexigenic) and feeding suppressant (anorexigenic) signals to appropriately sensitize sensory circuits, promote appetitive behavior, and enhance food intake. Our study advances the cellular dissection of evolutionarily conserved signaling pathways that convert peripheral metabolic signals into feeding-related behavior.

Amyloid Precursor Protein in Drosophila Glia Regulates Sleep and Genes Involved in Glutamate Recycling.

Amyloid precursor protein (App) plays a crucial role in Alzheimer's disease via the production and deposition of toxic ß-amyloid peptides. App is heavily expressed in neurons, the focus of the vast majority of studies investigating its function. Meanwhile, almost nothing is known about App's function in glia, where it is also expressed, and can potentially participate in the regulation of neuronal physiology. In this report, we investigated whether Appl, the Drosophila homolog of App, could influence sleep-wake regulation when its function is manipulated in glial cells. Appl inhibition in astrocyte-like and cortex glia resulted in higher sleep amounts and longer sleep bout duration during the night, while overexpression had the opposite effect. These sleep phenotypes were not the result of developmental defects, and were correlated with changes in expression in glutamine synthetase (GS) in astrocyte-like glia and in changes in the gap-junction component innexin2 in cortex glia. Downregulating both GS and innexin2, but not either one individually, resulted in higher sleep amounts, similarly to Appl inhibition. Consistent with these results, the expression of GS and innexin2 are increased following sleep deprivation, indicating that GS and innexin2 genes are dynamically linked to vigilance states. Interestingly, the reduction of GS expression and the sleep phenotype observed upon Appl inhibition could be rescued by increasing the expression of the glutamate transporter dEaat1. In contrast, reducing dEaat1 expression severely disrupted sleep. These results associate glutamate recycling, sleep, and a glial function for the App family proteins.SIGNIFICANCE STATEMENT The amyloid precursor protein (App) has been intensively studied for its implication in Alzheimer's disease (AD). The attributed functions of App are linked to the physiology and cellular biology of neurons where the protein is predominantly expressed. Consequences on glia in AD are generally thought to be secondary effects of the pathology in neurons. Researchers still do not know whether App plays a role in glia in nonpathological conditions. We report here that glial App plays a role in physiology and in the regulation of sleep/wake, which has been shown recently to be involved in AD pathology. These results also associate glutamate recycling and sleep regulation, adding further complexity to the physiological role of App and to its implication in AD.

Resultados del trasplante cardíaco según el perfil clínico del receptor: 21 años de experiencia / Outcomes of Heart Transplantation Based on Recipient's Clinical Profile: 21-Year Experience

Introducción: El trasplante cardíaco continúa siendo el tratamiento de elección en pacientes con miocardiopatías graves sin otras opciones terapéuticas. Los resultados alentadores del trasplante cardíaco en términos de supervivencia han permitido ampliar los criterios de selección del receptor, lo que ha llevado a la inclusión de pacientes de mayor complejidad en lista de espera. Objetivo: Analizar los resultados del trasplante cardíaco del Hospital Universitario Fundación Favaloro a lo largo de 21 años de seguimiento. Material y métodos: Entre febrero de 1993 y diciembre de 2014 se realizaron 442 trasplantes cardíacos ortotópicos en un único centro. Se analizaron en forma retrospectiva las historias clínicas de los pacientes, excluyéndose los pediátricos y protegiendo la confidencialidad de los datos. Para el análisis se dividió la serie en período 1 (febrero 1993 - agosto 2003) y período 2 (septiembre 2003 - diciembre 2014). Resultados: Se observó durante el segundo período una prevalencia mayor de candidatos con miocardiopatía dilatada no coronaria versus coronaria y un incremento significativo de la indicación de trasplante cardíaco en la miocardiopatía dilatada chagásica. La prevalencia de hipertensión pulmonar aumentó, realizándose un número mayor de trasplantes cardíacos en condición de emergencia, con requerimiento de inotrópicos y soporte circulatorio mecánico con balón de contrapulsación intraaórtico. Conclusiones: Se han observado cambios en el perfil clínico de los receptores de trasplante cardíaco, ingresando en lista de espera pacientes con un número mayor de comorbilidades. La cuidadosa elección de candidatos a trasplante requiere una revisión continua y un análisis individualizado de los diferentes factores que determinan la supervivencia de los pacientes y su impacto en los resultados de los programas de trasplante.

Trasplante cardiorenal combinado en la enfermedad cardíaca y renal avanzada / Combined cardiorenal transplant in heart and advanced renal disease

Introducción: la insuficiencia renal (IR) es predictor de morbimortalidad postrasplante cardíaco (TxC). El trasplante cardiorenal (TxCR) combinado en candidatos a TxC con enfermedad renal severa, es una opción terapéutica. Nuestro objetivo es evaluar los resultados y seguimiento del TxCR en un único Centro. Material y métodos: Entre febrero de 1993 y diciembre de 2014 se realizaron 442 TxC. Desde el año 2006 se efectuaron TxCR con único donante en 20 pacientes (p). Los criterios de selección fueron: IR con ClCr ≤ 40 mil/min o requerimiento de diálisis en candidatos a TxC. Todos los p recibieron timoglobulina e inmunosupresión con tacrolimus, micofenolato mofetil y esteroides. La mediana de seguimiento fue 46 meses (7-96). Resultados: Edad media 58±7 años y 85% eran hombres. La creatinina (Cr) media 3,1+-2,5 mg/ dl y ClCr 27,5+10 mil/min. Requirieron diálisis 3p en el período pre trasplante y 4p se encontraban en diálisis crónica. Etiología de miocardiopatías dilatadas: coronaria 10p, no coronaria 9p y reTxC 1p; nefropatías: nefroangioesclerosis 5p, síndrome cardiorenal 10p, diabetes 2p, glomerulopatía 1p, poliquistosis 1p y nefritis tóxica 1p. La Cr a 30 días y a 1 año del TxCR fue 1,2+-0,4 mm/dl y 1,1+-0,2 mg/dl respectivamente. La mortalidad hospitalaria fue de 3/20p (15%), 2p por sepsis y 1p por falla del injerto cardíaco. Mortalidad alejada 5/17p (29%), 4p por sepsis y 1p por sarcoma hepatocelular. La supervivencia a 1 y 3 años fue del 76 y 72%. Conclusiones: En nuestra serie el TxCR fue un tratamiento seguro y eficaz en candidatos a TxC y con ClCr < 40 mil/min.

Introduction: renal failure (RF) is a post cardiac transplantation predictor of morbimortality. The combined cardiorenal transplant (CCRTx) in cardiac transplantation (CTx) candidates with chronic renal disease is a therapeutic option. Our aim was to evaluate the CCRTx follow up outcomes in a single Centre. Methods: Between 2/1993 and 12/2014 we performed 442 CTx. Since 2006, 20 patients (p) underwent CCRTx using allografts from the same donor. The inclusion criteria were: RF with CrCl ≤ 40 mil/min or dialysis requirement in CTx candidates. All p received Thymoglobulin and immunosuppression with tacrolimus, mycophenolate mofetil and steroids.Median follow up: 46 months (7-96). Results: Mean age: 58±7 years, 85% were male. Mean Creatinine (Cr): 3,1+-2,5 mg/dl and ClCr 27,5+10 mil/min. Three p required dialysis during the pre-transplantation phase and 4 p were under chronic dialysis. Etiologies: cardiomyopathies: coronary 10 p, noncoronary 9 p and re CTx, 1 p; nephropathies: nephroangiosclerosis 5 p, cardiorenal syndrome 10 p, diabetes 2 p, glomerulopathy 1 p, polycystosis 1 p and toxic nephritis 1 p. At 30 days and 1 year post CCRTx, Cr was 1,2+-0,4 mg/dl and 1,1+-0,2 mg/dl respectively. In-hospital mortality was 3/20 p (15%), 2 p due to sepsis and 1 p due to cardiac graft failure. Late mortality 5/17 p (29 %), 4p due to sepsis and 1 p due to liver sarcoma. Survival at 1 and 3 years was 76 and 72%, respectively. Conclusions: In our series CCRTx was a safe and effective treatment for CTx candidates with CrCl < 40 ml/min.

Cirugía de reemplazo valvular aórtico en pacientes octogenarios: resultados perioperatorios y seguimiento a mediano plazo / Aortic Valve Replacement in Octogenarian Patients: Perioperative Results and Mid-term Follow-up

Introducción El número de pacientes ancianos que requieren cirugía cardíaca por estenosis aórtica degenerativa ha ido en aumento en las últimas décadas; no obstante, a muchos de ellos se les contraindica por el solo hecho de su edad avanzada. Para evaluar si en nuestro país la cirugía en este grupo etario continúa siendo una opción válida, es necesario conocer los resultados quirúrgicos, las complicaciones y la percepción de calidad de vida ganada por parte de los pacientes, datos que son escasos en la bibliografía argentina. Objetivos Comunicar la experiencia de un centro en la cirugía de reemplazo valvular aórtico en octogenarios y su seguimiento a mediano plazo. Material y métodos Desde enero de 2005 a diciembre de 2010, 96 pacientes consecutivos mayores de 80 años portadores de estenosis valvular aórtica grave degenerativa fueron sometidos a cirugía de reemplazo valvular asociada o no con revascularización miocárdica en el Hospital Universitario Fundación Favaloro. Los datos se obtuvieron en forma retrospectiva y se compararon ambas poblaciones en términos de morbimortalidad. Se realizó un seguimiento de los pacientes para análisis de calidad de vida a través de entrevistas personales y telefónicas. Resultados La edad de la población fue de 82 ± 2 años, el 54% de sexo masculino. El síntoma más común fue la disnea de esfuerzo, presente en el 84% de los pacientes. En 84 pacientes (77%) se halló algún grado de disfunción renal previa. Según el EuroSCORE aditivo, el 78,1% fueron pacientes de riesgo alto y el 17,7% de riesgo muy alto. Se les realizó reemplazo valvular aórtico aislado a 55 pacientes (grupo I) y asociado con revascularización miocárdica a los 41 restantes (grupo II). La mortalidad total a los 30 días fue del 7,3%, 3,6% en el grupo I y 12,2% en el grupo II (ns). Teniendo en cuenta las cirugías electivas, estas cifras descienden a 5,3%, 4,3% y 6,9%, respectivamente (ns). Durante el seguimiento a 6 años se registró una mortalidad acumulativa del 14%. En el seguimiento, el 94% se encontraba en CF I-II de la NYHA y el 88% no debió reinternarse por causa cardiovascular. Conclusiones La cirugía de reemplazo valvular aórtico en pacientes octogenarios, asociada o no con revascularización miocárdica, realizada en un centro con experiencia y en forma electiva es un procedimiento con buenos resultados a corto y a mediano plazos, por lo que no debería contraindicarse teniendo en cuenta en forma aislada la edad o el puntaje de riesgo prequirúrgico.

Introduction Over the last decades the number of elderly patients requiring cardiac surgery due to degenerative aortic stenosis has consistently increased. However, this intervention is contraindicated in many of these patients due to their advanced age. To assess whether in our country this type of surgery is still a valid option, it is necessary to know the surgical results, complications and quality of life gained perceived by the patients, data which are scarce in the Argentine literature. Objectives The aim of this study was to communicate the experience of a center on aortic valve replacement in octogenarian patients and their mid-term follow-up. Methods From January 2005 to December 2010, 96 consecutive patients older than 80 years with degenerative severe aortic stenosis, underwent aortic valve replacement associated or not with coronary artery bypass grafting at the Hospital Universitario Fundación Favaloro. Retrospective morbidity and mortality data were compared between both populations. Follow-up to analyse quality of life was made through personal and telephone interviews. Results Mean age was 82±2 years and 54% were men. Exercise dyspnea was the most common symptom present in 84% of the study population. Eighty-four patients (77%) presented with some degree of previous renal dysfunction. According to the additive EuroSCORE, 78.1% of patients were at high and 17.7% at very high surgical risk. Isolated aortic valve replacement was performed in 55 patients (group I) and combined with coronary artery bypass grafting in the remaining 41 (group II). Overall 30-day mortality was 7.3%, 3.6% in group I and 12.2% in group II (ns). Taking into account elective surgeries, these percentages were reduced to 5.3%, 4.3% and 6.9%, respectively (ns). During the 6-year follow-up, cumulative mortality was 14%. At follow-up, 94% of patients were in FC I-II of the NYHA classification and 88% were not readmitted for a cardiovascular cause. Conclusions ...

Cirugía de reemplazo valvular aórtico en pacientes octogenarios: resultados perioperatorios y seguimiento a mediano plazo / Aortic Valve Replacement in Octogenarian Patients: Perioperative Results and Mid-term Follow-up

Introducción El número de pacientes ancianos que requieren cirugía cardíaca por estenosis aórtica degenerativa ha ido en aumento en las últimas décadas; no obstante, a muchos de ellos se les contraindica por el solo hecho de su edad avanzada. Para evaluar si en nuestro país la cirugía en este grupo etario continúa siendo una opción válida, es necesario conocer los resultados quirúrgicos, las complicaciones y la percepción de calidad de vida ganada por parte de los pacientes, datos que son escasos en la bibliografía argentina. Objetivos Comunicar la experiencia de un centro en la cirugía de reemplazo valvular aórtico en octogenarios y su seguimiento a mediano plazo. Material y métodos Desde enero de 2005 a diciembre de 2010, 96 pacientes consecutivos mayores de 80 años portadores de estenosis valvular aórtica grave degenerativa fueron sometidos a cirugía de reemplazo valvular asociada o no con revascularización miocárdica en el Hospital Universitario Fundación Favaloro. Los datos se obtuvieron en forma retrospectiva y se compararon ambas poblaciones en términos de morbimortalidad. Se realizó un seguimiento de los pacientes para análisis de calidad de vida a través de entrevistas personales y telefónicas. Resultados La edad de la población fue de 82 ± 2 años, el 54% de sexo masculino. El síntoma más común fue la disnea de esfuerzo, presente en el 84% de los pacientes. En 84 pacientes (77%) se halló algún grado de disfunción renal previa. Según el EuroSCORE aditivo, el 78,1% fueron pacientes de riesgo alto y el 17,7% de riesgo muy alto. Se les realizó reemplazo valvular aórtico aislado a 55 pacientes (grupo I) y asociado con revascularización miocárdica a los 41 restantes (grupo II). La mortalidad total a los 30 días fue del 7,3%, 3,6% en el grupo I y 12,2% en el grupo II (ns). Teniendo en cuenta las cirugías electivas, estas cifras descienden a 5,3%, 4,3% y 6,9%, respectivamente (ns). Durante el seguimiento a 6 años se registró una mortalidad acumulativa del 14%. En el seguimiento, el 94% se encontraba en CF I-II de la NYHA y el 88% no debió reinternarse por causa cardiovascular. Conclusiones La cirugía de reemplazo valvular aórtico en pacientes octogenarios, asociada o no con revascularización miocárdica, realizada en un centro con experiencia y en forma electiva es un procedimiento con buenos resultados a corto y a mediano plazos, por lo que no debería contraindicarse teniendo en cuenta en forma aislada la edad o el puntaje de riesgo prequirúrgico.(AU)

Introduction Over the last decades the number of elderly patients requiring cardiac surgery due to degenerative aortic stenosis has consistently increased. However, this intervention is contraindicated in many of these patients due to their advanced age. To assess whether in our country this type of surgery is still a valid option, it is necessary to know the surgical results, complications and quality of life gained perceived by the patients, data which are scarce in the Argentine literature. Objectives The aim of this study was to communicate the experience of a center on aortic valve replacement in octogenarian patients and their mid-term follow-up. Methods From January 2005 to December 2010, 96 consecutive patients older than 80 years with degenerative severe aortic stenosis, underwent aortic valve replacement associated or not with coronary artery bypass grafting at the Hospital Universitario Fundación Favaloro. Retrospective morbidity and mortality data were compared between both populations. Follow-up to analyse quality of life was made through personal and telephone interviews. Results Mean age was 82±2 years and 54% were men. Exercise dyspnea was the most common symptom present in 84% of the study population. Eighty-four patients (77%) presented with some degree of previous renal dysfunction. According to the additive EuroSCORE, 78.1% of patients were at high and 17.7% at very high surgical risk. Isolated aortic valve replacement was performed in 55 patients (group I) and combined with coronary artery bypass grafting in the remaining 41 (group II). Overall 30-day mortality was 7.3%, 3.6% in group I and 12.2% in group II (ns). Taking into account elective surgeries, these percentages were reduced to 5.3%, 4.3% and 6.9%, respectively (ns). During the 6-year follow-up, cumulative mortality was 14%. At follow-up, 94% of patients were in FC I-II of the NYHA classification and 88% were not readmitted for a cardiovascular cause. Conclusions ...(AU)

Trasplante cardíaco ortotópico: resultados del Hospital Universitario Fundación Favaloro / Orthotopic Heart Transplantation: Results from the Hospital Universitario Fundación Favaloro / Orthotopic Heart Transplantation: Results from the Hospital Universitario Fundación Favaloro

Introducción Los resultados favorables a lo largo de cuatro décadas de experiencia clínica han consolidado al trasplante cardíaco como el tratamiento de elección en la insuficiencia cardíaca refractaria a todo tratamiento y lo convierten en la terapéutica de elección. Objetivo Comunicar los resultados de pacientes con trasplante cardíaco ortotópico realizados en el Hospital Universitario Fundación Favaloro con 16 años de seguimiento. Material y métodos Se analizaron retrospectivamente 335 trasplantes cardíacos ortotópicos consecutivos efectuados en 333 pacientes entre febrero de 1993 y diciembre de 2009. El seguimiento fue del 94%. El 7% fueron trasplantes cardíacos pediátricos y el 2%, cardiorrenales. El 35% de los pacientes eran portadores de miocardiopatía isquémico-necrótica. En el 42% (142 pacientes) fueron electivos y en el 58% (193 pacientes) se realizaron en urgencia/emergencia. La supervivencia se analizó mediante curvas de Kaplan-Meier. Resultados La supervivencia global a 1, 5, 10 y 15 años fue del 80%, 74%, 71% y 65%, respectivamente. La condición de electivo versus urgencia/emergencia no mostró diferencias significativas en la mortalidad global. Tampoco la etiología de la miocardiopatía, incluso en pacientes con miocardiopatía chagásica. La mortalidad hospitalaria fue del 12,5%, sin diferencia significativa en los trasplantes electivos versus urgencia/emergencia. Luego del primer año, la incidencia de rechazo celular grave fue < 3%. La incidencia global de rechazo humoral fue del 4,5%. Se diagnosticaron síndromes linfoproliferativos en 11 pacientes (3,5%). Desarrollaron insuficiencia renal el 21% de los pacientes, diabetes mellitus el 24%, hipertensión arterial el 69% y dislipidemia el 70%. Conclusión En nuestro centro, la supervivencia postrasplante cardíaco a 1, 5, 10 y 15 años fue del 80%, 74%, 71% y 65%, respectivamente, comparable a la de los registros internacionales.

Background The favorable outcomes achieved during four decades of clinical experience have consolidated heart transplantation as the treatment of choice of refractory heart failure. Objective To report the outcomes of patients undergoing orthotopic heart transplantation at the Hospital Universitario Fundación Favaloro during 16 years of follow-up. Material and Methods A total of 335 consecutive orthotopic heart transplantations performed in 333 patients from February 1993 to December 2009 were retrospectively analyzed. Follow-up was 94%. Seven percent corresponded to pediatric heart transplantation and 2% to heart-kidney transplantation. Thirty five percent of patients had ischemic cardiomyopathy. Transplants were elective procedures in 42% of cases (142 patients) and 58% (193 patients) were urgent/emergency procedures. Survival was analyzed using Kaplan-Meier curves. Results Survival rates at 1, 5, 10 and 15 years were 80%, 74%, 71% and 65%, respectively. There were no significant differences between elective and urgent/emergency procedures. Survival was also similar for the different etiologies, even in patients with Chagas cardiomyopathy. In-hospital mortality was 12.5%, with no significant differences between elective and urgent/emergency procedures. After the first year, the incidence of severe cellular rejection was < 3%. The global incidence of humoral rejection was 4.5%. Lymphoproliferative syndrome was diagnosed in 11 patients (3.5%). Twenty one percent of patients developed kidney failure, 24% diabetes mellitus, 69% hypertension and 70% dyslipemia. Conclusion In our center, survival rates after heart transplantation at 1, 5, 10 and 15 years were 80%, 74%, 71% and 65%, respectively.

[Clinical finding and follow-up of chronic constrictive pericarditis]. / Clínica y seguimiento de la pericarditis constrictiva crónica.

The aim of this study was to describe the etiology, clinical findings, diagnostic methods, treatment, outcome and long-term prognosis of 35 patients with chronic constrictive pericarditis (CCP) that were prospectively analyzed according to a pericardial disease protocol performed in our Institution. Etiology of CCP was idiopathic in 24 patients (68%), and specific in 11 (32%). The majority (34 patients, 97%) underwent pericardiectomy. Perioperative mortality was 12% (4/33) no deaths were registered among patients with idiopathic CCP. Median follow-up was 5.6 years (percentile 25-75: 2.4-7.4 years). The cumulative actuarial survival probability was 97% at 1 year (confidence interval [CI] 80% to 99%); 83% at 5 years, (95% CI 65% to 93%); 78% at 7 years, (95% CI 60% to 90%), and 69% at 10 years (95% CI 50% to 84%). In conclusion, nowadays CCP is generally an idiopathic disease with late diagnosis. The clinical course of the disease produces severe symptoms of congestive heart failure. In a 10 years follow-up 2/3 of patients are alive and improved their quality of life. Idiopathic form of pericarditis did not show mortality during early postoperative period.

Clínica y seguimiento de la pericarditis constrictiva crónica / Clinical finding and follow up of chronic constrictive pericarditis

El objetivo de este estudio fue describir la etiología, presentación clínica, métodos diagnósticos, tratamiento, evolución y pronóstico alejado de 35 pacientes con pericarditis constrictiva crónica que fueron evaluados prospectivamente de acuerdo a un protocolo de enfermedad pericárdica que se aplica en nuestra Institución. En 24 (68%) la pericarditis constrictiva fue idiopática y 11 (32%) presentaron etiología definida, realizándose pericardiectomía en 34 (97%). Hubo 4 (12%) muertes intrahospitalarias, todas con etiología definida. La mediana de seguimiento fue de 5.6 años (percentilos 25-75: 2.4-7.4 años). La supervivencia de acuerdo al método de Kaplan-Meier fue de 97% al año (IC 95% 80 - 99%), 83% a los 5 años (IC 95% 65 - 93%), 78% a los 7 años (IC 95% 60 - 90%), y 69% a los 10 años (IC 95% - 50% - 84%). En conclusión, la pericarditis constrictiva crónica es una enfermedad generalmente idiopática, de diagnóstico tardío, cuyo tratamiento es la pericardiectomía. Los pacientes con etiología específica presentaron mayor mortalidad intrahospitalaria. En el seguimiento a 10 años 2/3 de los pacientes están vivos y con mejoría de los síntomas.

The aim of this study was to describe the etiology, clinical findings, diagnostic methods, treatment, outcome and long-term prognosis of 35 patients with chronic constrictive pericarditis (CCP) that were prospectively analyzed according to a pericardial disease protocol performed in our Institution. Etiology of CCP was idiopathic in 24 patients (68%), and specific in 11 (32%). The majority (34 patients, 97%) underwent pericardiectomy. Perioperative mortality was 12% (4/33) no deaths were registered among patients with idiopathic CCP. Median follow-up was 5.6 years (percentile 25-75: 2.4-7.4 years). The cumulative actuarial survival probability was 97% at 1 year (confidence interval [CI] 80% to 99%); 83% at 5 years, (95% CI 65% to 93%); 78% at 7 years, (95% CI 60% to 90%), and 69% at 10 years (95% CI 50% to 84%). In conclusion, nowadays CCP is generally an idiopathic disease with late diagnosis. The clinical course of the disease produces severe symptoms of congestive heart failure. In a 10 years follow-up 2/3 of patients are alive and improved their quality of life. Idiopathic form of pericarditis did not show mortality during early postoperative period.

The circadian biology of the marbled crayfish.

The parthenogenetic marbled crayfish (Procambarus spec.) has recently been introduced as a new preparation for neuroethological studies. Since isogeneity apparently limits inter-individual variation, this otherwise typical decapod species may be especially valuable for circadian studies. Locomotor activity of isolated marbled crayfish and agonistic activity of small social groups maintain circadian rhythmicity in constant darkness. As potential signals of circadian time information, levels of 5HT, N-acetylserotonin and melatonin were determined in brains of marbled crayfish at different daytimes. However, location and structural organization of crustacean circadian pacemakers are still elusive. Immunocytochemical and backfill studies in the marbled crayfish revealed neural structures that may correspond to portions of circadian pacemaker systems in the insect optic lobe. Position and additional chemical contents in two pigment-dispersing hormone-expressing neuron groups resembled insect pigment-dispersing factor-expressing cells in the lamina and the accessory medulla, a neuropil discussed as center for integration of timing information. Here, we discuss new findings about the possible organization of the circadian system of the marbled crayfish in the light of current knowledge about circadian clocks in crustacea.

Mixomas cardíacos: presentación clínica, resultados quirúrgicos y pronóstico a largo plazo / Cardiac Myxomas: Clinical Presentation, Surgical Outcomes and Long-term Prognosis

Introducción Los tumores cardíacos primarios constituyen una patología poco frecuente y de ellos el mixoma es el más común. Con el progreso acelerado de los métodos por imágenes se ha incrementado la frecuencia de su identificación in vivo. El cuadro clínico de presentación varía ampliamente de acuerdo con el tamaño y la localización tumoral. En Latinoamérica son escasas las comunicaciones acerca de los resultados quirúrgicos de la resección de mixomas cardíacos y del pronóstico a largo plazo. Objetivos Analizar la forma de presentación anatomoclínica, los resultados perioperatorios y la evolución de pacientes con mixoma cardíaco sometidos a resección quirúrgica. Material y métodos Revisión de 59 casos de mixomas cardíacos operados en nuestro centro entre 1992 y 2006. El seguimiento se realizó mediante consulta clínica, encuesta telefónica y ecocardiografía. Resultados La edad media fue de 53 ± 16,8 años. El 54,2% eran mujeres. La localización tumoral más frecuente fue en la aurícula izquierda en el 81% de los casos. La forma clínica de presentación fue obstructiva en el 52,5%, embólica en el 37,2%, constitucional en el 27,1%, arritmia supraventricular en el 22% y asintomática en el 10,1%. En dos casos (3,4%) se trató de recurrencias tumorales. El diámetro tumoral mayor se relacionó con la presentación obstructiva y la arritmia supraventricular. El diámetro tumoral menor se asoció con la presentación embólica. La localización ventricular se observó en pacientes más jóvenes. Se realizó resección tumoral asociada con revascularización coronaria en el 8,4% y cirugía valvular y/o de grandes vasos en el 13,5%. La mortalidad posoperatoria fue del 1,7% y las complicaciones más frecuentes fueron bloqueo auriculoventricular completo en el 23,7%, arritmia supraventricular en el 23,7% y bajo volumen minuto en el 18,6%. El seguimiento alejado se realizó en el 94,8% de los casos, con un promedio de 78,3 meses. El 65,5% de los pacientes evolucionaron asintomáticos. La complicación más frecuente durante el seguimiento fue la arritmia supraventricular en el 13,7%. Se constató un caso de recidiva tumoral. La mortalidad alejada fue del 6,8% (n = 4). Conclusiones El mixoma cardíaco habitualmente se diagnostica en pacientes sintomáticos. La cirugía posee una morbimortalidad baja, buen pronóstico a largo plazo y una tasa baja de recidiva en el seguimiento.

Background Primary heart tumors are very unfrequent, and among them, myxomas are most common. The development of new diagnostic imaging techniques has increased the in vivo diagnosis of cardiac myxomas. The clinical presentation varies with tumor size and location. In Latin America there is scanty information about the surgical results and long-term prognosis after the surgical resection of cardiac myxomas. Objectives To analyze the clinical presentation, pathological features, perioperative results and long-term outcomes of patients with cardiac myxoma undergoing surgical resection. Material and Methods We conducted a retrospective analysis of 59 cases of cardiac myxomas operated on in our center between 1992 and 2006. Follow-up was obtained through clinic visits, telephone interview and echocardiography. Results Mean age was 53±16.8 years and 54.2% were women. Myxomas were more frequently located in the left atrium (81%). The presence of symptoms related to obstruction was the most frequent clinical presentation (52.5%), followed by symptoms related to embolization (37.2%), constitutional symptoms (27.1%) and supraventricular arrhythmias (22%); 10.1% of cases were asymptomatic. Recurrences occurred in 2 cases (3.4%). The tumor diameter correlated with the presence of symptoms related to obstruction and with supraventricular arrhythmias. Embolism was associated with smaller tumors. Ventricular location was observed in younger patients. Tumoral resection was associated with coronary revascularization in 8.4% of cases and with heart valve and/or great vessel surgery in 13.5% of patients. Post-operative mortality was 1.7% and the most frequent complications were: complete atrioventricular block (23.7%), supraventricular arrhythmias (23.7%) and low cardiac output syndrome (18.6%). Complete long-term follow-up was achieved in 94.8% of cases; mean follow-up was 78.3 months. During follow-up, 65.5% of patients remained asymptomatic. Supraventricular arrhythmia was the most frequent complication (13.7%). A recurrence occurred in one patient. Late mortality rate was 6.8% (n=4). Conclusions Cardiac myxoma is usually diagnosed in asymptomatic patients. Surgery has low morbidity and mortality with favorable long-term outcomes and low recurrence rate during follow-up.

Surgical treatment of ascending aortic complications in Marfan syndrome: early and long-term outcomes.

Findings in 54 patients (mean age 39 years, range 18-66 years, 25% female) were analyzed. Of these patients, 21 had dissection of the ascending aorta (15 acute and six chronic) and 33 had aneurysm of the ascending aorta. Surgery was classified as emergency surgery in three cases, as urgent in 15, and as scheduled surgery in 36. The Bentall-De Bono procedure was performed in 39 patients, aortic valve reimplantation was carried out in nine, Cabrol's operation was performed in three, and a homograft was used in three. The mean diameter of the ascending aorta was 66.6 mm. Overall, in-hospital mortality was 3.7% (33.3% for emergency surgery vs. 2.8% for scheduled surgery; P< .001). During the mean follow-up period of 4 years (range, 2 months-14 years), seven patients died, including four who died due to type-B aortic dissection. The actuarial survival rate at 2, 5 and 10 years was 94%, 83% and 75%, respectively, with 88%, 67% and 43% of patients, respectively, not requiring reoperation. Elective aortic root replacement was associated with a low risk and a good survival rate.

Tratamiento quirúrgico de las complicaciones de la aorta ascendente en el síndrome de Marfan. Resultados inmediatos y a largo plazo / Surgical Treatment of Ascending Aortic Complications in Marfan Syndrome: Early and Long-Term Outcomes

Se analizaron los resultados en 54 pacientes con unamedia de edad de 39 (18-66) años; el 25% eran mujeres;21 pacientes presentaban disección (aguda en 15 y crónicaen 6 pacientes) y 33, aneurisma. La operación fuede máxima urgencia en 3 pacientes, urgente en 15 y programada en 36. Utilizamos tubo valvulado en 39 pacientes, reimplante valvular en 9, técnica de Cabrol en 3 y homoinjerto en 3. El diámetro promedio aórtico fue de 66,6 mm. La mortalidad hospitalaria total fue del 3,7% (máxima urgencia, 33,3%; programada, 2,8%; p < 0,001). Durante el seguimiento (media, 4 años [2 meses-14 años]) fallecieron 7 pacientes, 4 por disección aórtica tipo B. A los 2, a los 5 y a los 10 años, la supervivencia actuarial fue del 94, el 83 y el 75% y la libertad de reoperación, del 88, el 67 y el 43%, respectivamente. El reemplazo electivode la aorta ascendente tiene bajo riesgo y buena supervivencia

Findings in 54 patients (mean age 39 years, range 18-66 years, 25% female) were analyzed. Of these patients,21 had dissection of the ascending aorta (15 acute andsix chronic) and 33 had aneurysm of the ascending aorta.Surgery was classified as emergency surgery in threecases, as urgent in 15, and as scheduled surgery in 36.The Bentall-De Bono procedure was performed in 39patients, aortic valve reimplantation was carried out innine, Cabrol’s operation was performed in three, and ahomograft was used in three. The mean diameter of theascending aorta was 66.6 mm. Overall, in-hospitalmortality was 3.7% (33.3% for emergency surgery vs.2.8% for scheduled surgery; P<.001). During the meanfollow-up period of 4 years (range, 2 months-14 years),seven patients died, including four who died due to type-B aortic dissection. The actuarial survival rate at 2, 5 and 10 years was 94%, 83% and 75%, respectively, with 88%, 67% and 43% of patients, respectively, not requiringreoperation. Elective aortic root replacement wasassociated with a low risk and a good survival rate

Segurança e eficácia tardia do stent com eluição de paclitaxel no infarto agudo do miocárdio: um estudo caso-controle / Safety and long-term efficacy of paclitaxel-eluting stent for acute myocardial infarction: a case-control study

Introdução: A segurança e a eficácia tardia de stents com eluição de paclitaxel (SEP) ainda são debatidas no infarto agudo do miocárdio (IAM). Método: Para avaliar o desempenho dos SEP em pacientes com IAM tratados com intervenção coronária percutânea (ICP), 60 pacientes foram selecionados para uma análise tipo caso-controle, comparando um grupo com SEP (TaxusTM) e um grupo controle com o stent convencional análogo (Express IITM). Os parâmetros para escolha dos controles foram o comprimento e o diâmetro do stent, e a presença de diabetes melito. Eventos cardíacos adversos maiores foram avaliados durante o seguimento clínico. Reestudo angiográfico tardio foi realizado em todos os pacientes. Avaliação ultra-sonográfica foi realizada no grupo SEP. Resultados: As características basais foram semelhantes entre os grupos. Após 24,9 ± 5,3 meses de acompanhamento, houve uma revascularização da lesão-alvo (RLA) no grupo SEP (nova ICP), e uma morte não-cardíaca, um reinfarto e seis RLA (duas cirurgias e quatro novas ICP) no grupo controle. O grupo SEP apresentou menor risco de nova revascularização (3,3% vs. 23,3%; p = 0,02). Ao reestudo angiográfico realizado, em média, 8,7 ± 3,1 meses após o procedimento índice, a perda angiográfica tardia foi de 0,21 ± 0,29 mm vs. 0,60 ± 0,76 mm (p = 0,01) e a taxa de reestenose binária foi de 3,3% vs. 33,3% (p = 0,002) nos grupos SEP e controle, respectivamente. À ultra-sonografia, o grupo SEP apresentou obstrução neointimal intra-stent porcentual média de 4,7 ± 6,8%. Má aposição do stent foi observada em 8 (34,8%) pacientes. Conclusão: O SEP (TaxusTM) mostrou-se seguro e efetivo em paciente com IAM, durante seguimento clínico de dois anos.

Background: The long-term safety and efficacy of paclitaxeleluting stents (PES) remains debated for patients with acute myocardial infarction (AMI). Method: To evaluate the performance of PES in patients with AMI treated with percutaneous coronary intervention (PCI), 60 patients were subjected to a matched analysis comparing PES stent (TaxusTM) with an analogous bare metal stent (Express IITM) control group. Matching parameters included stent length and diameter, and diabetes mellitus. Major adverse cardiac events were evaluated during follow up. Late angiographic restudy was obtained for all patients. Intravascular ultrasound (IVUS) evaluation was performed in PES group. Results: Baseline and procedural characteristics were similar between PES and control groups. After a mean follow-up of 24.9 ± 5.3 months, there was 1 target lesion revascularization (TLR) in the PES group (re-stenting) and 1 non cardiac death, 1 re-AMI and 6 TLR (2 surgical revascularizations and 4 re-PCI) in the control group. Patients of PES group had a lower risk of repeat revascularization (3.3 vs. 23.3%; p = 0.02). At angiographic restudy 8.7 ± 3.1 months after index procedure, angiographic late loss was 0.21 ± 0.29 vs. 0.60 ± 0.76 mm (p = 0.01) and the binary reestenosis rate was 3.3 vs. 33.3% (p = 0.002) in the PES vs. control groups respectively. At IVUS evaluation, average percent in-stent neointimal obstruction of PES group was 4.7 ± 6.8%. Stent malapposition was observed in 8 patients (34.8%). Conclusion: Paclitaxel-eluting stents (TaxusTM) appeared safe and effective in patients with acute myocardial infarction at a two-year period follow-up.

Predicción del riesgo en cirugía coronaria propuesta de un score clínico para mortalidad / Prediction of prognosis in coronary surgero. Proposal of a clinical score that predicts mortality after coronary artery surgery

El objetivo de este trabajo es analizar los resultados de la cirugía coronaria pura, identificar predictores de mortalidad hospitalaria con el de confecciónar un score de riesgo... Los ancianos, las mujeres, los procedimientos no programados, la reoperación, la angina inestable, la insuficiencia renal crónica y el deterioro grave de la función ventricular predicen una mayor mortalidad. El score propuesto resultó útil para predecir mortalidad hospitalaria en cirugía coronaria

Influencia del sexo en los resultados de la cirugía coronaria. Análisis comparativo entre hombres y mujeres / Influence of gender on coronary surgery results. Comparative analysis between men and women

El propósito del presente trabajo fue comparar las características clínicas, técnica quirúrgica y resultados hospitalarios entre hombres (H) y mujeres (M) sometidos a cirugía coronaria (CC)...Se observó que ambos sexos presentan diferencias significativas en las características clínicas basales, en la técnica quirúrgica y en los resultados hospitalarios, con peor evolución en el sexo femenino