Topical cooling for myocardial protection: the results of a prospective randomized study of the "shallow technique".

INTRODUCTION AND BACKGROUND: Respiratory distress following cardiac surgery is a troublesome complication. In several cases it is associated to cool-related phrenic nerve injury (PNI) after adoption of iced slush or hypothermic cardiopulmonary bypass. We compare two different strategies for myocardial protection: the "shallow technique" (ST) (dripping and prompt removal of cold saline solution from the epicardial surface) plus normothermic cardiopulmonary bypass, versus mild hypothermic cardiopulmonary bypass plus iced slush. METHODS: Two hundred forty-nine patients undergoing elective cardiac surgery were randomly assigned to receive either ST (Group A) or iced slush (Group B). Occurrence of postoperative PNI (abnormal diaphragmatic movement plus alteration of nerve conduction) was evaluated. Multivariate analysis was performed for identification of factors associated to PNI. Patients had a 6-month follow-up. RESULTS: PNI and failure of extubation occurred more frequently in Group B (p = 0.009 and p = 0.034, respectively), but there was no statistically significant difference in mean intensive care unit stay. Diabetes and the use of iced slush were independent predictors of phrenic dysfunction, while internal thoracic artery (ITA) harvest was a significant risk factor only among Group B patients. Abnormal diaphragmatic movement was persistent at 6 months only in 30% of Group B individuals who suffered this complication in the early postoperative. CONCLUSIONS: ST likely reduces the incidence of postoperative PNI and might be protective mainly in the event of ITA harvest. It should be considered as a valuable tool for myocardial protection protocols.

[Guided transcatheter valvulotomy in pulmonary atresia with intact ventricular septum]. / Valvulotomía mecánica percutánea dirigida en la atresia pulmonar con septo íntegro.

Transcatheter valvulotomy in pulmonary atresia with an intact ventricular septum can be used as a first step to create biventricular circulation and to stimulate further development of the hypoplastic right ventricle. We describe our experience in a case of a neonate with this congenital cardiac defect who underwent successful transcatheter perforation of the atretic pulmonary valve. This report highlights the utility of a special technique based on the use of a gooseneck snare positioned just above the atretic valve to guide the advance of a coronary guidewire. Other therapeutic alternatives are considered.

Valvulotomía mecánica percutánea dirigida en la atresia pulmonar con septo íntegro / Guided transcatheter valvulotomy in pulmonary atresia with intact ventricular septum

La valvulotomía percutánea con catéter en la atresia pulmonar con septo íntegro puede ser el primer paso para establecer una circulación en serie con el posterior desarrollo del ventrículo derecho. Presentamos nuestra experiencia en un neonato con esta cardiopatía, al que realizamos una apertura mecánica, haciendo especial referencia a la técnica empleada con guía especial para desobstrucción coronaria y dirigida con catéter-lazo abierto sobre la válvula pulmonar atrésica. Se exponen otras técnicas alternativas y se discute la evolución de esta paciente en función de su desarrollo anatómico (AU)

Patch enlargement of the posterior mitral leaflet in ischemic regurgitation.

We discuss our early experience in 2 patients with a patch enlargement technique for treating chronic ischemic mitral regurgitation due to restricted motion of the posterior mitral leaflet. This technique corrects the restricted motion and offers better coaptation without compromising the mitral orifice.