[Role of surgery in the treatment of acute ischemic syndromes]. / Papel de la cirugía en el tratamiento de los síndromes isquémicos agudos.

The acute coronary syndromes, like unstable angina and acute myocardial infarction without S-T segment elevation, still common manifestation in coronary disease. The difference between these two entities is the symptoms severity, mainly expressed by Troponins elevation as a biochemical marker of myocardial necrosis. These acute coronary syndromes required, first of all, an aggressive medical treatment in order to stabilise a control the symptoms. Coronary artery bypass surgery has, so far, a similar indication based on the obstructive coronary artery lesion; all of them considered of high risk.

[Unusual case: injury of the 4 heart valves in a patient with old heart injury caused by fire arm. Review of the literature]. / Un caso insólito: lesión de las 4 válvulas cardiacas en un paciente con lesión cardiaca antigua por proyectil de arma de fuego. Revisión de la literatura.

We review the literature on heart wounds. Along the history surgeons regarded heart wounds as forbidden place for therapeutic approach. We present a patient who sustained a bullet wound to the heart and two years later 3 knife' stabs in the same place injuring its 4 valves and inducing 2 fistulae: one from the aorta to the pulmonary artery, the other from left-ventricle and the pulmonary artery. Surgery was successful in repairing the damage without the need of valve replacement.

[Reconstructive surgery of the mitral valve. Experience with 400 cases]. / Cirugía reconstructiva mitral. Experiencia de 400 casos.

From january 1980 to december 1992 a total of 400 valvulopathies were subjected to conservative mitral procedures: 364 had rheumatic heart disease, 33 were congenital abnormalities and 3 probably myxomatous. Functional class and the cardiomegaly, were in grade III and IV in most cases. Different procedures were done; the most common one was commisurotomy, also subvalvular apparatus opening, annuloplasty ring and a newly designed procedure called "Tension Stitch". The results were satisfactory, with a reoperation rate of 9.2%, mostly caused by fibrosis which in turn caused dysfunction. A second cause were technical problems. The mortality rate was 2%, and was not caused by the procedure itself but because of bad clinical status of the patients. The follow up period was 13 years and showed an actuarial survival curve of 98%, with 90.8% free of reoperation and a very good post-op quality of life. We present this analysis in a effort to bring this procedure to the attention of cardiac surgeons, considering it as an alternative to prosthesis placement.

[Incomplete ventricular laceration post mitral valve change. Report of a case and review of the literature]. / Laceración ventricular incompleta post cambio valvular mitral. Reporte de un caso y revisión de la literatura.

There are numerous reports concerning left ventricular rupture after mitral valve replacement, and it has been classified according to location, treatment and prognosis. A somewhat less terrific complication has appeared as modifications have been introduced to the surgical technique, decreasing the frequency of rupture, but otherwise increasing the frequency of incomplete laceration, which has seldom appeared in literature. We review the case of a patient with incomplete left ventricular laceration after mitral valve replacement.

[Is age a limitation in coronary revascularization? Comparative group analysis]. / Es la edad una limitante para la revascularización coronaria? Análisis comparativo de grupos.

It is a well known fact that in the last decade the longevity of the population has grown, which in turn has resulted in a larger group of octogenary patients being taken to coronary artery bypass procedures. Nevertheless, older age has always been considered a predisposing factor for complications. In this paper we analyze our recent experience with octogenary patients submitted to coronary artery bypass graft surgery, comparing the morbi-mortality of this group with a comparative younger age group. We found no increase in serious complications. Thus surgery should be offered irrespective of age with acceptable survival.

The transseptal approach for mitral valve replacement revisited.

We describe our experience with the transseptal approach for mitral valve replacement, a technique that we applied especially in cases of 3rd and 4th operations wherein numerous adhesions made the usual left atrial approach difficult. We report 39 cases of mitral procedures in which we used 3 slightly different transseptal approaches, depending on the cardiac anatomy and the preferences of the surgeon. There were no complications associated with any of these approaches. Indeed they made the mitral valve procedure easier, because they enabled full exposure of the mitral valvular and subvalvular apparatus. We also propose the transseptal approach as a very safe and reproducible technique for use in patients with friable tissues, heavily calcified mitral valves, or small left atria- and in patients who must undergo combined tricuspid and mitral procedures. In this series, there were no conduction abnormalities secondary to the approach, nor were there any procedure-related deaths.

[Left internal mammary artery in octogenarians. Is its use in coronary revascularization justified?]. / Mamaria interna izquierda en octogenarios. Se justifica su uso en la revascularización coronaria?

Given the longer survival of the population, the possibility for an octogenarian to get a coronary artery bypass procedure is more likely. It has been customary not to implant arterial conduits in this particular group of patients, in the belief that they increase the morbidity-mortality of the procedure, without longer survival. We undertook a retrospective analysis of a total of 148 patients older than 70 years subjected to coronary artery bypass procedures with left internal mammary artery implanted during a twelve year period. The mortality was 3.37%, there were no increased perioperative complications such as bleeding or mediastinal infections. It is our believe that even in this group of elderly patients the internal mammary artery is of benefit in the short and the long terms, without an increased perioperative complications.

[Submammary skin incision for longitudinal medial sternotomy]. / Incisión submamaria para esternotomía media longitudinal.

The submammary incision has been postulated as an alternative in median sternotomy approach since 1960. We used this incision in 32 females patients from 1 to 24 years. The diagnoses were atrial septal defects (ASD) 23 patients, ventricular septal defect (VSD) 2 patients, double outlet right ventricle 1 patient, supravalvular aortic stenosis 1 patient, ASD with VSD 3 patients and partial anomalous pulmonary venous connection 1 patient. Nine patients had a complication: cheloid scar 1 patient, seroma 2 patients, wound dehiscence 3 patients, and diminution of sensitivity 3 patients. We conclude, that this type of surgical approach is an excellent alternative for women with good aesthetic and psychological results. Their complications are easy to correct.

[Bidirectional cavopulmonary diversion for tricuspid atresia. Experience in the National Institute of Cardiology]. / Derivación cavopulmonar bidireccional para la atresia tricuspídea. Experiencia en el Instituto Nacional de Cardiología.

Bidirectional cavopulmonary shunt is an alternative palliative procedure for patients with congenital cyanotic heart disease, specially those patients less than "ideal" candidates for a Fontan's procedure. We present our results with this shunt in patients with tricuspid atresia. Twenty patients with tricuspid atresia were operated on with this shunt, with these associated defects: 20 atrial septal defect, 17 ventricular septal defect, 10 pulmonary stenosis, 1 pulmonary atresia and 1 transposition of the great arteries. Sex: 10 males and 10 females; the age was 27 days to 6 years (mean 1.8 years), the weight was 3.2 kg to 24 kg (mean 10.7 kg), the mean pulmonary artery pressure was 11 to 24 mmHg (mean 17 mmHg), pulmonary vascular resistance was 1.5 to 5 UW (mean 3.1 UW). Postoperative oxygen saturation improved 15 to 120%. All patients survived the surgical procedure. Three patients died in the immediate postoperative period, 2 due to a complications in the postoperative period and 1 due to sepsis. There were two late deaths, 1 sudden death after 6 months of the shunt, and 1 due to sepsis after a Fontan's procedure. Four patients presented pleural effusion and 2 pericardial effusion, they resolved well. We have 15 patients alive and well, in functional class I, and minimal cyanosis. We can conclude that this surgical procedure is useful in the management of patients with tricuspid atresia.

[Aorto-septal approach (modified Konno procedure). Surgical alternative in the management of diffuse aortic subvalvular stenosis]. / Abordaje aorta-septal (Konno modificado). Alternativa quirúrgica en el manejo de la estenosis subvalvular aórtica difusa.

The surgical treatment of diffuse subaortic stenosis by insertion of a left ventricular apico-aortic valved conduct and Konno-Rastan procedures often fails to provide satisfactory results. These procedures require the insertion of a prosthetic valve. Some patients with diffuse subaortic stenosis have a normal aortic orifice and the replacement of normal aortic valve is questionable. Since 1984 Vouhé' modification of the Konno' procedure was using this described with adequate relief of the diffuse subaortic stenosis preserving the aortic valve. We present our experience with 5 patients in 10 years was using this surgical alternative.

[Myotomy-myomectomy as treatment of localized hypertrophic cardiomyopathy]. / Miotomía-miectomía como tratamiento de la miocardiopatía hipertrófica localizada.

We report the surgical treatment of 23 patients with local hypertrophic cardiomyopathy (LHM). Fifteen patients, group I (65.3%), with LHM were treated by myotomy-myectomy alone. Eight patients, group II (34.7%), with LHM and other cardiac disease, was treated by myotomy-myectomy and complementary procedure (mitral or aortic replacement, correction of congenital malformation). This group II had the major morbidity and mortality. Five years follow up had a 76.14% survival.

[The long-term follow-up of 1000 patients with a valve replacement by the prosthesis of the Instituto Nacional de Cardiología Ignacio Chávez]. / Evolución a largo plazo de mil pacientes con reemplazo valvular con prótesis "Instituto Nacional de Cardiología Ignacio Chávez".

The long-term follow-up of patients with bioprosthetic valves manufactured at the Instituto Nacional de Cardiología Ignacio Chávez is presented. From February 1983 to May 1990, 1068 patients were operated and 1252 valves were replaced. Eighty two percent had rheumatic heart disease with one or more injured valves. In 17% it was a replacement of a failing valve. Seventy three percent of the patients had a low or medium-low socioeconomical status. There were 176 perioperative deaths in the first month after the operation and 150 patients were lost to follow-up. The rest (740) are the subject of this report. Mortality associated with valve related complications had a probability of 0.74 +/- 0.05, it had a significative increase after month 70th, with a 88% survival at that time. The functional class in the whole group improved 90%, with confidence limits for binomial distribution between 85 and 97%. There was also a significant reduction in heart enlargement. There were 161 prosthesis dysfunctions due to valve calcification or rupture, 50 were replaced. Twenty-three patients had hemolysis, and 19 infective endocarditis. There were 6.5% with systemic embolism in spite that only one half of those in which there was an indication, different of the valve replacement, received anticoagulant medication. The use of this prosthesis is on economical and medical satisfactory solution for the problem of a great number of our population of patients.

[Postoperative course of prosthetic valve replacement]. / Evolución postoperatoria en el recambio valvular protésico.

In order to know the post-operative outcome of patients with valvular replacement due to prosthetic dysfunction, we reviewed the clinical charts of 94 patients operated at the Instituto Nacional de Cardiología "Ignacio Chávez" between January 1986 and December 1988. Eighty four cases were replaced by the first time the remaining 10 by a second time. Diagnosis of prosthetic dysfunction was made by clinical, radiological, echocardiographic and haemodynamic parameters. The most frequent causes of dysfunction were the rupture of prosthetic leaflets, stenosis with calcific deposition and paravalvular leaks. The global mortality rate was 19.15%, higher than the native valve replacement group. The most important predictors of surgical mortality were: 1) poor ventricular function (functional classes III and IV), 2) aortic clamping period, 3) the need of a second prosthetic replacement and 4) the time of prosthetic dysfunction. Thus, we conclude that it is of great importance the early recognition of prosthetic valve dysfunction. The need of special surgical procedures in these cases should be evaluated in order to reduce morbidity and mortality.

Intracardiac extension of malignant uterine tumors. Echocardiographic detection and successful surgical resection.

The echocardiographic findings of two unusual cases of malignant uterine tumors that invaded the heart are reported. A woman previously operated on for invasive cervical carcinoma had multiple embolic phenomena and evidence of obstruction to mitral flow. An echocardiogram showed a mass in the left atrium that reached the mitral valve ring. The tumor was implanted in a pulmonary vein and was removed with no complications. Cell type indicated metastatic carcinoma of the cervix. In the second case the patient had a large abdominal mass and precordial manifestations of obstruction and regurgitation of the tricuspid valve. An echocardiogram showed that a mass emanating from the inferior vena cava filled the right atrium and part of the right ventricle. The trajectory of the tumor was followed to its origin in an ovarian vein by tomography. The entire tumor was removed and identified as endometrial stromal sarcoma. An increase in operations with or without radiation therapy for malignant tumors has augmented the frequency of metastatic invasion of the heart; intracavitary extension tends to results from embolization or propagation along great veins. This is the first report of a uterine carcinoma reaching the heart by way of the pulmonary veins and of invasion of the heart by endometrial stromal sarcoma, both with successful excision.

[40 years' experience in the surgical treatment of constrictive pericarditis]. / Cuarenta años de experiencia en el tratamiento quirúrgico de la pericarditis constrictiva.

In order to know early and late results of pericardiectomy on the treatment of chronic constrictive pericarditis in the Instituto Nacional de Cardiología Ignacio Chávez, we review the records of 58 patients with the diagnosis of constrictive pericarditis who underwent surgical treatment between 1947 to 1987. Tuberculosis was the most frequent cause (68.3%) followed by idiopathic cases (24.1%). Preoperatively 3.4% were in New York Heart Association Class I, 31% in Class II, 48.3% in Class III and 17.2% in Class IV. There were 4 in-hospital deaths (overall operative mortality 6.89%). Operative mortality in the last ten years was 0%. Low output was the most common nonfatal complication of pericardiectomy (15.5%). Accidental right atrial tear happened in 8.6%. Mean post-operative follow-up was 5.6 +/- 6.3 years (longest 25.6 years). Mortality per patient year was 2.04%. Actuarial survival estimates were 82% and 71% at 5 to 10 years respectively. Postoperatively 76% were in New York Heart Association Class I (p less than 0.001), 16% in Class II (p less than 0.001), 8% in Class III (p less than 0.001) and none in Class IV (p less than 0.05). Operative mortality, long-term survival and post-operative functional Class were not significantly influenced by preoperative functional Class nor by the duration of symptoms. We conclude that pericardiectomy is an effective treatment of symptomatic chronic constrictive pericarditis because it provides an important and durable improvement in symptoms and functional Class, and it has a low operative mortality.

[Coronary revascularization in the geriatric patient]. / Revascularización coronaria en el paciente geriátrico.

In order to determine the current status of coronary revascularization in the elderly, we studied 102 patients aged 65 to 77 years (mean 68 years) who had surgery at the Instituto Nacional de Cardiología "Ignacio Chávez". Seventy eight (76.4%) were male and 24 (23.5%) female. The coronary risk factors were cigarette smoking, systemic arterial hypertension and familiar history of coronary heart disease. Fifty five patients (54%) had myocardial infarction prior to surgery and in 29 (28.4%) the time between the ischemic event and surgery was less than one year. Ninety Patients (88.2%) presented with unstable and 12 (11.7%) with stable angina. Ejection fraction was less than 40% en 32 patients (31%). Coronary angiograms showed one vessel disease in 5 cases (4.9%), two vessel involvement in 29 (28.4%), three vessel lesions in 56 (55.8%) and left main coronary artery in 12 (11.7%). The patients underwent a mean of 2.1 bypasses (range 1 to 4). Perioperative mortality was 10.7%. Actuarial survival and angina pectoris relapse were 80 and 24% respectively at 6 years follow-up. We conclude that old age does not rule-out surgery for coronary heart disease.

[Study using non-invasive methods in prostheses of bovine pericardium in aortic position manufactured at the Ignacio Chávez National Institute of Cardiology]. / Estudio por procedimientos no invasivos de las prótesis de pericardio bovino en posición aórtica manufacturadas en el Instituto Nacional de Cardiología Ignacio Chávez.

We studied 28 patients to whom a prosthestic valve of bovine pericardium manufactured in the Instituto Nacional de Cardiología Ignacio Chávez (INCICH) were implanted in aortic position, from February 1983 to May 1985. We analyzed the clinic follow-up and the prosthetic function was studied by Phonocardiography, Echocardiography M mode, Two-Dimensional and pulsed wave Doppler recordings obtained before and after surgery. The patient were 26 males, 2 females whose age varied from 12 to 66 years. The aortic valve disease was rheumatic in 12, congenital in 11 and of other type in 5. After surgery 26 patients are in functional class I, one in class II and one died, but death was not related to prosthetic valve function. In the Phonocardiogram we observed significant diminution of the ventricular ejection time of 32 +/- 2 msec. to 29 +/- 2 msec. (P less than 0.05), the aortic valve opening sound was of less intensity than the valve closure sound, with relation between both of 0.53. All of them had a systolic ejection murmur. In the Echocardiogram we observed a significant decrease of the end diastolic diameter of 53 +/- 11 mm to 45 +/- 10 mm (P less than 0.05), the end systolic diameter decreased from 37 +/- 13 mm to 33 +/- 10 mm., but the difference was not significant. The aortic prosthetic flow by pulsed Doppler Echocardiography had a maximum velocity of 137 +/- 23 cm/sec., it represents a valvular gradient of 7.5 +/- 0.02 mmHg. Early diastolic regurgitant flow was recorded in two patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral valve replacement in children with a Björk-Shiley prosthesis]. / Reemplazo valvular mitral en niños con protésis de Björk-Shiley.

This report documents our experience with mitral valve replacement in children. Between 1978 and 1982, 30 replacements have been performed in patients under 15 years of age. Twenty seven patients (90%) with rheumatic heart disease and 3 (10%) had congenital disease. Their functional capacity prior to operation was as follows: Nine patients fell into class II, 18 into class III and 2 into class IV. Preoperative cardiac catheterization, was undertaken in 26 patients, the mean pulmonary arterial wedge pressure was 27.4 +/- 8 mmHg, the pulmonary artery mean pressure was 48 +/- 20 mmHg, the left ventricular end diastolic pressure was 11.7 +/- 5.6 mmHg. One child died in the operative period. Twenty six patients (90%) have been followed for a mean period of 22.7 months. Late mortality occurred in three patients (11%). Bacterial endocarditis, thromboembolism and valve maldisfunction were not present. The post operative NYHA functional class was as follows: twenty two children fell into class I, and one patient fell into class II. The actuarial survival rate 5 years after operation was 79%. We believe that the Björk-Shiley prosthesis offer excellent results in children when repair of the natural valve is not possible.

Reemplazo valvular mitral en ninos con protesis de Bjork-Shiley. / Mitral valve replacement in children with Bjork-Shiley prosthesis

Se analiza la experiencia con protesis de Bjork-Shiley en ninos. Entre enero de 1978 y junio de 1982 se efectuaron 30 reemplazos valvulares en ninos con edad promedio de 13 anos. En 27 pacientes (90%), la lesion era reumatica y en 3 casos (10%) lo era congenita. La clase funcional pre-operatoria fue: clase II en 9 pacientes, clase III en 18 pacientes y clase IV en 2 casos. De este lote se efectuo cateterismo cardiaco preoperativo en 26 pacientes, siendo la PCP de 27.4 +/- 8 mmHg, la presion media de la arteria pulmonar de 48 +/- 20 mmHg y la presion diastolica final del ventriculo izquierdo de 11.7 +/- 5.6 mmHg. La mortalidad operatoria fue de un caso (3.3%). De los 29 sobrevivientes se efectuo seguimiento en 26 casos (90%) con promedio de 22.7 meses. Hubo 3 muertes tardias (11%). No se observaron trombosis de la protesis, embolismo periferico ni endocarditis. De los 23 pacientes sobrevivientes, 22 pasaron a clase funcional I y un caso a clase II. La sobrevida actuarial a 5 anos es de 79%. Concluimos que el reemplazo con protesis de Bjork-Shiley en ninos es una muy buena alternativa cuando no es posible efectuar plastia y reconstruccion de la valvula mitral