Resultados a largo plazo de la valvuloplastía mitral con balón / Long term results of mitral balloon valvuloplasty

Background: Mitral balloon valvuloplasty (MBV) is the therapy of choice for the treatment of symptomatic mitral stenosis with suitable anatomy. Although its short and mid-term results are favorable, there is a paucity of information about long-term follow-up. Aim: To assess the late results of MBV. Material and Methods: A cohort of 225 patients aged 8 to 20 years who were subjected to a MBV from 1989 to 2001, was studied. All variables at the time of the procedure, short and long-term results and major events during follow-up (new mitral intervention and mortality) were recorded. Uni and multivariate analysis were used to assess prognosis. Results: The mean follow-up lapse was 13.5 years (range 8 to 20 years). During this period, 88 patients (39.1%) remained event-free and in acceptable functional capacity. Eight percent died, 8% required a second MBV and 43.5% required a surgical mitral valve replacement. A post-procedural area equal or greater to 1.9 cm² was associated with a greater likelihood of free-event survival (log rank test: p = 0.02/Cox proportional regression model: coefficient 0.54, p = 0.04). Conclusions: MBV is effective, although there is a high chance of new interventions in the long-term follow-up. A larger post-procedure mitral area is associated with a better prognosis.

[Long term results of mitral balloon valvuloplasty]. / Resultados a largo plazo de la valvuloplastía mitral con balón.

BACKGROUND: Mitral balloon valvuloplasty (MBV) is the therapy of choice for the treatment of symptomatic mitral stenosis with suitable anatomy. Although its short and mid-term results are favorable, there is a paucity of information about long-term follow-up. AIM: To assess the late results of MBV. MATERIAL AND METHODS: A cohort of 225 patients aged 8 to 20 years who were subjected to a MBV from 1989 to 2001, was studied. All variables at the time of the procedure, short and long-term results and major events during follow-up (new mitral intervention and mortality) were recorded. Uni and multivariate analysis were used to assess prognosis. RESULTS: The mean follow-up lapse was 13.5 years (range 8 to 20 years). During this period, 88 patients (39.1%) remained event-free and in acceptable functional capacity. Eight percent died, 8% required a second MBV and 43.5% required a surgical mitral valve replacement. A post-procedural area equal or greater to 1.9 cm² was associated with a greater likelihood of free-event survival (log rank test: p = 0.02/Cox proportional regression model: coefficient 0.54, p = 0.04). CONCLUSIONS: MBV is effective, although there is a high chance of new interventions in the long-term follow-up. A larger post-procedure mitral area is associated with a better prognosis.

[Are low-molecular-weight heparins safe in patients with chronic kidney disease?]. / Heparinas de bajo peso molecular en pacientes con enfermedad renal crónica: es seguro su uso?

Due to their efficacy and convenience, low-molecular-weight heparins (LMWH) are used as substitutes of unfractionated heparin. Unfortunately, most of the evidence about safety and usefulness of LMWH have excluded patients with chronic kidney disease (CKD), in whom their elimination clearance is reduced, allowing an increased anticoagulant effect. Accordingly, there is a growing number of reports about major and fatal bleeding episodes in this group of patients using LMWH. At the present stage of knowledge, there is no definitive cut-off value of renal function to adjust the doses or avoid the administration of LMWH, making their effects unpredictable in patients with CKD. Hence, it is reasonable to avoid the use of these drugs in patients with CKD, while awaiting for more evidence that supports their safer use.

Heparinas de bajo peso molecular en pacientes con enfermedad renal crónica ¿Es seguro su uso? / Are low-molecular-weight heparins safe in patients with chronic kidney disease?

Due to their effcacy and convenience, low-molecular-weight heparins (LMWH) are used as sustitutes of unfractionated heparin. Unfortunately, most of the evidence about safety and usefulness of LMWH have excluded patients with chronic kidney disease (CKD), in whom their elimination clearance is reduced, allowing an increased anticoagulant effect. Accordingly, there is a growing number of reports about major and fatal bleeding episodes in this group of patients using LMWH. At the present stage of knowledge, there is no defnitive cut-off value of renal function to adjust the doses or avoid the administration of LMWH, making their effects unpredictable in patients with CKD. Hence, it is reasonable to avoid the use of these drugs in patients with CKD, while awaiting for more evidence that supports their safer use.

[Metabolic Syndrome: clinical and pathophysiological basis for a rational therapeutical approach]. / Síndrome metabólico: Bases clínicas y fisiopatológicas para un enfoque terapéutico racional.

Regardless of the diagnostic criteria, the metabolic syndrome is found at least in 20% of the population. The adipose tissue plays an important role in the insulin resistance found in this syndrome. Free fatty acids released by intra-abdominal adipocytes produce an inflammatory and pro-thrombotic response and the persistence of the insulin resistance state, phenomenon termed lipotoxicity. This altered phenotype explains the development of the different components of the metabolic syndrome, such as hypertension, dyslipidemia and altered glucose metabolism. The treatment is based on weight loss and healthy lifestyle. A balanced diet, physical activity and avoidance of smoking are key management features. The use of drugs with pleiotropic effects, which inhibit the renin angiotensin aldosterone axis or acts on the peroxisome proliferators-activated receptors (PPAR) seems promising.

Síndrome metabólico: bases clínicas y fisiopatológicas para un enfoque terapéutico racional / Metabolic Syndrome: clinical and pathophysiological basis for a rational therapeutical approach

Regardless of the diagnostic criteria, the metabolic syndrome is found at least in 20 percent of the population. The adipose tissue plays an important role in the insulin resistance found in this syndrome. Free fatty acids released by intra-abdominal adipocytes produce an inflammatory and pro-thrombotic response and the persistence of the insulin resistance state, phenomenon termed lipotoxicity. This altered phenotype explains the development of the different components of the metabolic syndrome, such as hypertension, dyslipidemia and altered glucose metabolism. The treatment is based on weight loss and healthy lifestyle. A balanced diet, physical activity and avoidance of smoking are key management features. The use of drugs with pleiotropic effects, which inhibit the renin angiotensin aldosterone axis or acts on the peroxisome proliferators-activated receptors (PPAR) seems promising.

Neumotórax espontáneo: revisión de 50 casos / Spontaneous pneumothorax: a review of 50 cases

Se define el neumotórax como la presencia de aire en la cavidad pleural. Se clasifica según su etiología, su condición fisiopatológica y su magnitud. El neumotórax espontáneo (NE) corresponde a aquél no causado por trauma u otro factor precipitante conocido, y puede ser primario (NEP), cuando el parénquima pulmonar es sano o con alteraciones mínimas, o secundario (NES), cuando existe alguna patología parenquimatosa pulmonar condicionante. Existen guías internacionales de tratamiento, a pesar de lo cual muchas veces el manejo es variable y no estandarizado. Se presenta una revisión de 50 casos de NE egresados durante 5 años del Servicio de Cirugía Adultos del Hospital Dr. Gustavo Fricke, realizando su perfil epidemiológico, exponiendo los criterios de tratamiento utilizados en nuestro hospital y comparando las formas de enfrentamiento con las descritas en otros centros. Un 66 por ciento de los pacientes se consideraron como NEP y un 34 por ciento como NES. La edad media de los casos fue de 37.2 años. Un 86 por ciento correspondió a sexo masculino y sólo un 14 por ciento al femenino. Como tratamiento de elección, se realizó una pleurotomía mínima (94 por ciento), de preferencia con tubos de grueso calibre. En 26 por ciento de los pacientes se utilizaron técnicas complementarias, como pleurodesis por tubo pleural, apicectomía del lóbulo superior, bulectomía o pleurodesis quirúrgica. En 10 pacientes se realizó toracotomía, en 2 casos una videotoracoscopía (VATS),y sólo en un paciente se realizó pleurodesis química a través del tubo pleural. Se estima necesario protocolizar el manejo del neumotórax y la selección de pacientes candidatos a resolución quirúrgica, como guía para cirujanos no toráxicos.