[Incidental diagnosis of an ostium-secundum-type interatrial communication during coronary surgery]. / Diagnóstico casual de una comunicación interauricular tipo ostium secundum durante cirugía coronaria.

Preoperative assessment of a 73-year-old woman scheduled for coronary revascularization revealed signs of severe disease in three coronary vessels, mild mitral valve insufficiency, moderate tricuspid insufficiency and moderate-to-severe pulmonary hypertension, with preserved left ventricular function. During surgery pulmonary artery catheter measurements confirmed pulmonary hypertension and the presence of very high cardiac output, leading to suspicion of atrial septal defect. Peripheral vein and right atrial blood samples revealed a sudden increase of 23 mm Hg in PO2 and of 22% in oxygen saturation. Finding the opening in the wall of the right atrium gave diagnostic confirmation of an ostium secundum defect 3 cm in diameter. The defect was closed and the coronary vessel bypasses were created. Upon weaning from extracorporeal circulation, the sudden oximetric increase was seen to have disappeared and pulmonary artery pressures had decreased. Postoperative course was satisfactory, with normal sinus rhythms alternating with episodes of atrial fibrillation. We stress the importance of invasive hemodynamic monitoring and transesophageal echography during heart surgery to confirm diagnoses that have not been established during preoperative assessment.

Diagnóstico casual de una comunicación interauricular tipo ostium ecundum durante cirugía coronaria / Ostium secundum atrial septal defect: fortuitous diagnosis during heart surgery

Una mujer de 73 años fue programada para cirugía de revascularización coronaria. En el estudio previo se evidenció afectación grave coronaria de tres vasos, insuficiencia mitral de grado leve, insuficiencia tricuspídea moderada e hipertensión pulmonar de grado moderadograve, con función ventricular izquierda conservada.Durante el periodo operatorio las medidas a través de un catéter de arteria pulmonar confirmaron la hipertensión pulmonar y la existencia de un gasto cardiaco muy elevado que hicieron sospechar la existencia de una comunicación interauricular. La extracción de muestras de sangre de vena periférica y de aurícula derecha mostró un salto oximétrico en la PO2 de 23 mm Hg y 22 por ciento en la saturación de oxígeno. La apertura de la aurícula derecha confirmó la existencia de un defecto tipo ostium secundum de 3 cm de diámetro. Se procedió al cierre del defecto y a la realización de los puentes coronarios, observándose a la salida de circulación extracorpórea la desaparición del salto oximétrico y el descenso de las presiones de la arteria pulmonar. La evolución postoperatoria fue satisfactoria, alternando el ritmo sinusal con episodios de fibrilación auricular. Destacamos la importancia de la monitorización hemodinámica invasiva y de la ecografia transesofágica durante la cirugía cardiaca para confirmar diagnósticos no establecidos en el examen preoperatorio (AU)

[Life events, quality of life and social support prior to acute cerebral vascular disease, as predictive factors of the quality of life and functional state following stroke]. / Acontecimientos vitales, calidad de vida y apoyo social previos a la enfermedad vascular cerebral aguda, como factores predictores de la calidad de vida y situación funcional posteriores al ictus.

INTRODUCTION: The repercussion of stroke on quality of life has been evaluated but not the possible relation between the quality of life before and months after an acute stroke. OBJECTIVE: To study the possible relation between quality of life, social support, stressful life events prior to the stroke and quality of life, social support and functional state months after. PATIENTS AND METHODS: A prospective study was made of 34 patients (71.7 +/- 8 years; 19 (56%) men; 15 (44%) women with stroke, by means of two evaluations: personal interview within the first 36 hours (quality of life--Nothingham health profile (NHP)-, perception of social support and stressful life events--Holmes and Rake inventory-) and an interview over the phone 16.5 +/- 5.3 months after the stroke (NHP, perception of social support and functional state--Rankin scale-). RESULTS: Following the stroke there was deterioration in perception of social support (19.8 +/- 3 vs 12.5 +/- 8; p = 0.000) and in the degree of social isolation of the NHP (9.4 +/- 20 vs 21.1 +/- 30; p = 0.03). The only relation found was between the following variables: pain at the first evaluation and pain (r = 0.45; p = 0.007) at the second evaluation; mobility at the first evaluation and emotional state (r = 0.39; p = 0.029) and social support (r = 0.37; p = 0.027) at the second evaluation; sleepiness at the first evaluation and energy (r = 0.55; p = 0.0006), pain (r = 0.39; p = 0.022), emotional state (r = 0.35; p = 0.038), mobility (r = 0.34, p = 0.048) and sleepiness (r = 0.51; p = 0.001) at the second evaluation. CONCLUSION: Our results indicate that there is little relationship between the previous state and that following stroke, and that the deterioration in perception of support and social isolation is due to the stroke itself.

Acontecimientos vitales, calidad de vida y apoyo social previos a la enfermedad vascular cerebral aguda, como factores predictores de la calidad de vida y situación funcional posteriores al ictus / Live events quality of life and social support prior to acute cerebral vascular disease, as predictive factors of the quality of life and functional state following stroke

Introducción. Se ha valorado la repercusión del ictus en la calidad de vida pero no la posible relación entre la calidad de vida previa y la que tienen los pacientes meses después del episodio agudo. Objetivo. Estudiar la posible relación entre calidad de vida, apoyo social y acontecimientos vitales estresantes previos al ictus y calidad de vida, apoyo social y situación funcional meses después del mismo. Pacientes y métodos. Estudio prospectivo de 34 pacientes (71,7 ± 8 años; 19 (56%) varones; 15 (44%) mujeres) con ictus mediante dos valoraciones: entrevista personal en las primeras 36 horas (calidad de vida –perfil de salud de Nottingham (PSN)–, percepción de apoyo social y acontecimientos vitales estresantes –inventario de Holmes y Rake–) y entrevista telefónica 16,5 ± 5,3 meses después del ictus (PSN, percepción de apoyo social y situación funcional –escala de Rankin–). Resultados. Después del ictus se produce un deterioro en la percepción del apoyo social (19,8 ± 3 frente a 12,5 ± 8; p= 0,000) y en la dimensión de aislamiento social del PSN (9,4 ± 20 frente a 21,1 ± 30; p= 0,03). Sólo se encontró relación entre las siguientes variables: dolor en la primera evaluación y dolor (r= 0,45; p= 0,007) en la segunda evaluación; movilidad en la primera evaluación y estado emocional (r= 0,39; p= 0,029) y apoyo social (r= 0,37; p= 0,027) en la segunda evaluación; sueño en la primera evaluación y energía (r= 0,55; p= 0,0006), dolor (r= 0,39; p= 0,022), estado emocional (r= 0,35; p= 0,038), movilidad (r= 0,34; p= 0,048) y sueño (r= 0,51; p= 0,001) en la segunda evaluación. Conclusión. Nuestros resultados sugieren que la relación existente entre la situación previa y la posterior al ictus es escasa, y que el deterioro en la percepción del apoyo y el aislamiento social se deben al ictus en sí mismo (AU)

Introduction. The repercussion of stroke on quality of life has been evaluated but not the possible relation between the quality of life before and months after an acute stroke. Objective. To study the possible relation between quality of life, social support, stressful life events prior to the stroke and quality of life, social support and functional state months after. Patients and methods. A prospective study was made of 34 patients (71.7 ± 8 years; 19 (56%) men; 15 (44%) women with stroke, by means of two evaluations: personal interview within the first 36 hours (quality of life –Nothingham health profile (NHP)–, perception of social support and stressful life events –Holmes and Rake inventory–) and an interview over the phone 16.5 ± 5.3 months after the stroke (NHP, perception of social support and functional state –Rankin scale–). Results. Following the stroke there was deterioration in perception of social support (19.8 ± 3 vs 12.5 ± 8; p= 0.000) and in the degree of social isolation of the NHP (9.4 ± 20 vs 21.1 ± 30; p= 0.03). The only relation found was between the following variables: pain at the first evaluation and pain (r= 0.45; p= 0.007) at the second evaluation; mobility at the first evaluation and emotional state (r= 0.39; p= 0.029) and social support (r= 0.37; p= 0.027) at the second evaluation; sleepiness at the first evaluation and energy (r= 0.55; p= 0.0006), pain (r= 0.39; p= 0.022), emotional state (r= 0.35; p= 0.038), mobility (r= 0.34, p= 0.048) and sleepiness (r= 0.51; p= 0.001) at the second evaluation. Conclusion. Our results indicate that there is little relationship between the previous state and that following stroke, and that the deterioration in perception of support and social isolation is due to the stroke itself (AU)

[Patent foramen ovale as a cause of recurrent cerebral embolism. Closure with minimally invasive surgery]. / Foramen oval permeable como causa de embolismo cerebral repetido. Cierre con cirugía mínimamente invasiva.

We report a clinical case of a 63-year-old patient, referred with a history of repeated strokes, whose only cause was a patent foramen ovale with shunt right to left diagnosed by transesophageal echocardiography. He underwent minimally invasive surgery, through right parasternal minithoracotomy, practising defect closure. We comment on the value of echocardiography for diagnosing this pathology and the utility of this surgical technique for repairing these defects.

[Occult rupture of the aortic arch caused by a traffic accident]. / Rotura oculta de cayado aórtico tras un accidente de tráfico.

A patient presented to our emergency department from another hospital diagnosed with pelvic fracture after a motor vehicle accident. In the ensuing 12 hours, chest pain developed, and a widened mediastinum on chest radiography was found. Posterior aortography showed aortic arch rupture. During surgery, we found a complete circumferential disruption of the arch between the brachiocephalic trunk and the carotid artery. Even though thoracic aortic injuries rarely occur in motor vehicle accidents, thoracic arch ruptures are extremely uncommon. This injury should be suspected after high-speed motor vehicle accidents, when accompanied with chest pain or widened mediastinum.

[Is crystalloid cardioplegia still a valid technique for myocardial myocardial protection?]. / Sigue siendo válida la cardioplejía cristaloide como técnica de protección miocárdica?

OBJECTIVES: The routine use of a cardioplegic solution for myocardial protection during the ischemic phase of cardiac surgery represents a great therapeutic advance. Two cardioplegic solutions are currently in use: crystalloid and blood solutions. As blood cardioplegia has been shown to offer superior myocardial protection, its use at present is widespread. We did a retrospective study to assess whether crystalloid cardioplegia might nevertheless continue to be useful. PATIENTS AND METHODS: Forty patients with heart disease underwent surgery between March 1994 and March 1995, with the use of crystalloid cardioplegia (group A). Blood cardioplegia was used in 72 patients during the same period (group B). RESULTS: There were no significant differences in clinical (age, arterial hypertension, diabetes, chronic bronchial disease, severity of angina, severity of heart disease) or surgical (emergency, percent use of the internal thoracic artery, duration of extracorporeal circulation) variables. The percentage of patients with low ejection fraction was higher in group B as a result of preoperative selection. The mean number of grafts was higher in group B than in group A (3.5% and 2.5, respectively) (p < 0.01). Postoperative results (use of inotropics, counterpulsation balloon, creatine phosphokinase, perioperative myocardial infarction or hospital mortality) were not significantly different. The percent of supraventricular arrhythmias after surgery was higher in group A than in group B (20% and 5%, respectively) (p < 0.05) and lactic dehydrogenase level was lower in group A than in group B (472 and 572 mu/l, respectively) (p < 0.05). CONCLUSIONS: We believe that crystalloid cardioplegia continues to be a valid and effective myocardial protection technique in heart patients with preserved left ventricular systolic function.

[Anomalous origin of the left coronary artery from the pulmonary artery in adults. Long-term follow up]. / Origen anómalo de la arteria coronaria izquierda desde la arteria pulmonar en adultos. Seguimiento a largo plazo.

Anomalous origin of the left coronary artery from the pulmonary artery is a serious pathology, that untreated supposes a high mortality. Usually it becomes symptomatic in early infancy, but some cases reach adult life with no symptoms. We report four cases diagnosed in teenagers and adults, three of them with the oldest ages known in worldwide literature and one of them the oldest reported until now. We have completed a long follow-up in the various surgical techniques, where we did not observe any differences in their prognosis, and we recommend an anti-arrhythmia treatment joined with surgical treatment in adult patients with this pathology.

Anomalous left coronary artery originating from the pulmonary artery in an adult.

We report the case of a 63-year-old man who presented at our hospital with paroxysmal atrial fibrillation. He was found to have an anomalous left coronary artery originating from the pulmonary artery. The patient underwent successful revascularization with the use of a left internal mammary artery bypass graft.

[Hypertrophic obstructive myocardiopathy complicated by severe mitral insufficiency secondary to rupture of the chordae tendineae]. / Miocardiopatía hipertrófica obstructiva complicada con insuficiencia mitral severa secundaria a rotura de cuerdas tendinosas.

A case of suddenly increasing dyspnea in a patient with hypertrophic obstructive cardiomyopathy is reported. Transesophageal echocardiography showed severe mitral regurgitation secondary to ruptured chordae tendineae. Mitral valve replacement was done, correcting both mitral regurgitation and subaortic gradient. Utility of transesophageal echocardiography in diagnosis and therapeutic options are discussed.

A comparative study of the St. Jude Medical and Björk-Shiley convexo-concave prostheses in isolated valve replacement.

This is a study of 199 consecutive patients who survived isolated mitral or aortic valve replacement with a Björk-Shiley (B-S) or St. Jude Medical (SJM) prostheses. Mean follow-up was 36 months. Preoperative status was similar for both groups (B-S or SMJ). Five year survival rates for mitral valve replacement (MVR) were 91% for B-S and SJM, and for aortic valve replacement (AVR) 96% vs 91% for SJM (p less than 0.06). Linearized incidence of thromboembolism in MVR was 5.62% patient year for BS and 5.23% patient year for SJM (p = NS). Classical risk factors for thromboembolism were evaluated on a univariate analysis: no single risk factor was identified. Only the association of two or more was possibly significant. The presence of inadequate anticoagulation (prothrombin index greater than 50%) was the main risk factor for thromboembolism, as the incidence rate was 19% per patient year when poorly anticoagulated versus 4.6% per patient year incidence in the whole series (p less than 0.01).

Anomalous origin of the left coronary artery from the pulmonary artery. Surgical alternatives depending of the age of the patient.

Four cases of anomalous origin of the left coronary artery from the pulmonary artery, three of which were operated upon in our Centre, are presented. An aortocoronary bypass with reversed autologous saphenous vein was carried out in both of the children; and in the adult, the anomalous ostium was closed from the interior of the pulmonary artery. After 84, 72, and 4 months of evolution, respectively, they were found to be asymptomatic, the mitral insufficiency had disappeared and the venous graft remained patent. In this paper, the clinical form of presentation, diagnostic possibilities and surgical treatment are analysed.

[Patch angioplasty in isolated left main coronary artery stenosis]. / Angioplastia con parche en estenosis aislada del tronco de la arteria coronaria izquierda.

A 50 year old male with isolated left main coronary artery disease was surgically treated with saphenous vein patch angioplasty. Surgery results are reviewed by coronariography 2 months later and we comment its use as alternative technique in selected cases.