[Prognostic value of myocardial perfusion SPECT in multivessel coronary disease patients with left ventricular dysfunction, comparing revascularized and non-revascularized patients]. / Valor pronóstico del SPECT de perfusión miocárdica en pacientes coronarios con enfermedad multivaso y disfunción ventricular izquierda, comparando revascularizados y no revascularizados.

OBJECTIVE: We investigated the prognostic value of 99mTc-Tetrofosmin myocardial SPECT (99mTc-TF) in dysfunctional multivessel coronary disease patients who underwent revascularization (RV) or only medical treatment (MT). METHODS: In 78 coronary patients with 2-3 diseased vessels and left ventricular ejection fraction (EF) <= 40% (24 10%), we have assessed the extension of the stress perfusion defect, and percent of reversibility (R) by quantification of stress-rest myocardial SPECT 99mTc-TF bull's eyes (2 days-protocol), lung/heart ratio (LH) calculated in the original stress SPECT images, and EF by equilibrium radionuclide ventriculography obtained at 24 h. A R value >= 8% was used to identify viable (V) patients. A total of 28 patients underwent RV and 50 only received MT. After a mean follow-up of 22.9 20 months (3-60), they were considered as coronary events (CE): cardiac death, non-fatal infarction and heart transplant. CE rate was 20.5% (16/78). RESULTS: No significant differences were found in the pre-revascularization study characteristics, except a significantly higher mean R value in RV (10.6 9.5%) than in MT patients (6.4 7.8%) p: 0.03, and the main difference was that RV patients showed less CE 2/28 (7%) than the MT group 14/50 (28%) p: 0.02. The CE rate was lower in V patients who underwent RV (6%) than in V patients with MT (45%) p: 0.03, but no significant difference was obtained in non-V patients between RV (7%) and MT (16%) groups. In viable patients, the corresponding survival curves (Kaplan-Meier) showed a CE-free survival at 5 years of 79% in patients RV and of 42% in MT patients, p: 0.03, without significant difference in non-V patients. CONCLUSIONS: Patients with viable myocardium by myocardial SPECT have a good prognosis after revascularization, and show higher risk of CE if they are only medically treated. Myocardial viability is an indispensable assessment in prognosis evaluation and, above all, in therapeutic decision making in dysfunctional multivessel coronary disease patients.

Valor pronóstico del SPECT de perfusión miocárdica en pacientes coronarios con enfermedad multivaso y disfunción ventricular izquierda, comparando revascularizados y no revascularizados* / Prognostic value of myocardial perfusion spect in multivessel coronary disease patients with left ventricular dysfunction, comparing revascularized and non-revascularized patients

Objetivo: Investigamos el valor pronóstico del SPECT miocárdico con 99mTc-Tetrofosmin (99mTc-TF) en pacientes disfuncionales con coronariopatía multivaso, que sufrieron revascularización (RV) o fueron sometidos sólo a tratamiento médico (TM).Métodos: En 78 pacientes coronarios con 2-3 vasos afectos y fracción de eyección del ventrículo izquierdo (FE) 40 por ciento (24 ñ 10 por ciento) hemos valorado la extensión del defecto de perfusión de esfuerzo (E), el porcentaje de reversibilidad (R), mediante cuantificación del diagrama polar a partir del SPECT miocárdico de esfuerzo-reposo (protocolo 2 días), el índice pulmón/miocardio (P/M), calculado en las imágenes originales del SPECT de esfuerzo, y la FE, mediante ventriculografía isotópica de equilibrio, obtenida a las 24 h del SPECT. Se utilizó un valor de R 8 por ciento para identificar a los pacientes viables (V). Un total de 28 pacientes sufrieron RV (by-pass) y 50 recibieron sólo TM. Tras un seguimiento medio de 22,9 ñ 20 meses (3-60) se consideraron como accidentes cardíacos (AC): muerte cardíaca, trasplante cardíaco e IAM, que aparecieron en 16/78 (20,5 por ciento). Resultados: No se encontraron diferencias significativas en las características del estudio pre-revascularización, salvo una R media mayor en los RV (10,6 ñ 9,5 por ciento) que en los de TM (6,4 ñ 7,8 por ciento) p: 0,03, siendo lo principal la menor incidencia de AC en los RV, 2/28 (7,1 por ciento) que en los de TM, 14/50 (28 por ciento) p: 0,02. Hubo menor incidencia de AC en los pacientes V que fueron RV (6 por ciento) que en los pacientes V con TM (45 por ciento), p: 0,03, no siendo significativa la diferencia en los pacientes no V entre los RV (7 por ciento) y los de TM (16 por ciento). Se obtuvieron las correspondientes curvas de supervivencia (Kaplan-Meier), que mostraron, en los pacientes V, una probabilidad de supervivencia libre de AC a los 5 años del 79 por ciento en pacientes RV y del 42 por ciento en pacientes con TM, p: 0,03, sin ser significativas las diferencias en los pacientes no V. Conclusiones: Los pacientes con miocardio viable en el SPECT miocárdico, presentaron buen pronóstico tras revascularización y mostraron mayor riesgo de AC cuando recibieron sólo tratamiento médico. La detección de viabilidad miocárdica es una valoración indispensable en la evaluación pronóstica, y sobre todo en la toma de decisiones terapéuticas en los pacientes disfuncionales con coronariopatía multivaso (AU)

[Cardiac cysts. A case of isolated cardiac hydatidosis]. / Quistes cardíacos. Un caso de hidatidosis cardíaca aislada.

In the presence of cardiac cysts we must discard a hydatid disease, even if there is no involvement of other organs. Imaging techniques are useful for guiding the initial diagnosis. The presence of daughter vesicles or multiple cysts is very characteristic. We present a patient affected by cardiac hydatid disease, in the form of multiple cardiac cysts, without extracardiac affectation, who presented pericardial chest pain. The patient was dealt with surgery to avoid the risks of a cyst rupture.

[Biatrial thrombosis]. / Trombosis biauricular.

A fifty-eight year old patient presented subacute right heart failure. Transthoracic and transesophageal echocardiography revealed thrombi in both atria, and initial anticoagulation and subsequent surgical treatment were successful. Echocardiography is defined as being decisive to diagnosis, and the role of surgery in the treatment of these patients is commented.

Kent bundle visualized in situ at operation after unsuccessful radiofrequency ablation.

Kent bundles are seldom visualized at operation, but, in the patient described, the pathway was subepicardial, running superficial to the right coronary artery. This was probably why radiofrequency ablation failed. When this unusual pathway course is encountered, the epicardial approach should be used at operation.

[Pulmonary valvular agenesis treated with cryopreserved pulmonary homograft]. / Agenesia valvular pulmonar tratada con homoinjerto pulmonar crioconservado.

We report successful treatment of pulmonary valve agenesia with pulmonary stenosis and ventricular septal defect by infundibular resection, patch-closure of the VSD and implantation of a cryopreserved pulmonary homograft. Cases with mild to moderate hypoplasia of the pulmonary annulus are particularly well suited for direct pulmonary homograft implantation, while cases with severe hypoplasia and high right ventricular pressure after correction may be better treated with aortic homografts. Some technical aspects of homograft implantation (doing first the proximal suture, preserving the normal configuration of the valvular sinuses and using the subvalvular homograft tissue to enlarge the right ventricular outflow tract) may prevent significant valvular incompetence.

Giant aneurysm of the high internal carotid artery: surgical treatment.

We report the successful surgical treatment of a patient with a giant aneurysm of the high internal carotid artery by resection of the aneurysm and end-to-end anastomosis at the skull base, after resection of the styloid process and section of the stylohyoid and digastric muscles. No shunt was used and no major neurologic deficits resulted. Thirty months after operation the repaired artery is patent, with no evidence of stenosis or residual aneurysm and with good distal perfusion. Surgical treatment of high carotid artery aneurysms is possible with rather simple techniques; excision of the aneurysm followed by restoration of continuity of the carotid ends should be the treatment of choice regardless of the location of the aneurysm.

Late cardiac tamponade after open heart surgery.

Delayed cardiac tamponade after open heart surgery is relatively uncommon, but constitutes a life-threatening condition that must be diagnosed and managed promptly. We report 21 patients who developed cardiac tamponade 5 to 53 days after open heart operations. Possible etiological factors included anticoagulant therapy (19 patients), excessive mediastinal drainage in the postoperative period (10 patients), postpericardiotomy syndrome (4 patients), and coagulation disorders (1 patient). The clinical presentation was insidious and the diagnosis was often difficult to establish at the outset. A high index of clinical suspicion and echocardiography were the most reliable means to reach an early diagnosis. Twenty patients in whom delayed tamponade was suspected were operated and all of them survived. In one patient tamponade was not diagnosed antemortem and he died; on autopsy left heart compression by a large loculated clot was found. Decompression of the pericardial space can be accomplished by pericardiocentesis or by surgical means (subxiphoid pericardiotomy, median sternotomy, or thoracotomy). Although pericardiocentesis alone may be effective, mainly when the postpericardiotomy syndrome is the suspected etiology, we recommend open procedures since the presence of blood clots and adhesions has been a frequent finding.

Rare anomalies of atrioventricular connection: hidden or supernumerary valves with imperforate right atrioventricular connection.

We report two hearts with rare anomalies of the atrioventricular connection. Both cases showed muscular partitions within the right ventricle, giving it a double-chambered morphology. In case 1 the floor of the right atrium was muscular, creating the impression of the absent connexion variant of tricuspid atresia. A hypoplastic valve, however, was seen in the right ventricular inlet chamber. Case 2 apparently showed an imperforate Ebstein's anomaly of the tricuspid valve but a supernumerary valve, draining into the left ventricle, was found in a chamber that might correspond to part of the coronary sinus.

Dysplasia of AV valve in complete AV canal with tetralogy of Fallot: surgical repair.

A five-year-old girl underwent surgery for tetralogy of Fallot and complete persistent atrioventricular (AV) canal. At operation, severe dysplasia of the right side of the common AV valve was found, with an accessory orifice and muscularization of a leaflet. Repair was carried out by closing the AV defect, through a combined right atrial and right ventricular approach, by a pericardial patch with a large anterior extension. Closure of the resulting mitral cleft, resection of anomalous muscle bundles and pulmonary valvotomy were also performed. Postoperatively the patient presented severe tricuspid regurgitation. Repair of the valve was deemed impossible and valve replacement was considered to have a very high risk due to the age of the patient, the small size of the right ventricle, and the previous repair of the AV defect. A modified Fontan operation was, therefore, considered preferable and successfully carried out. After the second operation, mediastinal infection developed and was successfully treated by local irrigation of diluted providone-iodine solution.

Anomalous mitral 'cleft' with abnormal ventriculo-arterial connection: anatomical findings and surgical implications.

Seven specimens with a 'cleft' mitral valve associated with anomalous chordal fixation and abnormal ventriculo-arterial connection are presented. Four were associated with a discordant ventriculo-arterial connection, two with double-outlet right ventricle, and one with double-outlet left ventricle. In six the chordae from the cleft were attached to the anterior border of a small ventricular septal defect. In the seventh the chordae were attached to an accessory papillary muscle in the left ventricular outflow tract. These clefts differ from those of atrioventricular defects. The cleft is more anterior, there are no septal defects of the atrioventricular canal type, and no deficiency of the basal ventricular septum. Mitral regurgitation or left ventricular outlet obstruction are possible consequences of the anomaly.

Ebstein's anomaly of the left-sided atrioventricular (AV) valve in AV discordance.

Prosthetic valve replacement of the left-sided atrioventricular (AV) valve was performed in a patient with AV discordance and Ebstein's anomaly of the left-sided AV valve without other associated anomalies. An anatomical study of 22 specimens with AV discordance did not show a case with similar anatomy; 5 hearts had mild degrees of downward displacement of the attachment of the left-sided AV valve leaflets, with marked dysplastic changes and variable degrees of hypoplasia. The surgical implications are different according to the degree of downward displacement of the leaflets. This feature and the size of the annulus and the morphologically right ventricle should be considered in preoperative evaluation, along with the operative approach, possible presence of atrialization of the wall of the proximal chamber and the relation of the left AV valve to the conduction system. Preoperative diagnosis of the anomaly is possible by angiocardiography and other methods.

Anatomically corrected malposition (surgical repair).

Anatomically corrected malposition is a rare anomaly usually associated with other complex malformations. However, less complicated cases do occur and we report one such case treated surgically with success. Our experience underlines the importance of careful digital examination of the right ventricle from the atrium to determine the position of the septum, as the position of the left anterior descending coronary artery can be misleading.