Post-introduction observation of transcatheter aortic valve implantation in Galicia (Spain).

RATIONALE, AIMS AND OBJECTIVES: Transcatheter aortic valve implantation constitutes an example of a technology introduced into the Galician Health Care System basket and subjected to a post-introduction observational study after coverage. This paper aims to describe the process and results of this experience, illustrating the main challenges and opportunities in using these studies for supporting decision making. METHODS: The study protocol was developed by a multidisciplinary team consisting of experts from the Galician HTA Agency (avalia-t), interventional cardiologists and cardiac surgeons. Together they agreed on the information that was relevant and feasible for collection, and planned the study design, data collection and analysis of results. RESULTS: During the 1-year recruitment period, 94 patients underwent percutaneous aortic valve replacement in the three authorized centres. Implantation rate and prosthesis models differed substantially across the centres. Overall, procedural success rate was 96.8% and hospital mortality was 7.4%. Complications during post-surgical admission were recorded in 40.4% of patients. Moderate residual aortic regurgitation was observed in 10% of patients, and the procedure was associated with a stroke rate of 3.3% at 30 days and 5.3% at 1 year. CONCLUSIONS: Post-introduction observation has made it feasible to determine the use of this procedure within the SERGAS context and has enabled the assessment of performance in real-life conditions. The proposed strategic actions and interventions have been drawn up based upon the collective judgement of a group of experienced professionals, and have served to establish recommendations on further research that would be required to optimize health benefits.

Primary pulmonary artery sarcoma: a new surgical technique for pulmonary artery reconstruction using a self-made stapled bovine pericardial graft conduit.

Primary pulmonary artery sarcoma is an uncommon neoplasm with a grim prognosis. Complete resection is the only treatment that can improve the patient's survival. The role of multimodality treatment is still controversial, although adjuvant chemotherapy possibly could improve outcomes of these patients. Several pulmonary artery reconstructive techniques have been reported in the scientific literature, such as patch reconstruction, end-to-end anastomosis, synthetic prosthesis or biological grafts. In this article, we propose a new surgical option for pulmonary artery reconstruction after radical tumour resection using a self-made stapled bovine pericardial graft conduit in a patient with a mass in the pulmonary trunk and right pulmonary artery. We believe that the use of this technique adds safety and effectiveness, and reduces the surgical time.

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study.

OBJECTIVE: To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries. METHODS: Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011. RESULTS: The most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years. CONCLUSIONS: Traumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis.

Traumatic aortic injury score (TRAINS): an easy and simple score for early detection of traumatic aortic injuries in major trauma patients with associated blunt chest trauma.

PURPOSE: To develop a risk score based on physical examination and chest X-ray findings to rapidly identify major trauma patients at risk of acute traumatic aortic injury (ATAI). METHODS: A multicenter retrospective study was conducted with 640 major trauma patients with associated blunt chest trauma classified into ATAI (aortic injury) and NATAI (no aortic injury) groups. The score data set included 76 consecutive ATAI and 304 NATAI patients from a single center, whereas the validation data set included 52 consecutive ATAI and 208 NATAI patients from three independent institutions. Bivariate analysis identified variables potentially influencing the presentation of aortic injury. Confirmed variables by logistic regression were assigned a score according to their corresponding beta coefficient which was rounded to the closest integer value (1-4). RESULTS: Predictors of aortic injury included widened mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic fracture. Area under receiver operating characteristic curve was 0.96. In the score data set, sensitivity was 93.42 %, specificity 85.85 %, Youden's index 0.79, positive likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation data set, sensitivity was 92.31 % and specificity 85.1 %. CONCLUSIONS: Given the relative infrequency of traumatic aortic injury, which often leads to missed or delayed diagnosis, application of our score has the potential to draw necessary clinical attention to the possibility of aortic injury, thus providing the chance of a prompt specific diagnostic and therapeutic management.

Implante transapical de «válvula dentro de otra válvula» como tratamiento alternativo para la degeneración estructural de una bioprótesis aórtica / Transapical valve-in-valve implantation as a treatment option for structural degeneration of an aortic bioprosthesis

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Costes evitables y eficiencia económica en cirugía cardíaca / Avoidable costs and economic efficiency in cardiac surgery

El objetivo de este artículo es estudiar los costes evitables y su incidencia en la eficiencia económica para la unidad asistencial de Cirugía Cardíaca. Con este propósito se identifican y se cuantifican determinadas variables como estancias y reintervenciones, a fin de determinar qué parte de estos costes pueden ser considerados como evitables. Asimismo, también se cuantifica el coste de oportunidad de estos costes evitables en términos del impacto que éstos tienen sobre la reducción de la lista de espera. Los resultados obtenidos indican que la cuantía de los costes evitables supone un 3 % del total de los costes, y en términos de coste de oportunidad implica renunciar a una reducción del 30 % de la lista de espera

The aim of this paper is to study the avoidable costs and its incidence on economic efficiency for the heart surgery unit of assistance. We identify and quantify some variables of interest such as stay, re-entry, and re-intervention in order to compute the quantity of cost that can be considered as avoidable. Also, we obtain the opportunity cost of these avoidable costs as the impact that they have on the waiting list of patients. The empirical results indicate that the avoidable cost are 3 % of the total cost, and the opportunity cost supposes to give up a reduction about 30 % in the waiting list of patients

Insuficiencia cardíaca secundaria a rotura traumática de la válvula aórtica / Cardiac Failure due to Traumatic Aortic Valve Rupture

La insuficiencia cardíaca aguda secundaria a disfunción valvular es frecuente como complicación del infarto agudo de miocardio, la endocarditis o los traumatismos torácicos penetrantes que afectan al corazón y a los grandes vasos. Menos frecuente es la asociación a traumatismos torácicos cerrados. Presentamos el caso de un varón de 69 años de edad con insuficiencia cardíaca aguda tras un traumatismo torácico importante con fractura esternal. El ecocardiograma transesofágico demostró una insuficiencia aórtica grave. El paciente fue intervenido quirúrgicamente. Se encontró una rotura de bordes libres del velo no coronariano y coronariano derecho. Se efectuó cirugía de reemplazo valvular aórtico por bioprótesis, con evolución posterior favorable (AU)