Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE). / Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE).

Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

[Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital]. / Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario.

OBJECTIVE: This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. METHODS: The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. RESULTS: Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). CONCLUSIONS: The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9).

[Red cell transfusion and long-term survival in non-complicated heart surgery]. / Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada.

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n=703) and those who did (n=959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. STUDY ENDPOINTS: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P=.02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio=1.4, 95%CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality.

[Preoperative anemia in coronary surgery: a risk factor?]. / Anemia preoperatoria en la cirugía coronaria: ¿un factor de riesgo?

INTRODUCTION AND OBJECTIVES: Preoperative anemia as a risk factor of adverse outcomes after coronary surgery has not been well-established. This study has aimed to analyze the association between preoperative anemia and postoperative adverse events and in-hospital mortality in the patients undergoing isolated coronary artery bypass graft surgery in the Son Dureta hospital. METHODS: All the patients undergoing isolated coronary artery bypass graft surgery with extracorporeal circulation from November 2002 to June 2007 were included. Preoperative anemia was defined as hemoglobin (Hb)<13g/dL in men and Hb<12g/dL in women. The association between postoperative cardiac and noncardiac adverse events and the presence or absence of preoperative anemia and concomitant surgical risk, assessed by logistic EuroScore, were analyzed. RESULTS: A total of 623 patients were included. The rate of preoperative anemia was 34.5%. Patients with Euroscore > or =4 had higher incidence of preoperative anemia than patients with Euroscore<4 (41% vs. 27%; p=0.0001). There were no statistically significant differences in the rate of postoperative adverse events related to the presence or absence of preoperative anemia. Median ICU and hospital length of stay were longer in patients with preoperative anemia than in patients without preoperative anemia (ICU: 3.2+/-2.5 days vs. 3.7+/-2.8, p=0.004; in-hospital: 17.5+/-11.3 days vs. 14.7+/-10.2, p=0.001). Hospital mortality rate was 0.8% (95% CI 0.3-1.9). There were no differences in the mortality rate of the patients with and without preoperative anemia (0.9% vs 0.7%, p=0.8). CONCLUSIONS: In this study, preoperative anemia in patients undergoing coronary artery bypass graft surgery was not associated with increased hospital morbidity-mortality. However, ICU and hospital length of stay were longer in patients with preoperative anemia. The limitation of the sample size prevents us from confirming whether preoperative anemia is a risk factor after coronary surgery or not.

Anemia preoperatoria en la cirugia coronaria: un factor de riesgo? / Preoperative anemia in coronary surgery: A risk factor?

Objetivo: El papel de la anemia preoperatoria como factor de riesgo en la cirugía coronaria no está bien establecido. El objetivo de este estudio es analizar la asociación de la anemia preoperatoria con las complicaciones postoperatorias y la mortalidad hospitalaria en los enfermos operados de cirugía coronaria aislada en el Hospital de Son Dureta. Material y métodos: Se incluyeron en este estudio todos los pacientes operados de cirugía coronaria aislada con circulación extracorpórea desde noviembre de 2002 hasta junio de 2007. La anemia preoperatoria se definió según los criterios de la OMS como una hemoglobina inferior a 13g/dl en los hombres e inferior a 12g/dl en las mujeres. Los efectos adversos postoperatorios cardíacos y no cardíacos se analizaron en función de la presencia o ausencia de la anemia preoperatoria y de la estratificación del riesgo quirúrgico, sobre la base del valor del EuroSCORE logístico. Resultados: Se incluyeron 623 pacientes. La incidencia de anemia preoperatoria fue del 34,5%. Esta incidencia fue mayor en pacientes con EuroSCORE de 4 o más que con EuroSCORE inferior a 4 (el 41 y el 27%; p=0,0001). No hubo diferencias significativas entre la incidencia de complicaciones postoperatorias de los pacientes con anemia y sin anemia. La estancia media en la UCI y hospitalaria fue más larga en los pacientes con anemia preoperatoria que en los pacientes sin ella (UCI: 3,2±2,5 días y 3,7±2,8; p=0,004; hospitalaria: 17,5±11,3 días y 14,7±10,2; p=0,001). La mortalidad hospitalaria fue del 0,8% (intervalo de confianza del 95%: 0,3-1,9). No hubo diferencias en la mortalidad de los pacientes con anemia preoperatoria y sin anemia preoperatoria (el 0,9 y el 0,7%; p=0,8). Conclusiones: En este estudio, la anemia preoperatoria en los pacientes operados de cirugía coronaria aislada no se asoció con una mayor morbimortalidad hospitalaria, aunque la estancia hospitalaria fue más larga. La limitación del tamaño de la muestra impide confirmar que la anemia preoperatoria sea o no un factor de riesgo en la cirugía coronaria (AU)

Introduction and objectives: Preoperative anemia as a risk factor of adverse outcomes after coronary surgery has not been well-established. This study has aimed to analyze the association between preoperative anemia and postoperative adverse events and inhospital mortality in the patients undergoing isolated coronary artery bypass graft surgery in the Son Dureta hospital. Methods: All the patients undergoing isolated coronary artery bypass graft surgery with extracorporeal circulation from November 2002 to June 2007 were included. Preoperative anemia was defined as hemoglobin (Hb)<13g/dL in men and Hb<12g/dL in women. The association between postoperative cardiac and noncardiac adverse events and the presence or absence of preoperative anemia and concomitant surgical risk, assessed by logistic EuroScore, were analyzed. Results: A total of 623 patients were included. The rate of preoperative anemia was 34.5%. Patients with Euroscore >4 had higher incidence of preoperative anemia than patients with Euroscore<4 (41% vs. 27%; p=0.0001). There were no statistically significant differences in the rate of postoperative adverse events related to the presence or absence of preoperative anemia. Median ICU and hospital length of stay were longer in patients with preoperative anemia than in patients without preoperative anemia (ICU: 3.2±2.5 days vs. 3.7±2.8, p=0.004; inhospital: 17.5±11.3 days vs. 14.7±10.2, p=0.001). Hospital mortality rate was 0.8% (95% CI 0.3-1.9). There were no differences in the mortality rate of the patients with and without preoperative anemia (0.9% vs 0.7%, p=0.8). Conclusions: In this study, preoperative anemia in patients undergoing coronary artery bypass graft surgery was not associated with increased hospital morbidity-mortality. However, ICU and hospital length of stay were longer in patients with preoperative anemia. The limitation of the sample size prevents us from confirming whether preoperative anemia is a risk factor after coronary surgery or not (AU)

[Predictive value of the EuroSCORE model in cardiac surgery in our site]. / Valor predictivo del modelo EuroSCORE en la cirugía cardíaca de nuestro centro.

OBJECTIVE: The use of risk prediction models in cardiac surgery makes it possible to compare and evaluate health care quality between different institutions in countries. This study aimed to assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model in estimating the risk of mortality of cardiac surgery patients of our hospital. PATIENTS AND METHODS: The additive and logistic EuroSCORE models were applied to all patients who underwent cardiac surgery with extracorporeal circulation from the time the cardiac surgery unit was opened in our center in November 2002 until February 2006. All data were obtained prospectively when the patients were admitted to the Intensive Care Unit. Mortality observed was compared with that estimated in the following subgroups: global cardiac surgery, isolated coronary surgery, isolated valvular surgery, combined valvular and coronary surgery and thoracic aorta surgery. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. RESULTS: We studied 1,053 patients who had several differences with the EuroScore model population. Overall observed mortality was 2.2% (95% CI 1.2 - 3.1). The EuroSCORE models overestimated mortality (additive predicted 5%, logistic predicted 4.6%). Mortality of coronary bypass graft surgery was 1.2% and both EuroSCORE models overestimated it. Discriminative power of both models was good with an Area under ROC curve for both models of 0.78 and 0.79. CONCLUSIONS: The use of both EuroSCORE models overestimated overall observed mortality and that of the different surgical subgroups of cardiac surgery performed in our institution.

Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement.

BACKGROUND: We evaluated the midterm results of the Ross operation in active advanced endocarditis. METHODS: Between June 1994 and June 2000 a pulmonary autograft aortic root replacement was performed in 11 consecutive patients who had urgent or emergent procedures for active endocarditis with extensive involvement of the aortic root (10 native, 1 prosthetic). Patients ranged in age from 26 to 45 years (median, 33 years). Indications for operation were uncontrolled infection (n = 5), hemodynamic deterioration (n = 3), or both (n = 3). Four patients were in the New York Heart Association class III, 6 in class IV, and 1 was operated on while in cardiogenic shock. Four patients (36%) suffered an embolic cerebrovascular accident preoperatively. The endocarditis affected the mitral valve in 2 patients and the tricuspid valve in 1 patient. RESULTS: There was no early or late death. Recurrent endocarditis was not detected in any of the patients during the follow-up period ranging up to 72 months (median, 40 months). CONCLUSIONS: The autograft may well be the best substitute for aortic root reconstruction in advanced endocarditis.

Aortic root replacement with a pulmonary autograft in young adults: medium-term results in 70 patients.

BACKGROUND: Pulmonary autograft aortic valve replacement has been introduced in our institution in selected adult patients in light of the known disadvantages and limitations of conventional prosthetic valves. METHODS: We prospectively evaluated the use of the pulmonary autograft in a series of 70 young adults (31.2+/-8.7 years, range 16 to 49 years) operated on from March 1992 to April 1997 with aortic root replacement only. RESULTS: There were no in-hospital deaths and two noncardiac-related late deaths during follow-up of up to 62 months (mean 33 months). Thromboembolic complications were not observed. One patient required reoperation for infective endocarditis 4.3 years after surgery. Discharge echo-Doppler studies showed normal autograft and allograft valve function. Serial echo-Doppler studies showed no significant progression of aortic insufficiency and no dilatation of the autograft. A severe stenosis of the pulmonary allograft developed in 1 patient. CONCLUSION: Aortic root replacement with a pulmonary autograft, although more complex than conventional prosthetic valve replacement, is a safe, effective, and reproducible procedure in properly selected adult patients. Long-term results remain to be evaluated.