La revascularización transmiocárdica con láser; una nueva vieja técnica. Pero ¿Es esfectiva? estudio retrospectivo sobre una cohorte de 453 pacientes / Transmyocardial revascularization with laser; a "new old Technique" but, is it useful? A study on a cohort of 453 patients

La cardiopatía isquémica, a pesar de las medidas higiénicas que se han tomado últimamente, sigue siendo una enfermedad de alta prevalencia en nuestro medio. Ello conlleva a que, tras tratamientos médico, quirúrgico y/o percutáneo, se tenga una cohorte de pacientes de difícil control médico y sin posibilidades intervencionistas. Para éste grupo de pacientes se ha desempolvado una antigua técnica ya descrita a inicios de los 60 del siglo XX, inspirada en el corazón de los reptiles, consistente en realizar perforaciones del miocardio en lo que se ha llamado revascularización transmiocárdica con láser (RTML). Sin embargo, al respecto de los resultados hay muchas opiniones encontradas. Para averiguar si en nuestro medio ésta técnica es útil, se ha revisado la historia de 453 pacientes intervenidos entre mayo de 1999 y noviembre de 2004. Se consideraron tres grupos que se denominaron Grupo I (53 pacientes), aquellos pacientes en los que no se pudo realizar revascularización quirúrgica completa y se complementó con RTML en los territorios no pontados, Grupo II (269 ptes.), aquellos que pudieron ser pontados en todos los vasos que lo necesitaban y Grupo III (130 ptes.), aquellos que no pudieron ser pontados en todos los vasos y no se hizo nada más. El seguimiento indicó que la necesidad de medicación no difería entre los tres grupos, la mortalidad tanto hospitalaria como en el seguimiento, tampoco se veía influida y sí parecía existir una mayor tendencia a agruparse en el grupo de mejor grado funcional cuando se aplicaba RTML. Concluimos que el tratamiento RTML no parece aportar grandes beneficios aunque no implique riesgos añadidos (AU)

Even after the application of higienical measures, ischemic cardiopathy is still a highly prevalent disease in our environment. After treating those patients medically, surgically and/or percutanously there will be a cohort of cases with difficult medical control and with no more possibilities. To treat those patients, an old technique, described at the beginning of the sixties of last century, and inspired in the heart of reptilians, has been recalled. This technique, called Transmyocardial Revascularization with Laser (TMRL), consists in piercing the whole myocardium with a laser beam. But the results are controversial. To discover the usefulness of this technique, a retrospective study on 453 operated on among may 1999 and november 2004 was performed. Three groups were considered: Group I (53 patients) formed by those patients not able to revascularize totally and complemented by TMRL in the areas not bypassed. Group II (269 pts) in which every patient could be completelyrevascularized. Group III (130 pts) in which those patients not able to be completely revascularized were just left without any more techniques. The follow-up indicated that the need of medication was not different among groups and the mortality in-hospital as well as in the follow-up, was similar in every group. The patients in group I were, in the long run, in a better functional class than in the other groups. So for we conclude that TMRL associated to surgical coronary by-pass does not implies better results but do not causes higher risks neither at the operation nor in the follow-up (AU)

[Haemophilus influenzae type B meningitis: typical and atypical presentation]. / Meningitis por Haemophilus influenzae tipo B: presentación típica y atípica.

We present 2 cases of Haemophilus influenzae meningitis. The first is a patient with atypical simptomatology: abdominal pain, fever and two days later pain in the back of his legs. Abdominal pathology was not found. The cerebrospinal fluid (CSF) showed polymorphonuclear cells, hyperproteinorachia and lowered glucose. CSF culture revealed Haemophilus influenzae, blood culture was sterile. The second had suffered surgery at maxilar and ethmoid sinuses four years before, and unknown germ meningitis 6 months before. Haemophilus influenzae was isolated from CSF cultures and CSF rhinorrhea was detected by isotopic cisternography.

Osteogenesis imperfecta and coronary artery surgery. A case report.

A new case of Osteogenesis Imperfecta (OI) suffering ischemic heart disease is reported. The patient was successfully operated on in our Institution and the bibliographic search showed only another case of such an association of diseases successfully treated by surgery. This patient proves that coronary artery surgery procedures are possible when OI complicates the cardiac ischemic syndrome.

[Infectious endocarditis caused by Q fever]. / Endocarditis infecciosa por fiebre Q.

A case of aortic valve endocarditis caused by Coxiella burnetii and operated on with success is reported. The patient is doing well at 18 months follow up. Diagnosis of Q-fever endocarditis was made by high antibodies against phase I Coxiella burnetii antigens titration and by demonstration of aortic valvular vegetations by bidimensional echocardiography. Our patient suffered emergency aortic valve substitution due to acute hemodynamic failure and started a long-term treatment with doxycycline and rifampicin. Some interesting aspects about the diagnosis and treatment of this patient are reviewed because long-term follow-up and serological controls are still rare in the literature.

Submammary median sternotomy.

A vertical skin incision is used as routine approach for sternotomy. The resulting scar is often disappointing and the top is visible and unpleasant, especially for young women. In 35 women ranging from 10 to 48 years (mean 29.2 years), median sternotomy was performed via a submammary skin incision. In all cases an open heart surgical procedure was performed. Adequate exposure of the heart was achieved in every case and there were no technical problems related to this approach, no hospital mortality or major complications. The cosmetic result is excellent and this approach is certainly justified in open heart surgery for young women.

[Use of both internal mammary arteries; not everything is advantageous]. / Utilización de ambas arterias mamarias internas; no todo son ventajas.

The internal mammary artery is considered the elective graft for performing aortocoronary by-pass as its long-term results have proven better than those obtained with the internal saphenous vein. Our results in a series of 21 patients in whom both internal mammary arteries were used are reported. Four patients (19.04%) needed reoperation for sternal dehiscence and two of them had mediastinitis (9.52%). Those patients were successfully treated by continuous povidone-iodine flushing. A clear statistical difference was found between this group of patients, in whom both internal mammary arteries were used, and the rest of the patients (182 patients) in whom just the internal saphenous vein and/or only one internal mammary artery was used. The second group presented 8 cases of sternal dehiscence (4.39%) and 1 mediastinitis (0.55%).

Rate-responsive pacing: clinical experience.

Single chamber, rate-responsive pacing is emerging as a new modality in cardiac pacing and in the near future, dual chamber rate-responsive pacing may be the optimal solution for most pacemaker patients. In this report we describe our short- and long-term clinical experience with two different rate-responsive pacemakers: the RS4, an asynchronous atrial sensing ventricular pacemaker, and the TX-pacemaker, which senses the evoked QT after a ventricular paced beat, as an indicator of metabolic demand. Both systems use a single ventricular lead. Nine patients received RS4 and 10 patients received TX units. All of these patients had AV block and good ventricular function except for three patients with sinus node disease in the TX group. Between 1 and 3 months after implantation, a 24-hour Holter monitoring was performed, during which two maximal symptom-limited treadmill exercise tests (Bruce protocol) were conducted in VVI (70 bpm) and rate-responsive modes, in a random fashion. The mean follow-up was 25 months in RS4 group and 10 months in TX group. Significant improvements in patient exercise tolerance were found in the rate-responsive mode (9.0 vs. 6.6 METs in VVI) with similar results in both groups (RS4 and TX) despite higher ventricular pacing rates in the TX group (121 bpm vs. 102 bpm in RS4). An autolimited rate-responsive pacemaker-mediated tachycardia, induced by retrograde ventriculo-atrial conduction, was observed in a patient with an RS4.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis and treatment of subacute free wall ventricular rupture after infarction.

Ventricular rupture is usually a sudden, lethal complication after acute myocardial infarction (MI). Some patients, however, may survive several hours after ventricular rupture, and there is time for surgical repair if the diagnosis is made quickly. In 1980 and 1981, 7 patients underwent operation for ventricular rupture at our institution. Bedside hemodynamic studies with a Swan-Ganz catheter confirmed the diagnosis of pericardial tamponade. Urgent operation with cardiopulmonary bypass was performed. Control of hemorrhage was obtained by covering the ventricular tear and the surrounding infarcted myocardium with a wide Teflon patch. Four patients are alive and well 2, 3, 4, and 10 months after operation. Clinically, free wall ventricular rupture should be suspected when any patient recovering from an acute MI experiences chest pain and cardiovascular collapse. Bedside hemodynamic monitoring will confirm the diagnosis of cardiac tamponade, and urgent operation will save some of these patients.