Anemia hemolítica secundaria a plastía mitral: caso clínico local y revisión de la literatura / Hemolytic anemia after mitral valve repair: case report

Una mujer de 54 años sometida a una reparación mitral se presenta 2 meses después con anemia hemolítica. El mecanismo de ésta correspondió a dehiscencia de la cuadrantectomía y a falta de endotelización de un sector del anillo, que se evidenció mediante ecografía transesofágica y se confirmó por hallazgos operatorios. Se resecó el anillo mitral y se implantó una prótesis de Saint Jude, y no hubo recurrencia de la hemólisis. Se incluye una discusión con revisión de la literatura.

A 54 year old woman was subjected to a mitral valve repair of a mixomatous degenerative valve with severe mitral insufficiency. Quadrantectomy, mitral chords transfer from P2 to a A2 and implantation of a rigid Edwards 28 ring were performed. Two months later the patient was diagnosed with severe hemolytic anemia. Trans esophageal echocardiography revealed severe mitral insufficiency and at surgery a dehiscence at the base of the qudrantectomy in addition to a non endothelysed sector of the mitral ring were found. A Saint-Jude mitral prosthesis was inserted. At follow up, no recurrence of hemolysis occurred.

A randomized controlled trial to prevent post-operative atrial fibrillation by antioxidant reinforcement.

OBJECTIVES: This study was designed to assess whether the reinforcement of the antioxidant system, through n-3 fatty acids plus antioxidant vitamin supplementation, could reduce the incidence of post-operative atrial fibrillation. BACKGROUND: Therapy to prevent post-operative atrial fibrillation remains suboptimal. Although oxidative stress plays a key role in the pathogenesis of this arrhythmia, antioxidant reinforcement has produced controversial results. METHODS: A total of 203 patients scheduled for on-pump cardiac surgery were randomized to placebo or supplementation with n-3 polyunsaturated fatty acids (2 g/day) (eicosapentaenoic acid:docosahexaenoic acid ratio 1:2), vitamin C (1 g/day), and vitamin E (400 IU/day). The primary outcome was the occurrence of post-operative atrial fibrillation. Secondary outcomes were the biomarkers related to oxidative stress and inflammation. RESULTS: Post-operative atrial fibrillation occurred in 10 of 103 patients (9.7%) in the supplemented group versus 32 of 100 patients (32%) in the placebo group (p < 0.001). Early after surgery, placebo patients presented with increased levels of biomarkers of inflammation and oxidative stress, which were markedly attenuated by antioxidant supplementation. The activity of catalase, superoxide dismutase, and glutathione peroxidase in atrial tissue of the supplemented patients was 24.0%, 17.1%, and 19.7% higher than the respective placebo values (p < 0.05). The atrial tissue of patients who developed atrial fibrillation showed NADPH oxidase p47-phox subunit protein and mRNA expression 38.4% and 35.7% higher, respectively, than patients in sinus rhythm (p < 0.05). CONCLUSIONS: This safe, well-tolerated, and low-cost regimen, consisting of n-3 polyunsaturated fatty acids plus vitamins C and E supplementation, favorably affected post-operative atrial fibrillation, increased antioxidant potential, and attenuated oxidative stress and inflammation. (Prevention of Post-Operative Atrial Fibrillation: Pathophysiological Characterization of a Pharmacological Intervention Based on a Novel Model of Nonhypoxic Pre-Conditioning; ISRCTN45347268).

Antioxidant therapy reduces oxidative and inflammatory tissue damage in patients subjected to cardiac surgery with extracorporeal circulation.

Ischaemia reperfusion injury is a pathophysiological event that occurs after cardiac surgery with extracorporeal circulation. This clinical event has been associated with the induction of oxidative and inflammatory damage in atrial tissue. Here, we tested whether combined omega 3 polyunsaturated fatty acids (n-3 PUFA)-antioxidant vitamin protocol therapy reduces oxidative and inflammatory cardiac tissue damage. This trial assigned 95 either-sex patients to supplementation with n-3 PUFA (2 g/day), or matching placebo groups, 7 days before on-pump surgery. Antioxidant vitamins C (1 g/day) and E (400 IU/day) or placebo were added from 2 days before surgery until discharge. Blood and atrial tissue samples were obtained during the intervention. Reduced/oxidized glutathione (GSH/GSSG) ratio, malondialdehyde (MDA) and protein carbonylation were determined in atrial tissue. Leucocyte count and high-sensitivity C-reactive protein (hs-CRP) in blood plus nuclear factor (NF)-κappaB activation in atrial tissue served for inflammation assessment. Lipid peroxidation and protein carbonylation were 27.5 and 24% lower in supplemented patients (p < 0.01). GSH/GSSG ratio was 38.1% higher in supplemented patients compared with placebo (p < 0.01). Leucocyte count and serum hs-CRP levels were markedly lower throughout the protocol in supplemented patients (p < 0.01). Atrial tissue NF-κB DNA activation in supplemented patients was 22.5% lower than that in placebo patients (p < 0.05). The combined n-3 PUFA-antioxidant vitamin protocol therapy here proposed reduced the oxidative stress and inflammation biomarkers, in patients undergoing on-pump cardiac surgery.

Lesión traumática de la aorta descendente por desaceleración / Traumatic injury of descending aorta by disacceleration

La mortalidad por accidentes en menores de 40 años ocupa un lugar prioritario en Chile. Los traumatismos de aorta torácica contribuyen en forma importante a la mortalidad y son rara vez diagnosticados. Presentamos nuestra experiencia con 5 casos operados de dislaceración traumática de aorta descendente. El diagnóstico se sospechó por un mediastino ancho a la Rx de tórax y se confirmó con TAC y angiografía en 3, sólo TAC en 1 y angiografía exclusiva en otro. Se intervienen entre 3 y 19 horas después del ingreso accediendo a la aorta descendente por toracotomía posterolateral izquierda con pinzamiento directo de la aorta en dos y con apoyo atrio-distal con bomba centrífuga en los otros 3. En todos se reemplazó el segmento lesionado con prótesis de Dacrón precoagulada. Un paciente fallece por isquemia visceral masiva y los otros 4 sobreviven. Todos los sobrevivientes se incorporan a una vida normal

Fármacos de uso actual en hipertensión arterial / Drugs presently used in arterial hypertension

La hipertensión arterial afecta alrededor del 15% de los adultos, siendo, en nuestro medio, la más frecuente de las enfermedades crónicas no transmisibles después del alcholismo. El arsenal terapéutico disponible es muy amplio y está demostrado que el tratamiento médico continuado y bien controlado modifica la historia natural de la enfermedad hipertensiva. Las consideraciones anteriores han impulsado a los autores a revisar y exponer en forma esquemática y práctica las características de los diversos fármacos hipotensores actualmente disponibles; sus mecanismos de acción, efectos adversos; posología e indicaciones clínicas