[Implantable pacemakers and defibrillators: implications for anesthesia and perioperative management]. / Marcapasos y desfibriladores automáticos implantables: implicaciones anestésicas y manejo perioperatorio.

The technological complexity of implantable devices for managing arrhythmias, specifically pacemakers and defibrillators, has increased spectacularly since their introduction a few decades ago. A growing number of patients with these devices are undergoing surgery and it is therefore essential to understand how they work and what the real associated risks are. Manuals and reference works on anesthesia may provide little information on these devices and their perioperative management. It is no longer satisfactory to place a magnet over these devices during surgery and assume that this action will protect the patient from the possible effects of electromagnetic interference. This review examines the basic principles and operation of implantable pacemakers and defibrillators, the relevant nomenclature, and the sources and effects of electromagnetic interference; the current recommendations for the perioperative management of patients fitted with these devices are also discussed.

Bilateral diaphragmatic paralysis after open heart surgery.

The purpose of the present case report is to present a case of bilateral diaphragmatic paralysis as a complication of open-heart surgery. A 47-year-old male was operated for aortic and mitral valve replacement. After discontinuation of sedation, bilateral diaphragmatic paralysis as well as motor and sensitive dysfunction in the four extremities was observed. The patient remained with mechanical ventilation support for twenty months. Two years after the operation a complete normalisation of the diaphragmatic motion was observed. Although uncommon, bilateral diaphragmatic paralysis after open-heart surgery could take place, being necessary long term mechanical ventilation support until recovery.

Apoptotic cell death and genetic control in graft coronary artery disease in heart transplant.

AIM: Apoptosis is a type of programmed cell death whereby, immunologic, genetic and biochemical mechanisms are involved in its control. On the other hand, graft coronary artery disease is the most important restrictive factor for the long-term survival of heart transplantation. The purpose of this study is to analyse both apoptotic cell lesions in transplanted patients that present coronary artery disease. METHODS: From August 1984 until December 1996, 148 heart transplants were carried out in the Clínica Universitaria de Navarra. In 102 patients, annual coronary angiography was performed, reaching a diagnosis of coronary artery disease in 30 patients. Study of apoptotic cell death was done in the tissue of endomyocardial biopsies on all patients by means of the TUNEL technique. Procedures of immunohistochemistry with antibodies antic-myc, p53 and bcl-2 were carried out and results were compared with a control group of 30 patients with homogeneous characteristics. RESULTS: All patients with coronary artery disease showed apoptotic cardiomyocytes, 13 patients to a mild degree, 14 to a moderate degree and 3 to a severe degree, while in the control group apoptosis was found only to a mild degree in 8 patients, obtaining a very significant statistical difference (p<0.0001). The expression of analysed oncoproteins was null in the 2 groups. CONCLUSION: Myocardial apoptosis is a constant finding in transplanted patients with coronary artery disease. We have not seen any correlation between the apoptotic process and genetic mechanisms.

[Myocardiopathies. IX. Surgical treatment of hypertrophic obstructive myocardiopathy: is it an underestimated alternative?]. / Miocardiopatías (IX) La cirugía de resección en la miocardiopatía hipertrófica obstructiva: recuperación de una herramienta infraestimada?

The aim of surgery in hypertrophic cardiomyopathy is to reduce the intraventricular obstacle, increase left ventricular compliance, correct mitral regurgitation and other associated lesions, such as coronary atherosclerosis disease or endocarditis. Several surgical techniques have been proposed; myotomy, myomectomy, mitral valve replacement and mitral valve plication. The last mentioned technique combined with myomectomy can be performed safely and may represent an alternative to mitral valve replacement in cases with enlarged and elongated mitral leaflets. We review the natural evolution of the disease and its treatment, emphasizing on the possible mechanism by which surgical treatment may ameliorate the disease.

[Right coronary artery originating from the left sinus of Valsalva. Surgical repair]. / Nacimiento de la arteria coronaria derecha en seno de Valsalva izquierdo. Corrección quirúrgica.

Anomalous origin of right coronary artery from left coronary sinus has been considered a minor disease without relevance. Currently it is associated with all symptoms derived from myocardial ischemia because of its lower coronary reserve. We present one patient with anomalous origin of right coronary artery from left coronary sinus surgically treated with saphenous vein aorto-coronary bypass. Doppler velocimetry shows the improvement of myocardial reserve after surgery.

Marcapasos y desfibriladores automáticos implantables: implicaciones anestésicas y manejo perioperatorio / Implantable pacemakers and defibrillators: implications for anesthesia and perioperative management

La complejidad tecnológica de los dispositivosimplantables para el manejo de las arritmias, concretamentede marcapasos y desfibriladores, ha aumentadode forma espectacular desde su introducción hace solamenteunas pocas décadas. Un número cada vez mayorde pacientes con estos dispositivos va a ser intervenidoquirúrgicamente, por lo que es primordial saber cómofuncionan y cuáles son los riesgos reales. Los manuales yreferencias de anestesia pueden proporcionar pocainformación sobre este tipo de aparatos y su manejoperioperatorio. Ya no es satisfactorio colocar durante lacirugía un imán encima de estos dispositivos y suponerque esta acción protege al paciente de los posibles efectosde las interferencias electromagnéticas. Este artículorevisa los principios básicos y el funcionamiento de estosequipos, la nomenclatura, las fuentes de interferenciaelectromagnética y sus efectos, así como las recomendacionesactuales para el manejo perioperatorio delpaciente portador de un marcapasos o un desfibriladorimplantable(AU)

The technological complexity of implantable devicesfor managing arrhythmias, specifically pacemakers anddefibrillators, has increased spectacularly since theirintroduction a few decades ago. A growing number ofpatients with these devices are undergoing surgery and itis therefore essential to understand how they work andwhat the real associated risks are. Manuals and referenceworks on anesthesia may provide little information onthese devices and their perioperative management. It is nolonger satisfactory to place a magnet over these devicesduring surgery and assume that this action will protectthe patient from the possible effects of electromagneticinterference. This review examines the basic principlesand operation of implantable pacemakers anddefibrillators, the relevant nomenclature, and the sourcesand effects of electromagnetic interference; the currentrecommendations for the perioperative management ofpatients fitted with these devices are also discussed(AU)