Cardiopatías congénitas, tratamiento quirúrgico y sus complicaciones en población pediátrica del Hospital Vicente Corral Moscoso, 2017 - Agosto 2019 / Congenital heart diseases, surgical treatment and complications in pediatric sample of Hospital Vicente Corral Moscoso, 2017-August 2019.

INTRODUCCIÓN: El corazón es el órgano más comúnmente afectado por anormalidades congénitas, con una incidencia de 0.8 por cada 100 nacidos vivos. Cerca de dos tercios de todos los procedimientos son en la actualidad realizados antes del año de edad, lo que mejora la sobrevida y la calidad de vida. Este estudio busca determinar cuáles son las principales intervenciones quirúrgicas realizadas para tratar las cardiopatías congénitas y sus complicaciones. MATERIALES Y MÉTODOS: Se realizó un estudio observacional, descriptivo de corte transversal; con 70 pacientes pediátricos diagnosticados y tratados quirúrgicamente por cardiopatías congénitas. Los datos fueron tomados de las historias clínicas mediante un formulario. El análisis estadístico se realizó utilizando el programa SPSS versión 15. RESULTADOS: La mediana de la edad fue de 1.1 años, el 60% fueron de sexo femenino. El 90% de las cardiopatías fueron no cianógenas. El diagnóstico más frecuente fue la persistencia del conducto arterioso (58.57%), seguido de la comunicación interventricular (12.86%). Según el tipo de procedimiento el 58.57% se realizaron para cierre de persistencia del conducto arterioso y un 12.86% fueron reparaciones quirúrgicas para cierre de comunicación interventricular. La mediana de estadía en la unidad de cuidados intensivos fue de 4 días y la mediada de estadía en la sala general de 5 días. La principales complicaciones observadas en esta población pediátrica sometida a un procedimiento quirúrgico fueron: la neumonía (11.4%) y la sepsis de origen no especificado (8.6%). CONCLUSIÓN: Los tratamientos para las cardiopatías congénitas se realizaron a edades tempranas (Media =2.5 ± 3.2 años). Más de la mitad de los procedimientos quirúrgicos realizados para cardiopatías quirúrgicas fueron para corregir la persistencia del conducto arterioso y la principal complicación fue la neumonía.

BACKGROUND: The heart is the most commonly affected organ by congenital diseases, with and incidence of 0.8 per 100 newborns. Nearly two thirds of all the surgical procedures are now a days performed before the first year of life, improving survival rate and life quality. This study aims to determine the frequency of the surgical interventions performed to treat congenital heart diseases and its complications. METHODS: An observational, descriptive cross sectional study was carried out; with 70 pediatric patients diagnosed and surgically treated for congenital heart diseases. The data was collected from the patient's medical records using a form. Statistical analysis was performed using SPSS version 15 software. RESULTS: The median age was 1.1 years, 60% of the sample were women. 90% of the heart diseases were non-cyanogenic. The most frequent diagnosis was: persistence of the arterial duct (58.57%), followed by interventricular communication (12.86%). The type of procedures corresponds to the heart disease, thus 58.57% were performed for closure of arterial duct persistence and 12.86% were surgical repairs for closure of interventricular communication. The median stay in the intensive care unit was 4 days and the median stay in general hospitalization room was 5 days. The main complications in this pediatric population undergoing a surgical procedure were: pneumonia (11.4%) and sepsis of unspecified origin (8.6%). CONCLUSION: Treatment for heart diseases were performed at early ages (average age= 2.5±3.2). More than half of the surgical procedures for congenital heart disease were performed to correct the persistence of the ductus arteriosus, the main complication was pneumonia.

Thoracic and cardiovascular operations in the United States, 1979 to 1984.

Using data from the National Center for Health Statistics, I conducted an in-depth analysis of numbers of thoracic and cardiovascular operations from 1979 to 1984. This is the first full 5 year period since the inception of International Classification of Diseases, Ninth Revision, Clinical Modification codes, and the findings delineate the present status of thoracic and cardiovascular surgery in the United States. During the study period there was a 34% increase in total numbers of thoracic and cardiovascular operations. Since 1970 there has been a total increase in numbers of thoracic and cardiovascular operations of 150%. In 1983 thoracic and cardiovascular surgeons performed 191,000 coronary artery bypasses. This operation is the most common thoracic and cardiovascular procedure and has become the nineteenth most common operation now performed in this country. Pacemaker placement, revision, or removal (190,000) is the second most common thoracic and cardiovascular operation and the country's twentieth. The twenty most common thoracic and cardiovascular operations constitute 87% of all thoracic and cardiovascular operations. In 1983 thoracic and cardiovascular operations represented 3% of all operations completed in this country. These figures represent the dynamics of thoracic and cardiovascular surgical practice. They demonstrate that numbers of thoracic and cardiovascular operations have consistently increased over the past 15 years. However, this increase is almost entirely due to the advent of coronary artery bypass.

Risk stratification theme for congenital heart surgery.

Surgical practice is changing and auto-evaluation of quality of care, organized by scientific societies, is very likely to become an obligation during this new decade. This evaluation requires a common nomenclature, a registry, and risk stratification. The primary purpose of risk stratification is to offer the possibility of objective analysis of surgical outcomes according to the complexity of the pathology treated. Registries, databases containing select essential data on a complete population, are not able to produce a statistically reliable risk stratification model. Academic databases, like that of the Congenital Heart Surgeons Society, contain comprehensive data on select patients, and are able to produce risk stratification, but only very slowly. The absence of risk discrimination in current registries penalizes centers treating complex pathologies. They may be reluctant to release their results without the security of risk stratification. Given the diversity of congenital heart surgery, a new method has been developed to stratify risks: the complexity score. This approach is based on the perceived opinions of a group of 50 internationally recognized surgeons and centers. It allows a hierarchical classification of surgical procedures according to mortality, morbidity, and surgical difficulty. Surgical procedures are scored globally on simple pathologies and in detail according to seven categories of risks. The complexity score in congenital heart surgery, also known as the Aristotle Score, is currently being developed as a collaborative effort of the members of the European Association for Cardio-thoracic Surgery, the Society of Thoracic Surgeons, the Congenital Heart Surgeons Society, and the European Congenital Heart Surgeons Foundation, and should be available next year.

The changing pattern of thoracic surgery in the United Kingdom 1963-1982.

During the period 1963-1982 a total of 11,459 patients with general surgical and thoracic conditions were admitted to the Churchill and John Radcliffe Hospitals in Oxford under the care of a single thoracic surgeon. 55.1% of the admissions were for general surgical conditions whereas 44.9% were for a thoracic disorder. The total period has been studied by dividing it into three subgroups of 7, 6 and 7 years (1963-1969, 1970-1975, 1976-1982). The percentage of thoracic patients treated during the three periods was found to be 48.86%, 41.73% and 50.11% respectively. The three periods studied have been subdivided into major disease groups and the changes in these groups have been studied in detail. During this 20-year period there has been a dramatic change in the makeup of a typical thoracic surgical practice. This is in part due to the changing pattern and prevalence of many of the diseases treated by thoracic surgeons, but is also due to a change in referral patterns, the distribution of patients between thoracic and general surgeons and also the dichotomy emerging between thoracic and cardiac surgeons.

Características clínicas y quirúrgicas de pacientes sometidos a cirugía de válvula mitral en una ins titución de salud de Barranquilla, Colombia / Clinic al and surgic al characteristics of patients undergoing mitral valve surgery at a health ins titution in Barranquilla, Colombia

Introducción: la incidencia de las anomalías valvulares cardiacas ha aumentado entre otras razones por los avances en métodos diagnósticos y conocimiento de predecesores etiológicos como desenca­ denantes de la condición clínica, que inicia la probabilidad diagnostica y seguimiento temprano en pa­ cientes en estadios iniciales de la enfermedad, disminuyendo de esta manera el impacto económico por aumento de la morbimortalidad. Objetivo: describir las características clínicas y quirúrgicas de pa­ cientes sometidos a cirugía de válvula mitral en una institución prestadora de servicios de salud de re­ ferencia para el distrito de Barranquilla, Colombia, durante los años 2014 a 2016. Metodología: estudio descriptivo, en el que se revisó de forma retrospectiva las historias clínicas de pacientes con patología mitral que requirieron intervención quirúrgica de tipo plastia, cambio biológico o mecánico, entre los años 2014 y 2016. El análisis de la información se realizó a través del software SPSS. Re­ sultados: durante el periodo de estudio se realizaron 276 cirugías valvulares en la institución de salud objeto de estudio, de las cuales 98 fueron cirugías sobre válvula mitral, excluyéndose 20 historias clí­ nicas que no contenían la totalidad de las variables analizadas. El antecedente clínico más frecuente fue la enfermedad coronaria (38,5%), seguido del infarto de miocardio (23,1%); el 20,5% de los pa­ cientes presentaron arritmia tipo fibrilación auricular y la cirugía sobre válvula mitral más realizada fue recambio biológico (42%). Conclusión: las características clínicas y quirúrgicas de los pacientes inclui­ dos en el estudio, son similares a las descritas en la literatura nacional e internacional, por lo que podría tomarse como precedente de presentación y de esta manera ir construyendo una clínica para la identificación rápida y veraz de los pacientes con alteraciones valvulares, permitiendo su abordaje temprano y disminuyendo la carga económica para el sistema de salud.

Introduction: cardiac valvular anomalies have increased their presentation, in part due to advances in diagnostic methods and knowledge of etiological predecessors as triggers of the clinical condition that initiates the diagnostic probability and early follow­up in patients in the initial stages of the di­ seas e, thus decreasing the economic impact due to increased morbidity and mortality. Objective: to describe the clinical and surgical characteristics of patients undergoing mitral valve surgery at a re­ference center in the district of Barranquilla during the years 2014 to 2016.Methodology: descriptive, retrospective, cross­sectional study in a health institution in the district of Barranquilla. Patients with mitral pathology who required surgical intervention of the plasty type, biological or mechanical chan­ ge, were included between 2014 and 2016. Data analysis performed in SPSS according to the natu­ re of the variables. Results : during the study period, 276 valve surgeries were performed, of which 98 were valve surgeries, 20 patients were excluded due to incomplete clinical history; the most pre­ valent antecedent was coronary disease in 38.5% followed by myocardial infarction with 23.1%; 20.5% of the patients presented arrhythmia type atrial fibrillation; the most performed mitral valve surgery was a 42% biological replacement. Conclusion: the clinical and surgical characteristics of the patients included in the study, correspond to those described in national and international litera­ ture, so it could be taken as a precedent for presentation and thus build a presentation clinic for quick and accurate identification of the patients with valvular alterations, allowing their early ap­ proach and decreasing the economic burden for the health system.

Only half of the chronic pain after thoracic surgery shows a neuropathic component.

UNLABELLED: Chronic pain is a common complication after thoracic surgery. The cause of chronic post-thoracotomy pain is often suggested to be intercostal nerve damage. Thus chronic pain after thoracic surgery should have an important neuropathic component. The present study investigated the prevalence of the neuropathic component in chronic pain after thoracic surgery. Furthermore, we looked for predictive factors for prevalence and intensity of chronic pain. We contacted 243 patients who underwent a video-assisted thoracoscopy (VATS) or thoracotomy in the period between January 2004 and September 2006 by mail. Patients retrospectively received a questionnaire with the Dutch version of the PainDETECT Questionnaire, a validated screening tool for neuropathic pain. Results were analyzed from 204 patients (144 thoracotomies, 60 VATS). The prevalence of chronic pain was 40% after thoracotomy and 47% after VATS. Definite chronic neuropathic pain was present in 23% of the patients with chronic pain, with an additional 30% having probable neuropathic pain. Greater probability of neuropathic pain (ie, a higher total score of the PainDETECT) correlated with more intense chronic pain. Predictive factors for chronic pain were younger age (P = .01), radiotherapy (P = .043), pleurectomy (P = .04) and more extensive surgery (P < .001). PERSPECTIVE: Up to half the chronic pain after thoracic surgery is not associated with a neuropathic component, which has not been reported to date. More extensive surgery and pleurectomy are predictive factors for chronic pain after thoracic surgery, suggesting a visceral component apart from nerve injury.

Classification of procedures in the domain of thoracic surgery--a study of reliability in coding.

This paper relates a study of reliability of coding of surgical procedures in the domain of thoracic surgery. The reliability measured is inter-coder variability in form of agreement. Four classifications were used by four physicians on 100 patient cases. The classifications, having differing granularity and structure, were analyzed using a statistical method (kappa). These results are discussed and related to the differences between the classifications. One of the topics for discussion is how the granularity affects the degree of agreement, coupled to the usefulness of the classification. Also the concept of using formal methods for representing classifications is discussed, how this will affect how classifications are designed and used.

Quality assurance of paediatric cardiac surgery: a prospective 6-year analysis.

OBJECTIVE: To audit effective quality assurance methods to monitor outcomes following paediatric cardiac surgery at a single institution. METHODS: All patients undergoing cardiac surgery from January 1996 to December 2001 were enrolled prospectively. Patients were stratified by complexity of surgical procedure into four groups, with Category 4 being the most complex procedure. Outcome measures included death, length of admission and morbidity from complications. RESULTS: A total of 1815 patients underwent 1973 surgical procedures. Of these, 1447 (73.3%) were cardiopulmonary bypass procedures, and 543 (27.5%) were more complex (Category 3 and 4) procedures. Median patient age was 3.5 years (range, 1 day-20 years) and patient weight 15.0 kg (range, 900 g to 90 kg). Sixty-six patients (3.6%) died during the study period. Of the procedures in 1996, 22.7% were classified as complex compared with 29.2% of procedures in 2001. The annual surgical mortality ranged from 1.9-4.7% (P = 0.20), and when mortality was adjusted for complexity of surgery, there was no significant yearly variation in the mortality rate (P = 0.57). Analysis of individual surgeon's results showed no significant difference in the mortality rate by complexity of surgery performed (P = 0.90). Mean ventilation times did not change significantly over time (P = 0.79). The yearly incidence of significant neurological complications ranged from 0.6% to 4.5% and the incidence of arrhythmias from 4.2% to 8.0%. No difference was detected between the years. CONCLUSIONS: Stratifying complexity of surgery proved valuable in monitoring surgical outcomes and detecting differences in performance over time as large subgroups were created for analysis.

Surgery for pulmonary tuberculosis.

During the period 1990-1994 a total of 578 operations were performed in 502 patients with various forms of tuberculosis. Most of the patients (68%) were men aged 20 to 50 years (70%). Sputum cultures were positive in 55% of the patients. More than half of all patients were chronic smokers, and about 10% were alcoholics or drug addicts. There were no human immunodeficiency virus-infected patients, and none with acquired immunodeficiency syndrome. The most frequent surgical interventions were, according to the classification adopted in Russia, for cavernous or fibrocavernous tuberculosis (196 cases) and tuberculomas (161 cases). The main operative procedures used were pulmonary resection (n = 280) and pneumonectomy or pleuropneumonectomy (n = 80). Diseased intrathoracic lymph nodes were ablated in 62 patients. Thoracoplasty or thoracomyoplasty were performed in 46 cases, thoracostomy in 37, closure of a thoracic wall defect in 27, and reamputation of the main bronchial stump in 6. Postoperative complications arose in 20% of the patients. More than half occurred in the pleural cavity or bronchi and were associated with tuberculous infection. The postoperative hospital case-fatality rate was 2%. The overall clinical efficacy by the time of discharge was 82.7% (95% in tuberculomas). Reactivation of tuberculosis over the first 3 years after discharge occurred in 6.6% of the patients. Most patients with large or multiple caverns, tuberculomas, intrathoracic caseous lymphadenitis, or various complications of pulmonary tuberculosis cannot be cured (or are not amenable to care in principle) by means of antibacterial therapy because of irreversible morphologic changes in the lungs, bronchi, pleura, lymph nodes, or thoracic wall. For this reason, indications for surgical management of pulmonary tuberculosis should be generally expanded. Excessively long antibacterial therapy for tuberculosis is often inadvisable. Although the availability of standardized regimens of antibacterial therapy is strategically essential, each patient must be treated according to an individual plan. In certain cases thoracic surgeons should be enlisted to participate in the development of such plans.

Ventilação não invasiva após cirurgia cardiovascular: um ensaio clínico randomizado / Non-invasive ventilation after cardiovascular surgery: a randomized clinical trial

Fundamentos: A hipoxemia é a complicação mais comum no pós-operatório (PO) de cirurgia cardíaca, sendo consequência principalmente da formação de atelectasias, edema intersticial alveolar e acúmulo de secreção pulmonar. Essas alterações aumentam a incidência de infecções pulmonares, tempo de internação na UTI e custos hospitalares. Objetivo: Avaliar as trocas gasosas e alterações hemodinâmicas de pacientes hipoxêmicos submetidos à ventilação não invasiva (VNI) no PO imediato de cirurgia cardiovascular. Métodos: Ensaio clínico randomizado conduzido na UTI cirúrgica de um hospital cardiológico. Foram incluídos pacientes com hipoxemia (300>PaO2/FiO2>150) uma hora após extubação orotraqueal, no PO imediato de cirurgia cardiovascular eletiva e que foram submetidos à cateterização da artéria pulmonar no bloco cirúrgico (BC). O grupo-controle recebeu oxigenoterapia e o grupo-intervenção, VNI e oxigênio durante três horas consecutivas. Na análise estatística foram utilizados os testes t de Student, Mann-Whitney, exato de Fisher, ANOVA e generalized estimating equation (GEE). Resultados: Estudados 42 pacientes. Os pacientes do grupo-intervenção (n=21) apresentaram melhora significativa da relação PaO2/FiO2 (p=0,007). Houve discreta diferença entre os grupos na pressão capilar pulmonar (p=0,012), no índice cardíaco (p=0,006) e na pressão venosa central (p=0,022).

Background: Hypoxemia is the most common complication during the post-operative stage of cardiovascular surgery, due mainly to atelectasis, alveolar interstitial edema and accumulations of pulmonary secretions. These changes may increase the incidence of lung infections with longer ICU stays and consequently higher hospital costs. Objective: To evaluate gas exchanges and hemodynamic alterations in hypoxemic patients under non-invasive ventilation (NIV) during the immediate post-operative period subsequent to cardiovascular surgery. Methods: A randomized clinical trial conducted in the surgical ICU of a cardiology hospital of patients with hypoxemia (300>PaO2/FiO2>150) one hour after orotracheal extubation during the post-operative period immediately after elective cardiovascular surgery who underwent pulmonary artery catheterization in the surgical ward. The control group received oxygen therapy, while the intervention group received NIV plus oxygen for three consecutive hours. For the statistical analysis, we used the Student t, Mann-Whitney, Fisher’s exact tests, as well as ANOVA and generalized estimating equations (GEE). Results: Among the 42 patients studied, the intervention group (n=21) presented significant improvements in the PaO2/FiO2 ratio (p=0.007), with little difference between the groups for pulmonary capillary pressure (p=0.012), cardiac index (p=0.006) and central venous pressure (p=0.022).

Temporary atrial epicardial pacing as prophylaxis against atrial fibrillation after heart surgery: a meta-analysis.

INTRODUCTION: Recent studies have reported the use of temporary epicardial atrial pacing as prophylaxis for postoperative atrial fibrillation (AF). The aim of this study was to assess the effect of pacing therapies for prevention of postoperative AF using meta-analysis. METHODS AND RESULTS: Using a computerized MEDLINE search, eight pacing prophylaxis trials with 776 patients were included in the meta-analysis. Trials compared control patients to patients randomized to right atrial, left atrial, or biatrial pacing used in conjunction with either fixed high-rate pacing or overdrive pacing. Overdrive biatrial pacing (OR 2.6, CI 1.4-4.8), overdrive right atrial pacing (OR 1.8, CI 1.1-2.7), and fixed high-rate biatrial pacing (OR 2.5, CI 1.3-5.1) demonstrated a significant antiarrhythmic effect for prevention of AF after open heart surgery. Furthermore, studies investigating overdrive left atrial pacing and fixed high-rate right atrial pacing have been underpowered to assess efficacy. CONCLUSION: Biatrial overdrive and fixed high-rate pacing and right atrial fixed high-rate pacing reduced the risk of new-onset AF after open heart surgery, and the relative risk reduction is approximately 2.5-fold. These results imply that various pacing algorithms are useful as a nonpharmacologic method to prevent postoperative AF.

Aspectos da funcão pulmonar após revascularizacão do miocárdio relacionados com risco pré-operatório / Pulmonary function aspects after myocardial revascularization related to preoperative risk

OBJETIVOS: Comparar os valores das complacências dinâmica e estática, da resistência de vias aéreas (Cdin, Cest e Raw) e do índice de troca gasosa (PaO2/FiO2), no pós-operatório de cirurgia de revascularizacão miocárdica (RM) com os parâmetros de normalidade e comparar os valores destas variáveis entre grupos com e sem fatores de risco no pré-operatório. MÉTODO: Questionamento aos doentes a respeito de antecedentes pulmonares, sintomas respiratórios, tabagismo e comorbidades. Após cirurgia de RM, foram feitas as medidas de Cdin, Cest, Raw e do PaO2/FiO2. As variáveis foram comparadas com a normalidade e relacionadas às variáveis pré e pós-operatórias pelo Teste não-paramétrico de Mann-Whitney e pelo Teste para uma proporcão (p<0,05). RESULTADO: Foram avaliados 70 doentes (61 por cento homens), com idade entre 26 e 77 anos. Em relacão à normalidade, apresentaram diminuicão da Cdin e da Cest, 64 e 66 pacientes, respectivamente, e 24 apresentaram aumento da Raw. Aproximadamente 50 por cento apresentaram reducão do PaO2/FiO2. Não houve diferenca significante das variáveis pós-operatórias com respeito aos antecedentes pulmonares, sintomas respiratórios e tabagismo. Nos pacientes com comorbidades, o PaO2/FiO2 foi significativamente menor e, nos homens, a Cdin e a Cest foram maiores que nas mulheres. CONCLUSAO: As complacências pulmonares estão diminuídas na maioria dos pacientes, e a resistência das vias aéreas está aumentada em um terco deles. O índice de troca gasosa encontra-se diminuído em metade deles. A presenca de antecedentes pulmonares, sintomas respiratórios e tabagismo não influencia as variáveis mecânicas, mas o índice de troca gasosa é influenciado pela presenca de comorbidades.

Variabilidad de observador en procedimientos diagnósticos afines a la cirugía cardiotorácica / Orserver variability of diagnostic procedures related to cardiothoracic surgery

La reproducibilidad de resultados es una de las condiciones principales para la validez de un escrito médico. La medición de la variabilidad de observador es una estrategia que nos permite identificar el grado de precisión de los resultados obtenidos en la investigación clínica que aborde o requiera la utilización de instrumentos de diagnóstico clínico. Se hace en el presente trabajo una presentación de los conceptos sobre el tema y posteriormente revisamos la literatura de nuestro país en el área cardiológica y neumológica publicada de enero de 1980 a julio de 1993, encontrando que en 13 años, en cuatro revistas, sólo dos artículos informan haber medido la variabilidad de observador en trabajos de ecocardiografía, electrocardiografía, microscopía y hemodinamia, lo que nos lleva a concluir que se debe hacer más énfasis en la determinación de la misma ya que puede contribuir a explicar las discrepancias observadas en una investigación, además de las que son atribuibles al azar, al paciente, a los equipos auxiliares de diagnóstico o a una muestra insuficiente

Anestesia para cirugía de tórax video asistida

La Cirugía Torácica Videoasistida (CAVDT) constituye en la actualidad una alternativa corrientemente utilizada para el tratamiento quirúrgico de una variedad de patologías que afectan los órganos intratorácicos. Se utiliza para el diagnóstico y tratamiento de enfermedades de la pleura y el espacio pleural, (biopsias pleurales, pleurodesis con talco, drenaje de hemotórax coagulado y pleurectomías); procedimientos sobre el pulmón (biopsias, resección de nódulos y tomores benignos) y otros procedemientos sobre el mediastino (timectomías y resección de tumores benignos). También se ha empleado para la realización de miotomías del esófago y cirugías antirreflujo. La principal ventaja radica en la menor morbilidad como resultado de la ausencia de una iniciación quirúrgica que comprometa los grandes músculos de la pared torácica y que requiera la separación de las costillas para acceder a la cantidad pleural. Esto se traduce en disminución significativa del dolor quirúrgico, menor compromiso de la función respiratoria en el postoperatorio inmediato, disminución de la estancia hospitalaria y menor incapacidad funcional. La evaluación preoperatoria es la misma empleada para la cirugía torácica convencional. Es importante tener en cuenta que en un porcentaje de estas pacientes puede ser necesaria la conversión a un procedimiento de toracotomía. Durante la cirugía es indispensable el empleo de intubación y ventilación selectiva y el anestesiólogo dispone de varias alternativas para mantener un intercambio gaseoso adecuado durante el trascurso del procedimiento