Reclamos contra la conducta ética en el ejercicio de la medicina. Análisis de las causas ingresadas a un Tribunal de Ética del Colegio Médico de Chile

Background: The Ethics Committees of medical associations define standards of conduct to avoid improper professional behavior. Aim: To identify the areas of professional behavior with most allegations of misconduct. Material and Methods: Analysis of all ethical claims received at the Regional Ethics Court of the Chilean Medical Association between 2016 and 2021. Results: Of 323 cases analyzed, 17% of complaints argued a failure in achieving a satisfactory standard of medical care, 15% unprofessional behavior, 14% disruptive interaction among physicians, 12% failure to fulfill therapeutic expectations, 6% poor quality of care, 6% fraud, 6% complains against institutions, 6% sexual misconduct, 6% inappropriate billing, 3% diagnostic errors, 3% inappropriate social behaviors, 1% refusal to provide a sick leave and 1% illegal practice. Only 41.5% of complaints were filed against registered physicians, thus limiting the capabilities of the medical ethical board. Conclusions: The most common complaints observed were professional misconduct and relationship problems between physicians.

Instalación ecoguiada del balón de contrapulsación intraaórtico (BCPIA) vía arteria axilar por abordaje extratorácico en pacientes en espera de trasplante cardíaco / Echo-guided installation of Inta aortic balloon counterpulsation via the extra thoracic axillary artery

Resumen El balón de contrapulsación intraaórtico (BCPIA) es el dispositivo más frecuentemente utilizado para otorgar soporte mecánico en pacientes con insuficiencia cardíaca terminal y compromiso hemodinámico refractario al soporte inotrópico. Se han utilizado diferentes tipos de abordajes para la instalación del BCPIA a través de las extremidades superiores, ya sea vía arteria subclavia o últimamente vía arteria axilar. Con el objetivo de evitar la inmovilidad física asociada al BCPIA instalado vía arteria femoral, aumentar la comodidad del paciente, simplificar la técnica de instalación del catéter y facilitar los cuidados de enfermería necesarios para su mantención, hemos diseñado y utilizado un abordaje simple y seguro para su inserción. Bajo técnica ecoguiada y utilizando un set de micro punción, se realizó la canulación de la arteria axilar en su porción externa (lateral al borde externo del músculo pectoral menor). Con la ayuda de fluoroscopía, el BCPIA fue avanzado hasta posicionarlo en la aorta descendente bajo la emergencia de la arteria subclavia izquierda. En dos pacientes con insuficiencia cardíaca terminal INTERMACS 2, con deambulación restringida debido a la necesidad permanente de soporte inotrópico y BCPIA femoral, bajo visión ecoguiada se realizó la reinstalación de este catéter a través de la arteria axilar izquierda, utilizando anestesia local y fluoroscopía en el laboratorio de hemodinamia. La rehabilitación fue posible rápidamente en ambos pacientes, realizándose el transplante cardíaco ortotópico después de 10 y 69 días de soporte mecánico con BCPIA, sin mayores efectos adversos.

Abstract Intra aortic balloon counterpulsation (IABP) is the most frequently used procedure to give mechanic support in patients with terminal heart failure and hemodynamic compromise refractory to inotropic support. Different approaches have been utilized to install upper extremity IABP, via either the axillary or subclavian arteries. In order to circumvent the limitations associated to long lasting femoral IABP support, simplify the technique, increase patient comfort and facilitate nursing care, we designed a simplified approach. Using echo guidance, the axillary artery was accessed with a micropuncture set just outside the external margin of the pectoral minor muscle. With the help of fluoroscopy the IABP catheter was advanced and its correct position in the descending aorta was confirmed. Two patients in INTERMACS 2 end stage heart failure, bedridden due to permanent inotropic support and femoral IABP, underwent echo guided axillary IABP placement under local anesthesia and fluoroscopy in the catheterization laboratory. Both patients gained rapid access to rehabilitation and received orthotopic heart transplantation after 10 and 69 days of uneventful IABP support.

Retrasplante cardíaco: reporte de un caso / Cardiac re-transplantation: case report

RESUMEN: El Trasplante cardíaco es la mejor alternativa para la insuficiencia cardíaca terminal, logrando buenos resultados de sobrevida y calidad de vida a largo plazo. Una de las causas más importantes de morbimortalidad es la falla del injerto, la que puede ser secundaria, entre otros, a rechazo agudo y/o vasculopatía y su presencia requiere considerar todas las alternativas terapéuticas, dentro de las cuales está el retrasplante. Los resultados de sobrevida en retrasplante cardíaco son buenos. No obstante, los pacientes presentan los riesgos de una terapia inmunosupresora más intensa, así como el desarrollo recurrente de vasculopatía del injerto. Por lo que se considera una opción en pacientes cuidadosamente seleccionados, dado que la experiencia internacional demuestra que la sobrevida del retrasplante es menor que en el primer trasplante. Presentamos el caso de un paciente trasplantado a los 42 años, quien desarrolla una enfermedad vascular del injerto e insuficiencia cardíaca con capacidad funcional IV, por lo cual se decidió realizar un retrasplante cardíaco.

ABSTRACT: Cardiac transplantation is the best alternative for terminal heart failure, achieving good long-term survival and life quality. One of the most important causes of morbidity and mortality is graft failure, which may be secondary, among others, to acute rejection and / or vasculopathy and its presence requires the consideration of all therapeutic alternatives, re transplantation being one of them. The results of survival in cardiac retransplantation are good; however, they present the risks of a more intense immunosuppressive therapy as well as the recurrent development of graft vasculopathy. Therefore, it is considered an option in carefully selected patients given that international experience shows that the survival of retransplantation is lower than in primary cases. We present the case of a 42 year old transplanted patient , who developed graft vascular disease with progressive deterioration of his ventricular function leading to functional class IV. for which a cardiaccardiac retransplantation was performed.

Mixoma cardíaco: experiencia de 28 años en resección quirúrgica / Cardiac myxomas. Analysis of 78 cases

Background: The incidence rates of cardiac tumors are low. Aim: To report the clinical presentation of cardiac myxomas and long-term evolution after resection. Material and Methods: Review of a database of surgical patients undergoing surgical resection of a cardiac myxoma in a public hospital between 1990 and 2018. Results: Seventy-eight patients aged 53 ± 15 years (65% females) were included. The most frequent comorbidities were arterial hypertension (40.5%), hypothyroidism (15%) and diabetes mellitus (12%). The main presenting symptoms were dyspnea (33%), neurological deficit secondary to embolism (30%) and acute pulmonary edema (5%). The most common location was the left atrium, in 87%. During surgery, cardiopulmonary bypass and aortic cross-clamp times were 50.2 ± 19.6 and 33.4 ± 15.2 min, respectively. One patient died due to severe neurological involvement. Follow-up was completed in seventy-seven patients, with a mean echocardiographic follow-up time of 10.4 ± 7.7 years. Thirty-four patients were followed for more than 10 years. Six patients (7.7%) died during the follow-up and in six patients (7%) a recurrence was identified. Conclusions: Cardiac myxoma usually has nonspecific symptoms. Surgical excision offers excellent short and long-term results. Complications and recurrence rates are low in non-hereditary myxomas but obligates to perform echocardiographic follow-up for early diagnosis of recurrence.

Sobrevida a 10 años de pacientes egresados luego de cirugía por endocarditis infecciosa en un hospital público / Hospital mortality and long-term survival of 103 patients with infective endocarditis requiring surgery

Background Infective endocarditis (IE) is a serious disease with high mortality, especially among the most severe cases undergoing surgery. Aim To analyze the clinical features, perioperative mortality and long-term survival of patients with infective endocarditis requiring surgery. Material and Methods Review of medical records of patients who underwent heart valve surgery for active infective endocarditis in a public hospital between 1995 and 2008. Demographic characteristics and comorbidities were described. Perioperative and 10 year survival were analyzed retrieving death certificates from the Chilean Identification Service. Results Data from 103 patients aged 46 ± 14 years (74% males) was analyzed. Thirty five percent of patients had an underlying predisposing heart condition such as congenital heart disease in 18.5% and prosthetic valves in 10%. The most common location was the aortic valve and the most common surgical procedure was heart valve replacement with a mechanical prosthetic valve in 87% of the cases. Pathogen identification in blood cultures was achieved in 48% of the cases. The most common causative microorganisms were S. aureus in 12%, coagulase-negative Staphylococcus in 11%, S. viridans in 10% and Enterococcus in 7%. Hospital mortality was 20.4% and ten-year survival was 65%. Conclusions Patients with severe IE requiring surgical treatment still have high perioperative and late mortality.

Recomendaciones de manejo de pacientes con asistencia circulatoria mecánica de corta duración / Recommendations for the management of patients with short-term mechanical circulatory assistance

There has been a progressive increase in the use of mechanical circulatory support in our country in the last years, mainly in the short-term: as a bridge to cardiac transplant or recovery, which has allowed to rescue patients from a population that concentrates high rates of complications and mortality. This motivated that the Ministry of Health convened a series of experts in the area of heart failure, transplantation and mechanical circulatory support, representatives of different public and private health centers in Chile, with the objective of developing recommendations on the use of short-term mechanical assistance devices, which would serve as a reference for the proper management of these patients. This clinical experts consensus document contains topics related to: definitions and general concepts; indications; contraindications; specific aspects of starting, follow-up and weaning of the devices; process of transfer of patients in circulatory assistance from one center to another and finally criteria of organization, means and competences to be fulfilled by the centers that offer this therapeutic option.

Endocarditis por Lactococcus garvieae en un paciente sometido a hemodialisis crónica. Primer caso reportado en Chile y revisión de la literatura / Lactococcus garvieae endocarditis in a patient undergoing chronic hemodialysis. First case report in Chile and review of the literature

Resumen Los casos reportados de infección por Lactococcus garvieae son escasos y sólo uno asociado a hemodiálisis. Comunicamos el caso de endocarditis infecciosa de curso fatal por L. garvieae en un paciente con una enfermedad renal crónica sometido a hemodiálisis y portador de diverticulosis colónica no complicada. Se realiza una revisión de los casos publicados y se discuten los actuales desafíos diagnósticos y terapéuticos de este patógeno, capaz de producir infecciones graves y potencialmente fatales en pacientes susceptibles. Este sería el segundo caso de infección asociada a hemodiálisis y el primero reportado en Chile.

Reports of Lactococcus garvieae infections in humans are scarce, and only one of them in a patient under-going hemodialysis. We report the first case of Lactococcus garvieae infection in Chile, presenting as an infective endocarditis, ultimately fatal, in a patient with uncomplicated colonic diverticulosis and end stage renal failure undergoing chronic hemodialysis. We review the published cases and discuss the diagnostic and therapeutic challenges associated with this new, increasingly diagnosed pathogen, capable of producing serious infections in susceptible patients.

Asistencia ventricular intracorpórea en falla cardiaca terminal / Left ventricular assistant devices for end-stage heart failure: report of two cases

In the last 2 decades, there have been significant advances in medical treatment of heart failure. However, there is a group of patients who are refractory to the available medical therapy and progress inevitably to a state of end-stage heart failure, whose only therapeutic alternative is cardiac transplantation. But this is an option limited by the scarce availability of donors. Therefore many patients die waiting for an organ. Recently, extra or intracorporeal left ventricular devices have emerged as a viable alternative for patients with end-stage heart failure waiting for a heart transplant. These devices discharge the left ventricle, increasing cardiac output and improving systemic perfusion. This year, in our hospital we began a left ventricular device implantation program for the most severely ill patients on the waiting list for cardiac transplantation. We report two males aged 30 and 53 years, in whom a left ventricular device was successfully implanted, using a minimally invasive surgical technique developed at the University of Hannover in Germany.

Tumor intracardíaco como presentación de leiomiomatosis intravascular / Intracardiac tumor as presentation of intravascular leiomyomatosis

Presentamos un caso de leiomiomatosis intravascular que se extiende a cavidades cardiacas derechas, siendo tratado mediante cirugía en un tiempo.

We present a case of an intravenous leiomyomatosis extending into the right cardiac chambers, which was treated by one stage surgery.

¿Es suficiente la protección otorgada por gafas plomadas en cardiología intervencionista? / Protection against ionizing radiation by leaded glass googles during interventional cardiology

Background: It is not known whether leaded glass goggles with 0.25 mm Pb equivalency, used in interventional cardiology procedures, attenuate radiation below the levels established by the latest recommendation of the International Commission on Radiological Protection (ICRP). Aim: To assess ifthe degree of attenuation of the secondary ionizing radiation achieved by the use of 0.25 mm Pb leaded glass goggles, in occupationally exposed workers in interventional cardiology procedures, meets the latest ICRP recommendations. Material and Methods: A prospective investigation was carried out to compare the eye exposure to secondary ionizing radiation received by occupationally exposed personnel in a 9 months period. A set of two thermo luminescent dosimeters was arranged in the front and back of leaded glass goggles in a cohort ofseven members of an interventional cardiology service, exposed to 1057 consecutive procedures. Results: The monthly dose equivalent measurement performed in front ofthe goggles ranged between 1.1 and 6.5 mSv, for paramedics and interventional cardiologists. The radiation measured in the back of the glass varied between 0.66 and 2.75 mSv, respectively. The degree of attenuation of the dose at eye level ranged from 40% to 57.7%, respectively. The projected annual exposure would reach 33 mSvfor the interventional cardiologist. Conclusions: With a similar load ofwork and wearing 0.25 mm Pb equivalent glass goggles, interventional cardiologists will exceed the crystalline equivalent dose limit recommended by the ICRP (20 mSv/year averaged over the past 5 years).

Shock cardiogénico refractario: rescate con ECMO, asistencia ventricular y trasplante / Cardiogenic shock: rescue with ECMO, ventricular assist and heart transplantation

Presentamos un caso de infarto agudo al miocardio complicado con shock cardiogénico y arritmias ventriculares refractarias. El paciente requirió oxigenación por membrana extracorpórea (ECMO) antes de su traslado a un hospital con asistencia ventricular izquierda (LVAD) y programa de trasplante de corazón. El paciente tuvo una buena recuperación después de 16 días de soporte con LVAD seguido de trasplante cardiaco, lo que muestra los beneficios de la terapia multimodal en casos complejos de shock cardiogénico refractario.

A case of acute myocardial infarction complicated with cardiogenic shock and refractory ventricular arrhythmias is described. The patient required extracorporeal membrane oxygenation (ECMO) prior to transfer to a hospital with a left ventricular assist device (LVAD) and heart transplantation program. He made a good recovery after 16 days of LVAD support followed by heart transplantation, showing the benefits of multimodal therapy incomplex cases of refractory cardiogenic shock Palabras clave: Infarto agudo del miocardio, shock cardiogénico,asistencia biventricular, ECMO.

Comparación de angiografía coronaria con el ultrasonido intracoronario como patrón de referencia en el diagnóstico de vasculopatía post trasplante cardíaco / Comparison of coronary angiography and intra-coronary ultrasound as gold standard in the diagnosis of post cardiac transplantation vasculopathy

Antecedentes: La Vasculopatía del injerto (VDI) es la principal causa de muerte tardía del trasplante cardiaco (TX). Un diagnóstico precoz de esta complicación tendría un impacto en la terapia y pronóstico de esta afección. El ultrasonido intracoronario (IVUS), permite un diagnóstico precoz y certero de VDI, pero en la mayoría de los centros aún se utiliza la coronariografía. Objetivo: Evaluar la validez de la coronariografía en el diagnostico de VDI en pacientes trasplantados cardiacos, comparado con el IVUS. Metodología: Estudio transversal, en el cual se analizó una muestra de 36 pacientes con un tiempo promedio de trasplante de 3,7 +/- 3,7 años, a quienes se realizó simultáneamente un examen de coronario-grafía y un IVUS. Se evaluó la reproducibilidad contrastando los resultados de la interpretación visual de la coronariografía versus la coronariografía con análisis cuantitativo. Se calculó la Sensibilidad, Especificidad, Valores predictivos (VPP, VPN), Likelihoods y el coeficiente de equivalencia de Spearman-Brown. Resultados: La coronariografía cualitativa mostró ser más exacta que la cuantitativa, con una sensibilidad 30,4 por ciento [95 por ciento IC= 11,6 - 49,2], una especificidad 92,3 por ciento [95 por ciento IC= 77,8 - 106,7], VPP 87,5 por ciento [95 por ciento IC= 64,5 - 110,4], VPN 42,8 por ciento [95 por ciento IC= 24,5 - 61,1], LR (+) 3,9 [95 por ciento IC 0,55 - 28,7] y un LR (-) 0,75 [95 por ciento IC= 0,55 - 1,03]. La coronariografía cualitativa y cuantitativa son moderadamente equivalentes con un coeficiente de equivalencia Spearman Brown de 0,65. Conclusión: La validez y la reproducibilidad de la coronariografía en el paciente con TX es moderada y debería ser complementada con IVUS para el diagnóstico de VDI.

Background: Graft vasculopathy (GV) is the main cause of late death following cardiac transplantation (TX). Early diagnosis of this condition may have an impact upon treatment and prognosis of this complication. Intravascular ultrasound (IVUS) allows an early and accurate diagnosis of GV. However, most centers continue to use coronary angiography for this purpose. Aim: to evaluate coronary angiography for the diagnosis of GV in relation to IVUS in post TX patients. Methods: In a cross-sectional study the results of coronary angiography and IVUS, used as gold standard, were compared in 36 patients with a mean post TX follow up of 3.7 +/- 3.7 years. Results were compared between visual and quantitative coronary angiography. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), likelihood ratios and the equivalence Spearman-Brown coefficient were calculated. Results: Visual evaluation of coronary angiography was more accurate than quantitative coronary angiography. The sensitivity for GV was 30.4 percent (95 percent C.I. 11.6 - 49.2), specificity 92.3 percent (95 percent C.I. 77.8 - 106.7), PPV 87.5 percent (95 percent C.I. 64.5 - 110.4, NPP 42.8 percent (95 percent C.I. 24.5 - 61.1), likelihood ratio (+) 3.9 (95 percent C.I. 0.55 - 28.7), likelihood ratio (-) 0.75 (95 percent C.I. 0.55 -1.03). The Spearman Brown coefficient between visual and quantitative coronary angiography evaluation was 0.65. Conclusion: Accuracy and reproducibility of coronary angiography in the evaluation of GV is limited. IVUS should be used for better identification of GV.

Oximetría cerebral durante paro circulatorio hipotérmico y perfusión cerebral retrógrada / Cerebral oximetry during hypothermic circulatory arrest with retrograde cerebral perfusion

Se presenta el caso de una paciente de 54 años que ingresa con el diagnóstico de disección aórtica tipo A. La reparación del defecto y reemplazo se realiza con paro circulatorio hipotérmico profundo por comprometer el nacimiento del tronco braquiocefálico y perfusión cerebral retrógrada como método de protección cerebral. Durante todo el procedimiento se monitorizó la oximetría cerebral regional para evaluar disminuciones de la saturación y riesgo de isquemia en relación a cambios en la hemodinamia asociados al paro circulatorio, a la perfusión cerebral retrógrada y a las distintas medidas tomadas para aumentar el periodo libre de isquemia durante el paro. La disminución de la oximetría se relaciona a disminución del aporte de oxígeno, y por lo tanto, a un mayor riesgo de isquemia. En el presente caso, se observó el beneficio del uso de perfusión cerebral retrógrada como método de protección cerebral.

A case report of a 54 year patient with a type A aortic disecction is presented. Because of braquiocephalic compromise, the surgery was performed under deep hypotermic circulatory arrest. Retrograde cerebral perfusion was used for cerebral protection. Regional cerebral oxymetry was monitored during the entire procedure in order to correlate hemodynamic changes associated to circulatory arrest with reduction of saturation, risk of ischemia and therapeutics used for augmenting ischemic free periods. The reduction of oxygen supply correlates with low oxygen deliver and with high risk of ischemia. Benefits in cerebral protection were seen with the use of retrograde cerebral perfusion.