Cirugía coronaria sin circulación extracorpórea después de 20 años. Resultado y seguimiento en 1.353 pacientes en el sur de Chile

Background: The benefits of off-pump coronary artery bypass graft (OPCAB) compared with conventional on-pump coronary artery bypass graft are not well established although several studies show excellent long-term results. Aim: To assess and report the long-term results of OPCAB surgery in a 20-year period in a Chilean Regional Cardiac Surgery Center. Patients and Methods: Retrospective analysis of the medical records and surgical protocols of 1353 patients aged 61.3 ± 6.5 years, (69% males) subjected to OPCAB between June 1999 and December 2019. Results: Thirty-four percent of patients presented with unstable angina. On angiography, the left main coronary artery had a proximal obstruction in 15% of patients. Thirty five percent presented with a myocardial infarction of different territories. Thirty percent of patients were managed previously with angioplasty. Preoperative left ventricular function was 45.3% (30-65%). The mean surgical risk Euroscore was 2.84. The mean number of bypasses was 2.7 ± 0.63. 2.6%. Conversion to on pump technique was required in 2.6% of patients. Operative mortality was 2%, myocardial infarction occurred in 3.4%, a new revascularization procedure was required in 2.3% and 2.4% of patients had a stroke. Long term follow up was complete in most patients and 93% are in NHYA functional capacity I. Actuarial survival was 100, 98, 89, 75 and 66% at 1, 5, 10, 15 and 20 years. Actuarial combined cardiovascular events free survival was 100, 98, 87, 68 and 51% at 1,5,10, 15 and 20 years. Conclusions: OPCAB surgery is a safe surgical technique, with an excellent bypass durability and permeability. It also provides a prolonged time free from cardiac events such as mortality, angina, myocardial infarction, and freedom from a new coronary procedure.

Implante de conducto apicoaórtico en paciente con estenosis aórtica severa post reemplazo valvular protésico / Apicoaortic valved conduit implanted in a patient with severe aortic stenosis due to mismatched aortic valve prosthesis

Introducción: La estenosis aórtica fibrocálcica es el tipo de valvulopatía más frecuente, especialmente en los adultos mayores, siendo el reemplazo valvular aórtico el tratamiento definitivo. Un mal resultado post operatorio puede deberse a un mal funcionamiento de la válvula protésica. Caso clínico: Paciente de 42 años de edad sometido a reemplazo valvular aórtico por presentar estenosis aórtica severa fibrocálcica en una válvula bicúspide y aorta de pared muy fina. Evoluciona asintomático durante 4 años, al cabo de los cuales y luego de abandonar su tratamiento anticoagulante consulta por disnea y dolor anginoso. Un ecocardiograma muestra estenosis severa de la válvula protésica. Dado los antecedentes de su cirugía previa se decide implantar un conducto de dacrón valvulado ápico-aórtico a través de toracotomía posterolateral izquierda. Evolución post operatoria muy satisfactoria permaneciendo asintomático, con un seguimiento de 15 meses. La recidiva de la estenosis aórtica severa post reemplazo valvular protésico tiene en el bypass ápico-aórtico una excelente alternativa de tratamiento efectivo, especialmente cuando el recambio valvular tradicional implica un alto riesgo quirúrgico.

Introduction: The most frequent surgical procedure of severe left ventricular outflow tract obstruction due to severe aortic stenosis is aortic valve replacement, but there is an alternative and less conventional method described by Cooley used in patients with previous aortic valve replacement and severe aortic wall calcification that bypasses the left ventricular outflow tract through the implant of an apicoaortic valved conduit. Clinical case: We describe the case of 42 years old patient with severe aortic stenosis due to mismatched valve prosthesis previously installed treated by of apicoaortic conduit implanted through left posterolateral thoracotomy.

Cirugía de revascularización miocárdica de la arteria descendente anterior con arteria mamaria interna izquierda sin circulación extracorpórea: Experiencia en el largo plazo / Beating heart anterior descending coronary artery grafting with left internal mammary artery: A long term follow up experience

Background: In recent years the use of left internal mammary artery (LIMA) as a gran to anterior descending artery (DA) with the offpump technique has been associated with similar good long term results as with the on pump technique. Aún: To repon the results of LIMA to DA bypass grafting without extracorporeal circulation (EC) for isolated DA lesions. Patients and methods: Descriptive study of 80 patients subjected to coronary surgery between 1999 and 2007. Results: Mean age ofpatients was 63 + 10 years and 60 were male. There was no operative mortality or stroke. One patient with a myocardial infarction required a reoperation. Actuarial survival was 98% at 97 months. Conclusions: In this group ofpatients the use ofLIMA as a coronary bypass gran to DA with the off pump technique is a safe surgical procedure, providing a prolonged cardiac event free survival (mortality, angina, myocardial infarction, and need for a new coronary procedure).

Fibroelastoma valvular aórtico como causa de accidente cerebrovascular embólico: reporte de un caso / Aortic valve fibroelastoma as a cause of an embolic cerebrovascular accident: a case report

Los tumores cardíacos son una causa rara de accidente cerebrovascular embólico. Comunicamos el caso de una paciente de 65 años quien debuta su historia con un accidente cerebrovascular. El estudio de fuente embólica con ecocardiografía transesofágica demostró un fibroelastoma de la válvula aórtica en el borde libre del velo no coronariano. El tumor fue extraído mediante circulación extracorpórea. El estudio anatomopatológico confirmó el diagnóstico y la paciente se encuentra en capacidad funcional I y sin síntomas neurológicos a 19 meses de seguimiento.

Background: Cardiac tumors are an infrequent cause of an embolic source and aortic fibroelastoma is even more rare as causative of a stroke. We report a 65 year old female with no particular clinical history admitted to the hospital with an embolic cerebrovascular accident whose embolic source study with a transesophageal echocardiogram revealed a fibroelastoma in the free edge of the non coronarian leaflet of the aortic valve. The patient was subjected to surgery by means of extracorporeal circulation and the tumor was excised. The pathological study confirmed the diagnosis. Post operative recovery was uneventful with no neurological damage and after 19 months of follow up she is in functional class I.

Miniesternotomía para cirugía valvular aórtica: experiencia inicial en un centro cardiovascular en Chile / Ministernotomy for aortic valve surgery: report of 20 patients

Background: Aortic valve surgery can be performed through a reduced mid sternotomy with excellent long term results. Aim: To report the initial results obtained with this technique. Patients and methods: Descriptive study of 20 patients aged 48±11 years, subjected to valve replacement surgery for aortic valve disease between 2004 and 2007. Arterial and venous cannulation were performed with the usual method and extracorporeal circulation was performed with a mean perfusion of 4.5 L/min. Hypothermia and cardioplegia were performed infusing the hematic cardioplegic solution at 4°C in the aortic root or coronary ostia. Results: Sixteen patients were in functional class (FC) III. Fourteen patients had aortic insufficieney and six had predominant stenosis. There was no operative mortality One patient had a left hemothorax and was reoperated. All patients were discharged between 4 and 6 days after surgery. Mean follow up was 21 ± 4 months. AU patients are in FC I and free from cardiac events. Echocardiographic assessment was done in 16 patients, showing a good motility of valve disks. Actuarial survival probability was 100 percent and probability of freedom from cardiac events was 100 percent at 42 months of follow up. Conclusions: Ministernotomy is an excellent approach for aortic valve surgery providing good visualization ofthe ascending aorta, simplifying the surgical technique.

Factores asociados a mortalidad en la cirugía de reemplazo valvular por endocarditis complicada / Risk factors related to mortality in heart valve replacement for complicated endocarditis

La Endocarditis Infecciosa (El) es una enfermedad grave, dada por la agresividad del agente sobre el aparato cardiovascular y otros órganos. La cirugía de reemplazo valvular (CRV) es el tratamiento definitivo frente al fracaso del tratamiento médico, la cual está asociada a una elevada mortalidad al presentarse con daño estructural severo. Objetivo: Evaluar los factores asociados a mortalidad en pacientes sometidos a CRV por El. Pacientes y método: Estudio descriptivo de 32 pacientes consecutivos sometidos a CRV en el período 1993-2005, consignando antecedentes clínicos que determinen una probable mortalidad. Resultados: La mortalidad global fue de 25 por ciento, principalmente en los primeros 15 días (60 por ciento). Los principales factores asociados son sepsis (p =0.002), la cirugía mitro-aórtica (p <0.001) y la presencia de alcoholismo (p =0.049). La probabilidad de supervivencia actuarial es de 78 por ciento a 146 meses. Conclusión: La mortalidad de nuestra serie es semejante a otros centros, existiendo un mayor riesgo en los primeros días post CRV. El reemplazo bivalvular y la presencia de sepsis son los principales factores de riesgo precoz.

Infectious endocarditis is a severe illness related to the aggressiveness of the microbial agent to the cardiovascular system. Heart valve replacement surgery is the definitive treatment in these patients but is related to high mortality when the structural damage is severe. Objective: To assess risk factors related to mortality in patients operated for complicated endocarditis. Patients and method: Descriptive study of 32 patients operated between 1993-2005 period in which clinical factors were evaluated and related to mortality. Results: Overall mortality was 25 percent, mainly in the first two weeks after surgery (60 percent). Mortality related risk factors were sepsis (p =0.002), mitro-aortic replacement (p <0.001) and alcoholism (p =0.049). Actuarial survival probability is 78 percent to 146 months in the group. Conclusion: Mortality is similar to others cardiac centres and is higher in the first two weeks alter surgery. Mitro aortic replacement and sepsis are the main factors of early mortality risk.

Revascularización miocárdica de la arteria descendente anterior con arteria mamaria interna izquierda: comparación de dos técnicas en el largo plazo / Anterior descending coronary artery grafting with left internal mammary artery with and without extracorporeal circulation: comparison of two techniques in the long term follow up

En años recientes el uso de arteria mamaria interna izquierda (LIMA) como injerto a la arteria descendente anterior (DA) sin circulación extracorpórea (CEC) ha demostrado resultados similares a la técnica convencional. Objetivo: Comparar y comunicar los resultados obtenidos con el uso de LIMA a DA con y sin CEC en lesiones aisladas de la DA. Material y método: Estudio descriptivo de 85 pacientes en quienes se realizó cirugía coronaria entre 1992 y 2004. Resultados: Edad promedio fue 62.5 años (DE + 9.575, rango 35-77 años), 59 de sexo masculino; el test de ANOVA no demostró diferencias entre los grupos en relación a factores de riesgo preoperatorios, características angiográficas y presentación clínica. 40 pacientes fueron operados con CEC y 45 sin CEC. El tiempo quirúrgico promedio y en ventilador mecánico fue mas corto para el grupo sin CEC (p<0.005). No hubo mortalidad operatoria, infarto miocárdico, accidente cerebrovascular o necesidad de reoperación en el grupo con CEC. Se realizó una reoperación en 1 paciente sin CEC. En el seguimiento hubo 2 muertes alejadas debido a falla cardiaca y renal avanzadas en el grupo con CEC y ninguna en el grupo sin CEC. La probabilidad de sobrevida actuarial fue 96 por ciento a 139 meses en el grupo con CEC y 98 por ciento a 64 meses en el grupo sin CEC. Conclusiones: En este grupo de pacientes el uso de LIMA como injerto a la DA con ambas técnicas es un procedimiento seguro, el que provee un tiempo prolongado libre de eventos como mortalidad, angina, infarto miocárdico y necesidad de un nuevo procedimiento coronario en el seguimiento a largo plazo.

Background: In recent years the use of left internal mammary artery (LIMA) as a graft to anterior descending artery (DA) with the off pump technique has been associated with similar good long term results as with the on pump technique. Aim: To compare and report the results of LIMA to DA bypass grafting with and without extracorporeal circulation (EC) for isolated DA lesions. Patients and methods: Descriptive study of 85 patients subjected to coronary surgery between 1992 and 2004. Results: Mean age was 62.5 years (DE+9.575, range 35-77 years), 59 were male, ANOVAtest showed no differences between groups related to preoperative risk factors, angiographic characteristics and clinical presentation. 40 patients were operated on pump and 45 off pump. Mean operative time and time in mechanical ventilator were shorter for the off pump group (p<0.005). There was no operative mortality, myocardial infarction, stroke or need of a reoperation in the on pump group. There was a reoperation in 1 patient in the off pump group. In the follow up there were 2 late deaths because of advanced cardiac and chronic renal failure in the on pump group and none in the off pump group. Actuarial survival probability was 96 percent at 139 months in the on pump group and 98 percent at 64 months in the off pump group. Conclusions: In this group of patients the use of LIMA as a coronary bypass graft to DA with both techniques is a safe surgical procedure, providing a prolonged time free from cardiac events as mortality, angina, myocardial infarction, and need of a new coronary procedure in the long term follow up.

Revascularización miocárdica de la arteria descendente anterior con arteria mamaria interna izquierda con circulación extracorpórea: seguimiento a 10 años / Myocardial revascularization of the anterior descending coronary artery with left internal mammary artery by means of extracorporeal circulation: 10 years follow-up

Background: The use of left internal mammary artery (LIMA) as a graft to anterior descending artery (LAD) has been associated with better long term results in coronary surgery. Aim: To assess and report the long-term results of LIMA to LAD bypass grafting for isolated LDA lesions. Patients and methods: Retrospective analysis of the medical records and surgical protocols of 40 patients (aged 60±10 years, 28 male) subjected to coronary surgery between 1992 and 2002. Results: Thirty-four patients presented with unstable angina. On angiography, the LAD had a proximal obstruction in 35 patients. Sixteen presented with a myocardial infarction of the LAD territory. Six were managed previously with angioplasty; four had a new critical obstruction, 1 was catalogued as a procedure failure, and one was totally occluded. There was no operative mortality, myocardial infarction, stroke or need for re operation. There were two late deaths, caused by an advanced cardiac failure at 120 months in one patient, and chronic renal failure at 61 months of follow-up in another. Actuarial survival probability was 100%, 93% and 75% at 1, 5 and 10 years. Probability of freedom from angina was 98%, and freedom of suffering a new myocardial infarction was 100% at more than 10 years. The probability of no need for a new coronary procedure (angioplasty or surgery) also was 100% at more than 10 years. Conclusions: The use of LIMA as a coronary bypass graft to LAD is a safe surgical technique, with an excellent duration and permeability and also provides a prolonged time free from cardiac events as mortality, angina, myocardial infarction, and the need of a new coronary procedure.

Perfusión cerebral regional en recién nacidos sometidos a reconstrucción del arco aórtico: descripción de la técnica en dos entidades diferentes / Regional brain perfusion in newborn underwent to an aortic arch repair: description of the technique used in two different entities

Introducción: Recientemente se ha descrito una técnica de perfusión cerebral regional (PCR) que permitiría suprimir o al menos acortar el tiempo de paro circulatorio con hipotemia profunda (PCHP). Nuestro objetivo es comunicar la técnica de PCR empleada en dos entidades clínicas diferentes. Pacientes y métodos: Dos recién nacidos portadores de hipoplasia de corazón izquierdo e interrupción del arco aórtico, respectivamente, fueron sometidos a reparación completa con técnica de PCR, perfundiendo el cerebro a través de un tubo protésico implantado en la arteria innominada, con utilización de circulación extracorpórea e hipotemia profunda. Resultados: En ambos pudo hacerse una corrección muy satisfactoria y la PCR no agregó dificultad al procedimiento, acortándose ostensiblemente el tiempo de PCHP. Los dos pacientes fueron dados de alta sin evidencias de déficit neurológico. Conclusión: La PCR es un método reproducible, que permite acortar o suprimir la necesidad de PCHP en pacientes sometidos a reconstrucción del arco aórtico