Brazilian single-center experience with aortic root replacement in 448 patients: what is the best technique?

Abstract Introduction: The objective of this study was to evaluate whether a surgery with the use of valved conduit is capable of leading to better immediate and late results than those obtained by the valve-sparing aortic root reconstruction technique. Methods: Between January 2002 and June 2016, 448 patients underwent aortic root reconstruction. These were divided into three groups according to the technique used: 319 (71.2%) patients received mechanical valved conduits, 49 (10.9%) received biological valved conduits, and 80 (17.9%) underwent the valve-sparing aortic root reconstruction technique. The results were examined by univariate and multivariate analyses of Cox proportional hazards models with multiple logistic regression. Results: The hospital mortality rate was 7.5%. The mortality rates were 8.2%, 12%, and 2.5% in the mechanical valved conduit, biological valved conduit, and aortic valve-sparing groups, respectively, with no significant difference between groups (P=0.1). Thromboembolic complications and reoperation-free survival were also similar (P=0.169 and P=0.688). However, valve-sparing aortic root replacement was superior in terms of long-term survival (P<0.001), hemorrhagic-free survival (P<0.001), and endocarditis-free survival (P=0.048). Multivariate analysis showed that the following aspects had an impact on mortality: age > 70 years (P<0.001; hazard ratio [HR] 1.05), preoperative acute kidney injury (P<0.0042; HR 2.9), diagnosis of dissection (P<0.01; HR 2.0), previous cardiac surgery (P<0.027; HR 2.3), associated coronary artery bypass grafting (P<0.038; HR 1.8), reoperation for postoperative tamponade (P<0.004; HR 2.2) and postoperative acute kidney injury (P<0.02; HR 3.35). Conclusion: Valve-sparing technique seems to be the operation of choice, whenever possible, for aortic root reconstruction.

Primeros implantes de la válvula sin sutura Perceval S® en Argentina / First Perceval S™ Sutureless Aortic Valve Prosthesis Implantations in Argentina

RESUMEN El reemplazo valvular aórtico con prótesis sin sutura es una alternativa innovadora para el tratamiento de la estenosis aórtica en los ancianos y en los pacientes de alto riesgo. Aunque la experiencia mundial con estas prótesis lleva ya varios años, solo recientemente comenzó a comercializarse en Argentina el modelo Perceval S®. Se trata de una prótesis autoexpandible sin sutura hecha de pericardio bovino y montada en un stent de nitinol. En este estudio se presentan los primeros tres casos de reemplazo valvular aórtico con la bioprótesis Perceval realizados en Argentina. La técnica sin sutura es una alternativa prometedora para el reemplazo valvular aórtico quirúrgico con una bioprótesis, y, posiblemente, pueda competir con la terapéutica intravascular en los pacientes de alto riesgo.

ABSTRACT Aortic valve replacement with sutureless prostheses is an innovative alternative for the treatment of aortic stenosis in the el-derly and in high-risk patients. Although the world experience with these prostheses has been going on for several years, only recently, the Perceval S™ model, consisting of a self-expanding sutureless prosthesis made of bovine pericardium and mounted on a nitinol stent, has begun to be commercialized in Argentina. In this study, we present the first three cases of aortic valve replacement with Perceval bioprostheses performed in Argentina. The sutureless technique is a promising alternative for surgi-cal aortic valve replacement with a bioprosthesis, and may possibly compete with intravascular therapy in high-risk patients.

Hybrid approach of aortic diseases: zone 1 delivery and volumetric analysis on the descending aorta

Abstract Introduction: Conventional techniques of surgical correction of arch and descending aortic diseases remains as high-risk procedures. Endovascular treatments of abdominal and descending thoracic aorta have lower surgical risk. Evolution of both techniques - open debranching of the arch and endovascular approach of the descending aorta - may extend a less invasive endovascular treatment for a more extensive disease with necessity of proximal landing zone in the arch. Objective: To evaluate descending thoracic aortic remodeling by means of volumetric analysis after hybrid approach of aortic arch debranching and stenting the descending aorta. Methods: Retrospective review of seven consecutive patients treated between September 2014 and August 2016 for diseases of proximal descending aorta (aneurysms and dissections) by hybrid approach to deliver the endograft at zone 1. Computed tomography angiography were analyzed using a specific software to calculate descending thoracic aorta volumes pre- and postoperatively. Results: Follow-up was done in 100% of patients with a median time of 321 days (range, 41-625 days). No deaths or permanent neurological complications were observed. There were no endoleaks or stent migrations. Freedom from reintervention was 100% at 300 days and 66% at 600 days. Median volume reduction was of 45.5 cm3, representing a median volume shrinkage by 9.3%. Conclusion: Hybrid approach of arch and descending thoracic aorta diseases is feasible and leads to a favorable aortic remodeling with significant volume reduction.

Tendencias de la mortalidad por lesiones de tránsito en Argentina, 2002-2012 / Trends in mortality from traffic injuries in Argentina, 2002-2012

Introducción: Según la Organización Mundial de la Salud, las lesiones por el tránsito ocupan los primeros lugares entre las causas de muerte y es la primera entre los jóvenes de 15 a 29 años. El objetivo del estudio fue describir el perfil epidemiológico de las víctimas, evaluar la tendencia de la mortalidad por lesiones de tránsito (LT) y su asociación con el parque automotor y motovehícular en Argentina entre 2002 y 2012. Materiales y Métodos: Estudio ecológico con datos oficiales de mortalidad (codificados según CIE-10) y de parque automotor y motovehicular para el período2002-2012. La mortalidad por lesiones no intencionales inespecíficas fueron redistribuidas entre las no intencionales según la metodología de Global Burden of Disease. Se calcularon tasas brutas y ajustadas. Se realizaron modelos Poisson conefectos aleatorios para explorar asociaciones entre las variables en estudio. Resultados: Se estimó un aumento del número de muertes del 67 por ciento por el método de la redistribución. Se calculó para Argentina una tasa de mortalidad por lesiones de tránsito para el periodo de 13,1 por 100.000 habitantes. Las tasas de mortalidad por lesiones entre ocupantes de autos aumentaron de 8,8 a 11,1 por 100.000 habitantes durante el periodo de estudio. Los varones motociclistas presentaron un marcado aumento de la tasa de mortalidad, las regiones Noroeste y Noreste presentaron los mayores incrementos de 5 a 15 muertes por 100.000 habitantes del 2002 al 2012. La tendencia en peatones y ciclistas fue en descenso. Al realizar los modelos de Poisson con efectos mixtos se observo que el riesgo fue mayor en los jóvenes varones motociclistas de lassiete regiones de Argentina, con un riesgo de 1,88 por ciento (IC 95 por ciento 1.79-1.97) para el país. Conclusión: Se observaron grandes diferencias regionales, por tipo de usuario de la vía pública, por sexo y por edad, sustento para la implementación de políticas para revertirlas tendencias actuales.

Introduction: According to the World Health Organization, traffic injuries rank first among causes of death, especially in young people aged 15 to 29 years. The aim of the study was to describe the epidemiological profile of the victims, to assess the trend of mortality associated with traffic injuries (TI) and its association with the number of carsand motorcycles, in Argentina between 2002 and 2012. Methods: Ecological study based on official mortality data (coded according to ICD-10) and the number of cars and motorcycles, for the period 2002-2012. Mortality from un specified unintentional injuries was redistributed, according to the methodology of Global Burden of Disease. Crude and adjusted rates were calculated. Poisson models were developed to explore associations between the variables. Results: By the redistribution method, it was estimated an increase of 67 percent in death sassociated to traffic injury. The mortality rate was 13.1 per 100,000 inhabitants for the period. Mortality rate among occupants of cars increased from 8.8 to 11.1 per 100,000 in habitants during the period. Male Motorcyclists showed a marked increase in the mortality rate; the Northwest and Northeast regions registered the highest growth from 5to 15 deaths per 100,000 from 2002 to 2012. The mortality in pedestrians and cyclists showed a declining trend. By performing Poisson models, it was observed a higher inyoung men motorcyclists, in the different seven regions of Argentina, with a risk of 1.88 percent (95 percent CI 1.79-1.97) for the all country. Conclusion: There were regional differences considering sex, age and type of vehicle. This information could support policy implementation, in order to reverse current trends.

Surgical treatment of complex aneurysms and thoracic aortic dissections with the Frozen Elephant Trunk technique / Tratamento cirúrgico dos aneurismas complexos e dissecções da aorta torácica utilizando a técnica "Frozen Elephant Trunk"

Abstract Objective: Report initial experience with the Frozen Elephant Trunk technique. Methods: From July 2009 to October 2013, Frozen Elephant Trunk technique was performed in 21 patients (66% male, mean age 56 ±11 years). They had type A aortic dissection (acute 9.6%, chronic 57.3%), type B (14.3%, all chronic) and complex aneurysms (19%). It was 9.5% of reoperations and 38% of associated procedures (25.3% miocardial revascularization, 25.3% replacement of aortic valve and 49.4% aortic valved graft). Aortic remodeling was evaluated comparing preoperative and most recent computed tomography scans. One hundred per cent of complete follow-up, mean time of 28 months. Results: In-hospital mortality of 14.2%, being 50% in acute type A aortic dissection, 8.3% in chronic type A aortic dissection, 33.3% in chronic type B aortic dissection and 0% in complex aneurysms. Mean times of cardiopulmonary bypass (152±24min), myocardial ischemia (115±31min) and selective cerebral perfusion (60±15min). Main complications were bleeding (14.2%), spinal cord injury (9.5%), stroke (4.7%), prolonged mechanical ventilation (4.7%) and acute renal failure (4.7%). The need for second-stage operation was 19%. False-lumen thrombosis was obtained in 80%. Conclusion: Frozen Elephant Trunk is a feasible technique and should be considered. The severity of the underlying disease justifies high mortality rates. The learning curve is a reality. This approach allows treatment of more than two segments at once. Nonetheless, if a second stage is made necessary, it is facilitated. .

Resumo Objetivo: Relatar experiência inicial com a técnica "Frozen Elephant Trunk". Métodos: Entre julho de 2009 e outubro de 2013, 21 pacientes, 66% homens, média de idade de 56±11 anos, 66,7% portadores de dissecção da aorta tipo A de Stanford (9,6% agudas e 57,1% crônicas), tipo B (14,3%, todas crônicas) e aneurismas complexos (19%), foram operados pela técnica Frozen Elephant Trunk. Foram 9,5% de reoperações e 38% com procedimentos associados (25,3% revascularizações do miocárdio, 25,3% troca da valva aórtica e 49,4% tubos valvulados). Remodelamento da aorta foi avaliado com a comparação de angiotomografia pré-operatória e pós-operatória mais recente. Seguimento 100% dos pacientes, tempo médio de 28 meses. Resultados: Mortalidade hospitalar de 14,2%, sendo 50% nas dissecções do tipo A agudas, 8,3% nas tipo A crônicas, 33,3% nas tipo B crônicas e 0% nos aneurismas complexos. Tempos médios de CEC (152±24min), isquemia miocárdica (115±31min) e perfusão cerebral seletiva (60±15min). Principais complicações pós-operatórias foram sangramento (14,2%), acidente vascular encefálico (4,7%), paraplegia (9,5%), intubação>72h (4,7%) e insuficiência renal aguda (4,7%). Houve necessidade de complementação do tratamento (distal ao stent) em 19%. Houve trombose da falsa luz em 80%. Conclusão: Frozen Elephant Trunk é opção técnica a ser utilizada. A gravidade e extensão da doença justificam mortalidade mais elevada. A curva de aprendizado é uma realidade. Esta abordagem permite abordar mais de dois segmentos de aorta em um estágio, mas se necessário segundo estágio, este é facilitado. .

Abordaje transeptal para el reemplazo valvular mitral / Transseptal Approach for Mitral Valve Replacement

Introducción A pesar de que es técnicamente más demandante, el acceso a la válvula mitral por vía transeptal permite una exposición mayor de sus valvas y del aparato subvalvular, en especial en aurículas pequeñas, en reoperaciones o cuando se combina con el tratamiento de la válvula tricuspídea. Objetivos Evaluar las dificultades técnicas y las complicaciones asociadas con el abordaje transeptal para el reemplazo valvular mitral. Material y métodos Entre 2006 y 2009 se incluyeron 62 pacientes consecutivos a los que se les realizó reemplazo valvular mitral solo o asociado con revascularización miocárdica a través de un abordaje transeptal extendido al techo de la aurícula izquierda. Se evaluaron las dificultades técnicas y la morbimortalidad del procedimiento. Resultados En todos los pacientes se pudo realizar el abordaje sin dificultades técnicas con una exposición adecuada de la válvula mitral. La tasa de trastornos de conducción en el posoperatorio fue del 9,7% y la necesidad de implante de un marcapasos definitivo fue del 4,8%. De los pacientes que tenían fibrilación auricular previa (n = 18), el 83,3% recuperaron ritmo sinusal o nodal alto en el posoperatorio. Conclusiones El abordaje transeptal extendido al techo de la aurícula izquierda constituyó una alternativa de acceso a la válvula mitral, con una exposición mejor que el abordaje tradicional, aunque a expensas de una técnica más demandante. Los tiempos quirúrgicos, la mortalidad y las complicaciones fueron similares a los de la técnica convencional, a excepción de una probable incidencia mayor de ritmo nodal y bloqueo A-V. Posiblemente exista cierto beneficio en la recuperación del ritmo sinusal en los pacientes con fibrilación auricular crónica previa.

Background Despite mitral valve replacement through a transseptal approach requires technical expertise, it allows a better exposure of the mitral leaflets and subvalvular apparatus, especially when left atrium is small, during reoperations or in combination with tricuspid valve interventions. Objectives To evaluate the technical difficulties and complications associated with the transseptal approach for mitral valve replacement. Material and Methods Between 2006 and 2009 we included 62 consecutive patients undergoing isolated mitral valve replacement or associated with myocardial revascularization through a transseptal approach extended to the left atrium roof. Technical difficulties, morbidity and mortality related to the procedure were evaluated. Results The procedure did not show technical difficulties and the mitral valve was properly exposed in all cases. Postoperative conduction abnormalities rate was 9.7% and 4.8% of patients required a permanent pacemaker. In patients with preoperative atrial fibrillation (n=18), 83.3% were in sinus or junctional rhythm after the procedure. Conclusions The extended transseptal approach provided a better exposure of the mitral valve compared to conventional approach; yet technical expertise is required. The operative times and the incidence of mortality and complications were similar to those of the conventional technique, except for a probable greater incidence of junctional rhythm and AV block. Patients with previous atrial fibrillation may have the benefit of sinus rhythm restoration.

Derrame pericárdico grave: Ventana pericárdica percutánea con balón / Severe Pericardial Effusion: Percutaneous Balloon Pericardial Window

La mayoría de los pacientes con derrame pericárdico crónico son mujeres y mayores de 50 años. En esta presentación se describe el caso de una paciente de 63 años con derrame pericárdico crónico grave, con antecedente de carcinoma de mama izquierda irradiado, diagnóstico presuntivo no confirmado de tuberculosis pulmonar e hipotiroidea sustituida. Ante la recurrencia del derrame luego de pericardiocentesis y el fracaso del tratamiento antiinflamatorio con AINE se decidió realizar una ventana pericárdica percutánea, sin que se presentaran complicaciones técnicas. Se inició tratamiento con colchicina y se evaluaron las posibles causas: tuberculosa, oncológica, secundaria a hipotiroidismo o por radiación. Por exclusión se llegó a la etiología radiante. Al mes de la realización de la ventana pericárdica no se observaba derrame pericárdico en el ecocardiograma.

Most patients with chronic pericardial effusion are women aged 50 years or older. This presentation describes a 63- year old female patient with severe chronic pericardial effusion; she had received radiotherapy for cancer of the left breast, had a history an unconfirmed presumptive diagnosis of pulmonary tuberculosis and was under treatment for hypothyroidism. A pericardiocentesis was performed; nevertheless the patient presented recurrence of the pericardial effusion and was treated with NSAIDs. As this therapy failed, she underwent a percutaneous pericardial window with no adverse outcomes. The patient started treatment with colchicine. The potential causes of the pericardial effusion were tuberculosis, malignant neoplasms, hypothyroidism or radiotherapy. The latter etiology was considered as the most probable once the others had been excluded. An echocardiogram performed one month after the procedure showed no signs of pericardial effusion.

Anestesia intrduural y cirugía ambuattoria / Intradural anesthesia and ambulatory surgery

Se realizó un estudio transversal descriptivo a 190 pacientes sometidos a cirugía ambulatoria en la unidad quirúrgica del Hospital Clínico Quirúrgico Docente Amalia Simoni , desde abril de 2004 hasta de 2006.Las variables seleccionadas para el estudio fueron edad, sexo, patologías quirúrgicas e incidencia de la cefalea postpuncion dural. Predominó el sexo masculino (64.7 %) y el mayor porcentaje de los operados se encontraba entre los 36 y 46 años de edad, el diagnóstico operatorio mas frecuente fue la hernia inguinal para un 38.42. Consideramos que el uso de aguja espinal de 27 gauge con punta de lápiz por su incidencia mínima en la cefalea postpunción dural es recomendable para efectuar la anestesia espinal en la cirugía ambulatoria.

Descriptive cross-sectional study to 190 patients underwent to ambulatory surgery was carried out in the surgical unit at "Amalia Simoni" Surgical Clinical Teaching Hospital from April 2004 to April 2006. The selected variables for the study were the age, sex, surgical pathologies and incidence of headache dural postpuncture. Male sex predominated (64.7 %) and the major percentage of the operated was between 36 and 46 years-old, the most frequent operative diagnosis was the inguinal hernia for a 38.42%. We consider that the use of 27 gauge spinal needle with tip of pencil by its minimum incidence in the headache dural postpuncture is recommendable to perform the spinal anesthesia in the ambulatory surgery.

Dos técnicas anestésicas en cirugía nasal. Estudio comparativo utilizando máscara laríngea más anestesia local y sedación general balanceada / Comparative study using laringeal mask airway, local anesthesia and sedation versus endotracheal intubation and general anesthesia in nasal surgery

Objetivo: Demostrar que existen alternativas en el manejo de la cirugía nasal, además de las clásicas técnicas generales inhalatorias y endovenosas, en las que se realiza intubación orotraqueal para proteger la vía aérea de secreciones, sangrado, y mantener una vía continua de suministro de oxígeno. También, probar la utilidad de un instrumento tecnológicamente innovador, la máscara laríngea, que proporciona una vía aérea controlada, predecible y a través de la cual se puede administrar oxigeno y anestésicos inhalatorios, siendo minimamente estimulante y de colocación sencilla. Material y Métodos: Se obtuvo la muestra de los pacientes programados para rinoseptumplastía de Servicio de Otorrinolaringología. Se trata de 30 sujetos en dos grupos de 15 en forma aleatoria. El grupo experimental se manejo con inducción endovenosa para colocación de la LMA, a través de la cual se suministro oxígeno. Se dio mantenimiento con infusión continua de propofol a dosis de sedación y meperidina (dosis única). El grupo control recibió una técnica general balanceada, IOT previa inducción endovenosa, empleando en el mantenimiento enfluorano y fentanyl (bolos). En algunos grupos se infiltró lidocaína con epinefrina 1:200 000 en la región nasal. Resultados: En el grupo experimental se observó reducción del sangrado quirúrgico entre un 50 y 90 por ciento, del tiempo de recuperación postanestésica en un 25 por ciento. Se registraron mayores alteraciones de la frecuencia cardíaca y mayor retención de CO2. Conclusiones: Demostramos que una técnica de sedación endovenosa aunada a infiltración adecuada de la región nasal, suministrando oxígeno a través de la máscara laríngea, brinda condiciones adecuadas para el desarrollo del transanestésico en pacientes ASA. I y II

Agudeza visual potencial en pacientes glaucomatosos: análisis de una muestra / Visual acuity in glaucomatous patients: analysis of a sample

Se estudiaron 44 ojos en 22 pacientes glaucomatososs y 52 ojos en 26 pacientes normales, todos con medios claros usando el medidor de la agudeza visual potencial (PAM), aparato diseñado para evaluar agudeza retinal en pacientes con medios opacos y se encontró una buena correlación entre la agudeza visual tomada con tablas de Snellen y la tomada con el PAM, en pacientes glaucomatosos y el grupo de control, demostrando su utilidad en la evaluación de Función Retinal en pacientes en los que opacidades parciales de los medios dificulte la observación y evaluación directa de la retina