Síndrome aórtico agudo: Revisión de la literatura y actualización del tema / Acute aortic syndrome

Acute aortic syndrome (AAS) is a term that describes interrelated aortic emergencies with similar clinical characteristics and challenges. These are aortic dissection (AD), intramural hematoma (IH), and penetrating atherosclerotic ulcer (PAU). The incidence of AAS is three cases per 100.000 persons per year. Diverse genetic disorders and acquired conditions have been related to the pathogenesis of this disease. Clinical features of patients with any of the three conditions comprising AAS are very similar. A high degree of clinical suspicion and imaging studies are necessary for an accurate diagnosis. Prognosis is clearly related to underlying diagnosis and appropriate surgical repair, in the case of proximal involvement of the aorta. Involvement of distal segments of the aorta may require medical or endovascular therapy according to the presence of complications. After hospital discharge, patients require lifelong follow-up.

Disección aórtica tipo B y embarazo en un síndrome de Marfán: manejo y resultado / Type B aortic dissection and pregnancy in Marfan syndrome

El síndrome de Marfán es una enfermedad autosómica dominante del tejido conectivo, multisistémica y pronóstico determinado por las complicaciones cardiovasculares. Se presenta una paciente de 32 años, multípara, con el diagnóstico conocido de cinco años, posterior a disección aórtica toraco-abdominal (Standford B) y embarazo actual no planificado. Es manejada con betabloqueadores y las imágenes seriadas de aorta muestran disección estable en el segmento entre subclavia izquierda e ilíaca derecha con 41,8 mm en su diámetro mayor, sin comprometer la irrigación de órganos abdominales. Ingresa a las semana 32 para evaluación multidisciplinaria y parto programado. El examen con resonancia nuclear magnética de columna lumbosacra evidenció ectasia dural marcada a nivel de raíz S2. La evaluación fetal demostró un crecimiento en percentil 20 con bienestar hemodinámico y ecocardiografía normal. Previa inducción de madurez pulmonar y con 34+3 semanas, se efectúa cesárea electiva bajo anestesia espinal continua, con nacimiento sin compresión del fondo uterino, esterilización tubaria y postoperatorio inmediato en Unidad Coronaria por 48 horas. La evolución materna es sin incidentes. El recién nacido presentó enterocolitis necrotizante con buena respuesta al tratamiento médico.

Marfan syndrome is a multysistemic an autosomal-dominant disorder of connective tissue and cardiovascular complications determine its prognosis. We present a 32 year-old patient diagnosed five years previously after thoraco-abdominal aneurysm Standford B, and a current unplanned pregnancy. She was treated with beta blockers and evaluated with serial images of the aorta showing a stable thoraco-abdominal aneurysm initiated at the left subclavian artery to the right iliac artery of 41.8 mm at maximum diameter. The patient was hospitalized at 32 weeks to be evaluated in a multidisciplinary team planned delivery. Nuclear Magnetic Resonance on maternal spine detected dural ectasia at S2 and fetal evaluation shows growing at 20 percentile, hemodinamical wellbeing and normal echocardiography. After corticosteroids at 34 +3 weeks a cesarean section with tubal sterilization is performed, with continuous spinal anesthesia, without uterus compression and inmediate postoperative care at the Coronary Unit for 48 hours with satisfactory maternal evolution. The newborn presented a necrotizing enterocolitis at 7 days improving with medical therapy.

Manejo y fibrilación auricular en el postoperatorio de cirugía cardiaca / Management and evolution of atrial fibrillation in the postoperative cardiac surgery

Introduction: postoperative atrial fibrillation (POAF) is the most frequent arrhythmia in patients that undergo a cardiac surgery. POAF’s prevalence ranges from 10 to 65 percent. Most initial episodes of POAF occurred within the first few days alter cardiac surgery. The prevention of POAF is well known but there are no guidelines and no randomized clinical trial that have evaluated the acute management of the arrhythmia. The aim of this restrospective study was to know themanagement and intrahospital evolution of patients with POAF in our institution. Main results: among 426 patients undergoing a cardiac surgery, the incidence of POAF was 10 percent. We analyzed only 27 patients of the 42 with POAF. Five patients spontaneously restored sinus rhythm (SR) and in the others, the first approach to the management was with betablockers in 15 patients (70 percent). To restore SR, the treatment of choice was pharmacological, only with amiodarone, with 70 percent of conversion to SR. Only three patients needed direct current cardioversion to restore SR. At discharge 5 patients were in AF. Conclusion: the management and evolution of patients with POAF in our institution is similar than reported experiences. The initial treatment is to achieve rate control mainly with betablockers. To restore SR the drug of choice is amiodarone with an efficacy of 70 percent. In the minority of our patients direct current cardioversion was necessary to recover SR. Nearly 19 percent of POAF patients were discharged on AF and 44 percent with antiarrhythmic drugs.

Fibrilación auricular en el postoperatorio de cirugía cardiaca: factores de riesgo y morbimortalidad / Postoperative atrial fibrillation of cardiac surgery: risk factors and morbid-mortality

Introduction: postoperative atrial fibrillation (POAF) is the most frequent arrhythmia observed in patients undergoing a cardiac surgery. The worldwide incidence is 30 to 65 percent of cardiac surgery procedures, and is more frequent in patients undergoing a cardiac valve surgery. This arrhyhtmia implies an increment in the lenght and in the total costs of hospitalization, and is associated with serious adverse events like stroke, bleeding and death. The aim of this study was to know the incidence, risk factors, morbidity and mortality associated with POAF in our institution during one year. Main results: we analyze 321 patients that undergone a cardiac surgery during 2003. The incidence of POAF was 6,7 percent and the risk factors associated were the use of cold crystalloid cardioplegia (p < 0,05) and dyslipidemia (p < 0,05). Also, the left ventricle end diastolic diameter was larger but not significant (p = 0,053) in patients with POAF in comparison with patients without POAF. POAF results in an increment of the costs and the lenght of hospitalization. There was no mortality attributed to this arrhythmia in our patients. Conclusion: in this retrospective analysis of patients undergoing cardiac surgery there was a lower incidence of POAF in comparison with other series. The risk factors in this population of patients were the use of cold crystalloid cardioplegia and dyslipidemia. Although this arrhythmiawas associated with more days of hospitalization, there were no difference in mortality between patients with POAF and patients without POAF.

Infarto agudo del miocardio por oclusión total del tronco común de arteria coronaria izquierda tratado con revascularización percutánea endoluminal: caso clínico / Acute myocardial infarction caused by total occlusion of the left main coronary artery treated with percutaneous endoluminal revascularization: report of case

We report a 43 years old female who developed an intense precordial pain and arterial hypotension. The patient was admitted to the emergency room in cardiogenic shock. An emergency angiography revealed a total occlusion of the left main coronary artery. An endoluminal coronary angioplasty with the placement of two stents was performed and coronary reperfusion TIMI III was achieved. The patient had a good evolution and one month later, a surgical revascularization was done, to avoid new occlusions. She was discharged in good conditions and in functional capacity I

Revascularización miocárdica en un paciente con calcificación de la aorta ascendente y arco aórtico: aorta de porcelana / Myocardial revascularization in a patient with calcification of ascending aorta and aortic arch: porcelain aorta

El hallazgo de una aorta ascendente intensamente calcificada (aorta de porcelana) durante la cirugía de revascularización miocárdica ofrece dificultades tanto en la decisión de llevar a cabo la cirugía como en la elevada frecuencia de complicación neurológica que esta condición acarrea. Se presenta el caso de un paciente de 59 años operado de urgencia por una angina posinfarto miocárdico grave y en quien se encontró una aorta ascendente y arco aórtico totalmente calcificados. Enfrentados a esta situación se decidió efectuar una revascularización miocárdica utilizando perfusión arterial por vía femoral, cánula única cavoatrial y uso de un drenaje aurículo ventricular. Así, enfriando a 25º C y durante fibrilación ventricular espontánea se construyeron anastomosis distales con vena safena a la arteria circunfleja y arteria mamaria interna (AMI) a la arteria descendente anterior. Luego de defibrilar el corazón se efectuó la anastomosis venosa terminolateral a la AMI. El paciente fue retirado de bomba con bajo apoyo y completó un postopertorio sin incidentes. Una ecocardiografía transesofágica postoperatoria reveló la extensión y magnitud de la aterosclerosis en la aorta

Arteria epigástrica inferior: técnica de utilización como injerto libre en revascularización miocárdica / Inferior epigastric artery: technic by using it as free graft in myocardial revascularization

La arteria epigástricz inferior (AEI) ha surgido en el último tiempo como un conducto alternativo en la cirugía de revascularización miocárdica. Sus ventajas anatómicas y funcionales han influido en su uso. Hemos efectuado 27 revascularizaciones coronarias utilizando la AEI. Esta se ha indicado principalmente en pacientes menores de 60 años, para ofrecerles un mayor número de injertos arteriales al asociarlo al uso de la arteria mamaria interna, como también en portadores de várices bilaterales y safenectomizados. Ningún conducto disecado fue desechado. Su largo permite su utilización en cualquier vaso coronario. Un paciente falleció como consecuencia de su mala función ventricular previa. En el seguimiento alejado, el 92.3 por ciento de los pacientes se encuentran asintomáticos. La AEI es un conducto de fácil obtención y en su utilización hemos desarrollado alternativas que conducen a un buen resultado quirúrgico, faltando aún algunos años de seguimiento para determinar su comportamiento alejado

Evaluación de revascularización coronaria: comparación entre perfusión con Tc99m sestamibi-dipiridamol gatillado y ecografía-amrinona como predictores de viabilidad / Assessment of coronary revascularization: comparison between perfussion with Tc99m sestamibi-dipyridamol spect and echography-amrinone as predictors of viability

We studied left ventricular perfusion and motility in 37 patients with coronary artery disease and disturbances of parietal motility, aged 57 ñ 9 years old, before and after revascularization. Perfusion was assessed with dipyridamole-Tc99m SPECT and motility was assessed with 2 dimentional echocardiography with amrinone. Myocardial segments were defined as normal, viable or necrotic in both studies. Eighteen subjects were subjected to angioplasty and 19 to coronary bypass surgery. Submitted SPECT and echography were repeated 64 ñ 15 and 69 ñ 23 days after revascularization respectively. The concordance between SPECT and echocardiographic prerevascularization diagnosis was 60.1 percent. Eighty one percent of segment considered viable with SPECT and 71 percent thus considered with echocardiography improved after revascularization. Likewise, 50 percent of segments considered necrotic with SPECT and 68 percent of segment thus considered with echocardiography did not improve. It is concluded that althought there is a good concordance between both methods, they have limitations on the study of myocardial viability and should be considered as second choice