Cirugía mínimamente invasiva de la válvula aórtica. 15 años de experiencia en el Hospital Regional de Temuco, Chile / Ministernotomy for aortic valve surgery: a 15-year experience

Resumen Introducción: La cirugía de la válvula aórtica puede ser efectuada a través de una esternotomía reducida con menos trauma quirúrgico, una recuperación más rápida, mejores resultados cosméticos y excelentes resultados a largo plazo. Objetivo: Comunicar los resultados a largo plazo obtenidos con el abordaje mínimamente invasivo en el Hospital Regional de Temuco. Material y Método: Estudio de cohorte retrospectivo de 286 pacientes operados con técnica mini invasiva comparados con 1161 pacientes operados a través de esternotomía completa para reemplazo valvular aórtico por enfermedad valvular entre 2004 y 2019. La edad promedio fue 62,1±6,4 años. Para la canulación arterial y venosa se utilizaron cánulas de tamaño pequeño. El flujo de circulación extracorpórea promedio fue 4.5 L/min. Se utilizó cardioplejia sanguínea infundida por vía anterógrada y retrograda. Se utilizó estadística descriptiva con medidas de tendencia central y dispersión. Las variables categóricas fueron comparadas con el test de X^2 y las variables continuas con "t" test y ANOVA. La supervivencia actuarial se calculó mediante el método de Kaplan Meier con el programa Stata 14. Resultados: No hubo diferencia en la mortalidad a 30 días entre los grupos. Hallazgos similares se encontraron para arritmias, complicaciones cerebrales y bloqueo AV que requirió marcapasos. Hubo una diferencia estadísticamente significativa a favor del grupo de ministernotomía para reoperación por sangrado, días de estadía en UCI y estadía hospitalaria. El seguimiento promedio fue 101 ± 4 (1169 meses). La mayoría de los pacientes estaban en capacidad funcional I y libre de eventos cardiovasculares y reoperación. En el control post operatorio se hizo un ecocardiograma en el 86% de los pacientes mostrando buen resultado hemodinámico, similar en ambos grupos, y para distintas prótesis utilizadas. La probabilidad de sobrevida actuarial fue de 97% y la probabilidad de estar libre de eventos cardiovasculares fue 93% a 156 meses de seguimiento. Conclusión: La mini esternotomía es una técnica segura para la cirugía valvular aórtica con excelentes resultados en el largo plazo, permitiendo simplificar la cirugía, reducir los costos hospitalarios y permite una recuperación con menos secuelas cosméticas.

Abstract: Background: Aortic valve surgery can be performed through a reduced ministernotomy with less surgical trauma, improved cosmetics, faster recovery and excellent long-term results. Aim: To report the long-term results obtained with the minimally invasive approach technique in Southern Chile. Methods: A retrospective cohort study of 286 patients operated with the less invasive technique compared to 1161 patients operated on with full sternotomy for aortic valve replacement between 2004 and 2019 was performed. Arterial and venous cannulation was performed using small cannulas. Mean extracorporeal circulation flow was 4.5 L/min. Antegrade and retrograde cold cardioplegia was used. Statistical Analysis: Data are reported with measures of central tendency and dispersion. Categorical variables were compared with the X^2 test and ANOVA. Actuarial survival rate was calculated by Kaplan Meier method. The Stata 14 package was used for data analysis. Results: Demographic characteristics are shown in Table 1. Mean age of the whole cohort was 62.1 y/o (SD 6.4). There was no difference in 30 day mortality between groups. Incidence of arrhythmia, cerebral complications and AV block requiring pacemaker was similar between groups. There were no significant statistical differences in reoperation for bleeding, days of stay at the ICU and overall hospital stay. Mean follow up was 101 ± 4 (1169) months. After surgery most patients are in FC I and free from cardiac events and reoperation. In the postoperative period echocardiographic assessment was performed in 86% of patients showing similar hemodynamic function of the implanted valve. Actuarial survival rate was 97% and probability of freedom from cardiac events was 93% at 156 months of follow up. Conclusions: Ministernotomy is an excellent approach for aortic valve surgery which can be performed with very good results not inferior to those obtained with full sternotomy thus simplifying the surgical technique and reducing local hospital costs.

Lesiones precordiales: reporte de dos casos / Precordial injuries: report of two cases

Las heridas precordiales son una entidad poco frecuente y desafiante en cirugía de trauma en los servicios de Emergencia. La incidencia elevada de taponamiento y trauma cardiaco, así como su alta mortalidad obliga a tomar decisiones diagnósticas y terapéuticas rápidas y precisas. Material y Métodos: se presentan los casos de dos pacientes masculinos que ingresaron al servicio de Emergencia del Hospital Roosevelt con lesiones precordiales penetrantes con trauma pericárdico y cardiaco, con diferentes manifestaciones clínicas a los que se les realizó ventana pericárdica subxifoidea diagnóstica y seguido una esternotomía media con exposición pericárdica y cardiaca como abordaje y tratamiento quirúrgico definitivo. Discusión: Es de suma importancia reconocer los amplios escenarios de presentaciones clínicas del paciente con heridas en la región precordial y mantener un alto índice de sospecha de trauma y taponamiento cardiacos en todas las lesiones precordiales penetrantes en pacientes estables e inestables para no retrasar el diagnóstico y tratamiento quirúrgico temprano y adecuado. Las lesiones asociadas y complicaciones trans y postoperatorias aumentan la mortalidad de estos pacientes (AU)

Precordial wounds are rare and challenging lesions in Trauma Services. The high incidence of cardiac trauma and the high mortality requires fast and precise diagnostic and therapeutic decisions. Case report: Two male patients who were admitted to the Roosevelt Hospital Emergency Service with penetrating precordial injuries with pericardial and cardiac trauma are presented, with different clinical manifestations, who underwent a diagnostic subxiphoid pericardial window and a median sternotomy with pericardial and cardiac exposure as a definitive surgical approach and treatment. Discussion: Is important to recognize the broad scenarios of patients with wounds in the precordial region and to maintain a high index of suspicion of cardiac trauma and tamponade in all penetrating precordial injuries inclusive in stable patients to not delay diagnosis and treatment and a proper surgical intervention. Associated injuries and perioperative complications increase the mortality of these patients

Teratomas del mediastino / Mediastinum Teratomas

RESUMEN Introducción: Los teratomas se definen como tumores de tejidos extraños al órgano o sitio anatómico en el cual se originan. Los teratomas mediastinales no son frecuentes, representan alrededor del 5 por ciento al 10 por ciento de todos los tumores mediastinales. Objetivo: Describir los resultados del tratamiento quirúrgico de pacientes con diagnóstico de teratomas mediastinales. Métodos: Se estudiaron 12 pacientes tratados entre enero de 2001 y diciembre de 2018. Las variables evaluadas fueron sexo, edad, tipo histológico: maduro o inmaduro, vía de acceso quirúrgico, accidentes quirúrgicos y evolución postoperatoria. Resultados: Correspondieron 9 al sexo femenino y 3 al masculino. El promedio de edad fue de 33,3 años (17-60 años). Hubo predominio absoluto del tipo maduro (11). La esternotomía media fue el acceso más frecuente. La toracotomía se realizó cuando el tumor, voluminoso, ocupaba la mayor parte de un hemitórax. Los accidentes quirúrgicos fueron un desgarro pulmonar y una apertura del pericardio. De dos pacientes tratados mediante cirugía torácica videoasistida, uno fue convertido por sangrado venoso molesto. Al año de seguimiento todos estaban vivos, sin evidencias de recidiva. Conclusiones: Contrariamente a lo esperado, hay predominio del sexo femenino, mientras que la edad y el tipo histológico coinciden con la literatura. La esternotomía, aún hoy, es comúnmente aceptada, a pesar del auge de la cirugía torácica videoasistida. La resección total produce resultados excelentes para los teratomas benignos(AU)

ABSTRACT Introduction: Teratomas are defined as tumors of tissues foreign to the organ or anatomical site in which they originate. Mediastinal teratomas are rare, accounting for about 5-10 percent of all mediastinal tumors. Objective: To describe the outcomes of the surgical treatment of patients diagnosed with mediastinal teratomas. Methods: Twelve patients treated between January 2001 and December 2018 were studied. The variables evaluated were sex, age, histological type (mature or immature), surgical access route, surgical accidents, and postoperative evolution. Results: Nine patients corresponded to the female sex and three, to the male. The average age was 33.3 years (17-60 years). There was an absolute predominance of the mature type (11). Median sternotomy was the most frequent access. Thoracotomy was performed when the bulky tumor occupied most of a hemithorax. The surgical accidents were lung tear and opening of the pericardium. Of two patients treated by video-assisted thoracic surgery, one was converted for bothersome venous bleeding. At one year of follow-up, all were alive, with no evidence of recurrence. Conclusions: Contrary to expectations, there is predominance of the female sex, while age and histological type coincide with the literature. Sternotomy, even today, is commonly accepted, despite the rise of video-assisted thoracic surgery. Total resection produces excellent outcomes in benign teratomas(AU)

Absceso del mediastino anterior / Abscess in the Anterior Mediastinum

RESUMEN Se presenta una paciente de 54 años de edad con antecedentes de hipertensión arterial, que ingresa en el servicio de Medicina Interna por dolor torácico intenso, acompañado de falta de aire de moderada intensidad, decaimiento, tos y dificultad para tragar sobre todo los alimentos sólidos. Mediante estudios complementarios se diagnostica un tumor de mediastino anterior, lo que motiva su traslado al servicio de Cirugía General. En el acto quirúrgico se constata absceso del mediastino anterior, el cual se drena mediante esternotomía media, evoluciona favorablemente y es egresada 12 días después de la intervención quirúrgica(AU)

ABSTRACT We present a 54-year-old patient with a history of high blood pressure, admitted to the internal medicine service with severe chest pain, accompanied by a lack of air of moderate intensity, decay, cough and difficulty for swallowing, especially solid foods. Through complementary studies, an anterior mediastinal tumor is diagnosed, which motivates her transfer to the general surgery service. In the surgical act, abscess of the anterior mediastinum is verified and drained by means of median sternotomy. The patient evolves favorably and is discharged 12 days after the surgical intervention(AU)

O impacto da tecnologia no tratamento do trauma vascular iatrogênico cervicotorácico: estudo de dois casos com intervalo de três décadas e revisão da literatura / he impact of technology on treatment of iatrogenic cervicothoracic vascular traumas: a study of two cases three decades apart and a review of the literature

Complicações relacionadas ao acesso venoso cervicotorácico, como os pseudoaneurismas (PAs), podem ser devastadoras. Neste artigo, apresentamos dois casos semelhantes em que o avanço tecnológico impactou no diagnóstico, tratamento e resultados. Ambos pacientes apresentaram volumoso PA após a tentativa de punção venosa profunda. O primeiro caso, em 1993, diagnosticado por duplex scan , revelou grande PA oriundo da artéria subclávia direita. A artéria foi abordada por esternotomia mediana com extensão supraclavicular. O PA originava-se do tronco tireocervical, tratado com simples ligadura. No segundo caso, em 2017, angiotomografia revelou um PA originário da artéria vertebral, que foi tratado com técnica endovascular, mantendo a perviedade do vaso. Ambos evoluíram satisfatoriamente, apesar de abordagens bastante diferentes. A lesão vascular cervicotorácica representa um desafio propedêutico e terapêutico, com alto risco de ruptura. Os avanços tecnológicos diminuem os riscos de lesões vasculares com acesso cirúrgico difícil e devem estar entre as opções do cirurgião vascular

Complications such as pseudoaneurysms (PA) related to cervicothoracic venous access can be devastating. In this article, we present two similar cases in which technological advances impacted diagnosis, treatment, and results. Both patients developed massive PA after deep venous puncture attempts. The first case occurred in 1993 and was diagnosed by a duplex scan that revealed a large PA originating from the right subclavian artery. The artery was approached by median sternotomy with supraclavicular extension. The PA originated from the thyrocervical trunk and was treated with simple ligation. The second case was in 2017. Angiotomography revealed a PA originating in the vertebral artery, which was treated with endovascular techniques, maintaining vessel patency. Both patients progressed satisfactorily, despite quite different approaches. Cervicothoracic vascular lesions represent a diagnostic and therapeutic challenge, where the risk of rupture is high. Technological advances have reduced the risks involved in management of vascular injuries with difficult surgical access

Aortic valve replacement with a conventional stented bioprosthesis versus sutureless bioprosthesis: a study of 763 patients

Abstract Objective: The aim of this retrospective study was to compare early postoperative outcomes after aortic valve replacement (AVR) with sutureless bioprostheses and conventional stented bioprostheses implanted through median sternotomy. Methods: From January 2011 to December 2016, 763 patients underwent aortic valve replacement with bioprostheses; of these, 139 received a Perceval S sutureless valve (Group A) and 624 received a Perimount Magna Ease valve (Group B). These groups were further divided into A1 (isolated Perceval AVR), A2 (Perceval AVR with coronary artery bypass grafting [CABG]), B1 (isolated conventional stented bioprosthesis), and B2 (conventional stented bioprosthesis + CABG). Results: Patients in Group A were older (mean 74 years vs. 71 years; P<0.0001), predominantly women (53% vs. 32%; P<0.0001), had a higher logistic EuroSCORE (3.26 vs. 2.43; P<0.001), more preoperative atrial fibrillation (20% vs. 13%; P=0.03), and had a lower reopening rate for bleeding (2.1% vs. 6.7%; P=0.04). Compared to Group B1, Group A1 had shorter cross-clamp (mean 40 min vs. 57 min; P≤0.0001) and bypass times (mean 63 min vs. mean 80 min; P=0.02), and they bled less postoperatively (mean 295 ml vs. mean 393 ml; P=0.002). The mean gradient across Perceval valve was 12.5 mmHg while its effective orifice area was 1.5 cm2. Conclusion: In our retrospective study of 763 patients, sutureless valve group patients are older, mostly women, more symptomatic preoperatively, and have higher logistic EuroSCORE. They have shorter cross-clamp and bypass times, less postoperative bleeding, and reduced incidence of reopening. Further studies are needed to evaluate the clinical benefits in short, mid, and long-terms.

Fatores associados à mediastinite pós-esternotomia, caso-controle / Factors associated with post-mediastinitis. Case-control study

Fundamentos: A mediastinite é uma infecção grave pós-esternotomia mediana com prognóstico ruim, mesmo com diagnóstico e tratamento precoces. Objetivos: Avaliar o perfil dos pacientes submetidos à esternotomia, identificar fatores de risco para o desenvolvimento da mediastinite e avaliar o diagnóstico bacteriológico dos pacientes com esta infecção. Métodos: Estudo caso-controle realizado em um hospital de Belo Horizonte (MG) com pacientes submetidos à esternotomia mediana entre janeiro de 2015 e janeiro de 2016. A amostra foi de 65 pacientes, sendo 13 casos e 52 controles (1:4). Na análise estatística, foram adotados os testes t de Student, Mann-Whitney e exato de Fisher, além de regressão logística, ao nível de significância de 5%. Resultados: Houve predominância do sexo masculino (63,1%), e a idade média foi 58,8 ±10,3 anos. A evolução a óbito ocorreu em 9,2% dos pacientes e em 23,1% dos que apresentaram mediastinite. A cirurgia de revascularização do miocárdio foi realizada em 75,4% dos casos. Predominância do sexo masculino, maior tempo de internação, febre pós-cirúrgica, óbitos e maior número de fatores de risco foram características mais observadas nos pacientes que desenvolveram mediastinite. O microrganismo mais encontrado em pacientes com infecção mediastinal foi Staphylococcus aureus (30,7%), além de elevada ocorrência de bactérias Gram-negativas (46,2%). Conclusão: Esforços devem ser concentrados para o controle dos fatores de risco antes do procedimento, além do aprimoramento de medidas que possam diminuir ou eliminar o surgimento da mediastinite, visando à prevenção e ao melhor controle de infecções

Background: Mediastinitis is a severe post-median sternotomy infection with poor prognosis, even with early diagnosis and treatment. Objectives: To evaluate the profile of patients submitted to sternotomy, identify the risk factors for the development of mediastinitis and evaluate the bacteriological diagnosis of patients with this infection. Methods: Case-control study carried out in a large hospital in Belo Horizonte (MG, Brazil) in patients submitted to median sternotomy, from January 2015 to January 2018. The sample consisted of 65 patients, of which 13 were cases and 52, controls (1:4). For the statistical analysis, Student's t test, Mann-Whitney test and Fisher exact test were used, in addition to logistic regression, with a level of significance of 5%. Results: There was a predominance of males (63.1%), and the mean age was 58.8 ± 10.3 years. Evolution to death occurred in 9.2% of the patients and in 23.1% of those with mediastinitis. Myocardial revascularization was performed in 75.4% of the cases. Predominance of male gender, longer hospitalization time, post-surgical fever and death, and a greater number of risk factors were more frequent characteristics in patients who developed mediastinitis. The most common microorganism found in patients with mediastinal infection was Staphylococcus aureus (30.7%), in addition to a high occurrence of Gram-negative bacteria (46,2%). Conclusion: The results are in accordance with the literature. Efforts should be focused on the control of risk factors prior to the procedure, in addition to improving measures that can decrease or eliminate the onset of mediastinitis, aiming at infection prevention and control

Seguridad de la re-esternotomía media en el tratamiento paliativo de pacientes con corazón univentricular / Safety of repeat median sternotomy in the palliative treatment of patients with a univentricular heart

Resumen: Objetivo: Describir la morbimortalidad operatoria relacionada a re-esternotomía media en pacientes con corazón univentricular en el Instituto Nacional de Pediatría. Método: Estudio de serie de casos retrospectiva, descriptiva y analítica del año 2001 al 2016. Resultados: Se encontraron 65 pacientes que requirieron 76 procedimientos. Hubo 59 primeras re-esternotomías, con promedio de edad de 36 meses (4-176 meses) y peso 12.2 kg (3.2-21.5 kg); se realizaron 40 procedimientos de Glenn y 19 procedimientos de Fontan. Se practicaron 17 segundas re-esternotomías, con promedio de edad de 89 meses (48-156 meses) y 22.7 kg de peso (14.4-41 kg), en quienes se realizaron 17 procedimientos de Fontan. Hubo dos lesiones en primeras re-esternotomías, una lesión a la coronaria derecha con cambios electrocardiográficos, y una apertura incidental de la aurícula derecha que causó hipotensión. Reportamos una muerte secundaria a lesión de la aorta con sangrado masivo durante una segunda re-esternotomía, lo que representa una morbimortalidad del 3.9%. Conclusiones: Concluimos que la re-esternotomía es un procedimiento seguro en nuestro centro.

Abstract: Objective: To establish the morbidity and mortality of patients with univentricular hearts who underwent a repeat median sternotomy at the Instituto Nacional de Pediatría. Method: A retrospective review was performed on the clinical charts of all patients who under-went a repeat median sternotomy from 2001 to 2016. Results: Sixty-five patients underwent 76 surgeries by repeat median sternotomy. Fifty-nine patients had a first repeat median sternotomy, with a mean age of 36 months (range: 4-176 months) and a mean weight of 12.2 kg (range: 3.2-21.5 kg). Forty patients had a Glenn procedure, and 19 patients had a Fontan procedure. There were 17 patients with a second repeat median sternotomy, with a mean age of 89 months (range 48-156 months), and a mean weight of 22.7 kg (14.4-41 kg). A Fontan procedure was performed on all these 17 patients. A section of the right coronary artery with electrocardiographic changes and a right atrium tear that caused hypotension occurred during first repeat sternotomy. An aortic tear occurred during a second repeat sternotomy with massive bleeding and subsequent death. This represents 3.9% of re-entry injuries. Conclusion: It is concluded that repeat median sternotomy is a safe procedure.

Anterior minithoracotomy: a safe approach for surgical asd closure & asd device retrieval

Abstract Objective: Midline sternotomy is the preferred approach for device migration following transcatheter device closure of ostium secundum atrial septal defect. Results of patients operated for device migration were retrospectively reviewed after transcatheter closure of atrial septal defect. Methods: Among the 643 patients who underwent atrial septal defect with closure device, 15 (2.3%) patients were referred for device retrieval and surgical closure of atrial septal defect. Twelve patients underwent device retrieval and surgical closure of atrial septal defect through right antero-lateral minithoracotomy with femoral cannulation. Three patients were operated through midline sternotomy. Results: Twelve patients operated through minithoracotomy did not require conversion to sternotomy. Due to device migration to site of difficult access through thoracotomy, cardiac tamponade and hemodynamic instability, respectively, three patients were operated through midline sternotomy. Mean aortic cross-clamp time and cardiopulmonary bypass time were 28.1±17.7 and 58.3±20.4 minutes, respectively. No patient had surgical complication or mortality. Mean intensive care unit and hospital stay were 1.6±0.5 days and 7.1±2.2 days, respectively. Postoperative echocardiography confirmed absence of any residual defect and ventricular dysfunction. In a mean follow-up period of six months, no mortality was observed. All patients were in New York Heart Association class I without wound or vascular complication. Conclusion: Minithoracotomy with femoral cannulation for cardiopulmonary bypass is a safe-approach for selected group of patients with device migration following transcatheter device closure of atrial septal defect without increasing the risk of cardiac, vascular or neurological complications and with good cosmetic and surgical results.

Transverse sternal split: a safe mini-invasive approach for perventricular device closure of ventricular septal defect

Abstract Objective: Perventricular device closure of ventricular septal defect through midline sternotomy avoids the cardiopulmonary bypass, however, lacks the cosmetic advantage. Perventricular device closure of ventricular septal defect with transverse split sternotomy was performed to add the cosmetic advantage of mini-invasive technique. Methods: Thirty-six pediatric patients with mean age 7.14±3.24 months and weight 5.00±0.88 kg were operated for perventricular device closure of ventricular septal defect through transverse split sternotomy in 4th intercostal space under transesophageal echocardiography guidance. In case of failure or complication, surgical closure of ventricular septal defect was performed through the same incision with cervical cannulation of common carotid artery and internal jugular vein for commencement of cardiopulmonary bypass. All the patients were postoperatively followed, and then discharged from hospital due to their surgical outcome, morbidity and mortality. Results: Procedure was successful in 35 patients. Two patients developed transient heart block. Surgical closure of ventricular septal defect was required in one patient. Mean duration of ventilation was 11.83±3.63 hours. Mean intensive care unit and hospital stay were 1.88±0.74 days and 6.58±1.38 days, respectively. There was no in-hospital mortality. A patient died one day after hospital discharge due to arrhythmia. No patients developed wound related, vascular or neurological complication. In a mean follow-up period of 23.3±18.45 months, all 35 patients were doing well without residual defect with regression of pulmonary artery hypertension as seen on transthoracic echocardiography. Conclusion: Transverse split sternotomy incision is a safe and effective alternative to a median sternotomy for perventricular device closure of ventricular septal defect with combined advantage of better cosmetic outcomes and avoidance of cardiopulmonary bypass.

Left atrial myxoma following coronary artery bypass grafting with patient coronary arterial grafts: a rarity

Abstract The development of left atrial myxoma after coronary artery bypass graft surgery is a rare entity. A 60-year-old man with previous off-pump coronary artery bypass grafting four years ago with patent coronary grafts was diagnosed with left atrial mass. The patient underwent successful resection of the same through minimally invasive right anterolateral thoracotomy. Histopathology of the atrial mass confirmed the diagnosis of atrial myxoma.

Teratoma mediastinal anterior / Anterior Mediastinal Teratoma

Paciente de 57 años, fumador, antecedentes de salud que acudió a consulta por presentar tos seca de 3 meses de evolución. Se le diagnosticó unteratoma mediastinal, tumor poco frecuente en esa edad. En la radiografía de tórax se observó una masa mediastinal anterior que se confirmó con la tomografía computarizada y donde la localización y las características imaginológicas sugirieron el diagnóstico. Se realizó esternotomía media con exéresis del tumor, confirmando por anatomía patológica la presencia de un teratoma quístico maduro en el mediastino(AU)

A 57 year old male smoking patient, with healthy history presented to the clinic for having dry cough for 3 months of evolution. Mediastinal teratoma was diagnosed, a rare tumor at that age. An anterior mediastinal mass was observed on the chest X-ray, which was confirmed by computed tomography. The location and imaging characteristics suggested the diagnosis as well. A median sternotomy was performed with tumor excision, the pathological anatomy confirmed the presence of a mature cystic teratoma in the mediastinum(AU)

Retalho de omento maior no tratamento da mediastinite pós-operatória do lactente / Greater omentum flap in the treatment of infant postoperative mediastinitis

INTRODUÇÃO: A mediastinite pós-operatória é uma condição grave, com altas taxas de mortalidade. O retalho de omento maior é usado com êxito no tratamento de mediastinites pós-operatórias decorrentes de cirurgia cardíaca. O uso dessa abordagem não foi relatado em lactentes, provavelmente porque nessa idade o omento maior é membranáceo, pouco volumoso e possui tecido adiposo escasso. MÉTODOS: Entre julho de 2010 e agosto de 2014, foram tratados quatro lactentes com mediastinite pós-operatória decorrentes de cirurgia cardíaca, realizada por esternotomia. O tratamento cirúrgico consistiu em remoção dos fios de aço da osteossíntese esternal, desbridamento e lavagem do mediastino, seguidos da transposição de todo o omento maior para a cavidade mediastinal. O tratamento cirúrgico foi feito em um só tempo. Não foi feita nova síntese do esterno com fios de aço. RESULTADOS: Os quatro pacientes sobreviveram ao tratamento e obtiveram alta da unidade de tratamento intensivo sem infecção. CONCLUSÕES: Embora membranáceo e apresentando pequeno volume, o retalho de omento maior se mostrou um excelente método de abordagem da mediastinite pós-operatória do lactente.

INTRODUCTION: Postoperative mediastinitis is a serious condition that presents high mortality rates. The greater omentum flap has been used with good results in postoperative mediastinitis after cardiac surgery. The use of this approach has not been reported in infants probably because at this age, the greater omentum is membranous, not bulky, and has little amount of fatty tissue. METHOD: Between July 2010 and August 2014, four infants who presented with mediastinitis after a cardiac surgery via sternotomy were treated. The surgical treatment consisted of steel wire removal, debridement, and wound washing, followed by transposition of the entire greater omentum to the mediastinal cavity. Surgical treatment was performed in a single step. No rewiring of the sternum was performed. RESULTS: All four patients survived the treatment and were discharged from the intensive care unit without infection. CONCLUSIONS: Although membranous and not bulky, the use of a greater omentum flap proved to be an excellent approach in infant postoperative mediastinitis.

The analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after cardiac surgery.

Background: Median sternotomy, sternal spreading, and sternal wiring are the main causes of pain during the early recovery phase following cardiac surgery. Aim: This study was designed to evaluate the analgesic efficacy of continuous presternal bupivacaine infusion through a single catheter after parasternal block following cardiac surgery. Materials and Methods: The total of 40 patients (American Society of Anesthesiologist status II, III), 45–60 years old, undergoing coronary – artery bypass grafting were enrolled in this prospective, randomized, double‑blind study. A presternal catheter was inserted with continuous infusion of 5 mL/h bupivacaine 0.25% (Group B) or normal saline (Group C) during the first 48 postoperative hrs. Primary outcomes were postoperative morphine requirements and pain scores, secondary outcomes were extubation time, postoperative respiratory parameters, incidence of wound infection, Intensive Care Unit (ICU) and hospital stay duration, and bupivacaine level in blood. Statistical Methods: Student’s t‑test was used to analyze the parametric data and Chi‑square test for categorical variables. Results: During the postoperative 48 h, there was marked reduction in morphine requirements in Group B compared to Group C, (8.6 ± 0.94 mg vs. 18.83 ± 3.4 mg respectively, P = 0.2), lower postoperative pain scores, shorter extubation time (117 ± 10 min vs. 195 ± 19 min, respectively, P = 0.03), better respiratory parameters (PaO2/ FiO2, PaCO2 and pH), with no incidence of wound infection, no differences in ICU or hospital stay duration. The plasma concentration of bupivacaine remained below the toxic threshold (at T24, 1.2 ug/ml ± 0.3 and T48 h 1.7 ± 0.3 ug/ml). Conclusion: Continuous presternal bupivacaine infusion has resulted in better postoperative analgesia, reduction in morphine requirements, shorter time to extubation, and better postoperative respiratory parameters than the control group.

"Air embolism during fontan operation".

In patients with a right to left intracardiac shunt, air embolism results in an obligatory systemic embolization. Nonembolization of entrained air is described in a child with a single ventricle physiology who had earlier undergone bidirectional Glenn shunt construction and Damus–Kaye–Stansel anastomosis. The air entrainment was detected by intra-operative transesophageal echocardiography. The combined effect of a “diving bell” phenomenon and mild aortic valve regurgitation are suggested as the reasons for the confi nement of air into the ventricle preventing catastrophic systemic embolization.

Comparison of bolus and continuous infusion of esmolol on hemodynamic response to laryngoscopy, endotracheal intubation and sternotomy in coronary artery bypass graft / Comparação de esmolol em bolus e infusão contínua na resposta hemodinâmica à laringoscopia, intubação orotraqueal e esternotomia em cirurgia de revascularização coronária / Comparación del esmolol en bolos e infusión continua en la respuesta hemodinámica a la laringoscopia, intubación orotraqueal y esternotomía en cirugía de revascularización coronaria

BACKGROUND AND OBJECTIVE: The aim of this randomized, prospective and double blinded study is to investigate effects of different esmolol use on hemodynamic response of laryngoscopy, endotracheal intubation and sternotomy in coronary artery bypass graft surgery. METHODS: After approval of local ethics committee and patients' written informed consent, 45 patients were randomized into three groups equally. In Infusion Group; from 10 min before intubation up to 5th minute after sternotomy, 0.5 mg/kg/min esmolol infusion, in Bolus Group; 2 min before intubation and sternotomy 1.5 mg/kg esmolol IV bolus and in Control Group; %0.9 NaCl was administered. All demographic parameters were recorded. Heart rate and blood pressure were recorded before infusion up to anesthesia induction in every minute, during endotracheal intubation, every minute for 10 minutes after endotracheal intubation and before, during and after sternotomy at first and fifth minutes. RESULTS: While area under curve (AUC) (SAP × time) was being found more in Group B and C than Group I, AUC (SAP × T int and T st) and AUC (SAP × T2) was found more in Group B and C than Group I (p < 0.05). Moreover AUC (HR × T st) was found less in Group B than Group C but no significant difference was found between Group B and Group I. CONCLUSION: This study highlights that esmolol infusion is more effective than esmolol bolus administration on controlling systolic arterial pressure during endotracheal intubation and sternotomy in CABG surgery. .

JUSTIFICATIVA E OBJETIVO: o objetivo deste estudo prospectivo, randômico e duplo-cego foi investigar os efeitos do uso diferente de esmolol na resposta hemodinâmica à laringoscopia, intubação orotraqueal e esternotomia em cirurgia de revascularização coronária. MÉTODOS: após obter a aprovação do Comitê de Ética local e consentimento informado assinado pelos pacientes, 45 pacientes foram randomicamente divididos em três grupos. O Grupo I (infusão) recebeu 0,5 mg/kg/min de esmolol em infusão a partir de 10 min antes da intubação até 5 minutos após a esternotomia; o Brupo B (bolus) recebeu 1,5 mg/kg de esmolol em bolus IV a partir de 2 min antes da intubação e esternotomia; o grupo C (controle) recebeu NaCl a 0,9%. Todos os parâmetros demográficos foram registados. Os valores de frequência cardíaca e pressão arterial foram registrados desde antes da infusão até a indução da anestesia a cada minuto, durante a intubação endotraqueal, a cada minuto durante 10 min após a intubação endotraqueal e antes, durante e após a esternotomia no primeiro e quinto minutos. RESULTADOS: enquanto a área sob a curva (ASC) (SAP × tempo) foi maior nos grupos B e C que no Grupo I, a ASC (SAP × T int e T st) e ASC (SAP × T2) foram maiores nos grupos B e C que no Grupo I (p < 0,05). Além disso, a ASC (FC × T st)) foi menor no Grupo B que no Grupo C, mas não houve diferença significante entre os grupos B e I. CONCLUSÃO: este estudo destaca que a administração de esmolol em infusão é mais eficaz que em bolus para controlar a pressão arterial sistólica durante a intubação endotraqueal e esternotomia em CRC. .

JUSTIFICACIÓN Y OBJETIVO: el objetivo de este estudio prospectivo, aleatorizado y doble ciego fue investigar los efectos del diferente uso del esmolol en la respuesta hemodinámica a la laringoscopia, intubación orotraqueal y esternotomía en cirugía de revascularización coronaria. MÉTODOS: después de obtener la aprobación del Comité de Ética local y el consentimiento informado firmado por los pacientes, 45 de ellos fueron aleatoriamente divididos en 3 grupos. El grupo I (infusión) recibió 0,5 mg/kg/min de esmolol en infusión desde 10 min antes de la intubación hasta 5 min después de la esternotomía; el grupo B (bolo), que recibió 1,5 mg/kg de esmolol en bolo iv a partir de 2 min antes de la intubación y esternotomía; el grupo C (control) recibió NaCl al 0,9%. Todos los parámetros demográficos fueron registrados. Los valores de frecuencia cardíaca y presión arterial fueron registrados ya antes de la infusión y hasta la inducción de la anestesia cada minuto durante la intubación endotraqueal, cada minuto durante 10 min después de la intubación endotraqueal, y antes, durante y después de la esternotomía en el primer y quinto minutos. RESULTADOS: mientras que el área bajo la curva (AUC) (presión arterial sistólica [PAS] × tiempo) fue mayor en los grupos B y C que en el grupo I, el AUC (PAS ×T int y T st ) y AUC (PAS × T 2 ) fueron mayores en los grupos B y C que en el grupo I (p < 0,05). Además, el AUC (frecuencia cardíaca × T st ) fue menor en el grupo B que en el grupo C, pero no hubo diferencia significativa entre los grupos B e I. CONCLUSIÓN: este estudio destaca que la administración del esmolol en infusión es más eficaz que en bolos para controlar la PAS durante la intubación endotraqueal ...