Extracorporeal Membrane Oxygenation Uses in Refractory Cardiogenic Shock After Open-Heart Surgery

ABSTRACT Introduction: Extracorporeal membrane oxygenation (ECMO) is the first-line therapy for temporary mechanical circulatory support allowing cardiac and pulmonary recovery or as a bridge to further therapeutic alternatives. The aim of this study was to report clinical outcomes in adult patients with refractory cardiac failure after open-heart surgery undergoing ECMO in a single center with an ECMO unit in Chile. Methods: We retrospectively analyzed adults with refractory cardiac failure after open-heart surgery who required a venoarterial (VA) ECMO between 2016 and 2021. Results: Of 16 patients with VA ECMO, 60% were men (n=10), 90% had hypertension (n=14), 69% had < 30% of left ventricular ejection fraction (n=11), and the mean European System for Cardiac Operative Risk Evaluation II score was 12 ± 11%. ECMO support with central cannulation accounts for 81% (n=13), and an intra-aortic balloon pump was used in nine patients (56%). The mean time of support was 4.7 ± 2.6 days (1.5 - 12 days). ECMO weaning was achieved in 88% of patients, and in-hospital mortality was 44% (n=7) after discharge. The freedom from all-cause mortality at one year of follow-up of the entire cohort was 38% (n=6). Conclusion: VA ECMO is now a well-known life-saving therapeutic option, but mortality and morbidity remain high. Implementation of an ECMO program with educational training is mandatory in order to find the proper balance between patient benefits, ethical considerations, and public health financial input in South America.

Revascularización coronaria híbrida: un punto de encuentro entre cardiólogos intervencionistas y cirujanos cardíacos / Hybrid coronary revascularization: a meeting point between interventional cardiologists and cardiac surgeons

Resumen: La revascularización coronaria híbrida busca combinar el beneficio de las técnicas quirúrgicas y percutáneas para un manejo óptimo de pacientes seleccionados con enfermedad coronaria obstructiva multivaso. Esto permite asociar el beneficio del puente de arteria mamaria interna izquierda a la arteria descendente anterior (ADA) y combinarlo con el implante de stents en lesiones no-ADA. El objetivo de este trabajo es hacer una revisión de la literatura disponible con énfasis en sus resultados clínicos comparados con la estrategia convencional.

Abstract: Hybrid coronary revascularization seeks to combine the benefit of surgical and percutaneous techniques for optimal management of selected patients with multivessel coronary artery disease. This allows combining the benefit of the left internal mammary artery bypass to the anterior descending artery (LAD) and stent deployment in non-LAD lesions. The objective of this manuscript is to review the available literature with emphasis on its clinical results compared to the conventional strategy.

Veinte años de reparación de Ia válvula aórtica bicúspide insuficiente / Repair of the regurgitant bicuspid aortic valve: a twenty year experience

Introducción: La Insuficiencia Aórtica (IA) excepcionalmente es susceptible de reparación. Una de estas excepciones es la Válvula Aórtica Bicúspide (VAB). Objetivo: Analizar nuestros resultados de la reparación de la VAB insuficiente. Método: Se revisó la Base de Datos para el período enero 1994 a Julio 2014. Se identificaron 29 pacientes y se revisaron las fichas clínicas y protocolos operatorios. La supervivencia se certificó en el Registro Civil e Identificación de Chile. Resultados: Todos los pacientes fueron hombres. La edad promedio fue 39,4 años (19- 61 años). Cinco pacientes presentaban una endocarditis. El ecocardiograma preoperatorio demostró IA severa en 25 casos (86%) y moderada en 4. El diámetro sis-tólico fue 44 ± 7,1 mm y el diastólico 67,8 ± 6,7 mm. La fracción de acortamiento fue 35,96 ± 5,54%. En todos los casos la VAB presentaba fusión del velo coronariano izquierdo y derecho con rafe medio; en 3, el rafe era incompleto produciéndose un cleft. En 23 casos (79%) la IA era secundaria a prolapso del velo fusionado, en 3 a perforación de velo, en 1 a un cleft y en 2 a perforación y cleft. En 23 casos (79%) se efectuó una resección triangular y en 16 (55%) se complementó con una anuloplastía. En 3 se cerró una perforación y en otros 3 se efectuó un cierre primario de cleft. En 10 casos se realizó un procedimiento asociado. En todos los casos se realizó un ecocardiograma transesofágico intra-operato-rio. En 35% no hubo insuficiencia aórtica residual y en 65% esta fue mínima o leve. No hubo mortalidad operatoria. El seguimiento se completó en el 100%. Dos pacientes (7%) fallecieron por causas no cardiacas. Siete (24%) fueron re-operados, en promedio a los 7,14 años. La media de supervivencia fue 19,3 años (IC95% 17,6-21) y la supervivencia libre de re-operación 15,8 años (IC95% 13-18,7), a 20,6 años de seguimiento. El ecocardiograma efectuado en promedio a los 4,9 años demostró una reducción del diámetro sistólico de 6,15 ± 7,2 mm (p<0,05), del diastólico de 11,26 ± 8,7 mm (p<0,05) y de la fracción de acortamiento de 1,12 ± 5,57% (p<0,33). De los 22 pacientes no reoperados, 9 no tenían IA, en 6 esta era leve (1+) y en 3 leve a moderada (2+); 4 pacientes tenían una estenosis aórtica leve. Conclusión: La reparación quirúrgica de la válvula aortica bicúspide insuficiente tiene baja mortalidad peri-operatoria y excelente supervivencia alejada. Si bien el 24% de los pacientes requirió una re-operación, esta fue tardía en la mayoría de los casos.

Background: Aortic insufficiency (AI) is rarely amenable to surgical repair. One of the exceptions to that statement is the bicuspid aortic valve Aim: to analyze our results in the repair of a regur-gitant bicuspid aortic valve Method: A review of the cardiac surgery data base in the period January 1994 to July 2014 allowed the identification of 29 patients with AI and a bicuspid aortic valve submitted to surgical repair. The data from the clinical record and the surgical report was analyzed. Survival was established from the National Identification Service. Results: all patients were males. Mean age was 39.4 years (range 19-61). Five patients had infective endocarditis. Preoperative echocardiography revealed severe AI in 25 patients (86%) and moderate AI in 4. Left ventricular diastolic and systolic diameters were 67,8 ± 6,7 and 44 ± 7,1 mm, respectively. All patients presented fusion of the left and right leaflets with mid rafhe, and 3 patients had an incomplete rafhe with a cleft. AI was caused by prolapsed fu-sioned leaflet in 23 patients, leaflet perforation in 3, cleft in one and perforation plus cleft in 2 patients. Triangular resection was performed in 23 (79%) and complemented by annuloplasty in 16 (55%) patients. Three patients underwent closure of a perforation and 3 a repair of the cleft. An additional surgical procedure was performed in 10 patients. All patients underwent intra-operative TEE. 35% had no residual AI and 65% had minimal or mild AI. There was no surgical mortality. Follow up was completed in all patients. Two patients (7%) died from non cardiac causes. Seven patients (24%) had to be re-operated on, a mean of 7.1 years after the initial surgery. Mean survival rate was 19.3 (95% CI 17.6-21), and mean survival free from re-operation was 15.8 years (95%CI 13-18.7) at 20.6 years of follow up. Echo-cardiogram performed at a mean of 4.9 years after surgery showed a reduction of LV systolic diameter of 6,15 ± 7,2 mm (p<0,05), LV diastolic diameter of 11,26 ± 8,7 mm (p<0,05) and fractional shortening of 1,12 ± 5,57% (p<0,33). In the group of 22 patients who did not have a re-operation, AI was absent in 9, mild in 6 and moderate in 3; 4 patients had mild aortic stenosis. Conclusion: Surgical repair of the regurgitant bicuspid aortic valve has low peri-operative mortality rate and excellent late survival. Reoperation, required in 24% of patients, occurred late after the initial operation in most cases.