Falla cardio respiratoria severa tratada con asistencia cardiopulmonar extracorpórea: caso clínico / Treatment of severe respiratory failure with cardiopulmonary extracorporeal assistance

Cardiopulmonary extracorporeal assistance is a high complexity procedure for patients with acute respiratory failure, who have failed conventional ventilatory support. A 30 years old female patient with bacterial endocarditis and congestive cardiac failure subjected to cardiac surgery presented severe hypoxemia, right heart failure and pulmonary hypertension, and failed conventional treatment. Cardiopulmonary support with extracorporeal membrane oxygenation (ECMO) reverted the pathophysiologic alterations allowing a successful recovery

Ruptura traumática de la aorta torácica y tratamiento no operatorio de lesión esplénica concomitante: caso clínico / Traumatic rupture of thoracic aorta and non operative treatment of concomitant splenic lesion: report of 1 case

We report a 26 years old male that suffered a motorcycle accident resulting in a traumatic aortic rupture and splenic laceration. He was subjected to a surgical repair of the aortic lesion under complete heparinization. The splenic rupture was non operatively managed successfully

Resultados alejados de la cirugía reconstructora de la insuficiencia mitral / Long term results of reconstructive surgery for mitral insufficiency

Background: Surgical repair is the procedure of choice for mitral insufficiency since it preserves better left ventricular structure and function. Aim: To assess the long term clinical and echocardiographic results of mitral valve reconstructive surgery. Material and methods: A review of clinical and echocardiographic data of 68 patients (34 male, age range 17 to 82 years), subjected to surgical mitral valve repair between december 1991 and march 1998. Preoperative functional capacity of these patients was 2.96 ñ 0.7. Surgical repair was assessed using transesophagic echocardiography in all subjects. Results: The etiology of mitral insufficiency was degenerative in 43 patients, rheumatic in 10, infectious in 6, ischemic in 5 and miscellaneous in 4. The most frequent pathological findings were dilatation of the mitral ring in 42 percent of patients, chordae tendinae rupture in 32 percent and enlargement in 24 percent. A mitral anuloplasty was done in 90 percent of patients, a cuadrilateral resection of posterior leaflet in 52 percent and chordae tendinae transference in 12 percent. An additional surgical procedure was done in 34 percent of subjects. Three patients died during hospitalization (4.4 percent). During the follow up of 36.5 ñ 22.3 months, five patients died and one required a mitral valve replacement. The actuarial survival probability was 95.3 ñ 2.6 percent at one year and 83.5 ñ 6.5 percent at five years. The reoperation free survival was 100 percent at one year and 97.4 ñ 2.5 percent at five years. At the end of follow up the functional capacity improved to 1.25 ñ 0.4. echocardiography showed absence of mitral insufficiency in 48.4 percent of patients, minimal, mild and moderate insufficiency in 35.5, 14.5 and 1.6 percent of patients respectively. Conclusions: Surgical valve reconstruction in mitral insufficiency has satisfactory long term results and should be the procedure of choice for eligible patients

Cirugía coronaria mínimamente invasiva / Minimally invasive coronary artery surgery

Background: There is a growing interest to perform a left internal mammary artery (LIMA) graft to the left anterior descending coronary artery (LAD) on a beating heart through a minimally invasive access to the chest cavity. Aim: To report the experience with minimally invasive coronary artery surgery. Patients and methods: Analysis of 11 patients aged 48 to 79 years old with single vessel disease that, between 1996 and 1997, had a LIMA graft to the LAD performed through a minimally invasive left anterior mediastinotomy, without cardiopulmonary bypass. A 6 to 10 cm left parasternal incision was done. The LIMA to the LAD anastomosis was done after pharmacological heart rate and blood pressure control and a period of ischemic pre conditioning. Graft patency was confirmed intraoperatively by standard Doppler techniques. Patients were followed for a mean of 11.6 months /7-15 months). Results: All patients were extubated in the operating room and transferred out of the intensive care unit on the next morning. Seven patients were discharged on the third postoperative day. Duplex scanning confirmed graft patency in all patients before discharge; in two patients, it was confirmed additionally by arteriography. There was no hospital mortality, no perioperative myocardial infarction and no bleeding problems. After follow up, ten patients were free of angina, in functional class I and pleased with the surgical and cosmetic results. One patient developed atypical angina on the seventh postoperative month and a selective arteriography confirmed stenosis of the anastomosis. A successful angioplasty of the original LAD lesion was carried out. Conclusions: A minimally invasive left anterior mediastinotomy is a good surgical access to perform a successful LIMA to LAD graft without cardiopulmonary bypass, allowing a shorter hospital stay and earlier postoperative recovery. However, a larger experience and a longer follow up is required to define its role in the treatment of coronary artery disease

Rol diagnóstico de la combinación tomografía computada - angiografía en lesiones traumáticas de la aorta torácica / Diagnostic role of the combination of computed tomography and angiography in traumatic injury of thoracic aorta

Aim: To assess tha diagnostic value of the combination of computed tomography and angiography in aptients with blunt thoracic trauma and suspicion of aortic injury. Patients and methods: restrospective analysis of six patients, aged 22 to 72 years old, with traumatic thoracic aorta injury secondary to severe trauma, specially car accidents, seen between 1985 and 1994. Results: an early diagnosis was done in 3 patients. One patient, in whom diagnosis was delayed, died before surgery. In 3 cases, CAT scan showed indirect evidence of aortic rupture, consisting in alterations of aortic outline. In other 3 patients, it showed hemomediastinum, associated to a left hemothorax in one case. Angiography confirmed the diagnosis, localized and characterized yhe injury in all patients. Conclusions: the delay in the diagnosis of aortic injury may be fatal. The combination of CAT scan and angiography has a high sensitivity and specificity to localize and characterize lesions of the aorta or its branches or associated organs, essential step for surgical planning. CAT scan restrict the use of angiography, avoiding false negative studies, but cannot be used as the sole diagnostic procedure

Cardioplejia retrógrada por canulación transauricular derecha del seno coronario / Retrograde cardioplegia trrough right transatrial cannulation of the coronary sinus

LA infusión de solución cardiopléjica por vía anterógrada tiene una demostrada efectividad protectora del miocardio durante la cirugía cardiaca. Sin embargo, en presencia de enfermedad coronaria grave, reoperaciones e hipertrofia ventricular esta efectividad puede ser limitada. Por otra parte, en cirugía valvular, interfiere con el desarrollo expedito dela operación. En estas circunstancias, la infusión retrógrada de solución cardiopléjica permite una mejor distribución de ésta en el miocardio. En 42 pacientes (32 hombres) operados entre septiembre de 1991 y septiembre de 1992 se utilizó para la protección del miocardio la infusión retrógrada solución cardiopléjica cristaloide, exclusiva o adicionada a la infusión anterógrada, a través de la canulación transauricular derecha del seno coronario, con un catéter especialmente diseñado. Veintidós casos correspondieron a revascularizaciones miocárdicas, y 20, a procedimientos valvulares. Nueve pacientes (21 por ciento ) tenían una disfunción ventricular severa, 8 estaban cursando un infarto miocárdico, y 7 casos fueron reoperaciones. No hubo ningún caso de infarto perioperatorio electrocardiográfico, pero 2 pacientes (4,8 por ciento ) presentaron elevación de CPK-MB significativa para injuria miocárdica. Once pacientes (26 por ciento ) requirieron inótropos en el postoperatorio (dopamina y/o dobutamina en 9 casos). Ninguno requirió balón de contrapulsación. No hubo morbilidad relacionada con la canulación del seno coronario ni con la infusión retrógrada de solución cardiopléjica. No hubo mortalidad hospitalaria. En esta experiencia inicial, la canulación transauricular derecha del seno coronario permite la infusión retrógrada de solución cardiopléjica en forma simple y efectiva, ofreciendo una buena protección miocárdica