Redefiniendo el estándar de oro para el reemplazo valvular aórtico: mínimamente invasivo y recuperación acelerada / Redefining the gold standard for aortic valve replacement: minimally invasive with accelerated recovery

Background: Despite being introduced 20 years ago minimally invasive aortic valve replacement is only performed routinely in a minority of patients world-wide. Aim: To report the operative outcome of minimally invasive aortic valve replacement done through a partial upper sternotomy. Patients and Methods: Retrospective analysis of data recorded prospectively of 450 consecutive patients with a median age of 66 years (59% males) who had a minimally invasive aortic replacement. Results: 79% of patients had aortic stenosis. Cross clamp/cardiopulmonary bypass times (median) were 56 and 68 minutes respectively. Conversion to full sternotomy was required in 2.6% of patients, reoperation for bleeding in 2.9%. 1.6% suffered a stroke and 19% postoperative atrial fibrillation. 0.9% required a permanent pacemaker. Postoperative mortality was 0.9%. Median postoperative hospital stay was six days. Conclusions: Minimally invasive aortic valve replacement can be performed with satisfactory results.

Peripheral venoarterial extracorporeal membrane oxygenation for periprocedural Cardiogenic shock during interventional cardiology

ABSTRACT Background: Cardiogenic shock (CS) is uncommon in the cardiac catheterization laboratory (CCL) among patients undergoing coronary angiography. Periprocedural CS is more frequent in high-risk patients and in technically demanding procedures. Aim: To describe the clinical outcomes of patients who underwent peripheral venoarterial extracorporeal membrane oxygenation (pVA-ECMO) for CS associated with interventional cardiology procedures. Material and Methods: Review of clinical records of seven patients treated between January 2014 and October 2018. Results: pVA-ECMO was implanted within 6 hours of the interventional cardiology procedure. All patients had coronary artery disease and one of them also had symptomatic severe aortic stenosis. One patient entered the CCL in cardiac arrest. Percutaneous coronary intervention (PCI) was performed in all patients; four patients underwent an emergency procedure and five patients experienced PCI complications. One patient undergoing transcatheter aortic valve replacement suffered acute severe aortic regurgitation. An intra-aortic balloon pump was inserted at the CCL in five patients. Six patients experienced cardiac arrest. Mean SAVE score was -4.3 and baseline lactate 55 mg/dl. pVA-ECMO mean duration was 5 ± 4 days. Survival after both hospital discharge and 12 months of follow-up was 85.7% Regarding vascular access complications, we observed one access site hematoma and one episode of cannulation site bleeding requiring surgical repair. Conclusions: pVA-ECMO should be considered in patients with periprocedural CS as a bridge to recovery. Its use was associated with improved clinical outcomes in this series.

Antecedentes: El shock cardiogénico (SC) es infrecuente en el laboratorio de cateterismo cardíaco (LCC) entre pacientes que son sometidos a coronariografía. El SC peri-procedimiento es más frecuente en pacientes de alto riesgo y en procedimientos técnicamente complejos. Objetivos: Describir los resultados clínicos de pacientes que fueron conectados a oxigenación con membrana extracorpórea veno-arterial periférica (ECMO-VAp) por SC peri-procedimiento de cardiología intervencional. Material y Métodos: Revisión de fichas clínicas de siete pacientes tratados en nuestro centro desde enero de 2014 a octubre de 2018. Resultados: ECMO-VAp fue utilizado dentro de las primeras 6 horas del procedimiento. Todos los pacientes tenían enfermedad coronaria y uno de ellos tenía además estenosis aórtica severa. Un paciente ingresó al LCC en paro cardíaco. Una intervención coronaria percutánea (ICP) fue realizada en todos los pacientes; 4 se realizaron procedimientos de emergencia y 5 pacientes tuvieron complicaciones de la ICP. A un paciente se le realizó un reemplazo valvular aórtico percutáneo y desarrolló una insuficiencia valvular aórtica aguda severa. Se instaló un balón de contrapulsación en el LCC en 5 pacientes. Seis pacientes tuvieron un paro cardiorrespiratorio. El valor del score de SAVE fue de -4,3 y el lactato basal 55 mg/dL. La duración media del ECMO-VAp fue 5 ± 4 días. La sobrevida al alta y a los 12 meses fue 85,7%. Como complicaciones del sitio de acceso vascular se observaron 1 hematoma y un episodio de sangrado que requirió reparación quirúrgica. Conclusiones: ECMO-VAp debería ser considerado en pacientes con SC peri-procedimiento como un puente a recuperación; su utilización estuvo asociada con mejoría de resultados clínicos en esta serie.

En el modelo preclínico de insuficiencia cardíaca por disfunción sistólica en ratón (coartación de aorta torácica) la velocidad de flujo carotídeo determinada precozmente se asocia a función ventricular izquierda tardía / Carotid flow velocity is associated to late ventricular function in mice with preclinic systolic dysfunction induced by thoracic aortic coarctation

Resumen: Los modelos experimentales de falla cardíaca con fracción de eyección disminuida en murinos son pocos. Uno de estos modelos es el de coartación de la aorta torácica en el arco aórtico (COA) en ratones. Un aspecto importante en su desarrollo es la evaluación precoz del procedimiento y su relación con la función sistólica posterior. En este sentido, las velocidades de flujo carotídeo y la relación entre ambos flujos (derecho, pre-coartación; izquierdo post coartación) pueden permitir evaluar tempranamente la precisión del procedimiento y relacionarse más tardíamente con la función sistólica VI. Nuestro objetivo fue comparar precozmente (semana 2 post operatoria) las velocidades de flujo en ambas carótidas (Doppler continuo) y tardíamente (semana 5 postoperatoria) la función sistólica VI (Ecocardiograma de superficie) en ratones seudocoartados o sham (n= 6) vs ratones COA (n = 12). Se confirmó una diferencia estadísticamente significativa en la relación de velocidades de flujo entre ambas carótidas medida precozmente entre los ratones sham y COA (1,1 ± 0,1 vs 2,5 ± 0,5, p< 0,001), lo que se correlacionó con un deterioro significativo de la función sistólica del ventrículo izquierdo evaluada a las 5 semanas en los ratones COA. Conclusión: En este modelo preclínico de falla cardíaca por sobrecarga de presión con fracción de eyección VI disminuida en ratón, el aumento precoz de la velocidad de flujo en la arteria carótida derecha (pre-coartación en el modelo COA) y sobre todo de la relación entre las velocidades de flujo carotídeo entre ambas carótidas se asocia a deterioro importante de la función sistólica VI cinco semanas después de efectuada la COA, lo que permite predecir la efectividad del procedimiento en este modelo experimental.

Abstract: There are few experimental models of heart failure with reduced ejection fraction in murines. One of these models is transverse aortic coarctation (TAC) in mice. However, an important challenge in its development is the early evaluation of the procedure and its relationship with late systolic LV function. In this sense, carotid flow velocities and the relationship between both (right, precoarctation, left post-coarctation) may allow early evaluation of the accuracy of the procedure and be related to late LV systolic function. The aim was to compare early (week 2 post-operative) flow velocities determined in both carotid arteries (by continuous Doppler) with late (week 5 postoperative) LV systolic function (by echocardiogram) in sham (n= 6) vs. TAC (n: 12) mice. We confirmed a statistically significant difference in the early ratio of carotid flow velocities (left/right common carotid velocity ratio) between sham and TAC mice (1.1 ± 0.1 vs 2.5 ± 0.5, p< 0.001) and this correlated well with a deteriorated left ventricular function in the TAC mice after 5 weeks. In this preclinical model of cardiac failure due to pressure overload with reduced LV ejection fraction in the mouse, the early increase in right carotid flow velocity (precoarctation) and especially the relationship between precoarctation/postcoarctation carotid flow velocities is associated with significant impairment of LV systolic function five weeks after the TAC, which allows to predict the effectiveness of the procedure in this experimental model.

Recomendaciones de manejo de pacientes con asistencia circulatoria mecánica de corta duración / Recommendations for the management of patients with short-term mechanical circulatory assistance

There has been a progressive increase in the use of mechanical circulatory support in our country in the last years, mainly in the short-term: as a bridge to cardiac transplant or recovery, which has allowed to rescue patients from a population that concentrates high rates of complications and mortality. This motivated that the Ministry of Health convened a series of experts in the area of heart failure, transplantation and mechanical circulatory support, representatives of different public and private health centers in Chile, with the objective of developing recommendations on the use of short-term mechanical assistance devices, which would serve as a reference for the proper management of these patients. This clinical experts consensus document contains topics related to: definitions and general concepts; indications; contraindications; specific aspects of starting, follow-up and weaning of the devices; process of transfer of patients in circulatory assistance from one center to another and finally criteria of organization, means and competences to be fulfilled by the centers that offer this therapeutic option.

Síncope secundario a mixoma gigante del anillo mitral: reporte de un caso / Large mitral annulus myxoma presenting with syncope: report of one case

We report a 23-year-old woman, with three recent exertional syncopes. Transthoracic (TTE) and transesophageal (TEE) echocardiography found a large heterogeneous mass (38 x 35 mm) arising from the posterior mitral annulus, protruding in systole through the left ventricular outflow tract (LVOT). Heart MRI confirmed the echocardiography findings, suggesting a cardiac myxoma. Cardiac surgery accomplished the complete resection of the lesion, confirming a mass arising from the posterior mitral annulus and preserving mitral anatomy and function. Pathology was positive for a myxoma. Uneventful evolution allowed the discharge of the patient at the fifth postoperative day. Control TTE discarded any complication.

Hendidura de velo posterior que simula una válvula mitral de tres velos / Cleft of the posterior mitral valve leaflet simulating a three leaflet valve

Reportamos el caso de una mujer de 55 años, que completo terapia antibiótica por una periodontitis con buena respuesta clínica. Posteriormente, presentó fiebre y dolor lumbar, hospitalizándose para estudio. Destacaban parámetros inflamatorios elevados y hemocultivos positivos para Streptococcus Viridans. Estudio de imágenes confirmaron espondilodiscitis de L5-S1. Se efectuó un Ecocardiograma transesogáfico (ETE), que mostró una válvula mitral de aspecto tricúspide, con prolapso del velo posterior (P2-P3) e insuficiencia severa, más una endocarditis mural auricular izquierda por lesión de jet. Se efectuó cirugía cardíaca con reparación mitral. Los hallazgos intraoperatorios mostraron el aparato subvalvular y músculos papilares habituales. Por lo tanto, el aspecto de la válvula mitral fue interpretado como una hendidura profunda del velo posterior.

We report the case of a 55 year old woman, previously treated with antibiotics for periodontitis. She was admitted with fever and lumbar pain. An elevated C reactive protein (CRP) and positive blood cultures for Streptococcus Viridans were found and infectious spondylodiscitis of L5-S1 was confirmed. Transeso-phageal echocardiography (TEE) was performed. A tri-leaflet mitral valve and prolapse of posterior leaflet (P2-P3) were found and severe mitral regurgitation was present on doppler examination In addition, a left atrial mural vegetation (jet lesion) was found. At cardiac surgery mitral valve repair and resection of the mural vegetations were performed. The papillary muscles were normal, and this tri-leaflet aspect of the mitral valve was interpreted as a deep posterior cleft with symmetrical distribution of all remaining segments.