Instalación ecoguiada del balón de contrapulsación intraaórtico (BCPIA) vía arteria axilar por abordaje extratorácico en pacientes en espera de trasplante cardíaco / Echo-guided installation of Inta aortic balloon counterpulsation via the extra thoracic axillary artery

Resumen El balón de contrapulsación intraaórtico (BCPIA) es el dispositivo más frecuentemente utilizado para otorgar soporte mecánico en pacientes con insuficiencia cardíaca terminal y compromiso hemodinámico refractario al soporte inotrópico. Se han utilizado diferentes tipos de abordajes para la instalación del BCPIA a través de las extremidades superiores, ya sea vía arteria subclavia o últimamente vía arteria axilar. Con el objetivo de evitar la inmovilidad física asociada al BCPIA instalado vía arteria femoral, aumentar la comodidad del paciente, simplificar la técnica de instalación del catéter y facilitar los cuidados de enfermería necesarios para su mantención, hemos diseñado y utilizado un abordaje simple y seguro para su inserción. Bajo técnica ecoguiada y utilizando un set de micro punción, se realizó la canulación de la arteria axilar en su porción externa (lateral al borde externo del músculo pectoral menor). Con la ayuda de fluoroscopía, el BCPIA fue avanzado hasta posicionarlo en la aorta descendente bajo la emergencia de la arteria subclavia izquierda. En dos pacientes con insuficiencia cardíaca terminal INTERMACS 2, con deambulación restringida debido a la necesidad permanente de soporte inotrópico y BCPIA femoral, bajo visión ecoguiada se realizó la reinstalación de este catéter a través de la arteria axilar izquierda, utilizando anestesia local y fluoroscopía en el laboratorio de hemodinamia. La rehabilitación fue posible rápidamente en ambos pacientes, realizándose el transplante cardíaco ortotópico después de 10 y 69 días de soporte mecánico con BCPIA, sin mayores efectos adversos.

Abstract Intra aortic balloon counterpulsation (IABP) is the most frequently used procedure to give mechanic support in patients with terminal heart failure and hemodynamic compromise refractory to inotropic support. Different approaches have been utilized to install upper extremity IABP, via either the axillary or subclavian arteries. In order to circumvent the limitations associated to long lasting femoral IABP support, simplify the technique, increase patient comfort and facilitate nursing care, we designed a simplified approach. Using echo guidance, the axillary artery was accessed with a micropuncture set just outside the external margin of the pectoral minor muscle. With the help of fluoroscopy the IABP catheter was advanced and its correct position in the descending aorta was confirmed. Two patients in INTERMACS 2 end stage heart failure, bedridden due to permanent inotropic support and femoral IABP, underwent echo guided axillary IABP placement under local anesthesia and fluoroscopy in the catheterization laboratory. Both patients gained rapid access to rehabilitation and received orthotopic heart transplantation after 10 and 69 days of uneventful IABP support.

Ectasia coronaria y miocardiopatía hipertrófica: una entidad infrecuente / Coronary artery ectasia and hypertrophic cardiomyopathy: case report

Resumen Se presenta el caso de un paciente de 54 años que consulta por angina de esfuerzo de 2 años de evolución en quien se identifica una dilatación ectásica del árbol coronario con lesiones ateroscleróticas críticas y miocardiopatía hipertrófica septal obstructiva. Una revisión bibliográfica revela que es una asociación infrecuente de la cual solo existen reportes de casos aislados.

Abstract We present the case of a 54-year-old patient who presented with a history of 2 years with angina. Invasive studies revealed critical coronary artery stenosis coexisting with obstructive hypertrophic miopathy. This is a rare association with only isolated case reports.

Retrasplante cardíaco: reporte de un caso / Cardiac re-transplantation: case report

RESUMEN: El Trasplante cardíaco es la mejor alternativa para la insuficiencia cardíaca terminal, logrando buenos resultados de sobrevida y calidad de vida a largo plazo. Una de las causas más importantes de morbimortalidad es la falla del injerto, la que puede ser secundaria, entre otros, a rechazo agudo y/o vasculopatía y su presencia requiere considerar todas las alternativas terapéuticas, dentro de las cuales está el retrasplante. Los resultados de sobrevida en retrasplante cardíaco son buenos. No obstante, los pacientes presentan los riesgos de una terapia inmunosupresora más intensa, así como el desarrollo recurrente de vasculopatía del injerto. Por lo que se considera una opción en pacientes cuidadosamente seleccionados, dado que la experiencia internacional demuestra que la sobrevida del retrasplante es menor que en el primer trasplante. Presentamos el caso de un paciente trasplantado a los 42 años, quien desarrolla una enfermedad vascular del injerto e insuficiencia cardíaca con capacidad funcional IV, por lo cual se decidió realizar un retrasplante cardíaco.

ABSTRACT: Cardiac transplantation is the best alternative for terminal heart failure, achieving good long-term survival and life quality. One of the most important causes of morbidity and mortality is graft failure, which may be secondary, among others, to acute rejection and / or vasculopathy and its presence requires the consideration of all therapeutic alternatives, re transplantation being one of them. The results of survival in cardiac retransplantation are good; however, they present the risks of a more intense immunosuppressive therapy as well as the recurrent development of graft vasculopathy. Therefore, it is considered an option in carefully selected patients given that international experience shows that the survival of retransplantation is lower than in primary cases. We present the case of a 42 year old transplanted patient , who developed graft vascular disease with progressive deterioration of his ventricular function leading to functional class IV. for which a cardiaccardiac retransplantation was performed.

Mixoma cardíaco: experiencia de 28 años en resección quirúrgica / Cardiac myxomas. Analysis of 78 cases

Background: The incidence rates of cardiac tumors are low. Aim: To report the clinical presentation of cardiac myxomas and long-term evolution after resection. Material and Methods: Review of a database of surgical patients undergoing surgical resection of a cardiac myxoma in a public hospital between 1990 and 2018. Results: Seventy-eight patients aged 53 ± 15 years (65% females) were included. The most frequent comorbidities were arterial hypertension (40.5%), hypothyroidism (15%) and diabetes mellitus (12%). The main presenting symptoms were dyspnea (33%), neurological deficit secondary to embolism (30%) and acute pulmonary edema (5%). The most common location was the left atrium, in 87%. During surgery, cardiopulmonary bypass and aortic cross-clamp times were 50.2 ± 19.6 and 33.4 ± 15.2 min, respectively. One patient died due to severe neurological involvement. Follow-up was completed in seventy-seven patients, with a mean echocardiographic follow-up time of 10.4 ± 7.7 years. Thirty-four patients were followed for more than 10 years. Six patients (7.7%) died during the follow-up and in six patients (7%) a recurrence was identified. Conclusions: Cardiac myxoma usually has nonspecific symptoms. Surgical excision offers excellent short and long-term results. Complications and recurrence rates are low in non-hereditary myxomas but obligates to perform echocardiographic follow-up for early diagnosis of recurrence.

Sobrevida a 10 años de pacientes egresados luego de cirugía por endocarditis infecciosa en un hospital público / Hospital mortality and long-term survival of 103 patients with infective endocarditis requiring surgery

Background Infective endocarditis (IE) is a serious disease with high mortality, especially among the most severe cases undergoing surgery. Aim To analyze the clinical features, perioperative mortality and long-term survival of patients with infective endocarditis requiring surgery. Material and Methods Review of medical records of patients who underwent heart valve surgery for active infective endocarditis in a public hospital between 1995 and 2008. Demographic characteristics and comorbidities were described. Perioperative and 10 year survival were analyzed retrieving death certificates from the Chilean Identification Service. Results Data from 103 patients aged 46 ± 14 years (74% males) was analyzed. Thirty five percent of patients had an underlying predisposing heart condition such as congenital heart disease in 18.5% and prosthetic valves in 10%. The most common location was the aortic valve and the most common surgical procedure was heart valve replacement with a mechanical prosthetic valve in 87% of the cases. Pathogen identification in blood cultures was achieved in 48% of the cases. The most common causative microorganisms were S. aureus in 12%, coagulase-negative Staphylococcus in 11%, S. viridans in 10% and Enterococcus in 7%. Hospital mortality was 20.4% and ten-year survival was 65%. Conclusions Patients with severe IE requiring surgical treatment still have high perioperative and late mortality.

Traslado aéreo de un paciente con insuficiencia cardíaca conectado a ECMO / Air transfer of a heart failure patient on ECMO

El traslado aéreo con ECMO es una forma segura y eficaz de trasladar pacientes para obtener mejores opciones terapéuticas. Este caso clínico ilustra la factibilidad, de este modo de apoyo al tratamiento de pacientes críticos, en este caso de una valvulopatía con indicación quirúrgica.

Air transfer of patients on ECMO is a safe mode to allow for treatment of patients located in places with limited resources for intensive care treatments in cardiovascular disease. The present case illustrates the feasibility and conditions required to implement the procedure. The case herein reported was a patient with severe valvular heart disease requiring surgery.

Asistencia ventricular intracorpórea en falla cardiaca terminal / Left ventricular assistant devices for end-stage heart failure: report of two cases

In the last 2 decades, there have been significant advances in medical treatment of heart failure. However, there is a group of patients who are refractory to the available medical therapy and progress inevitably to a state of end-stage heart failure, whose only therapeutic alternative is cardiac transplantation. But this is an option limited by the scarce availability of donors. Therefore many patients die waiting for an organ. Recently, extra or intracorporeal left ventricular devices have emerged as a viable alternative for patients with end-stage heart failure waiting for a heart transplant. These devices discharge the left ventricle, increasing cardiac output and improving systemic perfusion. This year, in our hospital we began a left ventricular device implantation program for the most severely ill patients on the waiting list for cardiac transplantation. We report two males aged 30 and 53 years, in whom a left ventricular device was successfully implanted, using a minimally invasive surgical technique developed at the University of Hannover in Germany.

Shock cardiogénico refractario: rescate con ECMO, asistencia ventricular y trasplante / Cardiogenic shock: rescue with ECMO, ventricular assist and heart transplantation

Presentamos un caso de infarto agudo al miocardio complicado con shock cardiogénico y arritmias ventriculares refractarias. El paciente requirió oxigenación por membrana extracorpórea (ECMO) antes de su traslado a un hospital con asistencia ventricular izquierda (LVAD) y programa de trasplante de corazón. El paciente tuvo una buena recuperación después de 16 días de soporte con LVAD seguido de trasplante cardiaco, lo que muestra los beneficios de la terapia multimodal en casos complejos de shock cardiogénico refractario.

A case of acute myocardial infarction complicated with cardiogenic shock and refractory ventricular arrhythmias is described. The patient required extracorporeal membrane oxygenation (ECMO) prior to transfer to a hospital with a left ventricular assist device (LVAD) and heart transplantation program. He made a good recovery after 16 days of LVAD support followed by heart transplantation, showing the benefits of multimodal therapy incomplex cases of refractory cardiogenic shock Palabras clave: Infarto agudo del miocardio, shock cardiogénico,asistencia biventricular, ECMO.

Enfermedad coronaria aneurism tica severa en un adolescente con angina de esfuerzo secundaria a enfermedad de Kawasaki no diagnosticada previamente / Severe aneurisma I coronary artery disease probably caused by Kawasaki disease. Report of one case

We report a 16 year old male with a history of angina on exertion. A treadmill exercise test was positive for ischemia in concordance with a Thallium-201 scintigraphy showing a septal and infero-posterior reversible myocardial perfusi¢n defect. Coronary angiography disclosed severe aneurysmal coronary artery disease. Bilateral internal mammary coronary artery bypass grafting was successfully performed. Kawasaki disease is the most likely etiology, although not confirmed.