Cirugía cardiaca en el paciente con cáncer / Cardiac surgery in the cancer patient

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Three-dimensional versus two-dimensional transesophageal echocardiography in mitral valve repair.

OBJECTIVES: We sought to compare the diagnostic performance of 3-dimensional (3D) versus 2-dimensional (2D) echocardiography in patients with regurgitant mitral valve. BACKGROUND: An accurate assessment of morphology and function of the mitral valve is essential for surgical repair. Two-dimensional echocardiography has certain spatial limitations that could be overcome by 3D imaging. METHODS: Preoperative transesophageal 2D and 3D studies were compared with surgical findings in patients undergoing surgical repair for severe mitral regurgitation. RESULTS: A total of 81 consecutive patients underwent surgical repair (2002-2004). There was a high concordance (88%-100%) between both 2D and 3D studies and surgical findings in classification of involved segments. 3D imaging more accurately classified A1 segment defects (P = .05) and commissural dysfunction (P = .02). The 2D study incorrectly classified 22 segments, mainly corresponding to complex disease. The 3D study incorrectly classified 14 segments, unrelated to complex disease. Good agreement (94%, kappa 0.845) was found between non-expert and expert interpretations of 3D images. CONCLUSIONS: Three-dimensional echocardiography offers high accuracy in mitral valve evaluation. It may complement 2D study in patients with complex valve anatomy, where surgical decisions are more difficult. The images can be easily interpreted by professionals without a high degree of experience.

[Primary prophylaxis with the implantable cardioverter-defibrillator in heart failure: a clinical point of view]. / Profilaxis primaria con desfibrilador-cardioversor implantable en la insuficiencia cardiaca: un punto de vista clínico.

The implantable cardioverter-defibrillator (ICD) is one of the great inventions of modern cardiology. Its use for the prevention of sudden death in patients with left ventricular dysfunction has meant that clinical cardiologists are now fully involved in decision-making on the implantation of these devices. The majority of clinical trials, which have used low ejection fraction as the only or main criterion for patient recruitment, have shown that ICD use leads to a significant improvement in survival. Three trials, two of which were carried out soon after myocardial infarction and one of which was performed at the same time as surgical revascularization, were exceptions. However, it is important to be aware that the improvements observed in the most recent trials have not been as large as those seen in the initial studies. Reduced efficacy has meant that in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), for instance, 25 ICDs had to be implanted to save one life over a 2-year period. The most likely explanation for this observation is that the better prognosis achieved by present-day pharmacologic treatment of heart failure has reduced the margin of benefit associated with ICD use. Another consequence is that depressed left ventricular ejection fraction has lost some of its specificity in predicting sudden death. New predictive variables are needed to improve risk stratification in this population. Without these variables, the use of ICDs in the primary prevention of sudden death in patients with left ventricular dysfunction will not seem a very attractive option from the point of view of good clinical practice.

Sustained monomorphic ventricular tachycardia associated with unrepaired double-chambered right ventricle.

Double-chambered right ventricle (DCRV) is a congenital anomaly characterized by the division of the ventricular cavity into two chambers separated by an abnormal hypertrophied muscular band or by severe hypertrophy of the muscle wall. Two adult patients with a diagnosis of DCRV presented sustained monomorphic ventricular tachycardia. In both cases, the clinical tachycardia was induced with programmed stimulation. After surgically resecting, the muscular band tachycardia could no longer be induced in the patient who underwent follow-up electrophysiological study. The outcome was favourable; there was no clinical recurrence of ventricular tachycardia in the two patients at 48 and 36 months, respectively.

[Mitral valve repair for mitral regurgitation]. / Cirugía de reparación valvular en la regurgitación mitral.

We analyzed the results of mitral valve repair in 81 consecutive patients with severe mitral regurgitation. Of these patients, 66.6% had myxomatous degeneration, 11% ischemic disease, 8% chordal rupture, 5% congenital disease, and 3.7% endocarditis. Repair could not be achieved in five patients, and valve replacement was necessary. Six died during surgery (mortality 7%). During follow-up (mean 30 [8] months), there was one death due to refractory ischemic heart failure and mitral regurgitation (>or= 2/4) was observed in 11 patients. A good result (i.e., survival without a prosthesis, major complications, or mitral regurgitation >1/4) was obtained in 78% of patients with myxomatous degeneration versus 48% of those with other etiologies (P=.023). A good result was obtained more frequently in cases of isolated posterior cusp degeneration than in those involving degeneration of both cusps (85% vs 70%; P=.03).

Cirugía de reparación valvular en la regurgitación mitral / Mitral valve repair for mitral regurgitation

Analizamos los resultados de la reparación valvular mitral en 81 pacientes consecutivos con insuficiencia severa de la válvula. El 66,6% de los pacientes tenía degeneración mixoide; el 11%, etiología isquémica; el 8%, rotura de cuerdas; el 5%, congénita y el 3,7%, endocarditis. En 5 casos fue preciso sustituir la válvula al no conseguirse una reparación adecuada. La mortalidad operatoria fue de 6 pacientes (7%). En el seguimiento (media, 30 +/- 8 meses) hubo un fallecimiento por insuficiencia cardiaca isquémica refractaria y 11 pacientes quedaron con insuficiencia mitral >= 2/4. Se obtuvo buen resultado (supervivencia sin prótesis, regurgitación mitral > 1/4 o complicación mayor) en el 78% de los pacientes con afección mixoide frente al 48% de aquellos cuya enfermedad no era mixoide (p = 0,023). La tasa de buen resultado fue superior en la degeneración aislada del velo posterior que en la afección de ambos velos (85% frente a 70%; p = 0,003)

We analyzed the results of mitral valve repair in 81 consecutive patients with severe mitral regurgitation. Of these patients, 66.6% had myxomatous degeneration, 11% ischemic disease, 8% chordal rupture, 5% congenital disease, and 3.7% endocarditis. Repair could not be achieved in five patients, and valve replacement was necessary. Six died during surgery (mortality 7%). During follow-up (mean 30 [8] months), there was one death due to refractory ischemic heart failure and mitral regurgitation (>= 2/4) was observed in 11 patients. A good result (i.e., survival without a prosthesis, major complications, or mitral regurgitation >1/4) was obtained in 78% of patients with myxomatous degeneration versus 48% of those with other etiologies (P=.023). A good result was obtained more frequently in cases of isolated posterior cusp degeneration than in those involving degeneration of both cusps (85% vs 70%; P=.03)

Profilaxis primaria con desfibrilador-cardioversor implantable en la insuficiencia cardiaca: un punto de vista clínico / Primary Prophylaxis With the Implantable Cardioverter-Defibrillator in Heart Failure: a Clinical Point of View

El desfibrilador-cardioversor implantable (DCI) es uno de los grandes inventos de la cardiología moderna. Su empleo para la prevención de la muerte súbita en los pacientes con disfunción ventricular izquierda ha implicado de lleno al cardiólogo clínico en la toma de decisiones relacionada con la implantación de estos dispositivos. La mayoría de los ensayos realizados, que utilizaron una fracción de eyección deprimida como único o principal criterio para la inclusión de pacientes, han demostrado una mejora significativa de la supervivencia con el DCI. Tres ensayos ¬dos hechos en la fase precoz del postinfarto y uno al mismo tiempo que la cirugía de revascularización miocárdica¬ constituyen excepciones. Es preciso subrayar que en los ensayos más recientes las diferencias no han sido tan grandes como las obtenidas en los estudios iniciales. Esta disminución de la eficacia hace que en el SCD-HeFT, por ejemplo, hubiese que implantar 25 DCI para, en un horizonte de 2 años, salvar una vida. Este hecho se debe, muy probablemente, a la mejora pronóstica conseguida por el tratamiento farmacológico actual de la insuficiencia cardiaca, que estrecha el margen de beneficio posible del DCI. Como consecuencia, la fracción de eyección deprimida ha perdido cierto grado de especificidad en la predicción de muerte súbita. Se necesitan, pues, nuevas variables que mejoren la estratificación del riesgo en esta población. Mientras esto no suceda, la prevención primaria de muerte súbita con DCI en la disfunción ventricular izquierda será una terapia poco atractiva desde el punto de vista de una práctica clínica responsable (AU)

The implantable cardioverter-defibrillator (ICD) is one of the great inventions of modern cardiology. Its use for the prevention of sudden death in patients with left ventricular dysfunction has meant that clinical cardiologists are now fully involved in decision-making on the implantation of these devices. The majority of clinical trials, which have used low ejection fraction as the only or main criterion for patient recruitment, have shown that ICD use leads to a significant improvement in survival. Three trials, two of which were carried out soon after myocardial infarction and one of which was performed at the same time as surgical revascularization, were exceptions. However, it is important to be aware that the improvements observed in the most recent trials have not been as large as those seen in the initial studies. Reduced efficacy has meant that in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT), for instance, 25 ICDs had to be implanted to save one life over a 2-year period. The most likely explanation for this observation is that the better prognosis achieved by present-day pharmacologic treatment of heart failure has reduced the margin of benefit associated with ICD use. Another consequence is that depressed left ventricular ejection fraction has lost some of its specificity in predicting sudden death. New predictive variables are needed to improve risk stratification in this population. Without these variables, the use of ICDs in the primary prevention of sudden death in patients with left ventricular dysfunction will not seem a very attractive option from the point of view of good clinical practice (AU)

[Left ventricular dysfunction induced by monomorphic ventricular arrhythmias: large improvement in ventricular function after radiofrequency ablation of the arrhythmic source]. / Disfunción ventricular izquierda inducida por arritmias ventriculares monomórficas: gran mejoría de la función ventricular tras ablación con radiofrecuencia del foco arrítmico.

Left ventricular systolic dysfunction related to ventricular arrhythmias is a relatively poorly understood entity. To increase our knowledge base, we describe 5 patients in whom the link between ventricular dysfunction and ventricular arrhythmia was unequivocally established. All patients had repetitive monomorphic ventricular arrhythmias and left ventricular systolic dysfunction (ejection fraction < or =40% and end-diastolic size > or =55 mm). The arrhythmogenic source was identified by electrophysiological study (right ventricle in 2 patients, left ventricle in 2, and left sinus of Valsalva in one), and was eliminated in all patients by radiofrequency catheter ablation. At 7+/-2 months post-ablation, large improvements were seen in left ventricular function and remodeling (ejection fraction >/=50% and end-diastolic size < or =51 mm in all cases), with no recurrence of arrhythmia during follow-up (10-69 months). This finding confirms that recurring ventricular arrhythmias can induce left ventricular dysfunction which may be reversible after ablation.

Disfuncion ventricular izquierda inducida por arritmias ventriculares monomorficas: gran mejoria de la funcion ventricular tras ablacion con radiofrecuencia del foco arritmico / Left ventricular dysfunction induced by monomorphic ventricular arrhythmias: large improvement in ventricular function after radiofrequency ablation of the arrhythmic source

Disfunción ventricular izquierda inducida por arritmias ventriculares monomórficas: gran mejoría de la función ventricular tras ablación con radiofrecuencia del foco arrítmico. La disfunción ventricular izquierda ocasionada por arritmias ventriculares es una entidad poco conocida. Para contribuir a su difusión presentamos los casos de 5 pacientes en los que se pudo establecer de forma inequívoca la conexión arritmia-disfunción ventricular. Todos tenían arritmias ventriculares monomórficas repetitivas y disfunción ventricular izquierda(fracción de eyección ? 40% y dimensión tele-diastólica ? 55 mm). En el estudio electrofisiológico se detectó un foco arritmogénico intraventricular localizado en el ventrículo derecho en 2 casos, en el ventrículo izquierdo en otros 2 y en el seno de Valsalva izquierdo en el quinto; en todos fue suprimido mediante ablación con catéter. A los 7 ± 2 meses postablación se observó una gran mejoría de la función sistólica y el remodelado ventricular izquierdo (fracción de eyección ? 50% y dimensión telediastólica ? 51 mm en los 5 enfermos), sin recurrencia de la arritmia durante el seguimiento(10-69 meses). Estos hallazgos confirman que las arritmias ventriculares repetitivas pueden causar disfunción ventricular, reversible tras ablación con radiofrecuencia

Left ventricular systolic dysfunction related to ventricular arrhythmias isa relatively poorly understood entity. To increase our knowledge base, we describe 5 patients in whom the link between ventricular dysfunction and ventricular arrhythmia was unequivocally established. All patients had repetitive monomorphic ventricular arrhythmias and left ventricular systolicdys function (ejection fraction ?40% and end-diastolic size ?55 mm). The arrhythmogenic source was identified by electrophysiological study (right ventricle in 2 patients, left ventricle in 2, and left sinus of Valsalva inone), and was eliminated in all patients by radiofrequency catheter ablation. At 7±2 months post-ablation, large improvements were seen in left ventricular function and remodeling (ejection fraction ?50% and end-diastolic size ?51 mm in all cases), with no recurrence of arrhythmia during follow-up (10-69 months). This finding confirms that recurring ventricular arrhythmias can induce left ventricular dysfunction which may be reversible after ablation

Utility of adenosine 5'-triphosphate in predicting early recurrence after successful ablation of manifest accessory pathways.

OBJECTIVES: The purpose of this study was to determine whether administration of adenosine 5'-triphosphate (ATP; 20-40 mg) after successful ablation of accessory pathway (AP) with manifest preexcitation is useful for detecting residual conduction and predicting early recurrences. BACKGROUND: The reported incidence of recurrence of AP conduction after an initially successful procedure is 5% to 10%. Little information on the variables related to early recurrence has been reported. METHODS: We prospectively used 108 ATP tests on 100 consecutive patients (66 men, mean age 36 +/- 15 years) with manifest preexcitation. Five minutes after successful ablation, intravenous boluses of ATP at increasing doses were injected until the target effect of second- or third-degree AV block or AP conduction was observed. RESULTS: The effect of ATP was AV block (negative test) in 82 cases (76%), conduction over previously ablated AP (positive test) in 9 cases (8.3%), and no achievement of target effect (nondiagnostic test) in 17 cases (15.7%). Thirteen early recurrences were observed in 12 patients. In all 9 (100%) patients with positive ATP test and in 4 (4.9%) of the 82 patients with negative ATP test, conduction over the AP recurred (relative risk 20; 95% confidence interval 8-53; P < .000001). The diagnostic accuracy of the test (analyzing the target effect) was 95%, sensitivity 69%, specificity 100%, and positive and negative predictive values 100% and 95%, respectively. CONCLUSIONS: ATP administration after successful ablation of APs has a high predictive value for early recurrence and may help optimize the duration of the ablation procedure.

Fibroelastoma papilar cardíaco: una causa tratable de accidente cerebrovascular / Cardiac papillary fibroelastoma: a treatable cause of cerebrovascular events

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[Does the EuroSCORE identify patients at minimum risk of mortality from heart surgery?]. / ¿Se puede identificar mediante el EuroSCORE a los pacientes con mortalidad mínima en cirugía cardíaca?

INTRODUCTION AND OBJECTIVES: Risk of hospital death is one of the key factors considered by the clinical cardiologist when weighting indications for surgery. Risk estimation scales establish distinct levels of risk in quantitative terms. The aim of the present study was to investigate whether a low EuroSCORE value corresponds to low mortality in our setting. PATIENTS AND METHODS: During 1999-2000 we prospectively calculated the EuroSCORE for all patients who underwent isolated coronary (CS) or valvular (VS) surgery. We then analyzed intrahospital mortality of patients with a low EuroSCORE. The validation group consisted of patients who underwent surgery in 2001 and obtained a low EuroSCORE. RESULTS: During 1999-2000 we identified 116 patients (16.2% of all patients treated with isolated CS or CV) with a low EuroSCORE (50 8.6 years; 65% male). Fifty-seven of these patients underwent isolated CS, and 59 of them isolated VS. Intrahospital mortality was zero. In 2001 we identified 59 (16.1%) such patients (49 8.7 years; 68% male), of whom 35 underwent isolated CS and 24 underwent isolated VS. Intrahospital mortality during this period was again zero. CONCLUSIONS: A low EuroSCORE identifies a population of patients with minimum risk of mortality after isolated coronary or valve surgery. The score may be useful as a sentinel indicator in analyses of the complex issue of quality of cardiac surgery.

¿Se puede identificar mediante el EuroSCORE a los pacientes con mortalidad mínima en cirugía cardíaca? / Does the EuroSCORE identify patients at minimum risk of mortality from heart surgery?

Introducción y objetivos. El nivel de riesgo de muerte hospitalaria ha sido uno de los factores clave que el cardiólogo clínico ha sopesado a la hora de establecer una indicación quirúrgica. Las escalas de estimación de riesgo evalúan cuantitativamente el riesgo, estableciendo niveles muy diferentes. El objetivo de nuestro estudio es investigar si, en nuestro medio, un valor mínimo del EuroSCORE se corresponde, en efecto, con una mínima mortalidad. Pacientes y métodos. Durante 1999 y 2000 cuantificamos prospectivamente el EuroSCORE de todos los pacientes con cirugía de revascularización coronaria y valvular aisladas. Analizamos la mortalidad intrahospitalaria en aquellos con un valor mínimo del EuroSCORE. Los pacientes intervenidos en el año 2001 que obtuvieron un valor mínimo del EuroSCORE constituyeron el grupo de validación. Resultados. Durante 1999-2000 identificamos a 116 (16,2 por ciento del total de la cirugía de revascularización coronaria y cirugía valvular aisladas) pacientes (50 ñ 8,6 años; un 65 por ciento, varones) con un valor mínimo del EuroSCORE. Se realizó cirugía coronaria en 57 pacientes y cirugía valvular en 59. La mortalidad intrahospitalaria fue nula. En el año 2001 identificamos a 59 (16,1 por ciento del total) pacientes (un 68 por ciento, varones; 49 ñ 8,7 años). De ellos, 35 fueron sometidos a cirugía coronaria y 24 a cirugía valvular. La mortalidad en este período también fue nula. Conclusiones. Un valor mínimo del EuroSCORE identifica a una población de pacientes cuyo riesgo de fallecimiento, tras una cirugía coronaria o valvular aisladas, es mínimo. Este valor podría ser utilizado como indicador centinela en el complejo tema de la calidad en la cirugía cardíaca (AU)

[Infectious endocarditis: degree of discordance between clinical guidelines recommendations and clinical practice]. / Endocarditis infecciosa: grado de discordancia entre lo recomendado por las guías clínicas y lo realizado en la práctica.

INTRODUCTION AND OBJECTIVES: The present study was made to investigate the degree of discordance between the recommendations of clinical guidelines and actual practice in the care of patients with infectious endocarditis. MATERIAL AND METHODS: Data was gathered on 34 patients that were admitted to our hospital for native valve infection over a 4-year period. The degree of discordance (%) was obtained by comparing each clinical history with a catalog of 15 specific actions recommended in the clinical guidelines for four consecutive phases: pre-diagnosis, hospital diagnosis, antibiotic treatment, and surgical treatment. A system was constructed, scoring each phase with the greatest detected error (on a severity scale of 0 to 8 points) and adding together the scores for the four phases. RESULTS: The mean degree of discordance was 30.5% (range, 0-66%). Scores of more than six points were clearly associated with an unfavourable evolution. CONCLUSIONS: The recommendations of clinical guidelines for infectious endocarditis are inadequately followed in practice, which can affect the course of the disease. It is necessary to increase adherence to clinical guidelines in practice, in order to improve the care of patients with this serious disease.

Endocarditis infecciosa: grado de discordancia entre lo recomendado por las guías clínicas y lo realizado en la práctica / Infectious endocarditis: degree of discordance between clinical guidelines recommendations and clinical practice

Introducción y objetivos. Este estudio pretende investigar el grado de discordancia que existe entre las recomendaciones de las guías clínicas y la práctica real de atención a los pacientes con endocarditis infecciosa.Material y métodos. Se recogió información de 34 enfermos hospitalizados por infección sobre válvula nativa en un período de 4 años. El grado de discordancia ( por ciento) se obtuvo cotejando cada historia clínica con un catálogo de 15 acciones, distribuidas en 4 fases consecutivas: prediagnóstico, diagnóstico hospitalario, tratamiento antibiótico y tratamiento quirúrgico. Se construyó, además, un tanteador, puntuando cada fase con la mayor de las incorrecciones detectadas (en una escala de gravedad entre 0 y 8) y sumando las puntuaciones de las 4 etapas.Resultados. El grado medio de discordancia fue del 30,5 por ciento (rango, 0-66 por ciento). En cuanto al tanteador, un valor superior a 6 mostró una clara asociación con evolución desfavorable. Conclusiones. Las recomendaciones de las guías clínicas sobre endocarditis se llevan a la práctica de forma deficiente en nuestro medio y esto puede influir en el desenlace de la enfermedad. Se debe, pues, aumentar el grado de concordancia teórico-práctica con el fin de mejorar los cuidados globales que se dispensan a los pacientes que presentan esta grave enfermedad (AU)

[Vasovagal syncope in pediatric patients: a medium-term follow-up analysis]. / El síncope vasovagal en pacientes pediátricos: un análisis de la evolución a medio plazo.

INTRODUCTION AND OBJECTIVES: Little information is available on the evolution of pediatric patients with vasovagal syncope. We therefore aimed to assess the medium-term clinical outcome of children evaluated by tilt testing for syncope of unknown origin. PATIENTS AND METHOD: Fifty-one children under 17 years of age who had undergone tilt testing were identified from a data base and studied prospectively. Kaplan-Meier and Cox regression analyses were performed to estimate syncope-free survival, its predictors, and the relative risks of several patient subgroups. RESULTS: Forty-seven (92%) of the children were followed for a mean 21 9 months. The rate of recurrence of syncope was considerably lower than that estimated during history taking before the tilt test (19% vs 47%; p < 0.01). Although the low rate made it difficult to identify predictors, several potential predictors emerged from the multivariate analysis. Only the history of more than one syncope before the tilt test (vs. isolated syncope) was found to have independent predictive value (p = 0.04). The cumulative probability of recurrence projected for a period of 38 months was 66.2% (SEM = 16.5%) for children with more than one syncope before testing vs. 0% for those who had experienced only one. No other events occurred. CONCLUSIONS: The medium-term prognosis seems to be good for children with vasovagal syncope of unknown origin, given the low rate of recurrence, regardless of the results of tilt testing. The only predictor of recurrent syncope was pretest history, such that children with only one syncope before testing experience no recurrence and those with one or more episodes are estimated to have an increasingly higher likelihood of recurrence. These data may be useful for the recommending tilt testing and for planning therapy for children with vasovagal syncope.

El síncope vasovagal en pacientes pediátricos: un análisis de la evolución a medio plazo / Vasovagal syncope in pediatric patients: a medium-term follow-up analysis

Introducción y objetivos. Existe poca información sobre la evolución de los pacientes pediátricos con síncope de origen vasovagal. Este estudio, en consecuencia, está destinado a analizar la evolución de este tipo de pacientes. Pacientes y método. A partir de una base de datos prospectiva se identificaron 51 enfermos menores de 17 años a los que se había realizado prueba de basculación por sospecha de síndrome vasovagal. Se analizaron diversas variables pre, intra y postest para investigar si su distribución era diferente en relación con la recurrencia de síncope en el seguimiento. Se definieron subgrupos en relación con los predictores y se estimaron las diferentes curvas de recurrencia por el método de Kaplan-Meier. Resultados. Se completó un seguimiento medio de 21 ñ 9 meses en 47 (92 por ciento) de los 51 pacientes. La tasa de recurrencia se redujo notablemente respecto a la observada en la anamnesis pretest (del 19 al 47 por ciento; p = 0,01). Esta baja tasa hizo difícil encontrar predictores de recidiva. De hecho, después del análisis multivariado, sólo 2 subgrupos presentaron diferencias significativas: más de un síncope pretest, comparado con sólo uno (p = 0,04). Para un seguimiento proyectado de 38 meses, la probabilidad acumulativa de recurrencia de los primeros fue de 66,2 por ciento (SEM = 16,5 por ciento), frente a una probabilidad nula en los segundos. No hubo otros acontecimientos. Conclusiones. Los niños con síncope vasovagal parecen tener un buen pronóstico a medio plazo, ya que la tasa de recidiva es baja, con independencia del resultado del test de basculación. En los enfermos con síncope único pretest, la tasa de recidiva es nula; por el contrario, los que han tenido más de un síncope antes del test de basculación se estima que tienen una probabilidad progresivamente elevada de recurrencia. Estos datos pueden ser útiles a la hora de indicar un test de basculación y planear la terapéutica en los pacientes pediátricos con síndrome vasovagal (AU)

Trombosis valvular protésica: ¿cuál es la terapia inicial más apropiada? / Prosthetic valve thrombosis: what is the most appropriate initial therapy?

Introducción y objetivos. Este estudio pretende investigar cuál es la mejor terapia inicial para los pacientes que sufren una trombosis protésica obstructiva. Métodos. Se analizaron los datos históricos de 47 pacientes que en un período de 8 años habían sido diagnosticados de trombosis protésica en 2 hospitales terciarios. Resultados . Las prótesis afectadas eran mitrales en 34 casos (2 biológicas), aórticas en 12 y doble prótesis mitroaórtica en uno. En 12 casos la trombosis no producía obstrucción. En los 35 restantes, la obstrucción protésica fue tratada con heparina (n = 2), trombólisis (n = 19) o cirugía (n = 14). Todos los enfermos del grupo de trombólisis sobrevivieron a la hospitalización, si bien seis necesitaron ser operados antes del alta por persistencia de un gradiente elevado (n = 5) o anomalías en el desplazamiento de un disco (n = 1). Cinco de los 14 pacientes del grupo de cirugía directa fallecieron, dos antes de que la operación pudiera llevarse a efecto. En consecuencia, la tasa de mortalidad, examinada bajo el prisma de intención de tratar, fue muy favorable para la trombólisis (p = 0,008), y ello a pesar de que el índice de gravedad (en una escala de 0 a 4) era superior en este grupo: 3,3 ñ 0,6 frente a 2,1 ñ 0,9 en los pacientes del grupo de cirugía directa; p < 0,0001. Conclusiones. La trombólisis, en términos de mortalidad hospitalaria, constituye una alternativa mejor que la cirugía directa para combatir la obstrucción trombótica protésica. Aun cuando el resultado pueda resultar subóptimo, permite operar al paciente en mejores condiciones clínicas y, por tanto, con un menor riesgo (AU)