Válvulas de rápido implante versus válvulas tradicionales en reemplazo valvular aórtico en pacientes de riesgo intermedio / Rapid-Deployment Valve versus Conventional Valves in Aortic Valve Replacement in Intermediate-Risk Patients

RESUMEN Introducción: El reemplazo valvular aórtico (RVA) en pacientes con riesgo quirúrgico intermedio (RI) es el más desafiante al momento de decidir el tipo de prótesis a utilizar. Las válvulas de rápido implante (RD-V) serían una alternativa a considerar en este grupo específico. Objetivos: Comparar mortalidad temprana, complicaciones postoperatorias y parámetros hemodinámicos transvalvulares en el RVA con válvulas tradicionales vs. RD-V en pacientes de RI. Material y métodos: Estudio retrospectivo y observacional de pacientes consecutivos de RI (STS-PROM 4-8) intervenidos por RVA con prótesis tradicionales y RD-V en el período 2007-2023. Resultados: Se incluyeron 205 pacientes (140 con prótesis tradicionales vs. 65 con RD-V). El riesgo preoperatorio fue semejante en ambos grupos (STS-PROM 5,07% vs. 5,7%, p=0,210). El abordaje miniinvasivo fue más frecuente en RD-V (32,3% vs 0,7%, p<0,001). El tiempo de circulación extracorpórea y clampeo fue significativamente menor en RD-V (134,5 vs.100 min y 104 vs 73 min respectivamente, p<0,001). Hubo tendencia a menor implante de marcapasos con las válvulas tradicionales (4,3% vs. 10,8%, p=0,075). No se observaron diferencias significativas en las complicaciones postoperatorias; hubo fuerte tendencia a menor mortalidad a los 30 días con RD-V (0% vs. 5,7% para válvulas tradicionales, p=0,057). El gradiente protésico medio postoperatorio fue significativamente menor para el grupo RD-V (7,90±3,3 mmHg vs. 12,74±6,07 mmHg, p<0,001). No hubo diferencias respecto a incidencia de trombosis valvular o endocarditis protésica. Conclusiones: Las válvulas de rápido implante presentaron tendencia a menor mortalidad, menor tiempo de circulación extracorpórea/clampeo, mejor perfil hemodinámico y mayor facilidad de implante por abordaje miniinvasivo.

ABSTRACT Background: Aortic valve replacement (AVR) in intermediate-risk (IR) patients is particularly challenging when determining the type of prosthesis to use. Rapid-deployment valves (RD-V) are emerging as a potential alternative in this patient population. Objectives: To compare early mortality, postoperative complications, and transvalvular hemodynamic parameters between AVR with conventional valves and RD-V in IR patients. Methods: We conducted a retrospective observational study of consecutive IR patients (STS-Prom score 4-8) undergoing AVR with conventional prostheses and RD-V between 2007 and 2023. Results: A total of 205 patients were included (140 AVR vs. 65 RD-V). Surgical risk was similar between both groups (STS-Prom 5.07 % vs. 5.7 % respectively, p = 0.210). The minimally invasive approach was more common in the RD-V group (32.3% vs. 0.7%, p < 0.001). The cardiopulmonary bypass time and aortic cross-clamp time was significantly shorter in the RD-V group (134.5 vs. 100 min and 104 vs. 73 min, respectively, p < 0.001). There was a trend to lower incidence of pacemaker implantation in the conventional valve group (4.3% vs. 10.8%, p = 0.075). There were no significant differences in postoperative complications, and a strong trend to lower 30-dat mortality with RD-V (0% vs. 5.7% for conventional valves, p = 0.057). The mean postoperative gradient across the prosthesis was significantly lower in the RD-V group (7.90 ± 3.3 mm Hg vs. 12.74 ± 6.07 mm Hg, p < 0.001). There were no differences in the incidence of valve thrombosis or prosthetic endocarditis. Conclusions: Rapid deployment valves demonstrated trend to lower mortality, shorter cardiopulmonary bypass time and aortic cross-clamp time, improved hemodynamic profile, and were easier to implant via a minimally invasive approach.

Tranexamic Acid in Cardiac Surgery: A Case Report of an Infrequent Adverse Reaction to a Common Medication.

Life-threatening anaphylaxis to tranexamic acid (TXA) is rare but critical in cardiac surgery. A 76-year-old patient undergoing elective ascending aorta replacement developed severe anaphylactic shock shortly after anesthesia induction. Subsequent skin prick tests confirmed a positive TXA reaction. While TXA and lysine derivatives were avoided in the second surgery, the patient experienced hyperfibrinolysis. Guided by rotational thromboelastometry, hemostatic therapy led to a successful outcome with minimal postoperative bleeding. This report emphasizes the importance of drug risk awareness and strategies to mitigate excessive bleeding in cardiac surgery.

Anesthetic and Perioperative Considerations for Combined Heart-Kidney Transplantation.

OBJECTIVE: To describe detailed perioperative features of combined heart and kidney transplant (HKT). DESIGN: Retrospective study. SETTING: Tertiary care university hospital. PARTICIPANTS: All consecutive HKT recipients aged 18 years and older. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After approval of the Institutional Review Board, the authors studied all consecutive adult patients who underwent HKT between January 2013 and July 2016. Recipient and donor's demographic data, hemodynamic profile, and perioperative data were analyzed. Actuarial survival rate was 57% and 43% for in-hospital and after a mean follow-up of 135 (266) days, respectively. Among patients who required postoperative hemodialysis (n = 4), 75% (n = 3) died during hospital stay. In unadjusted analysis, patients who died had a lower postoperative cardiac index (5.4 [2.7] v 3.2 [1] L/min/m2; p = 0.034) and central venous pressure (11 [5] v 8.5 [3] mmHg; p = 0.032). All patients underwent a nonstaged surgery. When compared with preoperative hemodynamic variables, early postoperative values showed decreased systemic vascular resistance (1,333 [433] dyn/s/cm-5v 595 [176] dyn/s/cm-5; p = 0.028) and higher cardiac output (4.3 [1.4] L/min v 6.7 [3] L/min; p = 0.018). Median hospital stay was 63 (44) days. CONCLUSIONS: Anesthesiologists should be actively involved in perioperative strategies on how to manage these critical patients with severe cardiac and noncardiac comorbidities applying their expertise to HKT procedure.

Is patient-prosthesis mismatch a perioperative predictor of long-term mortality after aortic valve replacement?

OBJECTIVES: To determine the perioperative predictors of long-term mortality after aortic valve replacement (AVR). The authors hypothesized that perioperative variables are more important predictors of mortality than patient-prosthesis mismatch (PPM). DESIGN: A retrospective study of prospectively collected data. SETTING: A tertiary care university hospital. PARTICIPANTS: One-hundred-ninety-nine adult patients who underwent AVR. INTERVENTIONS: After Research and Ethics Committee approval, the authors studied consecutive adult patients that underwent AVR in 1999 from the time of procedure to 5 years later. Demographic data, hemodynamic profile obtained after the induction of anesthesia, and perioperative data were analyzed. Primary endpoint was 5-year survival. MEASUREMENTS AND MAIN RESULTS: Actuarial survival rate was 95.98%, 91.46%, and 81.91% at 30 days, 1 year, and 5 years, respectively. On univariate analysis, patients who died were significantly older (p<0.0001), had pulmonary hypertension (PHT), longer cardiopulmonary bypass (CPB) (p = 0.0001) and cross-clamping duration (p = 0.003), more frequent return to CPB (p = 0.036), or the use of an intra-aortic balloon pump to wean from CPB (p = 0.015). PPM was not related to 5-year mortality (p = 0.0649). Using Cox survival analysis, the only independent risk factors related to 5-year mortality after AVR were PHT using the mean arterial pressure-to-mean pulmonary artery pressure ratio (HR: 1.39, 95% CI 1.01-1.92, p = 0.0413) and the presence of complex separation from CPB (HR: 2.66, 95% CI 1.08-6.50, p = 0.0324). CONCLUSIONS: In patients undergoing AVR, 5-year survival was mostly related to the severity of PHT and intraoperative factors, mainly complexity of weaning from CPB.

La anestesia general y el odontopediatra

1.La anestesia general debe administrarse en un medio adecuado y convenientemente acondicionado, en quirófano o en lugares donde haya todos los elementos de monitoraje y reanimación. 2.El médico pediatra evaluará en todos los casos el riesgo quirúrgico y las posibilidades de aplicarla. 3.Su administración estará a cargo del personal idóneo: médico anestesiólogo con entrenamiento pediátrico. 4.Se debe informar a los padres de probables complicaciones y obtener su consentimiento para la intervención que debe ser por escrito. 5.El odontólogo estará familiarizado con el protocolo y procedimientos del hospital. 6.Como la intervención debe efectuarse en un período de tiempo relativamente corto (no más de 2 horas) el odontólogo trabajará eficazmente y en forma sistemática. 7.Prescribirá las indicaciones pre y post operatorias que debe recibir el niño. 8.Una evaluación posterior al tratamiento realizado varias horas después, permitirá al odontólogos dar el alta al paciente, registrándolo en la ficha médica del hospital. Los datos estadísticos recopilados por las Cátedras de Odontopediatría de la Facultad de Odontología (U.N.C.) son demostrativos de que la Anestesia General es un medio de excepción, que adecuadamente empleada nos ofrece resultados satisfactorios

La anestesia general y el odontopediatra

1.La anestesia general debe administrarse en un medio adecuado y convenientemente acondicionado, en quirófano o en lugares donde haya todos los elementos de monitoraje y reanimación. 2.El médico pediatra evaluará en todos los casos el riesgo quirúrgico y las posibilidades de aplicarla. 3.Su administración estará a cargo del personal idóneo: médico anestesiólogo con entrenamiento pediátrico. 4.Se debe informar a los padres de probables complicaciones y obtener su consentimiento para la intervención que debe ser por escrito. 5.El odontólogo estará familiarizado con el protocolo y procedimientos del hospital. 6.Como la intervención debe efectuarse en un período de tiempo relativamente corto (no más de 2 horas) el odontólogo trabajará eficazmente y en forma sistemática. 7.Prescribirá las indicaciones pre y post operatorias que debe recibir el niño. 8.Una evaluación posterior al tratamiento realizado varias horas después, permitirá al odontólogos dar el alta al paciente, registrándolo en la ficha médica del hospital. Los datos estadísticos recopilados por las Cátedras de Odontopediatría de la Facultad de Odontología (U.N.C.) son demostrativos de que la Anestesia General es un medio de excepción, que adecuadamente empleada nos ofrece resultados satisfactorios (AU)