Role of Isolated Limb Perfusion in the Era of Targeted Therapies and Immunotherapy in Melanoma. A Systematic Review of The Literature.

BACKGROUND: Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP. METHODS: PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000-2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures. RESULTS: Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria. DISCUSSION: ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era. CONCLUSIONS: ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies.

Sequential antimicrobial therapy in mediastinitis after cardiac surgery: An observational study of 81 cases / Tratamiento antimicrobiano secuencial en mediastinitis poscirugía cardiaca: estudio observacional de 81 casos

INTRODUCTION: Mediastinitis is an infrequent but serious complication of cardiac surgery. Antimicrobial treatment guidelines are not well established. The aim was to describe the efficacy of sequential intravenous to oral therapy in selected post-surgical mediastinitis patients. METHODS: A retrospective observational study including cases of mediastinitis after cardiac surgery, defined according to CDC criteria, at a third-level university hospital between January 2002 and December 2016. Sequential antimicrobial therapy was proposed in clinically stable patients. Rates of cure, relapse, and hospital stay were compared between patients who received sequential intravenous to oral therapy and those who received therapy exclusively by the intravenous route. RESULTS: Eighty-one cases were included. Sequential intravenous to oral therapy was performed in 48 (59.3%) patients on median day 15. No differences in baseline characteristics or causal microorganisms were found between the two cohorts. The average duration of antibiotic therapy was 41.2 ± 10.09 days. The most commonly used drugs in sequential therapy were quinolones in 31 (64.6%) cases and rifampicin, always in association with another antibiotic, in 25 (52.1%). Hospital stay was shorter in the sequential therapy group (57.57 ± 34.03 vs. 84.35 ± 45.67; P = 0.007). Cure was achieved in 77 (92.8%) patients. Overall in-hospital mortality was less frequent in the group that received sequential therapy (2.1% vs. 15.2%; P = 0.039). There were no differences in relapse between the two cohorts (4.2% vs 9.1%; P = 0.366). CONCLUSION: Sequential antimicrobial treatment in selected patients with post-surgical mediastinitis may be as effective as exclusively intravenous treatment, reducing risks, hospital stay and associated costs

INTRODUCCIÓN: La mediastinitis es una complicación grave pero infrecuente de la cirugía cardiaca. Las pautas de tratamiento antimicrobiano no han sido bien definidas. El objetivo es describir la eficacia del tratamiento antimicrobiano secuencial, de intravenoso a oral, en pacientes seleccionados con mediastinitis. MÉTODO: Estudio observacional retrospectivo en el que se incluyeron los casos de mediastinitis relacionados con la cirugía cardiaca, según criterios del CDC, en un hospital universitario entre enero de 2002 y diciembre de 2016. Una vez estabilizados los pacientes, se propuso completar el tratamiento antimicrobiano de forma secuencial, pasando de la vía intravenosa a la oral. Se compararon las tasas de curación, las recidivas y la estancia hospitalaria entre los pacientes que recibieron ambos regímenes. RESULTADOS: Se incluyeron 81 casos. El tratamiento antimicrobiano secuencial se utilizó en 48 (59,3%) pacientes, en una media de 15 días. No se encontraron diferencias respecto a las características basales y microorganismos causales en ambos grupos. La duración media del tratamiento antibiótico fue de 41,2 ± 10,09 días. Los antimicrobianos más utilizados en el tratamiento secuencial fueron quinolonas en 31 (64,6%) y rifampicina, siempre asociada a otro antibiótico, en 25 (52,1%). La estancia hospitalaria fue menor en el grupo con tratamiento secuencial (57,57 ± 34,03 vs. 84,35 ± 45,67; p = 0,007). En conjunto, curaron 77 (92,8%) pacientes. La mortalidad hospitalaria fue inferior en el grupo tratado secuencialmente (2,1% vs. 15,2%; p = 0,039). No hubo diferencias en recidivas entre ambos grupos (4,2% vs 9,1%; p = 0,366). CONCLUSIÓN: El tratamiento antimicrobiano secuencial en pacientes con mediastinitis posquirúrgica seleccionados puede tener una eficacia similar al tratamiento exclusivamente intravenoso, permitiendo reducir riesgos y costes asociados

Implante sin introductor de válvula Portico por acceso transaxilar. Experiencia inicial de un «equipo multidisciplinario» real / Sheathless transaxillary transcatheter aortic valve implantation using the Portico valve system. Initial experience of a real-world "Heart Team"

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Sequential antimicrobial therapy in mediastinitis after cardiac surgery: An observational study of 81 cases.

INTRODUCTION: Mediastinitis is an infrequent but serious complication of cardiac surgery. Antimicrobial treatment guidelines are not well established. The aim was to describe the efficacy of sequential intravenous to oral therapy in selected post-surgical mediastinitis patients. METHODS: A retrospective observational study including cases of mediastinitis after cardiac surgery, defined according to CDC criteria, at a third-level university hospital between January 2002 and December 2016. Sequential antimicrobial therapy was proposed in clinically stable patients. Rates of cure, relapse, and hospital stay were compared between patients who received sequential intravenous to oral therapy and those who received therapy exclusively by the intravenous route. RESULTS: Eighty-one cases were included. Sequential intravenous to oral therapy was performed in 48 (59.3%) patients on median day 15. No differences in baseline characteristics or causal microorganisms were found between the two cohorts. The average duration of antibiotic therapy was 41.2±10.09 days. The most commonly used drugs in sequential therapy were quinolones in 31 (64.6%) cases and rifampicin, always in association with another antibiotic, in 25 (52.1%). Hospital stay was shorter in the sequential therapy group (57.57±34.03 vs. 84.35±45.67; P=0.007). Cure was achieved in 77 (92.8%) patients. Overall in-hospital mortality was less frequent in the group that received sequential therapy (2.1% vs. 15.2%; P=0.039). There were no differences in relapse between the two cohorts (4.2% vs 9.1%; P=0.366). CONCLUSION: Sequential antimicrobial treatment in selected patients with post-surgical mediastinitis may be as effective as exclusively intravenous treatment, reducing risks, hospital stay and associated costs.

[Role of coronary artery revascularization and aneurysmectomy in ventricular arrhythmias in the chronic phase of myocardial infarction]. / Papel de la revascularización coronaria y la aneurismectomía en las arritmias ventriculares asociadas a infarto de miocardio crónico.

INTRODUCTION AND OBJECTIVES: The influence of coronary artery revascularization on the control of ventricular arrhythmias in patients with chronic myocardial infarction is uncertain. However, ablation of the arrhythmogenic circuit in these patients by aneurysm resection is useful for controlling ventricular arrhythmias. We made a prospective analysis of our clinical strategy in patients who were candidates for coronary artery revascularization and/or aneurysmectomy to determine its influence on the recurrence of ventricular arrhythmias. PATIENTS AND METHOD: Prospective study of 17 consecutive patients with chronic myocardial infarction and ventricular arrhythmias unrelated with an acute ischemic event, who had coronary artery disease and/or ventricular aneurysm susceptible to aggressive treatment. We evaluated our clinical strategy and the recurrence of ventricular arrhythmias during a mean follow-up period of 33.64 months. RESULTS: Two groups of patients were studied: patients with ventricular aneurysm (group I: 12 patients) and patients without ventricular aneurysm (group II: 5 patients). Seven patients of group I underwent endoaneurysmorrhaphy and endocardial resection (4 of these patients had associated revascularization procedures). Three patients were not candidates for aneurysmectomy or revascularization procedures. Two patients underwent only revascularization procedures. All the patients in group II were revascularized. The patients who underwent aneurysmectomy did not have recurrence of arrhythmias. In 5 of the 6 patients who underwent programmed electrophysiological stimulation after aneurysmectomy, no sustained arrhythmia could be induced. Patients who were only revascularized had a high rate of recurrence of ventricular arrhythmias (57%), which were inducible after revascularization. CONCLUSION: Aneurysmectomy and endocardial resection constituted, in our experience, an effective tool for controlling ventricular arrhythmias associated with left ventricular aneurysm. Coronary artery revascularization in patients with ventricular arrhythmias and chronic myocardial infarction probably does not prevent the recurrence of ventricular arrhythmias.

Papel de la revascularización coronaria y la aneurismectomía en las arritmias ventriculares asociadas a infartode miocardio crónico / Role of Coronary Artery Revascularization and Aneurysmectomy in Ventricular Arrhythmias in the Chronic Phase of Myocardial Infarction

Introducción y objetivos. La influencia de la revascularización coronaria en el control de las arritmias ventriculares, en pacientes con infarto de miocardio crónico, es incierta y el control de éstas es más evidente cuando se consigue resecar el circuito arritmogénico de un aneurisma. En este sentido, revisamos prospectivamente nuestra estrategia clínica en estos pacientes subsidiarios de revascularización coronaria y/o aneurismectomía con el objetivo de comprobar su influencia en la recurrencia de la arritmia. Pacientes y método. Estudio prospectivo de 17 pacientes consecutivos con infarto de miocardio crónico y arritmias ventriculares no relacionadas con isquemia aguda, que presentaban enfermedad coronaria y/o aneurisma ventricular subsidiario de tratamiento intervencionista. Se analiza la estrategia desarrollada y la recurrencia de las arritmias ventriculares a lo largo de un seguimiento de 33,64 meses de media. Resultados. Se consideraron 2 grupos de pacientes, según presentaran (grupo I) o no (grupo II) aneurisma de ventrículo izquierdo. De los 12 pacientes del grupo I, en siete se realizó endoaneurismorrafia y resección endocárdica (además, cuatro fueron revascularizados). Tres pacientes no fueron intervenidos por presentar un aneurisma no resecable y no ser subsidiario de revascularización. Dos pacientes sólo fueron revascularizados. Todos los pacientes del grupo II (5 pacientes sin aneurisma) fueron revascularizados. Los enfermos sometidos a aneurismectomía no tuvieron recurrencia de la arritmia, y ésta no se indujo en cinco de los 6 pacientes a los que se realizó estudio electrofisiológico postintervención. Los pacientes exclusivamente revascularizados presentaron una alta recurrencia arrítmica (57 por ciento) y su arritmia podía ser inducible tras la revascularización. Conclusiones. La aneurismectomía complementada con resección endocárdica constituyó, según nuestra experiencia, una eficaz herramienta para el control de las arritmias ventriculares asociadas a aneurisma de ventrículo izquierdo. La revascularización coronaria en pacientes con arritmias ventriculares e infarto de miocardio crónico no parece influir en la prevención de recurrencia arrítmica (AU)