Masa auricular derecha: la importancia del ecocardiograma al momento del diagnóstico de fibrilación auricular en el enfoque terapéutico / Right atrial mass: The importance of cardiac ultrasound at the time of diagnosis of atrial fibrillation in the therapeutic approach

Resumen Se presenta el caso de un varón de 70 años de edad, quien debutó con fibrilación auricular no valvular, en quien, dos meses después y mediante ecocardiografía, se objetivaron dos masas contiguas en la aurícula derecha. Las masas eran dependientes de la válvula de Eustaquio, alcanzaban el septo interauricular y se asemejaban a un mixoma. Ambas fueron resecadas mediante cirugía, sin complicaciones intraoperatorias ni postoperatorias. El estudio anatomo-patológico concluyó que eran compatibles con trombos sin componente tumoral. Durante el seguimiento permaneció asintomático y en ritmo de fibrilación auricular.

Abstract The case is presented on a 70 year-old male who debuted with non-valvular atrial fibrillation. Two months later, and using cardiac ultrasound, two contiguous masses were observed in the right atrium. The masses were hanging from the Eustachian (inferior vena cave) valve, reached the interatrial septum and resembled a myxoma. Both were surgically resected, with no intra- or post-operative complications. The patient remained asymptomatic and in atrial fibrillation rhythm during follow-up.

Oclusión iatrogénica de la arteria coronaria derecha durante sustitución valvular tricuspídea / Iatrogenic occlusion of the right coronary artery during tricuspid valve replacement

Resumen Se describe el caso de una mujer de 68 años que presentaba insuficiencia tricuspídea severa con ventrículo derecho dilatado, función sistólica levemente deprimida y ventrículo izquierdo no dilatado con fracción de eyección del 47%. Se intervino mediante cirugía realizándose una sustitución valvular tricúspide por prótesis mecánica ATS n( 33 e implante de electrodo de marcapasos epicárdico definitivo. En el postoperatorio inmediato presentó ascenso persistente del segmento ST en la cara inferior. Se implantó balón de contrapulsación intraaórtico y en el ecocardiograma urgente se observó disfunción ventricular global con aquinesia de la cara inferior. Se realizó coronariografía urgente observándose una imagen de angulación y deformidad a nivel distal de la arteria coronaria derecha no presente en la coronariografía prequirúrgica que sugería tracción externa del vaso, probablemente en relación con la sutura quirúrgica. Se intervino en forma percutánea implantándose stent farmacoactivo con lo cual se recuperó el flujo distal y se normalizó el segmento ST. La proximidad del anillo tricúspide a estructuras anatómicas como la arteria coronaria derecha hace posible su lesión durante la cirugía. El daño iatrogénico de la arteria coronaria derecha requiere diagnóstico y tratamiento precoz. Por ello esta complicación se debe incluir en el diagnóstico diferencial de disfunción ventricular derecha tras cirugía cardiaca.

Abstract The case is presented on a 68 year-old woman with severe tricuspid insufficiency. She also had a dilated right ventricle, a slightly depressed systolic function, and an undilated left ventricle with an ejection fraction of 47%. We treated her surgically, the tricuspid valve replacement was carried out with an ATS Nº 33 mechanical prosthesis and implanted a permanent epicardial pacemaker lead. In the immediate post operative period, she presented a persistent ST segment elevation on the inferior wall. An intra-aortic balloon pump was implanted; the urgent echocardiogram showed a global ventricular dysfunction with akinesia of the inferior wall. An urgent coronary angiography was performed, with an image of angulation and deformity being observed at distal level of the right coronary artery that was not present in the pre-surgical coronary angiography, which suggested an external traction of the vessela probably associated with a surgical suture. Percutaneous intervention was carried out, with a drug-eluting stent being implanted. It was percutaneously treated by implanting a drug-eluting stent restoring distal blood flow and normalizing the ST segment. The proximity of the tricuspid ring to anatomical structures like the right coronary artery means that it could be damaged during surgery. The iatrogenic damage to the right coronary artery requires an early diagnosis and treatment. For this reason, this complication must be included in the differential diagnosis of right ventricular dysfunction after cardiac surgery.

Resultados de la tromboendarterectomía pulmonar en la hipertensión pulmonar tromboembólica crónica / Pulmonary endarterectomy outputs in chronic thromboembolic pulmonary hypertension

Fundamento y objetivo: La cirugía de tromboendarterectomía pulmonar es el tratamiento de elección para la hipertensión pulmonar tromboembólica crónica; un factor de riesgo para la mortalidad hospitalaria son las resistencias vasculares pulmonares muy elevadas. El objetivo de este trabajo fue analizar los resultados inmediatos y a largo plazo de la cirugía para la hipertensión pulmonar tromboembólica crónica en pacientes con hipertensión pulmonar muy grave. Material y métodos: Desde febrero de 1996 hemos realizado 160 tromboendarterectomías pulmonares. Dividimos esta población en grupo 1 -40 pacientes con resistencias vasculares pulmonares ≥ 1.090dinas/s/cm-5- y grupo 2 -los 120 restantes-. Resultados: La mortalidad hospitalaria (15 frente a 2,5%), el edema pulmonar de reperfusión (33 frente a 14%) y la insuficiencia cardiaca (23 frente a 3,3%) fueron significativamente mayores en el grupo 1; pero al año, no hay diferencia en la situación clínica, hemodinámica y ecocardiográfica con el grupo 2. La supervivencia a los 5 años fue del 77% en el grupo 1 y del 92% en el grupo 2 (p=0,033). Excluyendo los primeros 46 enfermos, considerados curva de aprendizaje, no hubo diferencia en la mortalidad hospitalaria (3,8 frente a 2,3%) ni en la supervivencia (96,2% en el grupo 1 y 96,2% en el grupo 2 a los 5 años). Conclusiones: La tromboendarterectomía pulmonar tiene una morbimortalidad inicial mayor en pacientes con hipertensión pulmonar tromboembólica crónica muy grave, pero obtiene el mismo beneficio a medio-largo plazo. En nuestra experiencia, tras la curva de aprendizaje, la cirugía ofrece la misma seguridad y excelentes resultados a los pacientes más graves, y ninguna cifra de resistencias vasculares pulmonares debería ser considerada una contraindicación absoluta (AU)

Background and objective: Pulmonary thromboendarterectomy surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension; extremely high pulmonary vascular resistance constitutes a risk factor for hospital mortality. The objective of this study was to analyze the immediate and long-term results of the surgical treatment of chronic thromboembolic pulmonary hypertension in patients with very severe pulmonary hypertension. Material and methods: Since February 1996, we performed 160 pulmonary thromboendarterectomies. We divided the patient population in 2 groups: group 1, which included 40 patients with pulmonary vascular resistance≥1090dyn/sec/cm-5, and group 2, which included the remaining 120 patients. Results: Hospital mortality (15 vs. 2.5%), reperfusion pulmonary edema (33 vs. 14%) and heart failure (23 vs. 3.3%) were all higher in group 1; however, after one year of follow-up, there were no significant differences in the clinical, hemodynamic and echocardiographic conditions of both groups. Survival rate after 5 years was 77% in group 1 and 92% in group 2 (P=.033). After the learning curve including the 46 first patients, there was no difference in hospital mortality (3.8 vs. 2.3%) or survival rate after 5 years (96.2% in group 1 and 96.2% in group 2). Conclusions: Pulmonary thromboendarterectomy is linked to significantly higher morbidity and mortality rates in patients with severe chronic thromboembolic pulmonary hypertension. Nevertheless, these patients benefit the same from the procedure in the mid-/long-term. In our experience, after the learning curve, this surgery is safe in severe pulmonary hypertension and no level of pulmonary vascular resistance should be an absolute counter-indication for this surgery (AU)

Pulmonary endarterectomy outputs in chronic thromboembolic pulmonary hypertension. / Resultados de la tromboendarterectomía pulmonar en la hipertensión pulmonar tromboembólica crónica.

BACKGROUND AND OBJECTIVE: Pulmonary thromboendarterectomy surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension; extremely high pulmonary vascular resistance constitutes a risk factor for hospital mortality. The objective of this study was to analyze the immediate and long-term results of the surgical treatment of chronic thromboembolic pulmonary hypertension in patients with very severe pulmonary hypertension. MATERIAL AND METHODS: Since February 1996, we performed 160 pulmonary thromboendarterectomies. We divided the patient population in 2 groups: group 1, which included 40 patients with pulmonary vascular resistance≥1090dyn/sec/cm-5, and group 2, which included the remaining 120 patients. RESULTS: Hospital mortality (15 vs. 2.5%), reperfusion pulmonary edema (33 vs. 14%) and heart failure (23 vs. 3.3%) were all higher in group 1; however, after one year of follow-up, there were no significant differences in the clinical, hemodynamic and echocardiographic conditions of both groups. Survival rate after 5 years was 77% in group 1 and 92% in group 2 (P=.033). After the learning curve including the 46 first patients, there was no difference in hospital mortality (3.8 vs. 2.3%) or survival rate after 5 years (96.2% in group 1 and 96.2% in group 2). CONCLUSIONS: Pulmonary thromboendarterectomy is linked to significantly higher morbidity and mortality rates in patients with severe chronic thromboembolic pulmonary hypertension. Nevertheless, these patients benefit the same from the procedure in the mid-/long-term. In our experience, after the learning curve, this surgery is safe in severe pulmonary hypertension and no level of pulmonary vascular resistance should be an absolute counter-indication for this surgery.

Tromboendarterectomía pulmonar en 106 pacientes con hipertensión pulmonar tromboembólica crónica / Pulmonary Thromboendarterectomy in 106 Patients With Chronic Thromboembolic Pulmonary Hypertension

Introducción: La tromboendarterectomía pulmonar es el tratamiento de elección en la hipertensión pulmonar tromboembólica crónica. Presentamos nuestra serie completa con esta técnica. Métodos: Desde febrero de 1996 hasta junio de 2014, hemos realizado 106 tromboendarterectomías. Analizamos las características de la población, la mortalidad y morbilidad asociadas a la técnica y los resultados a largo plazo de supervivencia, mejoría funcional y resolución de la hipertensión pulmonar. Resultados: La edad media de la población fue 53 ± 14 años. El 89% estaba en clase funcional III-IV de la OMS. La presión pulmonar media prequirúrgica fue 49 ± 13 mmHg y las resistencias vasculares pulmonares 831 ± 364 dinas.s.cm-5. La mortalidad hospitalaria fue 6,6%. La morbilidad postoperatoria más relevante fue debida al edema pulmonar por reperfusión en el 20%, que fue factor de riesgo independiente (p = 0,015) para mortalidad hospitalaria. Con una mediana de seguimiento de 31 meses (rango intercuartil 50), la supervivencia a los 3 y 5 años es 90 y 84%. Al año de seguimiento, el 91% está en clase funcional I-II de la OMS, la presión pulmonar media en 27 ± 11 mmHg y las resistencias pulmonares vasculares en 275 ± 218 dinas.s.cm-5 (significativamente menores (p < 0,05) que las basales). En 14 pacientes se diagnosticó hipertensión pulmonar persistente; aun así, su supervivencia es, a los 3 y 5 años, 91 y 73%, respectivamente. Conclusiones: La tromboendarterectomía pulmonar ofrece resultados excelentes en el tratamiento de la hipertensión pulmonar tromboembólica crónica. Proporciona una elevada supervivencia a largo plazo, mejora la capacidad funcional y resuelve la hipertensión pulmonar en la mayoría de los pacientes

Introduction: Pulmonary thromboendarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension. We report our experience with this technique. Methods: Between February 1996 and June 2014, we performed 106 pulmonary thromboendarterectomies. Patient population, morbidity and mortality and the long-term results of this technique (survival, functional improvement and resolution of pulmonary hypertension) are described. Results: Subjects' mean age was 53 ± 14 years. A total of 89% were WHO functional class III–IV, presurgery mean pulmonary pressure was 49 ± 13 mmHg and mean pulmonary vascular resistance was 831 ± 364 dynes s cm-5. In-hospital mortality was 6.6%. The most important post-operative morbidity was reperfusion pulmonary injury, in 20% of patients; this was an independent risk factor (P = .015) for hospital mortality. With a 31-month median follow-up (interquartile range: 50), 3- and 5-year survival was 90% and 84% respectively. At 1 year, 91% were WHO functional class I–II; mean pulmonary pressure (27 ± 11 mmHg) and pulmonary vascular resistance (275 ± 218 dynes s cm-5) were significantly lower (P < .05) than before the intervention. Although residual pulmonary hypertension was detected in 14 patients, their survival at 3 and 5 years was 91% and 73%, respectively. Conclusions: Pulmonary thromboendarterectomy offers excellent results in chronic thromboembolic pulmonary hypertension. Long-term survival is good, functional capacity improves, and pulmonary hypertension is resolved in most patients

Pulmonary thromboendarterectomy in 106 patients with chronic thromboembolic pulmonary hypertension.

INTRODUCTION: Pulmonary thromboendarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension. We report our experience with this technique. METHODS: Between February 1996 and June 2014, we performed 106 pulmonary thromboendarterectomies. Patient population, morbidity and mortality and the long-term results of this technique (survival, functional improvement and resolution of pulmonary hypertension) are described. RESULTS: Subjects' mean age was 53±14 years. A total of 89% were WHO functional class III-IV, presurgery mean pulmonary pressure was 49±13mmHg and mean pulmonary vascular resistance was 831±364 dynes.s.cm(-5). In-hospital mortality was 6.6%. The most important post-operative morbidity was reperfusion pulmonary injury, in 20% of patients; this was an independent risk factor (p=0.015) for hospital mortality. With a 31-month median follow-up (interquartile range: 50), 3- and 5-year survival was 90 and 84%. At 1 year, 91% were WHO functional class I-II; mean pulmonary pressure (27±11mmHg) and pulmonary vascular resistance (275±218 dynes.s.cm(-5)) were significantly lower (p<0.05) than before the intervention. Although residual pulmonary hypertension was detected in 14 patients, their survival at 3 and 5 years was 91 and 73%, respectively. CONCLUSIONS: Pulmonary thromboendarterectomy offers excellent results in chronic thromboembolic pulmonary hypertension. Long-term survival is good, functional capacity improves, and pulmonary hypertension is resolved in most patients.