Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy. / Guía anestésico-quirúrgica en el tratamiento de la cirugía de aorta ascendente y del arco aórtico. Documento de consenso de la Sociedad Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor.

Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.

RETRACTED: Anesthesic and surgical guideline for the treatment of the thoraco-abdominal aorta. Consensus Document of the Spanish Societies of Anesthesia and Cardiovascular Surgery. / Guía anestésico-quirúrgica en el tratamiento de la patología de aorta toracoabdominal. Documento de Consenso de la Sociedad Española de Cirugía Cardiovascular Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor.

Este artículo ha sido retirado por indicación del Editor Jefe de la revista, después de constatar que parte de su contenido había sido plagiado, sin mencionar la fuente original: European Heart Journal (2014) 35, 2873 926.: https://academic.oup.com/eurheartj/article/35/41/2873/407693#89325738 El autor de correspondencia ha sido informado de la decisión y está de acuerdo con la retirada del artículo. El Comité Editorial lamenta las molestias que esta decisión pueda ocasionar. Puede consultar la política de Elsevier sobre la retirada de artículos en https://www.elsevier.com/about/our-business/policies/article-withdrawal

[Right heart support during coronary artery bypass grafting without cardiopulmonary bypass]. / Asistencia ventricular derecha en cirugía coronaria sin derivación cardiopulmonar.

BACKGROUND AND OBJECTIVES: Exposure of lateral and inferior coronary vessels during off-pump coronary artery bypass grafting may cause significant hemodynamic compromise due to right ventricular compression when tilting the heart. Some new right ventricular assistance devices have been developed in order to avoid this problem but only a few series have been published. A preliminary experience with a right heart circulatory support system is reported. METHODS: A total of eight patients underwent off-pump coronary artery bypass grafting using a right heart support device. Technical procedure and clinical outcome are analyzed. RESULTS: The right heart circulatory support device insertion and management were performed without any complication. A total of 21 distal coronary anastomoses were completed. They were located on the anterior descending artery(8), circumflex branches(6), diagonal branches(2), posterior descending artery(3) and right coronary artery(2). The right ventricular support device delivered flow at a medium rate of 2.2 L/min, providing hemodynamic stability when tilting the heart and exposing the coronary arteries. CONCLUSIONS: The use of right heart support devices is a simple and low risk procedure which may facilitate surgical anastomoses on lateral and inferior epicardial vessels during off-pump coronary artery surgery.

Apoptotic cell death and genetic control in graft coronary artery disease in heart transplant.

AIM: Apoptosis is a type of programmed cell death whereby, immunologic, genetic and biochemical mechanisms are involved in its control. On the other hand, graft coronary artery disease is the most important restrictive factor for the long-term survival of heart transplantation. The purpose of this study is to analyse both apoptotic cell lesions in transplanted patients that present coronary artery disease. METHODS: From August 1984 until December 1996, 148 heart transplants were carried out in the Clínica Universitaria de Navarra. In 102 patients, annual coronary angiography was performed, reaching a diagnosis of coronary artery disease in 30 patients. Study of apoptotic cell death was done in the tissue of endomyocardial biopsies on all patients by means of the TUNEL technique. Procedures of immunohistochemistry with antibodies antic-myc, p53 and bcl-2 were carried out and results were compared with a control group of 30 patients with homogeneous characteristics. RESULTS: All patients with coronary artery disease showed apoptotic cardiomyocytes, 13 patients to a mild degree, 14 to a moderate degree and 3 to a severe degree, while in the control group apoptosis was found only to a mild degree in 8 patients, obtaining a very significant statistical difference (p<0.0001). The expression of analysed oncoproteins was null in the 2 groups. CONCLUSION: Myocardial apoptosis is a constant finding in transplanted patients with coronary artery disease. We have not seen any correlation between the apoptotic process and genetic mechanisms.

The withholding and withdrawal of medical treatment: moral principles and the law

In most hospitals in Puerto Rico the dying process of terminally ill patients is inappropriately prolonged. And this occurs often without the patient's consent and in violation of basic ethical principles. Three erroneous beliefs are prevalent: 1--That withdrawing life support therapy is morally or legally different from not starting it. 2--That there is a moral and legal difference between appropriate acts and appropriate omissions. 3--That good medical practice is determined by the courts instead of the medical profession. Institutional policies are not in harmony with contemporary medical ethics. To avoid possible legal entanglements medical institutions permit their faculties to prolong the suffering of patients in violation of two basic moral principles: nonmaleficence and respect for autonomy. An illustrative case provides a philosopher and a moral theologian the opportunity to analyze the applicable moral principles. A professor of jurisprudence reviews statutes evolved at the State and Federal level that support the rights of patients and their families to refuse unwanted treatments. Medical faculties must ensure that institutional policies do not violate their professional ethics. The medical profession and the citizenry at large should lobby for the passage of statutes in Puerto Rico which clearly validate the necessary harmony between medical ethics and the law

[Evaluation and treatment of cardiac injuries]. / Evaluación y tratamiento de los traumatismos cardíacos.

Cardiac injuries caused by a heart traumatism are not frequent but, of great importance given their high morbidity. Two different groups in terms of etiology, clinical picture, application of diagnostic techniques, treatment and prognosis can be considered. On one hand, there are cardiac injuries caused by a thoracal contusion, which provokes a contused lesion can affect the free wall, the interventricular septum, the valves, the subvalvular apparatus, the conduction system and the coronary vessels and, on the other hand, cardiac injuries caused by penetrating objects. Cardiac injury can lead to a life-threatening hemodynamic instability which mandates prompt and clear diagnostic and therapeutic approaches.

The withholding and withdrawal of medical treatment: moral principles and the law #.

In most hospitals in Puerto Rico the dying process of terminally ill patients is inappropriately prolonged. And this occurs often without the patient's consent and in violation of basic ethical principles. Three erroneous beliefs are prevalent: 1--That withdrawing life support therapy is morally or legally different from not starting it. 2--That there is a moral and legal difference between appropriate acts and appropriate omissions. 3--That good medical practice is determined by the courts instead of the medical profession. Institutional policies are not in harmony with contemporary medical ethics. To avoid possible legal entanglements medical institutions permit their faculties to prolong the suffering of patients in violation of two basic moral principles: nonmaleficence and respect for autonomy. An illustrative case provides a philosopher and a moral theologian the opportunity to analyze the applicable moral principles. A professor of jurisprudence reviews statutes evolved at the State and Federal level that support the rights of patients and their families to refuse unwanted treatments. Medical faculties must ensure that institutional policies do not violate their professional ethics. The medical profession and the citizenry at large should lobby for the passage of statutes in Puerto Rico which clearly validate the necessary harmony between medical ethics and the law.

[Right coronary artery originating from the left sinus of Valsalva. Surgical repair]. / Nacimiento de la arteria coronaria derecha en seno de Valsalva izquierdo. Corrección quirúrgica.

Anomalous origin of right coronary artery from left coronary sinus has been considered a minor disease without relevance. Currently it is associated with all symptoms derived from myocardial ischemia because of its lower coronary reserve. We present one patient with anomalous origin of right coronary artery from left coronary sinus surgically treated with saphenous vein aorto-coronary bypass. Doppler velocimetry shows the improvement of myocardial reserve after surgery.

[Lymphoproliferative disease and cancer in the transplant patient]. / Enfermedad linfoproliferativa y cáncer en el enfermo trasplantado.

According to the Spanish Cardiac Transplantation Registry, malignant neoplasm remain the fifth leading cause of death in heart transplant recipients. Skin cancers are the most common malignancies and they are frequently associated to solar keratosis, warts and keratoacanthoma. Geographic areas are high cumulative ultraviolet exposure have a greater incidence of skin cancer. Skin tumors are often located in chronically sun-exposed areas of the body. Lymphoproliferative disorders are the second most frequent malignant neoplasm after heart transplantation. Incidence of lymphoma is 350 times greater in heart transplant recipients than in the general population. B-cell tumors are the most common histologic type and it is associated with infection by the Epstein-Barr virus. T-cell tumors account for a 12% of all lymphoproliferative diseases and are not related to viral infections. Kaposi's sarcoma is the thirth commonest neoplasm in heart transplant recipients. Other malignat tumors are: uterine cervix, vulva, scrotum, colon, stomach, kidney and biliary tract. Prevention of neoplasm in heart transplant recipients include a decrease of immunosuppression and the avoidance of multiple immunosuppressive drug association. Some cases of neoplasm regression have been described when immunosuppressive therapy is decreased.

Early structural deterioration with the mitroflow pericardial xenograft in the mitral position.

Early structural deterioration with the mitral Mitroflow pericardial valve requiring reoperation occurred in 6 patients. Clinical diagnosis of prosthetic failure was made 5 to 58 months after valve implantation (mean, 38 months). Re-replacement was carried out 22 to 80 months (mean, 55 months) after the initial operation. Mode of failures were cuspal tear without calcification in three valves and massive calcifications in the remaining bioprostheses. High incidence of early structural deterioration of the Mitroflow pericardial valve makes this new prosthesis an unsatisfactory alternative as a substitute in the mitral position.

Valve-related complications with the Hancock I porcine bioprosthesis. A twelve- to fourteen-year follow-up study.

Valve-related morbidity and mortality after heart valve replacement with the Hancock I porcine bioprosthesis has been retrospectively analyzed. From June 1974 through December 1976, 253 Hancock I bioprostheses (150 mitral and 103 aortic) were inserted in 220 selected patients who survived the operation and had follow-up until June 1989 (mean follow-up 13.5 years, with an accumulative follow-up of 2956.4 patient-years). One hundred seventeen patients had mitral valve replacement, 70 had aortic valve replacement, and 33 had combined mitral and aortic valve replacement. There were 27 thromboembolic events. The probability of being free from thromboembolism at 14 years was 81.0% +/- 7.4% for the mitral valve replacement group, 85.4% +/- 6.7% for the aortic group, and 67.1% +/- 18.4% for the mitral-aortic group. Fifteen episodes of prosthetic valve endocarditis occurred. There were 10 instances of nonstructural dysfunction (paravalvular leaks) in seven mitral valves (4.6%) and in three aortic valves (2.9%). One hundred twenty-two bioprostheses in 106 patients resulted in structural deterioration. The probability of freedom from structural deterioration at 14 years was 37.2% +/- 3.9% for the mitral group, 43.9% +/- 7.1% for the aortic group, and 30.1% +/- 8.9% for the mitral-aortic group. The logistic regression analysis between age at the time of operation and bioprosthetic life (structural deterioration-free period) demonstrates a linear regression curve (r = 0.53). There were 56 late deaths (27 patients died at reoperation). The actuarial survival rate (including hospital mortality) at 14 years was 57.2% +/- 5.4% for the entire series, with no statistically significant difference between groups. The probability of remaining free from valve-related morbidity and mortality at 14 years was 16.7% +/- 4.8% for the mitral group, 20.8% +/- 6.2% for the aortic group, and 14.0% +/- 7.0% for the mitral-aortic group. The long-term results of this series show that the clinical performance of the Hancock I porcine valve appears satisfactory during the first 6 years. The behavior of this bioprosthesis at 14 years' follow-up changes drastically, because only a minor group of patients is free from valve-related complications, justifying the restriction of its use for selected patients.

Reoperation for bioprosthetic valve dysfunction. A decade of clinical experience.

During the 1970s, initial clinical experience with bioprostheses determined their worldwide use. However, bioprosthetic reoperation (BPR) is now common, particularly in groups with extensive implantation of these valve substitutes. From January 1980 to December 1989, a total of 470 patients had a total of 618 reoperations for bioprosthetic dysfunction and were retrospectively analyzed. Eighty-seven patients required a second BPR, 21 a third BPR, 5 a fourth BPR and 1 patient a fifth BPR. Structural deterioration was the main cause of valve dysfunction for the first and second BPR. However, paravalvular leak and infective endocarditis were more frequent for the remaining additional reoperations. Hospital mortality was 12.6%, 14.9% and 37% after the first, second and third or subsequent BPR, respectively. Univariate statistical analysis shows as hospital mortality risk factors: age at the time of the surgery, preoperative NYHA functional class IV, emergency surgery, concomitant tricuspid surgery, double (mitro-aortic) valve dysfunction, active infective endocarditis as the cause of failure and prolonged aortic cross-clamping time. Hospital mortality declined from 19.8% to 11.8% for the first and second half decade, respectively (P less than 0.005). In conclusion, bioprosthetic valve reoperation entailed a higher hospital mortality, particularly in the risk group of patients. In our hands, surgical experience has determined the improvement of the clinical results in this group of patients.

[Factors affecting early graft patency after coronary grafts]. / Factores que influyen en la permeabilidad precoz de los injertos coronarios.

From June 1984 to December 1987, an early postoperative angiographic study was performed in 247 patients who underwent isolated coronary artery bypass surgery. The average age of these patients was 58.6 years, range 31 to 75 years. Preoperatively 50.8% of patients had myocardial infarction and 43.2% of them had unstable angina before surgery. Early coronary artery bypass angiogram was performed in 683 grafts (2.76 grafts per patient): 74 internal mammary artery grafts and 609 saphenous vein grafts. The distribution, location and type of the stenosis, distal coronary artery diameter, segmental myocardial contractility, and distal angiographic coronary filling are analyzed with a matching statistical method. Multivariate analysis showed significant predictors of early graft occlusion to be right coronary and circumflex artery, poor or non visible distal angiographic filling, coronary arteries smaller than 1.5 mm. The univariate analysis associates as risk factors hypokinetic or akinetic territories and multiple stenosis coronary arteries. It can be concluded that the early angiographic study demonstrate that coronary arteries with multiple stenosis, poor distal angiographic filling, smaller than 1.5 mm in diameter, coronary arteries perfusing hypokinetic or akinetic territories and the right coronary and left circumflex artery grafts have significantly lower early cumulative patency rates.

Submammary median sternotomy.

A vertical skin incision is used as routine approach for sternotomy. The resulting scar is often disappointing and the top is visible and unpleasant, especially for young women. In 35 women ranging from 10 to 48 years (mean 29.2 years), median sternotomy was performed via a submammary skin incision. In all cases an open heart surgical procedure was performed. Adequate exposure of the heart was achieved in every case and there were no technical problems related to this approach, no hospital mortality or major complications. The cosmetic result is excellent and this approach is certainly justified in open heart surgery for young women.

Enfermedad de Hansen, uvea, esclera y retina

Examinamos 37 pacientes diagnosticados de lepra estudiando sus lesiones uveales cristalinas y esclerales. De ellos 31 eran formas lepromatosas, 2 borderline lepromatosas , 2 borderline tuberculoide y 2 tuberculoides. En 6 casos no encontramos lesiones de ningún tipo. En los restantes casos observamos una disminución de la agudeza visual directamente relacionada con la duración de la enfermedad. Las uveites crónicas indolentes fueron la causa más importante de ceguera, de las mismas fueron signos típicos la atrofia iridiana peripupilar, los precipitados queráticos, las sinequias posteriores y la miosis. Un número sorprendentemente elevado de pacientes presentaban ptisis bulbi uni o bilateral por atrofia del cuerpo ciliar. Las lesiones esclerales estuvieron representadas por escleritis, episcleritis en los casos agudos. La ectasia y adelgazamiento escleral aparecieron como secuelas de la anteriores en menor número de pacientes. No hemos encontrado lesiones funduscópicas.

[Use of both internal mammary arteries; not everything is advantageous]. / Utilización de ambas arterias mamarias internas; no todo son ventajas.

The internal mammary artery is considered the elective graft for performing aortocoronary by-pass as its long-term results have proven better than those obtained with the internal saphenous vein. Our results in a series of 21 patients in whom both internal mammary arteries were used are reported. Four patients (19.04%) needed reoperation for sternal dehiscence and two of them had mediastinitis (9.52%). Those patients were successfully treated by continuous povidone-iodine flushing. A clear statistical difference was found between this group of patients, in whom both internal mammary arteries were used, and the rest of the patients (182 patients) in whom just the internal saphenous vein and/or only one internal mammary artery was used. The second group presented 8 cases of sternal dehiscence (4.39%) and 1 mediastinitis (0.55%).

Lepra dimorfa reaccional

Se presenta un caso de lepra dimorfa en un varón de 13 años, con múltiples lesiones cutáneas, placas, nódulos, pápilas, alopecia y neuropatía periférica. Bacilospopía positiva. Se le clasifica com BT con "downgrading reaction". A los 3 años del control persisten escasas lesiones, la bacteriología es negativa. Se hacen consideraciones sobre la inestabilidad y la frecuente evolúción sin terapéutica adecuada hacia el polo lepromatoso.