Perioperative management in cardiovascular surgery. / Manejo perioperatorio en cirugía cardiovascular.

Cardio-surgical patient care requires a comprehensive and multidisciplinary approach to develop strategies to improve patient safety and outcomes. In the preoperative period, prophylaxis for frequent postoperative complications, such as de novo atrial fibrillation or bleeding, and prehabilitation based on exercise training, respiratory physiotherapy and nutritional and cognitive therapy, especially in fragile patients, stand out. There have been great advances, during the intraoperative phase, such as minimally invasive surgery, improved myocardial preservation, enhanced systemic perfusion and brain protection during extracorporeal circulation, or implementation of Safe Surgery protocols. Postoperative care should include goal-directed hemodynamic theraphy, a correct approach to coagulation disorders, and a multimodal analgesic protocol to facilitate early extubation and mobilization. Finally, optimal management of postoperative complications is key, including arrhythmias, vasoplegia, bleeding, and myocardial stunning that can lead to low cardiac output syndrome or, in extreme cases, cardiogenic shock. This global approach and the high degree of complexity require highly specialised units where intensive care specialists add value and are key to obtain more effective and efficient clinical results.

Case-control study of risk factors for mediastinitis after cardiovascular surgery.

We report results of a case-control study in which we evaluated 41 risk factors potentially associated with the development of postsurgical mediastinitis. There were 163 case patients and 326 control patients. Independent risk factors kept in the final multivariate logistic regression model were obesity (defined as a body mass index of greater than 30), diabetes mellitus, chronic obstructive pulmonary disease, preoperative stay longer than 1 week, pulmonary hypertension, perioperative myocardial infarction, and reoperation.

[Early results with partial left ventriculectomy (the Batista operation)]. / Resultados precoces de la ventriculectomía parcial izquierda (operación de Batista).

INTRODUCTION AND OBJECTIVES: The shortage of donors as well as the morbidity and mortality associated with transplantation have led to development of other surgical options for end-stage dilated cardiomyopathy. Partial left ventriculectomy reducing ventricular diameter and mass has been proposed. We here in report the initial experience (not only limited to the alternative of transplantation) and immediate results obtained with this technique in our institution. METHODS: Six patients with dilated cardiomyopathy underwent surgery: 4 of idiopathic origin with exclusion criteria for heart transplantation and 2 of valvular or mixed etiology. Resection of a slice of the left ventricle was performed between the two papillary muscles, from the apex of the heart to the mitral annulus, and closure was carried out with a single suture with mitral annuloplasty in 5 cases (tricuspid repair in one and aortic valve replacement in two). RESULTS: An intraaortic balloon pump was required in two patients; one died from cardiogenic shock and the other died after several ventricular arrhythmias fifteen days after surgery. Intraoperative echocardiographic studies showed a significant reduction in both diastolic diameter (8.7 to 6.8 cm; p = 0.02) and mitral insufficiency and an increase in the ejection fraction (17 to 27%; p = 0.09) which were maintained on echography 10 days after surgery. CONCLUSIONS: This technique is a feasible, suitable therapeutic option for refractory congestive heart failure. Appropriate patient selection, the perioperative management and long-term support remain to be defined.

[Hybrid revascularization]. / Revascularización híbrida.

OBJECTIVE: To evaluate our initial experience in the combination of two less invasive procedures for myocardial revascularization, coronary artery bypass grafting without cardiopulmonary bypass and immediate posterior angioplasty, on untreated lesions (hybrid revascularization) as an alternative treatment to conventional surgery in selected patients. MATERIAL AND METHODS: From october 1996 to September 1998, 19 patients received hybrid revascularization. The mean age was 64 (47-76). Two patients underwent urgent surgery. Two patients had left main coronary disease, and 9 three-vessel disease. In general, we considered this procedure for patients with high-risk factors for cardiopulmonary bypass and two or more vessel disease. The internal mammary artery was connected to the left anterior descending artery in all 19 patients. All patients were moved to the hemodynamic ward immediately after surgery in 7 cases and before 48 h in the rest, 24 angioplasties were performed. A mean of 2.6 vessels per patient were revascularized and revascularization was complete in 15 patients (79%). RESULTS: One patient had perioperative myocardial infarction. There was no hospital mortality. Length of stay in the intensive care unit was 44 h (IQR = 49) and global postoperative stay was 8 days (IQR = 3.5). In the postoperative angiographic study, before the angioplasty, 95% of mammary arteries (CI 95% 74-100%) and 100% of saphenous grafts (CI 95% 59-100%) were patent. CONCLUSIONS: Combined revascularization allows almost complete revascularization, avoiding complications of cardiopulmonary bypass and minimizing surgical aggression. At the same time, it secures the graft of internal mammary artery to left anterior descending artery.

[The etiology of neurological complications after cardiopulmonary bypass surgery]. / Etiología de las complicaciones neurológicas tras cirugía extracorpórea.

INTRODUCTION: Cardiopulmonary bypass (CEC) in the surgical treatment of cardiac diseases may cause the appearance of neurological damage of an intensity which varies between minor neuropsychological disorders and global cerebral anoxia. There are two mechanisms for the production of these lesions: ischaemic and embolic. The mortality associated with this type of complication is low, but morbidity may be considerable. The neurological disorders derived from CEC may be classified according to the aetiology and clinical findings. In the first group are included: severe cerebral anoxia, embolic cerebro-vascular accidents, microvascular embolias, lesions of spinal vascularization and lesions of the peripheral nerves. In the second group are: encephalic focal lesions, convulsive crises, lesions of the extra-pyramidal system, alterations in the level of consciousness and neuropsychological disorders. METHODS: Quantification of neuronal damage has been attempted by: monitoring cerebral blood flow and neurone metabolism, EEG and study of intra-operative evoked potentials, echography of the carotid, cardiac and ascending aorta, transcranial doppler, fluorescein-angiography and the study of biochemical markers of neuronal and glial damage. Different studies have identified a series of factors which potentiate the risk of neurological lesions following CEC. These are: age, severe carotid disease, aortic atherosclerosis and previous cerebro-vascular haemorrhage, amongst others. An attempt is made to reduce the incidence of neurological complications by: pre-operative evaluation of carotid bruits, hypothermia, careful surgical technique and the use of drugs with a neuroglial protector effect. None of these methods gives sufficiently effective protection to the central nervous system subjected to the changes involved in the use of CEC. CONCLUSION: There are still many unknown aspects of neurone pathology in these circumstances, leaving a door open to investigation.

[Thromboendarterectomy as a treatment for chronic pulmonary hypertension]. / Tromboendarterectomía como tratamiento de la hipertensión pulmonar crónica.

Chronic pulmonary hypertension is an extremely difficult disease to diagnose and is usually identified by the exclusion of other more recognized causes of enlargement in mean pulmonary arterial resistance. Up to now, treatments proposed for this disease, have not been very successful. Medical procedures are not a long term proper solution which leads the process to an irreversible point whose only solution should be a pulmonary transplantation. In recent years, study groups have established a surgical method, alternative to transplantation, which has been able to increase, with a decrease in mortality rates, a longer and a better quality of life for the patients affected by this disease: we are talking about pulmonary thromboendarterectomy.

[Extracorporeal circulation in pregnancy: report of a case. Update and review of the literature]. / Circulación extracorpórea durante el embarazo: a propósito de un caso. Actualización y revisión de la literatura.

Parameters of flow, temperature and perfusion, and modifications in body fluids secondary to surgery with extracorporeal circulation do not imply an increase in maternal risk during pregnancy but they eventually considerably increase fetal morbimortality. We present the case of a 22 week pregnant woman with severe aortic stenosis who underwent extracorporeal surgery for valve replacement without fetal mortality during the procedure. Literature about the use of extracorporeal surgery in the treatment of valve pathology in pregnancy, the parameters in which the reduction of fetal morbimortality is based and alternative treatments are broadly reviewed.