Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular / Surgery in the Cardiovascular Surgical Intensive Care Unit

INTRODUCCIÓN: Analizar las indicaciones, acciones y resultados de las operaciones realizadas en la Unidad de Cuidados Intensivos (UCI) de Cirugía Cardiovascular. MÉTODOS: Análisis retrospectivo de pacientes adultos consecutivos intervenidos en la Unidad de Cuidados Intensivos (UCI). Se incluyeron todas las intervenciones practicadas. Se realizó estadística descriptiva. RESULTADOS: Entre 2008 y 2013 se intervinieron 3379 pacientes adultos consecutivos. Se practicaron en la UCI 124 intervenciones en 109 pacientes, 70 hombres (64,2%) y 39 mujeres (35,8%) con un promedio de edad de 61,6 años (12-80). Ello ha representado un 3,2%. Durante el mismo periodo de tiempo, se intervinieron en quirófano 185 pacientes por taponamiento cardiaco/hemorragia postoperatoria (5,5%). Las intervenciones previas fueron por cardiopatía valvular (34,9%), patología aórtica (22,9%), cardiopatía isquémica (15,6%), valvular/isquémica (12%), valvular/de la aorta (11%) y miscelánea (3,6%). Las indicaciones de intervención fueron hemorragia persistente 54 (43,5%), taponamiento cardiaco 41 (33%), bajo gasto cardiaco 13 (10,5%), parada cardíaca/arritmias 8 (6,5%), insuficiencia respiratoria 6 (4,8%) e isquemia de extremidades 2 (1,7%). Las intervenciones fueron: exploración mediastínica 73 (58,9%), colocación/retirada de ECMO 17 (13,7%), cierre esternal 16 (12,9%), resucitación abierta 9 (7,3%), drenaje subxifoideo 7 (5,6%) y embolectomía femoral 2 (1,6%). La mortalidad fue 33%. Hubo un caso de mediastinitis (0,9%), sin diferencias con la tasa de infecciones profundas en pacientes no intervenidos en UCI. CONCLUSIONES: La intervención en UCI es una alternativa segura y de rescate en subgrupos específicos de pacientes. no incrementa el riesgo de infección, evita el transporte de pacientes inestables y permite ahorrar tiempo en la decisión quirúrgica postoperatoria

BACKGROUND: To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS: Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS: Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS: Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings

[Surgery in the Cardiovascular Surgical Intensive Care Unit]. / Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular.

BACKGROUND: To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS: Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS: Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS: Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

Durability of the Liotta porcine bioprosthesis beyond two decades.

Porcine valves are generally known to have a limited durability. The case is reported of a 35-year-old male patient who underwent mitral valve replacement with a 28 mm Liotta porcine bioprosthesis. At reoperation 21 years later, the bioprosthesis was replaced (uneventfully) with a second porcine bioprosthesis. Pathological and X-radiographic examinations of the excised valve demonstrated focal calcification of the leaflets, confirming the long-term durability of the Liotta porcine bioprosthesis.

Hybrid procedures for complex aortic pathology: initial experience at a single center.

INTRODUCTION AND OBJECTIVES: To review experience at our center with the use of hybrid techniques for treating complex aneurysms of the thoracic aorta. METHODS: The medical records of 41 patients (40 male) with complex aortic aneurysms affecting supra-aortic or visceral vessels who underwent hybrid procedures between 1998 and 2007 were reviewed retrospectively. All patients were in American Society of Anesthesiologists category IV. They were divided in two groups: group A comprised 32 patients with aneurysms involving the aortic arch and its branches (2 ascending aorta replacements, 1 arch repair, 13 carotid-carotid bypasses, 12 carotid-subclavian bypasses, and 4 with total arch debranching); and group B comprised 9 patients with thoracoabdominal aneurysms and visceral vessel transpositions (4 partial and 5 total debranching). The mean age in group A was 69.3+/-1.3 (range, 62-73) years and in group B, 71.5+/-5.0 (range, 68-74) years. RESULTS: The mean hospital stay was 18+/-7.1 days (range, 5-35) and 12+/-8.2 days (range, 2-15) in groups A and B, respectively. Overall mortality was 12.2% (3.4% and 44.4% in groups A and B, respectively) and neurological morbidity was 3.4% and 11.1% in the two groups, respectively. CONCLUSIONS: The results obtained with hybrid treatment of the aortic arch area were comparable with those of conventional surgery. However, thoracoabdominal repair with complete revascularization of the visceral branches was associated with high mortality. Consequently, hybrid treatment is a valid option for high-risk patients who do not require complete revascularization in the visceral area.

Procedimientos híbridos para patología aórtica compleja. Experiencia inicial de un centro / Hybrid procedures for complex aortic pathology: initial experience at a single center

Introducción y objetivos. Revisar la experiencia de nuestro centro con técnicas híbridas para tratamiento de aneurismas complejos de la aorta torácica. Métodos. Se revisaron retrospectivamente los registros prospectivos de 41 pacientes (40 varones) con aneurismas torácicos que comprometían ramas supraaórticas o viscerales sometidos a procedimientos híbridos, en el periodo 1998-2007. Todos los pacientes fueron clasificados como ASA IV. Éstos fueron divididos en dos grupos: grupo A, 32 pacientes con aneurismas que involucraban el arco aórtico y sus ramas (2 sustituciones de aorta ascendente, 1 reparación de arco, 13 derivaciones carótido-carotídeas, 12 derivaciones carótido-subclavias y 4 transposiciones totales de troncos supraaórticos); grupo B, 9 pacientes con aneurismas toracoabdominales (4 transposiciones parciales y 5 totales de troncos viscerales). En el grupo A la media de edad fue 69,3 ± 1,3 (intervalo, 62-73) años, y en el grupo B fue 71,5 ± 5,0 (intervalo, 68-74) años. Resultados. La media de estancia hospitalaria fue 18 ± 7,1 días (intervalo, 5-35) y 12 ± 8,2 días (intervalo, 2-15) para los grupos A y B, respectivamente. La mortalidad global fue del 12,2% (el 3,4 y el 44,4% para los grupos A y B, respectivamente), con morbilidad neurológica del 3,4 y el 11,1%, respectivamente. Conclusiones. Los resultados de nuestros tratamientos híbridos en la zona del arco aórtico son comparables con los de la cirugía convencional. Las reparaciones toracoabdominales con revascularización completa de las ramas viscerales se asocian a mortalidad elevada. Así, la cirugía híbrida es una alternativa válida para pacientes de alto riesgo que no precisen la revascularización completa del área visceral (AU)

Introduction and objectives. To review experience at our center with the use of hybrid techniques for treating complex aneurysms of the thoracic aorta. Methods. The medical records of 41 patients (40 male) with complex aortic aneurysms affecting supra-aortic or visceral vessels who underwent hybrid procedures between 1998 and 2007 were reviewed retrospectively. All patients were in American Society of Anesthesiologists category IV. They were divided in 2 groups: group A comprised 32 patients with aneurysms involving the aortic arch and its branches (2 ascending aorta replacements, 1 arch repair, 13 carotid–carotid bypasses, 12 carotid–subclavian bypasses, and 4 with total arch debranching); and group B comprised 9 patients with thoracoabdominal aneurysms and visceral vessel transpositions (4 partial and 5 total debranching). The mean age in group A was 69.3 (1.3) (range, 62–73) years and in group B, 71.5 (5.0) (range, 68-74) years. Results. The mean hospital stay was 18 (7.1) days (range, 5-35) and 12 (8.2) days (range, 2-15) in groups A and B, respectively. Overall mortality was 12.2% (3.4% and 44.4% in groups A and B, respectively) and neurological morbidity was 3.4% and 11.1% in the 2 groups, respectively. Conclusions. The results obtained with hybrid treatment of the aortic arch area were comparable with those of conventional surgery. However, thoracoabdominal repair with complete revascularization of the visceral branches was associated with high mortality. Consequently, hybrid treatment is a valid option for high-risk patients who do not require complete revascularization in the visceral area (AU)

Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures.

OBJECTIVE: This study analyzes the anatomic structure of the mitral and tricuspid annuli, their relationship with the coronary arteries and veins, and how this anatomic distribution may affect atrial ablation with bipolar radiofrequency clamps, the only technology that ensures transmurality. METHODS: Nine explanted fresh human hearts were studied, two of them with left coronary dominance. Two types of bipolar radiofrequency clamps were positioned to reach the mitral and tricuspid annuli, and relationships within the atrioventricular junction were analyzed, including coronary sinus and coronary arteries. RESULTS: In all hearts studied, the coronary arteries and veins within the adipose tissue of the right or left atrioventricular groove lay in the atrial side, 3 to 18 mm away from the mitral or tricuspid annuli. When the bipolar radiofrequency clamp was closed toward the mitral annulus, the coronary sinus was always included between the jaws, and in left coronary-dominant hearts, the circumflex artery was also included. Nevertheless, the clamp never reached the annulus owing to the increase in thickness of the adipose tissue around the groove and the ventricular mass, leaving 5 to 10 mm of atrial myocardium free from the radiofrequency electrodes. In the right atrium, clamp placement toward the tricuspid annulus excluding the right coronary left 8 to 18 mm of atrial muscle free from the bipolar electrodes. CONCLUSIONS: Bipolar radiofrequency clamps are not sufficient to complete a Cox maze IV procedure. Moreover, they may compromise coronary arteries in patients with left coronary dominance. Lines to the atrioventricular annuli need to be completed with the cut-and-sew technique or with alternative monopolar energy devices.

Hybrid antegrade repair of the arch and descending thoracic aorta with a new integrated stent-Dacron graft in acute type A aortic dissection: a look into the future with new devices.

A young male patient underwent supracoronary replacement of the ascending aorta for acute type A dissection under hypothermic circulatory arrest. After discharge, he was readmitted two weeks later due to severe aortic regurgitation and acute arch redissection. Under a second period of hypothermic circulatory arrest three weeks after the initial operation, radical treatment with aortic valve replacement, replacement of the ascending aorta and arch, together with antegrade deployment of a stent-graft in the true lumen for frozen elephant-trunk technique, were successfully performed. Computed tomography at four weeks showed complete proximal repair and thrombosis of the false lumen. Transesophageal echocardiography at eight weeks confirmed repair. The patient is currently leading an active life. A hybrid approach for complex cases of acute type A dissection with arch involvement can be considered for the future.

Elective cardiac surgery using Celsior or St. Thomas No. 2 solution: a prospective, single-center, randomized pilot study.

OBJECTIVE: Celsior is a crystalloid solution specifically designed for solid-organ transplantation. Due to its advanced combination of solutes, we wanted to evaluate its safety, efficacy, and possible benefits when used as blood cardioplegia in elective cardiac surgery in a single-center, randomized, controlled clinical trial, comparing its performance with a well-established cardioplegic solution. METHODS: Patients programmed for aortic valve replacement were randomized to receive either St. Thomas No. 2 or Celsior as blood cardioplegia with the same administration protocol. Intraoperative and postoperative variables concerning myocardial protection were registered and compared. RESULTS: A total of 60 patients were enrolled and randomized (Celsior, 30; St. Thomas, 30). There were no significant differences in baseline and preoperative variables. Volume of cardioplegic solution, number of administrations needed and the amount of potassium added were similar in both groups. Patients in the Celsior group showed a higher incidence of spontaneous sinus rhythm after myocardial ischemia (77% vs 40%, p=0.004) and fewer patients required defibrillation (17% vs 43%, p=0.024) for ventricular reperfusion arrhythmias. Postoperatively, there were no significant differences in troponin I release, inotropic and vasopressor drug support, ICU stay, and postoperative evolution. There were no deaths in the study. CONCLUSIONS: Celsior solution used as blood cardioplegia is effective and seems to be safe in elective aortic valve replacement when compared in this pilot study with a standard cardioplegic solution used worldwide. Fast return to sinus rhythm and lower incidence of reperfusion arrhythmias in the Celsior group may reflect a better myocardial protection during cardioplegic arrest. More investigation is needed to elucidate its performance in elective surgery.

Preoperative risk stratification in infective endocarditis. Does the EuroSCORE model work? Preliminary results.

OBJECTIVE: There is an important role for risk prediction in cardiac surgery. Prediction models are useful in decision making and quality assurance. Patients with infective endocarditis (IE) have a particularly high risk of mortality. The aim was to assess the performance of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in IE. METHODS: The additive and logistic EuroSCORE models were applied to all patients undergoing surgery for IE (Duke criteria) between January 1995 and April 2006 within our prospective institutional database. Observed and predicted mortalities were compared. Model calibration was assessed with the Hosmer-Lemeshow test. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. RESULTS: One hundred and eighty-one consecutive patients undergoing 191 operations were analyzed. Observed mortality was 28.8%. For the entire cohort the mean additive score was 10.4 (additive predicted mortality of 14.2%). The mean logistic predicted mortality was 27.1%. Discriminative power was good for the additive and the logistic models for the entire series. Area under ROC curve were 0.83 (additive) and 0.84 (logistic) for the entire cohort, 0.81 and 0.81 for the aortic position, 0.91 and 0.92 for the mitral position, 0.81 and 0.81 for the native valve, 0.82 and 0.83 for the prosthetic valves, and 0.81 and 0.51 for the gram-positive microorganisms, respectively. CONCLUSIONS: This initial sample may be small; however, additive and logistic EuroSCORE adequately stratify risk in IE. Logistic EuroSCORE has been calibrated in IE, a special group of very high-risk patients. Further studies with larger sample sizes are required to confirm these initial results.

One-step surgical approach of a thoracic aortic aneurysm in Wiskott-Aldrich syndrome.

Wiskott-Aldrich syndrome is a primary immunodeficiency characterized by infections, thrombocytopenia, and eczema. We present a 33-year-old man with this syndrome who underwent a one-stage ascending aorta, aortic arch and descending aortic aneurysm repair under moderate hypothermia and continuous visceral and cerebral perfusion. Histologic examination showed the presence of an aortitis with granulomatous inflammatory response and multinucleated cells.

Erosion of lumbar vertebral bodies by an anastomotic false aneurysm late after implantation of a prosthetic aortic bifurcated graft.

False aneurysms are seen at any anastomotic level. Erosion of surrounding structures is a rare event that needs surgical treatment. The case of a patient with proximal Dacron bifurcated graft false aneurysm eroding lumbar vertebral bodies is presented. This is an uncommon but very serious complication from aortic grafts.

Splenic haemorrhage in a newborn as the first manifestation of wandering spleen syndrome.

Wandering spleen is an unusual condition in children and is even more rarely diagnosed in the neonatal period. A case of splenic haemorrhage after dystocic birth in a newborn is reported. Before surgery, results of imaging studies were suggestive of a ruptured spleen. On laparotomy, a big haematoma surrounding a wandering spleen was found. Haemorrhage aroused from short splenic arteria. Haemostasia and splenopexy were performed. The spleen proved later to be viable. The authors speculate that the haemorrhage was the first manifestation of the wandering spleen.

Valvuloplastia pulmonar percutánea en un paciente con síndrome de Alagille / Percutaneous pulmonary valvuloplasty in a patient with Alagilles syndrome

Se presenta el caso de una paciente de sexo femenino de 12 años de edad afectada de síndrome de Alagille o displasia arteriohepática con estenosis valvular pulmonar, en la que se realizó valvuloplastia pulmonar percutÔnea con balón. Se comenta la rareza del síndrome, su signología definitoria así como la terapéutica incruenta y aún poco utilizada para el tratamiento de la estenosis pulmonar (AU)

Valvuloplastia pulmonar percutánea en un paciente con síndrome de Alagille / Percutaneous pulmonary valvuloplasty in a patient with Alagille's syndrome

Se presenta el caso de una paciente de sexo femenino de 12 años de edad afectada de síndrome de Alagille o displasia arteriohepática con estenosis valvular pulmonar, en la que se realizó valvuloplastia pulmonar percutânea con balón. Se comenta la rareza del síndrome, su signología definitoria así como la terapéutica incruenta y aún poco utilizada para el tratamiento de la estenosis pulmonar