Cardiopatías congénitas, tratamiento quirúrgico y sus complicaciones en población pediátrica del Hospital Vicente Corral Moscoso, 2017 - Agosto 2019 / Congenital heart diseases, surgical treatment and complications in pediatric sample of Hospital Vicente Corral Moscoso, 2017-August 2019.

INTRODUCCIÓN: El corazón es el órgano más comúnmente afectado por anormalidades congénitas, con una incidencia de 0.8 por cada 100 nacidos vivos. Cerca de dos tercios de todos los procedimientos son en la actualidad realizados antes del año de edad, lo que mejora la sobrevida y la calidad de vida. Este estudio busca determinar cuáles son las principales intervenciones quirúrgicas realizadas para tratar las cardiopatías congénitas y sus complicaciones. MATERIALES Y MÉTODOS: Se realizó un estudio observacional, descriptivo de corte transversal; con 70 pacientes pediátricos diagnosticados y tratados quirúrgicamente por cardiopatías congénitas. Los datos fueron tomados de las historias clínicas mediante un formulario. El análisis estadístico se realizó utilizando el programa SPSS versión 15. RESULTADOS: La mediana de la edad fue de 1.1 años, el 60% fueron de sexo femenino. El 90% de las cardiopatías fueron no cianógenas. El diagnóstico más frecuente fue la persistencia del conducto arterioso (58.57%), seguido de la comunicación interventricular (12.86%). Según el tipo de procedimiento el 58.57% se realizaron para cierre de persistencia del conducto arterioso y un 12.86% fueron reparaciones quirúrgicas para cierre de comunicación interventricular. La mediana de estadía en la unidad de cuidados intensivos fue de 4 días y la mediada de estadía en la sala general de 5 días. La principales complicaciones observadas en esta población pediátrica sometida a un procedimiento quirúrgico fueron: la neumonía (11.4%) y la sepsis de origen no especificado (8.6%). CONCLUSIÓN: Los tratamientos para las cardiopatías congénitas se realizaron a edades tempranas (Media =2.5 ± 3.2 años). Más de la mitad de los procedimientos quirúrgicos realizados para cardiopatías quirúrgicas fueron para corregir la persistencia del conducto arterioso y la principal complicación fue la neumonía.

BACKGROUND: The heart is the most commonly affected organ by congenital diseases, with and incidence of 0.8 per 100 newborns. Nearly two thirds of all the surgical procedures are now a days performed before the first year of life, improving survival rate and life quality. This study aims to determine the frequency of the surgical interventions performed to treat congenital heart diseases and its complications. METHODS: An observational, descriptive cross sectional study was carried out; with 70 pediatric patients diagnosed and surgically treated for congenital heart diseases. The data was collected from the patient's medical records using a form. Statistical analysis was performed using SPSS version 15 software. RESULTS: The median age was 1.1 years, 60% of the sample were women. 90% of the heart diseases were non-cyanogenic. The most frequent diagnosis was: persistence of the arterial duct (58.57%), followed by interventricular communication (12.86%). The type of procedures corresponds to the heart disease, thus 58.57% were performed for closure of arterial duct persistence and 12.86% were surgical repairs for closure of interventricular communication. The median stay in the intensive care unit was 4 days and the median stay in general hospitalization room was 5 days. The main complications in this pediatric population undergoing a surgical procedure were: pneumonia (11.4%) and sepsis of unspecified origin (8.6%). CONCLUSION: Treatment for heart diseases were performed at early ages (average age= 2.5±3.2). More than half of the surgical procedures for congenital heart disease were performed to correct the persistence of the ductus arteriosus, the main complication was pneumonia.

Características clínicas y quirúrgicas de pacientes sometidos a cirugía de válvula mitral en una ins titución de salud de Barranquilla, Colombia / Clinic al and surgic al characteristics of patients undergoing mitral valve surgery at a health ins titution in Barranquilla, Colombia

Introducción: la incidencia de las anomalías valvulares cardiacas ha aumentado entre otras razones por los avances en métodos diagnósticos y conocimiento de predecesores etiológicos como desenca­ denantes de la condición clínica, que inicia la probabilidad diagnostica y seguimiento temprano en pa­ cientes en estadios iniciales de la enfermedad, disminuyendo de esta manera el impacto económico por aumento de la morbimortalidad. Objetivo: describir las características clínicas y quirúrgicas de pa­ cientes sometidos a cirugía de válvula mitral en una institución prestadora de servicios de salud de re­ ferencia para el distrito de Barranquilla, Colombia, durante los años 2014 a 2016. Metodología: estudio descriptivo, en el que se revisó de forma retrospectiva las historias clínicas de pacientes con patología mitral que requirieron intervención quirúrgica de tipo plastia, cambio biológico o mecánico, entre los años 2014 y 2016. El análisis de la información se realizó a través del software SPSS. Re­ sultados: durante el periodo de estudio se realizaron 276 cirugías valvulares en la institución de salud objeto de estudio, de las cuales 98 fueron cirugías sobre válvula mitral, excluyéndose 20 historias clí­ nicas que no contenían la totalidad de las variables analizadas. El antecedente clínico más frecuente fue la enfermedad coronaria (38,5%), seguido del infarto de miocardio (23,1%); el 20,5% de los pa­ cientes presentaron arritmia tipo fibrilación auricular y la cirugía sobre válvula mitral más realizada fue recambio biológico (42%). Conclusión: las características clínicas y quirúrgicas de los pacientes inclui­ dos en el estudio, son similares a las descritas en la literatura nacional e internacional, por lo que podría tomarse como precedente de presentación y de esta manera ir construyendo una clínica para la identificación rápida y veraz de los pacientes con alteraciones valvulares, permitiendo su abordaje temprano y disminuyendo la carga económica para el sistema de salud.

Introduction: cardiac valvular anomalies have increased their presentation, in part due to advances in diagnostic methods and knowledge of etiological predecessors as triggers of the clinical condition that initiates the diagnostic probability and early follow­up in patients in the initial stages of the di­ seas e, thus decreasing the economic impact due to increased morbidity and mortality. Objective: to describe the clinical and surgical characteristics of patients undergoing mitral valve surgery at a re­ference center in the district of Barranquilla during the years 2014 to 2016.Methodology: descriptive, retrospective, cross­sectional study in a health institution in the district of Barranquilla. Patients with mitral pathology who required surgical intervention of the plasty type, biological or mechanical chan­ ge, were included between 2014 and 2016. Data analysis performed in SPSS according to the natu­ re of the variables. Results : during the study period, 276 valve surgeries were performed, of which 98 were valve surgeries, 20 patients were excluded due to incomplete clinical history; the most pre­ valent antecedent was coronary disease in 38.5% followed by myocardial infarction with 23.1%; 20.5% of the patients presented arrhythmia type atrial fibrillation; the most performed mitral valve surgery was a 42% biological replacement. Conclusion: the clinical and surgical characteristics of the patients included in the study, correspond to those described in national and international litera­ ture, so it could be taken as a precedent for presentation and thus build a presentation clinic for quick and accurate identification of the patients with valvular alterations, allowing their early ap­ proach and decreasing the economic burden for the health system.

Complicaciones posoperatorias en cirugía mayor torácica y abdominal: definiciones, epidemiología y gravedad / Postoperative complications in thoracic and abdominal surgery: definitions, epidemiology and severity

Las complicaciones posoperatorias en pacientes sometidos a cirugía mayor torácica o abdominal son eventos frecuentes, asociados a una mala evolución. El objetivo de este trabajo es precisar las definiciones, características epidemiológicas y clasificaciones de severidad de las complicaciones posoperatorias en la cirugía mayor torácica y abdominal. Se realizó una revisión bibliográfica sobre las complicaciones posoperatorias en la cirugía mayor torácica y abdominal. Se presentan las definiciones atendiendo a las complicaciones posoperatorias. Se discuten los reportes referentes a la incidencia y mortalidad de las complicaciones más importantes. Por último, se abordan las principales herramientas de clasificación de severidad de las complicaciones posoperatorias. Las complicaciones posoperatorias son eventos frecuentes que incrementan las complicaciones y mortalidad. Deben aplicarse instrumentos de estratificación de riesgo, monitorizar estrechamente su aparición y gravedad, así como actuar rápida y oportunamente para su solución(AU)

Postoperative complications in patients undergoing thoracic or abdominal major surgery are frequent events associated with a poor evolution. The aim of this paper is to clarify the definitions, epidemiological characteristics and classifications postoperative complications severity in most thoracic and abdominal surgery. A literature review on postoperative complications in most thoracic and abdominal surgery was carried out. Definitions are stated regarding postoperative complications. Reports are discussed concerning the incidence and mortality of the most important complications. Finally, the main tools for postoperative complications severity classification are discussed. Postoperative complications are frequent events that increase complications and mortality. Risk stratification tools should be applied, their appearance and severity should be closely monitored, as well as to act quickly and timely for a solution(AU)

Ventilação não invasiva após cirurgia cardiovascular: um ensaio clínico randomizado / Non-invasive ventilation after cardiovascular surgery: a randomized clinical trial

Fundamentos: A hipoxemia é a complicação mais comum no pós-operatório (PO) de cirurgia cardíaca, sendo consequência principalmente da formação de atelectasias, edema intersticial alveolar e acúmulo de secreção pulmonar. Essas alterações aumentam a incidência de infecções pulmonares, tempo de internação na UTI e custos hospitalares. Objetivo: Avaliar as trocas gasosas e alterações hemodinâmicas de pacientes hipoxêmicos submetidos à ventilação não invasiva (VNI) no PO imediato de cirurgia cardiovascular. Métodos: Ensaio clínico randomizado conduzido na UTI cirúrgica de um hospital cardiológico. Foram incluídos pacientes com hipoxemia (300>PaO2/FiO2>150) uma hora após extubação orotraqueal, no PO imediato de cirurgia cardiovascular eletiva e que foram submetidos à cateterização da artéria pulmonar no bloco cirúrgico (BC). O grupo-controle recebeu oxigenoterapia e o grupo-intervenção, VNI e oxigênio durante três horas consecutivas. Na análise estatística foram utilizados os testes t de Student, Mann-Whitney, exato de Fisher, ANOVA e generalized estimating equation (GEE). Resultados: Estudados 42 pacientes. Os pacientes do grupo-intervenção (n=21) apresentaram melhora significativa da relação PaO2/FiO2 (p=0,007). Houve discreta diferença entre os grupos na pressão capilar pulmonar (p=0,012), no índice cardíaco (p=0,006) e na pressão venosa central (p=0,022).

Background: Hypoxemia is the most common complication during the post-operative stage of cardiovascular surgery, due mainly to atelectasis, alveolar interstitial edema and accumulations of pulmonary secretions. These changes may increase the incidence of lung infections with longer ICU stays and consequently higher hospital costs. Objective: To evaluate gas exchanges and hemodynamic alterations in hypoxemic patients under non-invasive ventilation (NIV) during the immediate post-operative period subsequent to cardiovascular surgery. Methods: A randomized clinical trial conducted in the surgical ICU of a cardiology hospital of patients with hypoxemia (300>PaO2/FiO2>150) one hour after orotracheal extubation during the post-operative period immediately after elective cardiovascular surgery who underwent pulmonary artery catheterization in the surgical ward. The control group received oxygen therapy, while the intervention group received NIV plus oxygen for three consecutive hours. For the statistical analysis, we used the Student t, Mann-Whitney, Fisher’s exact tests, as well as ANOVA and generalized estimating equations (GEE). Results: Among the 42 patients studied, the intervention group (n=21) presented significant improvements in the PaO2/FiO2 ratio (p=0.007), with little difference between the groups for pulmonary capillary pressure (p=0.012), cardiac index (p=0.006) and central venous pressure (p=0.022).

Cinética de la proteína C reactiva y la procalcitonina en el postoperatorio de cirugía cardíaca en niños / Kinetics of C-reactive protein and procalcitonin after paediatric cardiac surgery

Introducción y objetivos: En el postoperatorio de la cirugía cardíaca se produce una respuesta inflamatoria sistémica que dificulta la identificación de complicaciones. El objetivo fue estudiar el comportamiento de la proteína C reactiva (PCR) y la procalcitonina (PCT), valorando su relación con la gravedad y analizando su utilidad para detectar complicaciones. Métodos: Se estudió prospectivamente a 59 niños intervenidos mediante cirugía cardíaca abierta. Se determinaron la PCR y la PCT al ingreso en una unidad de cuidados intensivos pediátricos, a las 24, a las 48 y a las 72h. Se analizó la relación de la PCR y la PCT con la gravedad clínica valorada mediante las escalas Pediatric Risk Mortality y Therapeutic Intervention Scoring System, y el desarrollo de complicaciones (infecciosas y hemodinámicas). Resultados: La PCR y la PCT aumentaron en las primeras 24h, disminuyendo progresivamente en los 2 días posteriores. La PCR no se relacionó con la gravedad ni con la aparición de complicaciones. La PCT tras la cirugía, a las 24 y a las 48h presentó una moderada correlación con el Pediatric Risk Mortality (r=0,548; 0,434 y 0,446, respectivamente) y una baja con el Therapeutic Intervention Scoring System. Se obtuvieron unos puntos de corte para la PCT>0,17ng/ml (sensibilidad del 73,3%, especificidad del 72,2%) al ingreso y >1,98ng/ml (sensibilidad del 57,1%, especificidad del 87%) a las 48h para detectar complicaciones. No existieron diferencias en la PCR ni en la PCT entre los pacientes con complicaciones infecciosas y hemodinámicas. Conclusiones: En el postoperatorio de la cirugía cardíaca pediátrica la PCR no se correlaciona con la gravedad ni con la presencia de complicaciones. La PCT se correlaciona con la gravedad y puede detectar complicaciones posquirúrgicas (AU)

Introduction and objectives: The systemic inflammatory response syndrome developed after cardiac surgery impedes the detection of complications. The aim of our study was to examine the behaviour of C-reactive protein (CRP) and procalcitonin (PCT), as well as to evaluate its relationship with severity and to analyse its usefulness in the identification of complications. Methods: A total of 59 children who underwent cardiac surgery with cardiopulmonary bypass were prospectively studied. CRP and PCT were determined after surgery and at 24, 48 and 72 hours. The relationships between both parameters and the clinical severity were analysed (evaluated with PRISM and TISS scoring systems), as well as with the incidence of complications (infectious and haemodynamics). Results: Serum concentrations of CRP and PCT increased in the first 24 hours after surgery, with a gradual decrease over the following days. There was no association between CRP and severity or development of complications. A moderate correlation was observed between PCT after surgery, at 24 and 48 hours, and PRISM (r=0.548; 0.434 and 0.446) and a low correlation between PCT and TISS. When studying the identification of complications, we obtained cut-off values of PCT>0.17ng/ml (Ss 73.3%; Sp 72.2%) and PCT>1.98ng/ml (Ss 57.1%; Sp 87%) immediately and 48 hours after surgery. No differences were found in CPR and PCT levels among patients with infectious and haemodynamics complications. Conclusions: CPR does not correlate with the severity or the incidence of complications after paediatric cardiac surgery. PCT correlates with clinical severity and may be able to detect post-surgical complications (AU)

Only half of the chronic pain after thoracic surgery shows a neuropathic component.

UNLABELLED: Chronic pain is a common complication after thoracic surgery. The cause of chronic post-thoracotomy pain is often suggested to be intercostal nerve damage. Thus chronic pain after thoracic surgery should have an important neuropathic component. The present study investigated the prevalence of the neuropathic component in chronic pain after thoracic surgery. Furthermore, we looked for predictive factors for prevalence and intensity of chronic pain. We contacted 243 patients who underwent a video-assisted thoracoscopy (VATS) or thoracotomy in the period between January 2004 and September 2006 by mail. Patients retrospectively received a questionnaire with the Dutch version of the PainDETECT Questionnaire, a validated screening tool for neuropathic pain. Results were analyzed from 204 patients (144 thoracotomies, 60 VATS). The prevalence of chronic pain was 40% after thoracotomy and 47% after VATS. Definite chronic neuropathic pain was present in 23% of the patients with chronic pain, with an additional 30% having probable neuropathic pain. Greater probability of neuropathic pain (ie, a higher total score of the PainDETECT) correlated with more intense chronic pain. Predictive factors for chronic pain were younger age (P = .01), radiotherapy (P = .043), pleurectomy (P = .04) and more extensive surgery (P < .001). PERSPECTIVE: Up to half the chronic pain after thoracic surgery is not associated with a neuropathic component, which has not been reported to date. More extensive surgery and pleurectomy are predictive factors for chronic pain after thoracic surgery, suggesting a visceral component apart from nerve injury.

Experiencia del servicio de cirugía del hospital escuela Oscar Danilo Rosales Arguello en la cirugía cardiotorácica de enero 2002 a diciembre 2005 / Experience of the service of surgery of the hospital school Oscar Danilo Rosebushes Arguello in the surgery cardiotorácica of January 2002 to December 2005

La cirugía de corazón abierto no ha existido siempre, por el contrario ha sido el resultado del esfuerzo combinado de múltiples investigadores, siendo cada uno de ellos pioneros y visionarios en sus respectivas disciplinas. En Nicaragua al igual que el resto de los países Centroamericanos, calcular la situación real de las patologías cardiovasculares que requieren intervención quirúrgica es dificil débido a las precarias condiciones socioeconómicas que imperan en nuestros días, pero el apoyo de la cooperación externa ha permitido formar profesionales capaces y desarrollar la infraestructura mínima necesaria en el HEODRA para realizar procedimientos quirúrgicos avanzados y así resolver la problematica de los más necesitados en nuestro país. El presente estudio describe los hallazgos de las principales Cirugías Cardiotorácicas realizadas por profesionales nicaraguenses quienes a pesar de tener tantas limitaciones han logrado llevar a cabo intervenciones quirúrgicas complejas que han mejorado cuanlicuantitativamente la calidad de vida de los pacientes intervenidos. La población de estudio se caracterizó por tener edades comprendidas entre 0 y 65 años, predominando el sexo femenino, ser en su mayoría pobre y de escasa preparación académica, predominaron las cardiopatías congénitas seguida de las adquiridas, destacando el ductus arterioso persistente y la cardiopatía valvular reumática. Los principales procedimientos realizados fueron cierre quirúrgico de ductus arterioso persistente y cambio valvular, la complicación más frecuente fue la atelectasia y la evolución posquirúrgica ha sido satisfactoria en el 100 por ciento de los pacientes, todo los cuales han tenido seguimiento por consulta externa...

Aspectos da funcão pulmonar após revascularizacão do miocárdio relacionados com risco pré-operatório / Pulmonary function aspects after myocardial revascularization related to preoperative risk

OBJETIVOS: Comparar os valores das complacências dinâmica e estática, da resistência de vias aéreas (Cdin, Cest e Raw) e do índice de troca gasosa (PaO2/FiO2), no pós-operatório de cirurgia de revascularizacão miocárdica (RM) com os parâmetros de normalidade e comparar os valores destas variáveis entre grupos com e sem fatores de risco no pré-operatório. MÉTODO: Questionamento aos doentes a respeito de antecedentes pulmonares, sintomas respiratórios, tabagismo e comorbidades. Após cirurgia de RM, foram feitas as medidas de Cdin, Cest, Raw e do PaO2/FiO2. As variáveis foram comparadas com a normalidade e relacionadas às variáveis pré e pós-operatórias pelo Teste não-paramétrico de Mann-Whitney e pelo Teste para uma proporcão (p<0,05). RESULTADO: Foram avaliados 70 doentes (61 por cento homens), com idade entre 26 e 77 anos. Em relacão à normalidade, apresentaram diminuicão da Cdin e da Cest, 64 e 66 pacientes, respectivamente, e 24 apresentaram aumento da Raw. Aproximadamente 50 por cento apresentaram reducão do PaO2/FiO2. Não houve diferenca significante das variáveis pós-operatórias com respeito aos antecedentes pulmonares, sintomas respiratórios e tabagismo. Nos pacientes com comorbidades, o PaO2/FiO2 foi significativamente menor e, nos homens, a Cdin e a Cest foram maiores que nas mulheres. CONCLUSAO: As complacências pulmonares estão diminuídas na maioria dos pacientes, e a resistência das vias aéreas está aumentada em um terco deles. O índice de troca gasosa encontra-se diminuído em metade deles. A presenca de antecedentes pulmonares, sintomas respiratórios e tabagismo não influencia as variáveis mecânicas, mas o índice de troca gasosa é influenciado pela presenca de comorbidades.

La universidad en el desarrollo de la cirugía torácica española / The university in the development of thoracic surgery in Spain

En el trabajo se analizan las figuras de los profesores universitarios que desde 1911 pertenecieron a uno de los pilares básicos en el desarrollo de la cirugía torácica española. Es el momento en que existe cierta lucha entre la cirugía general y la especializada, que será salvado si se admite la especialización tras un período de formación en el tronco. A la Universidad no se le debe negar el gran mérito de haber formado a cirujanos íntegros con un amplio bagaje general que luego optarían por una especialidad. En el trabajo, se glosan las figuras de los profesores Ricardo Lozano Monzón, Francisco Martín Lagos, José Gascó, Benjamin Narbona, Carlos Carbonell Antolí, Rafael Vara López, Alfonso de la Fuente Chaos y José M. Beltrán de Heredia, con su formación previa, sus correspondientes precursores y sus respectivas escuelas. También se analizan la "praxis" docente y quirúrgica, y la labor científica. Se esboza la escritura de un próximo trabajo basado en la contribución valenciana a la especialidad de cirugía torácica general (AU)

The present article analyzes the figures of the university professors who, from 1911, formed part of one of the basic pillars in the development of "Spanish Thoracic Surgery". At that time, there was a certain amount of infighting between general and specialized surgery, which was resolved by allowing specialization after a period of training in general surgery. Universities should not be denied the great merit of having produced well-trained surgeons with a broad general foundation who would later choose a specialty. The figures of Ricardo Lozano Monzón, Francisco Martín Lagos, José Gascó, Benjamín Narbona, Carlos Carbonell Antolí, Rafael Vara López, Alfonso de la Fuente Chaos and José M. Beltrán de Heredia with their previous training, corresponding precursors and respective schools are described. Their teaching, surgical practice, and scientific activity are also described. A future article based on the contribution of Valencia to the specialty of general thoracic surgery is also outlined (AU)

Quality assurance of paediatric cardiac surgery: a prospective 6-year analysis.

OBJECTIVE: To audit effective quality assurance methods to monitor outcomes following paediatric cardiac surgery at a single institution. METHODS: All patients undergoing cardiac surgery from January 1996 to December 2001 were enrolled prospectively. Patients were stratified by complexity of surgical procedure into four groups, with Category 4 being the most complex procedure. Outcome measures included death, length of admission and morbidity from complications. RESULTS: A total of 1815 patients underwent 1973 surgical procedures. Of these, 1447 (73.3%) were cardiopulmonary bypass procedures, and 543 (27.5%) were more complex (Category 3 and 4) procedures. Median patient age was 3.5 years (range, 1 day-20 years) and patient weight 15.0 kg (range, 900 g to 90 kg). Sixty-six patients (3.6%) died during the study period. Of the procedures in 1996, 22.7% were classified as complex compared with 29.2% of procedures in 2001. The annual surgical mortality ranged from 1.9-4.7% (P = 0.20), and when mortality was adjusted for complexity of surgery, there was no significant yearly variation in the mortality rate (P = 0.57). Analysis of individual surgeon's results showed no significant difference in the mortality rate by complexity of surgery performed (P = 0.90). Mean ventilation times did not change significantly over time (P = 0.79). The yearly incidence of significant neurological complications ranged from 0.6% to 4.5% and the incidence of arrhythmias from 4.2% to 8.0%. No difference was detected between the years. CONCLUSIONS: Stratifying complexity of surgery proved valuable in monitoring surgical outcomes and detecting differences in performance over time as large subgroups were created for analysis.

Temporary atrial epicardial pacing as prophylaxis against atrial fibrillation after heart surgery: a meta-analysis.

INTRODUCTION: Recent studies have reported the use of temporary epicardial atrial pacing as prophylaxis for postoperative atrial fibrillation (AF). The aim of this study was to assess the effect of pacing therapies for prevention of postoperative AF using meta-analysis. METHODS AND RESULTS: Using a computerized MEDLINE search, eight pacing prophylaxis trials with 776 patients were included in the meta-analysis. Trials compared control patients to patients randomized to right atrial, left atrial, or biatrial pacing used in conjunction with either fixed high-rate pacing or overdrive pacing. Overdrive biatrial pacing (OR 2.6, CI 1.4-4.8), overdrive right atrial pacing (OR 1.8, CI 1.1-2.7), and fixed high-rate biatrial pacing (OR 2.5, CI 1.3-5.1) demonstrated a significant antiarrhythmic effect for prevention of AF after open heart surgery. Furthermore, studies investigating overdrive left atrial pacing and fixed high-rate right atrial pacing have been underpowered to assess efficacy. CONCLUSION: Biatrial overdrive and fixed high-rate pacing and right atrial fixed high-rate pacing reduced the risk of new-onset AF after open heart surgery, and the relative risk reduction is approximately 2.5-fold. These results imply that various pacing algorithms are useful as a nonpharmacologic method to prevent postoperative AF.

Risk stratification theme for congenital heart surgery.

Surgical practice is changing and auto-evaluation of quality of care, organized by scientific societies, is very likely to become an obligation during this new decade. This evaluation requires a common nomenclature, a registry, and risk stratification. The primary purpose of risk stratification is to offer the possibility of objective analysis of surgical outcomes according to the complexity of the pathology treated. Registries, databases containing select essential data on a complete population, are not able to produce a statistically reliable risk stratification model. Academic databases, like that of the Congenital Heart Surgeons Society, contain comprehensive data on select patients, and are able to produce risk stratification, but only very slowly. The absence of risk discrimination in current registries penalizes centers treating complex pathologies. They may be reluctant to release their results without the security of risk stratification. Given the diversity of congenital heart surgery, a new method has been developed to stratify risks: the complexity score. This approach is based on the perceived opinions of a group of 50 internationally recognized surgeons and centers. It allows a hierarchical classification of surgical procedures according to mortality, morbidity, and surgical difficulty. Surgical procedures are scored globally on simple pathologies and in detail according to seven categories of risks. The complexity score in congenital heart surgery, also known as the Aristotle Score, is currently being developed as a collaborative effort of the members of the European Association for Cardio-thoracic Surgery, the Society of Thoracic Surgeons, the Congenital Heart Surgeons Society, and the European Congenital Heart Surgeons Foundation, and should be available next year.

Classification of procedures in the domain of thoracic surgery--a study of reliability in coding.

This paper relates a study of reliability of coding of surgical procedures in the domain of thoracic surgery. The reliability measured is inter-coder variability in form of agreement. Four classifications were used by four physicians on 100 patient cases. The classifications, having differing granularity and structure, were analyzed using a statistical method (kappa). These results are discussed and related to the differences between the classifications. One of the topics for discussion is how the granularity affects the degree of agreement, coupled to the usefulness of the classification. Also the concept of using formal methods for representing classifications is discussed, how this will affect how classifications are designed and used.

Anestesia para cirugía de tórax video asistida

La Cirugía Torácica Videoasistida (CAVDT) constituye en la actualidad una alternativa corrientemente utilizada para el tratamiento quirúrgico de una variedad de patologías que afectan los órganos intratorácicos. Se utiliza para el diagnóstico y tratamiento de enfermedades de la pleura y el espacio pleural, (biopsias pleurales, pleurodesis con talco, drenaje de hemotórax coagulado y pleurectomías); procedimientos sobre el pulmón (biopsias, resección de nódulos y tomores benignos) y otros procedemientos sobre el mediastino (timectomías y resección de tumores benignos). También se ha empleado para la realización de miotomías del esófago y cirugías antirreflujo. La principal ventaja radica en la menor morbilidad como resultado de la ausencia de una iniciación quirúrgica que comprometa los grandes músculos de la pared torácica y que requiera la separación de las costillas para acceder a la cantidad pleural. Esto se traduce en disminución significativa del dolor quirúrgico, menor compromiso de la función respiratoria en el postoperatorio inmediato, disminución de la estancia hospitalaria y menor incapacidad funcional. La evaluación preoperatoria es la misma empleada para la cirugía torácica convencional. Es importante tener en cuenta que en un porcentaje de estas pacientes puede ser necesaria la conversión a un procedimiento de toracotomía. Durante la cirugía es indispensable el empleo de intubación y ventilación selectiva y el anestesiólogo dispone de varias alternativas para mantener un intercambio gaseoso adecuado durante el trascurso del procedimiento

Surgery for pulmonary tuberculosis.

During the period 1990-1994 a total of 578 operations were performed in 502 patients with various forms of tuberculosis. Most of the patients (68%) were men aged 20 to 50 years (70%). Sputum cultures were positive in 55% of the patients. More than half of all patients were chronic smokers, and about 10% were alcoholics or drug addicts. There were no human immunodeficiency virus-infected patients, and none with acquired immunodeficiency syndrome. The most frequent surgical interventions were, according to the classification adopted in Russia, for cavernous or fibrocavernous tuberculosis (196 cases) and tuberculomas (161 cases). The main operative procedures used were pulmonary resection (n = 280) and pneumonectomy or pleuropneumonectomy (n = 80). Diseased intrathoracic lymph nodes were ablated in 62 patients. Thoracoplasty or thoracomyoplasty were performed in 46 cases, thoracostomy in 37, closure of a thoracic wall defect in 27, and reamputation of the main bronchial stump in 6. Postoperative complications arose in 20% of the patients. More than half occurred in the pleural cavity or bronchi and were associated with tuberculous infection. The postoperative hospital case-fatality rate was 2%. The overall clinical efficacy by the time of discharge was 82.7% (95% in tuberculomas). Reactivation of tuberculosis over the first 3 years after discharge occurred in 6.6% of the patients. Most patients with large or multiple caverns, tuberculomas, intrathoracic caseous lymphadenitis, or various complications of pulmonary tuberculosis cannot be cured (or are not amenable to care in principle) by means of antibacterial therapy because of irreversible morphologic changes in the lungs, bronchi, pleura, lymph nodes, or thoracic wall. For this reason, indications for surgical management of pulmonary tuberculosis should be generally expanded. Excessively long antibacterial therapy for tuberculosis is often inadvisable. Although the availability of standardized regimens of antibacterial therapy is strategically essential, each patient must be treated according to an individual plan. In certain cases thoracic surgeons should be enlisted to participate in the development of such plans.