[Postoperative pain after cardiac surgery: neurobiological basis and treatment]. / Dolor en el postoperatorio de cirugía cardíaca: bases neurobiológicas y tratamiento.

INTRODUCTION: Despite the evolution of surgical techniques, pain continues to be one of the most frequent disorders in the postoperative period of cardiac surgery (CS), leading to the appearance of complications in the acute period and impairment of quality of life due to the appearance of chronic pain. In this narrative review, we aim to analyze the prognostic factors for the appearance of postoperative pain after CS, to locate and quantify the severity of neuropathic pain, and determine the most appropriate assessment methods in these patients. DEVELOPMENT: Postoperative pain in CS is a complex pain, which associates neuropathic, somatic and visceral components. Its origin is multifactorial; factors depending on the patient, the preoperative symptoms and the type of intervention, as well as sequelae derived from the surgery itself, determine the variability in its manifestation. Multiple studies have tried to identify the risk factors for its development, but the quantification of pain is limited by the subjective perception of the patients. CONCLUSIONS: Neurologists can play a relevant role in the differentiation of the different types of pain after CS, thanks to the understanding of its neurobiological bases, properly handling neuromodulators that control the neuropathic component of pain and collaborating in the indication of invasive techniques, necessary occasionally in the management of these patients.

TITLE: Dolor en el postoperatorio de cirugía cardíaca: bases neurobiológicas y tratamiento.Introducción. A pesar de la evolución de las técnicas quirúrgicas, el dolor sigue siendo uno de los trastornos más frecuentes en el postoperatorio de la cirugía cardíaca (CCA), lo que condiciona la aparición de complicaciones en la fase aguda y el deterioro de la calidad de vida por la aparición de dolor crónico. En esta revisión narrativa pretendemos analizar los factores pronósticos de la aparición de dolor postoperatorio tras CCA, localizar y cuantificar la gravedad del dolor neuropático y determinar cuáles son los métodos de evaluación más adecuados en estos pacientes. Desarrollo. El dolor postoperatorio en la CCA es un dolor complejo, que asocia componentes neuropáticos, somáticos y viscerales. Su origen es multifactorial; factores dependientes del paciente, de la clínica preoperatoria y el tipo de intervención, así como de secuelas derivadas de la propia cirugía, determinan la variabilidad en su manifestación. Múltiples estudios han intentado identificar los factores de riesgo de su desarrollo, pero la cuantificación del dolor se ve limitada por la percepción subjetiva del paciente. Conclusiones. Los neurólogos pueden tener un papel relevante en la diferenciación de los distintos tipos de dolor tras CCA, gracias a la comprensión de sus bases neurobiológicas, manejando adecuadamente neuromoduladores que controlen el componente neuropático del dolor y colaborando en la indicación de técnicas invasivas, necesarias ocasionalmente en el manejo de estos pacientes.

Dolor en el postoperatorio de cirugía cardíaca: bases neurobiológicas y tratamiento / Postoperative pain after cardiac surgery: neurobiological basis and treatment

Introducción: A pesar de la evolución de las técnicas quirúrgicas, el dolor sigue siendo uno de los trastornos más frecuentes en el postoperatorio de la cirugía cardíaca (CCA), lo que condiciona la aparición de complicaciones en la fase aguda y el deterioro de la calidad de vida por la aparición de dolor crónico. En esta revisión narrativa pretendemos analizar los factores pronósticos de la aparición de dolor postoperatorio tras CCA, localizar y cuantificar la gravedad del dolor neuropático y determinar cuáles son los métodos de evaluación más adecuados en estos pacientes. Desarrollo: El dolor postoperatorio en la CCA es un dolor complejo, que asocia componentes neuropáticos, somáticos y viscerales. Su origen es multifactorial; factores dependientes del paciente, de la clínica preoperatoria y el tipo de intervención, así como de secuelas derivadas de la propia cirugía, determinan la variabilidad en su manifestación. Múltiples estudios han intentado identificar los factores de riesgo de su desarrollo, pero la cuantificación del dolor se ve limitada por la percepción subjetiva del paciente. Conclusiones: Los neurólogos pueden tener un papel relevante en la diferenciación de los distintos tipos de dolor tras CCA, gracias a la comprensión de sus bases neurobiológicas, manejando adecuadamente neuromoduladores que controlen el componente neuropático del dolor y colaborando en la indicación de técnicas invasivas, necesarias ocasionalmente en el manejo de estos pacientes.(AU)

INTRODUCTION: Despite the evolution of surgical techniques, pain continues to be one of the most frequent disorders in the postoperative period of cardiac surgery (CS), leading to the appearance of complications in the acute period and impairment of quality of life due to the appearance of chronic pain. In this narrative review, we aim to analyze the prognostic factors for the appearance of postoperative pain after CS, to locate and quantify the severity of neuropathic pain, and determine the most appropriate assessment methods in these patients. DEVELOPMENT: Postoperative pain in CS is a complex pain, which associates neuropathic, somatic and visceral components. Its origin is multifactorial; factors depending on the patient, the preoperative symptoms and the type of intervention, as well as sequelae derived from the surgery itself, determine the variability in its manifestation. Multiple studies have tried to identify the risk factors for its development, but the quantification of pain is limited by the subjective perception of the patients. CONCLUSIONS: Neurologists can play a relevant role in the differentiation of the different types of pain after CS, thanks to the understanding of its neurobiological bases, properly handling neuromodulators that control the neuropathic component of pain and collaborating in the indication of invasive techniques, necessary occasionally in the management of these patients.(AU)

Cirugía de la válvula aórtica en octogenarios: factores de riesgo e impacto a largo plazo / Aortic valve surgery in octogenarians: Risk factors and long-term impact

Antecedentes y objetivos: Conocer los factores de riesgo, resultados e impacto a largo plazo de la cirugía valvular aórtica en pacientes con más de 80 años. Pacientes y métodos: Evaluamos 255 octogenarios consecutivos, intervenidos entre 2000 y 2013, y remitidos por valvulopatía aórtica (aislada o combinada con enfermedad coronaria) que, aun asociada a otras patologías, era la causa principal de limitación funcional del paciente. Resultados: La mortalidad se redujo del 14,08% (periodo 2000-2004) al 7,7% (cirugía valvular aislada, 4,4% y con bypass coronario, 3,3%) (periodo 2010-2013). La cirugía urgente, los procedimientos combinados, la enfermedad vascular periférica, un hematocrito postquirúrgico <24% y la necesidad de transfusión, fueron factores de riesgo independientes asociados a la mortalidad. Más del 50% de los pacientes presentó alguna complicación postoperatoria. La transfusión de hemoderivados se asoció a insuficiencia renal y respiratoria, y la anemia preoperatoria a mayor frecuencia de infarto de miocardio e ictus. La supervivencia a 1, 3, 5 y 10 años fue del 79,5; 74,3; 63,6 y 30,5%, respectivamente, con un 91,5% de los pacientes en clase funcional NYHA I-II. La supervivencia a largo plazo se redujo en caso de disfunción ventricular izquierda preoperatoria. La puntuación EuroSCORE I logística no resultó útil en nuestra población como predictor de mortalidad ni de supervivencia a medio-largo plazo. Conclusiones: La morbimortalidad de la cirugía valvular aórtica en los pacientes con más de 80 años ha descendido en los últimos años, aunque sigue siendo superior cuando la cirugía valvular se asocia a cirugía coronaria. La presencia de disfunción ventricular izquierda preoperatoria disminuye la supervivencia a largo plazo (AU)

Background and objectives: To understand the risk factors and long-term impact and results of aortic valve surgery in patients over age 80. Patients and methods: We consecutively evaluated 255 octogenarians who were operated on between 2000 and 2013 and referred for aortic valve disease (isolated or combined with coronary artery disease), which, even when associated with other diseases, was the primary cause of the patient's functional limitation. Results: The mortality rate decreased from 14.08% (2000-2004) to 7.7% (isolated valve surgery, 4.4%; with coronary bypass, 3.3%) (2010-2013). The independent risk factors associated with mortality were urgent surgery, combined procedures, peripheral vascular disease, a postsurgery hematocrit level <24% and the need for transfusion. More than 50% of the patients experienced a postoperative complication. Blood product transfusions were associated with renal and respiratory failure, and preoperative anemia was associated with an increased rate of myocardial infarction and stroke. Survival at 1, 3, 5 and 10 years was 79.5, 74.3, 63.6 and 30.5%, respectively, with 91.5% of patients in NYHA functional class I-II. Long-term survival was lower for cases of preoperative left ventricular dysfunction. The EuroSCORE I logistics score was not useful for our population as a predictor of mortality or of medium to long-term survival. Conclusions: The morbidity and mortality of aortic valve surgery for patients over age 80 has decreased in recent years, although it remains higher when valve surgery is combined with coronary surgery. The presence of preoperative left ventricular dysfunction decreases long-term survival (AU)

Aortic valve surgery in octogenarians: Risk factors and long-term impact. / Cirugía de la válvula aórtica en octogenarios: factores de riesgo e impacto a largo plazo.

BACKGROUND AND OBJECTIVES: To understand the risk factors and long-term impact and results of aortic valve surgery in patients over age 80. PATIENTS AND METHODS: We consecutively evaluated 255 octogenarians who were operated on between 2000 and 2013 and referred for aortic valve disease (isolated or combined with coronary artery disease), which, even when associated with other diseases, was the primary cause of the patient's functional limitation. RESULTS: The mortality rate decreased from 14.08% (2000-2004) to 7.7% (isolated valve surgery, 4.4%; with coronary bypass, 3.3%) (2010-2013). The independent risk factors associated with mortality were urgent surgery, combined procedures, peripheral vascular disease, a postsurgery hematocrit level <24% and the need for transfusion. More than 50% of the patients experienced a postoperative complication. Blood product transfusions were associated with renal and respiratory failure, and preoperative anemia was associated with an increased rate of myocardial infarction and stroke. Survival at 1, 3, 5 and 10 years was 79.5, 74.3, 63.6 and 30.5%, respectively, with 91.5% of patients in NYHA functional class I-II. Long-term survival was lower for cases of preoperative left ventricular dysfunction. The EuroSCORE I logistics score was not useful for our population as a predictor of mortality or of medium to long-term survival. CONCLUSIONS: The morbidity and mortality of aortic valve surgery for patients over age 80 has decreased in recent years, although it remains higher when valve surgery is combined with coronary surgery. The presence of preoperative left ventricular dysfunction decreases long-term survival.

La arteria gastroepiplóica como injerto en cirugía coronaria / Gastroepiploic artery graft for coronary artery bypass

INTRODUCCIÓN. La revascularización quirúrgica del miocardio ha demostrado ser una de las terapias más eficaces y duraderas en el tratamiento de la cardiopatía isquémica. En un intento de conseguir la revascularización completa del árbol coronario, se cuestiona constantemente en términos de permeabilidad el papel que pudieran jugar los distintos injertos, siendo el patrón de oro con el que comparar la arteria mamaria interna. CASO CLÍNICO. Varón de 68 años reintervenido por estenosis aórtica severa en el que se objetiva la permeabilidad de un bypasscon arteria gastroepiploica derecha a coronaria derecha al cabo de quince años. CONCLUSIÓN. Tras una revisión extensa de las series publicadas, valoramos positivamente el papel de la arteria gastroepiploicaderecha en la revascularización del territorio de la coronaria derecha ante los resultados óptimos presentados en términosde permeabilidad y morbimortalidad (AU)

INTRODUCTION. The myocardial revascularization surgery has proved to be one of the most effective and durable therapy inthe treatment of ischemic heart disease. In an attempt to achieve the complete tree coronary revascularization, are constantlyquestioned in terms of permeability the role they could play different grafts, being the gold standard against which to comparethe internal mammary artery (IMA). CASE REPORT. Male 68 years of age reoperated because of a severe aortic stenosis in who is observed a bypass right gastroepiploicartery (RGEA) to right coronary (RC) permeable after fifteen years. CONCLUSION. After an extensive review of the published series, we appreciate the positive role of revascularization RGEA in the territory of the RC before the optimal results presented in terms of permeability, morbidity and mortality (AU)

[Evaluation of the withdrawal of ACE inhibitors in coronary artery surgery]. / Valutazione della sospensione degli ACE-inibitori in chirurgia cardiaca coronarica.

During cardiac surgery, as a result of surgical aggression, myocardial ischaemia and cardiopulmonary bypass, the renin-angiotensin-aldosterone mechanism is intensely activated. Our aim is to document whether, in the case of patients undergoing chronic treatment with lisinopril, the non-withdrawal of this inhibitor's administration before cardiac surgery and the administering of a last dose on the day of the operation are associated with coronary haemodynamic alterations. A study was made of 18 patients submitted to myocardial revascularization under extracorporeal circulation and distributed in two groups: group A) without ACE inhibitorsplacebo, group B) with ACE inhibitors (Lisinopril). Coronary blood flow (CBF) was determined by inverted thermodilution via Baim's catheter. Coronary and metabolic haemodynamic values were calculated. Lisinopril had no significant influence on the CBF or on the other above-mentioned values. Therefore, it is not necessary to withdraw ACE inhibitors in cardiac surgery interventions.

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.

[Specific markers of myocardial injury in acute stroke]. / Determinacion de marcadores específicos de lesión miocárdica en la enfermedad cerebrovascular aguda.

INTRODUCTION: It is thought that any acute damage to the central nervous system and, more particularly, acute cerebrovascular disease (ACVD) can give rise to a myocardial lesion. Our aim is to apply the latest biochemical markers (troponin T, troponin I and myoglobin) to the study of this problem. PATIENTS AND METHODS: We conducted a retrospective study of 42 patients who were consecutively admitted to hospital with ACVD. The pathological antecedents and the clinical and electrocardiographic variables were considered in each case. A single determination of CK, CK MB, myoglobin, troponin T and troponin I was performed for each patient. RESULTS: The determination of the new biochemical markers was positive in a higher number of cases than CK and its MB fraction, or electrocardiographic alterations. This positivity, together with the troponin T and troponin I values correlate with mortality. CONCLUSIONS: We present the first research work to be published in Spanish that studies the new biochemical markers of myocardial damage in ACVD. We urge researchers to carry out further analyses on more extensive series in order to determine the influence myocardial damage has on mortality and to establish suitable therapeutic measures. This will also allow us to find out whether a certain location or size of the lesion can give rise to a higher predisposition to this kind of damage

Determinación de marcadores específicos de lesión miocárdicaen la enfermedad cerebrovascular aguda / Specific markers of myocardial injury in acute stroke

Introducción. Se considera que cualquier daño agudo del sistema nervioso central y, en concreto, la enfermedad cerebrovascular aguda (ECVA), puede dar lugar a lesión miocárdica. Pretendemos aplicar los nuevos marcadores bioquímicos (troponina T, troponina I y mioglobina), al estudio de este problema. Pacientes y métodos. Estudio prospectivo de 42 enfermos ingresados consecutivamente por ECVA. Se consideran los antecedentes patológicos, y variables clínicas y electrocardiográficas en cada caso. Se lleva a cabo en cada paciente una determinación única de CK, CK-MB, mioglobina, troponina T y troponina I. Resultados. La determinación de los nuevos marcadores bioquímicos resulta positiva en un mayor número de casos que la CK y su fracción MB, o las alteraciones electrocardiográficas. Esta positividad, así como los valores de troponina T y troponina I, se correlacionan con la mortalidad. Conclusiones. Presentamos el primer trabajo publicado en lengua española que estudia los nuevos marcadores bioquímicos de daño miocárdico en ECVA. Animamos al análisis de series más extensas de cara a comprobar la influencia del daño miocárdico en la mortalidad y establecer las medidas terapéuticas al efecto, así como para averiguar si alguna localización o tamaño lesional puede predisponer en mayor medida a dicho daño (AU)

Neurological complications after cardiopulmonary bypass: An update.

INTRODUCTION: Neurological complications are, at the present time, considered among the most important causes of morbidity and mortality after heart surgery. We evaluated their importance and risk factors. PATIENTS AND METHODS: We retrospectively reviewed 2, 528 consecutive patients who underwent cardiopulmonary bypass in a single center. In each one, we attended to previous vascular risk factors, such as surgical and postoperative events. We considered four categories of neurologic outcome: (1) persistent neurological focal deficits, (2) stupor or coma, (3) temporary neurological focal deficits, and (4) seizures. We carried out univariant and multivariant statistical analysis, looking for predictors of adverse neurologic events. RESULTS: Neurological complications occurred in 76 patients (3%); 36 of them (47%) had persistent neurological focal deficits, 18 (24%) stupor or coma, 18 (24%) temporary neurological focal deficits, and 27 (36%) seizures. Twenty-two patients with cerebral adverse outcomes died (29%), the overall mortality among the 2,528 cases being 5%. Predictors of risk were aortic aneurysm and aortic valve surgery, advanced age, female sex, and the use of intra-aortic balloon pump. A longer hospitalization time was noticed among patients with neurological side effects. DISCUSSION: Neurological complications are common and serious after heart surgery, as we have noticed with this series, the largest up to now, according to our review of the literature. They increase perioperative mortality and hospitalization time. Neurological morbidity and risk factors in our study are similar to those previously published.

[Neurological complications of aortic artery surgery]. / Complicaciones neurológicas de la cirugía de la arteria aorta.

INTRODUCTION: Improvement in cardiac surgery techniques has led to a considerable reduction in mortality following surgery of the aorta, dissection of the aorta and for aortic aneurysms. Although there are satisfactory vascular results following surgical repair, morbi-mortality related to neurological complications, both cerebral and spinal, is still very high. Repair of aortic lesions may lead to damage by two main mechanisms: ischemia secondary to prolonged obstruction of the aorta or to neurological lesions due to total circulatory arrest. DEVELOPMENT: After description of the mechanisms leading to cerebral and spinal lesions and the risk factors involved, we discuss methods of vascular protection and other means of neuro-protection, both spinal and cerebral. Of the vascular techniques for spinal protection, the most useful ones are short-circuits, or active or passive shunts, and cardiopulmonary by-pass. Amongst the vascular techniques for cerebral protection we describe total circulatory arrest and methods of anterograde and retrograde cerebral perfusion, and when these may be used. As general measures for nervous system protection, we describe the use of hypothermia and drugs such as corticosteroids, free radical blockers, antagonists of the excitatory amino-acids etc. CONCLUSIONS: In spite of the number of studies done, the extreme sensitivity of the nervous system to ischemia has meant that in few cases have encouraging results been seen. Neurological damage continues to be the main cause of morbi-mortality in patients with dissection or aneurysm of the aorta.

Hydatid cyst of the interventricular septum in a 3.5-year-old child.

An asymptomatic cardiac cyst located in the interventricular septum was diagnosed in a 3.5-year-old child by echocardiographic findings. Surgical ablation was done and histopathologic analysis confirmed a hydatid cyst. The patient was discharged without symptoms.

[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.

Role of epicardial pacing wire cultures in the diagnosis of poststernotomy mediastinitis.

Mediastinitis after cardiac surgery is difficult to diagnose in many cases. The transitory epicardial pacing wires used after surgery are placed in the mediastinum, so the culture of these wires could be useful for the diagnosis of this disease. To test this hypothesis, we routinely cultured the epicardial pacing wires of 565 patients undergoing extracorporeal circulation. Wires were removed on the 7th to 9th postoperative day under sterile conditions and were cultured with routine techniques used for the culture of venous catheters. Mediastinitis developed in 16 patients, and Staphylococcus aureus was the most common pathogen (81.25%). We had 103 positive and 462 negative cultures. There were 458 true-negative, 12 true-positive, 91 false-positive and 4 false-negative results. For mediastinitis in general, epicardial pacing wire culture has a sensitivity of 75%, specificity of 83.4%, positive predictive value of 11.6%, and negative predictive value of 99.1%. For Staphylococcus aureus mediastinitis, epicardial pacing wire culture has a sensitivity of 84.6%, specificity of 95.8%, positive predictive value of 32.3%, and negative predictive value of 99.6%. We conclude that a sterile culture of the epicardial pacing wires strongly contradicts a diagnosis of postsurgical mediastinitis.

Intracardiac thrombus trapped in a patent foramen ovale.

We describe a case of impending paradoxical embolism due to a thrombus trapped in a patent foramen ovale in a 22-year-old woman. Transthoracic and transesophageal echocardiography detected the thrombus. She was operated on and discharged asymptomatic.

[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.

[Aortic valve replacement via ministernotomy]. / Sustitución valvular aórtica por miniesternotomía.

Minimally invasive cardiac surgery is arising as an alternative technique in some cardiac operations. We present the first aortic valve replacement via ministernotomy. We describe in detail the technique of ministernotomy and the limitations that this new approach would have. We conclude with the advantages of minimally invasive cardiac surgery over conventional approach and review other techniques described in the literature.