Analysis of inflammatory response and utility of N-terminal pro brain-type natriuretic peptide in cardiac surgery with extracorporeal circulation.

OBJECTIVES: Cardiac surgery with cardiopulmonary bypass (CPB) elicits an inflammatory response. During and after cardiac surgery, we examined the pattern of cytokine release of interleukin (IL)-6, IL-8, and tumor necrosis factor (TNF)-alpha, to investigate inflammatory response. We analyzed N-terminal pro brain-type natriuretic peptide (NT-proBNP) as a marker of ventricular function. METHODS: Consecutive patients (n = 58) undergoing elective cardiac surgery with extra-corporeal circulation were recruited into the study. Blood samples for analysis of the biochemical markers were taken at seven time points for cytokines and TNF, and three for Nt-proBNP. RESULTS: All markers increased significantly after CPB. IL-6 and IL-8 levels were higher in men. IL-8 was related to a need for inotropic support. IL-6 was related to the time of CPB (P = 0.004), aortic clamping (P = 0.013), length of stay in intensive care unit (ICU) (P = 0.004) and mechanical ventilation for more than 12 h (P = 0.006). The levels of NT-proBNP were higher in cases of ventricular dysfunction (P = 0.003) and functional class III/IV (P = 0.001). The postoperative values were related to age (P < 0.05), creatinine values (P < 0.001), mechanical ventilation time (P < 0.001) and stay in the ICU (P = 0.001). CONCLUSION: Our data indicate a relationship between cytokine levels and sex, time of CPB and aortic clamping, The increase of cytokines correlates with a need for inotropic support, mechanical ventilation and length of stay in ICU. We confirmed the predictive role, and its utility in the risk stratification of the NT-proBNP, and its importance in early diagnosis of postoperative ventricular dysfunction.

[Cardiac surgery with extracorporeal circulation in cancer patients: influence on surgical morbidity and mortality and on survival]. / Cirugía cardiaca con circulación extracorpórea en pacientes oncológicos: influencia en la morbimortalidad quirúrgica y la supervivencia.

INTRODUCTION AND OBJECTIVES: Morbimortality related to cardiac surgery may be superior in patients with malignant neoplastic disease. Inflammatory phenomena and immunologic changes secondary to extracorporeal circulation use can also increase tumor recurrence. We evaluate characteristics and results of cardiac surgery in our neoplastic patients. METHODS: Out of 2146 consecutive patients who underwent cardiac surgery with extracorporeal circulation, 89 (4.2%) had been previously affected by cancer. Cancer was active (recent diagnosis or under treatment) in 33 patients (group A) and 56 (group B) were in remission. Both groups were matched with 165 patients with no tumor, according to age, gender, type of surgery, and comorbidity (group C). We retrospectively evaluated incremental risk factors for surgical morbimortality, survival and tumor recurrence. RESULTS: Median interval between cancer diagnosis and surgery was 60 months and mortality and morbidity were 4.5% and 36%, respectively, vs 5,4% and 32,7% in group C. During follow-up, 12 patients died (8 due to cancer), 16 suffered cancer recurrence and 2 new tumors were diagnosed. Statistical analysis did not permit us to identify any incremental risk factor for mortality. Postoperative morbidity was increased in case of preoperative renal failure. During follow-up, survival was significantly decreased in group A, in case of preoperative left ventricular dysfunction or pulmonary obstructive disease, and when interval between cancer diagnosis and cardiac surgery was under 2 years. CONCLUSIONS: We have not observed an increase in cardiac surgery morbimortality in cancer patients. Anyway, survival is decreased in case of active or recently diagnosed cancer.

Cirugía cardiaca con circulación extracorpórea en pacientes oncológicos: influencia en la morbimortalidad quirúrgica y la supervivencia / Cardiac surgery with extracorporeal circulation in cancer patients: influence on surgical morbidity and mortality and on survival

Introducción y objetivos. La morbimortalidad de la cirugía cardiaca parece ser mayor en los pacientes neoplásicos. Los fenómenos inflamatorios y las reacciones inmunitarias secundarias a la circulación extracorpórea pueden favorecer la recidiva tumoral. Evaluamos las características y los resultados de la cirugía cardiaca en nuestros pacientes oncológicos. Métodos. De 2.146 pacientes consecutivos sometidos a circulación extracorpórea, 89 (4,2%) presentaban una neoplasia. El cáncer estaba activo (recientemente diagnosticado o en tratamiento) en 33 pacientes (grupo A) y en remisión completa en 56 (grupo B). Se pareó ambos grupos con 165 pacientes sin tumor similares en edad, sexo, tipo de cirugía y comorbilidad (grupo C). Evaluamos retrospectivamente los factores de riesgo de morbimortalidad quirúrgica, supervivencia y recidiva tumoral. Resultados. La mediana del intervalo entre diagnóstico del cáncer y cirugía fue de 60 meses, con mortalidad y morbilidad hospitalarias del 4,5 y el 36%, respectivamente, frente al 5,4 y el 32,7% en el grupo C. Durante el seguimiento, fallecieron 12 pacientes (8 por causa tumoral), 16 sufrieron recidiva y 2, tumores nuevos. El análisis estadístico no permitió identificar ningún factor de riesgo de mortalidad. La morbilidad postoperatoria aumentó en pacientes con insuficiencia renal. Durante el seguimiento, la supervivencia disminuyó significativamente en el grupo A en caso de disfunción ventricular izquierda preoperatoria y enfermedad pulmonar obstructiva crónica y cuando el intervalo entre diagnóstico de cáncer y cirugía fue < 2 años. Conclusiones. No hemos observado un incremento en la morbimortalidad de la cirugía cardiaca en pacientes oncológicos. No obstante, la supervivencia disminuye en neoplasias activas o de diagnóstico reciente

Introduction and objetives. Morbimortality related to cardiac surgery may be superior in patients with malignant neoplastic disease. Inflammatory phenomena and immunologic changes secondary to extracorporeal circulation use can also increase tumor recurrence. We evaluate characteristics and results of cardiac surgery in our neoplastic patients. Methods. Out of 2146 consecutive patients who underwent cardiac surgery with extracorporeal circulation, 89 (4.2%) had been previously affected by cancer. Cancer was active (recent diagnosis or under treatment) in 33 patients (group A) and 56 (group B) were in remission. Both groups were matched with 165 patients with no tumor, according to age, gender, type of surgery, and comorbidity (group C). We retrospectively evaluated incremental risk factors for surgical morbimortality, survival and tumor recurrence. Results. Median interval between cancer diagnosis and surgery was 60 months and mortality and morbidity were 4.5% and 36%, respectively, vs 5,4% and 32,7% in group C. During follow-up, 12 patients died (8 due to cancer), 16 suffered cancer recurrence and 2 new tumors were diagnosed. Statistical analysis did not permit us to identify any incremental risk factor for mortality. Postoperative morbidity was increased in case of preoperative renal failure. During follow-up, survival was significantly decreased in group A, in case of preoperative left ventricular dysfunction or pulmonary obstructive disease, and when interval between cancer diagnosis and cardiac surgery was under 2 years. Conclusions. We have not observed an increase in cardiac surgery morbimortality in cancer patients. Anyway, survival is decreased in case of active or recently diagnosed cancer

Plasma troponins as markers of myocardial damage during cardiac surgery with extracorporeal circulation.

All types of cardiac surgery involve considerable injury to the myocardium. However, it is difficult to differentiate, in the immediate post-operative state, between ischemic alterations associated with the cardiac surgery itself and the pathological alterations of a peri-operative myocardial infarction. The diagnosis of damaged myocardium, classically performed with the enzymatic markers creatine kinase (CK) and its muscle fraction (CK-MB), has become more precise with the option of measuring cardiac troponins T and I. We measured these markers in 58 patients undergoing elective cardiac surgery with extra-corporeal circulation (ECC). The patients included 37 cases undergoing valve surgery, 14 for coronary revascularization, 6 for mixed procedures, and 1 for closure of an inter-atrial communication. The markers were measured in plasma at baseline (at anesthesia initiation), 5 min post-ECC commencement, following aorta de-clamping, during the surgical closure, and 6, 18 and 42 hrs after surgery. All the markers were increased significantly relative to the baseline values. Troponin I, CK and CK-MB values peaked between 6 and 18 hrs after surgery, troponin T between 18 and 42 hrs, and myoglobin at the surgical closure. The values of all markers were higher in patients undergoing coronary surgery compared to those in patients undergoing valve surgery. In the evaluation of myocardial damage after surgery, the measurement of classical markers such as CK and myoglobin remain valid, but other markers such as troponins provide significant additional diagnostic benefit and, thus, need to be included in the routine biochemical measurements for monitoring myocardial damage associated with the surgical procedure.

[Myocardial revascularization in the female population]. / Revascularización miocárdica en la población femenina.

OBJECTIVES: To analyze the factors that influence outcomes of surgical myocardial revascularization in the female population. PATIENTS AND METHOD: This is a retrospective study in which 128 woman, subjected to GABC[IBM1] from January to September 2004, were enrolled in an univariate and multivariate analysis of risk factors associated with morbidity and mortality. RESULTS: The mean age was 69.19 +/- 9.05 [IBM2] years, the most frequent pathologies, comorbilities, were dyslipemia, hypertension, and myocardial infarction. Unestable angina was found in 63.28% patients and stenosis in the left main coronary artery 42.96%; NYHA III-IV in 23.43%. The EuroSCORE mean preoperative risk was [IBM3] 5.57. Twelve surgeries were emergencies. Mean of grafts was 2.57. Mortality corresponded to 5.4% in programmed surgeries, 7% global. Univariate analysis identified this risk factors releated to mortality (p < 0.05): age older than 67 years, NYHA III-IV and emergency surgery, complicated in 25.2%. Follow-up was kept in 90.8% of patients, mean follow-up time was 17.11 (+/- 14.94) months; 115 patients did not present angina. The risk factor for angina during follow-up, in the univariate analysis (p < 0.05) was not having used the left internal thoracic artery as graft for the anastomosis of the anterior descending artery. CONCLUSIONS: Emergency surgery, age older than 67 years, and NYHA III-IV, were independent risk factors associated with mortality in this group. The use of artery grafts associated to reduced angina during follow-up.

Revascularización miocárdica en la población femenina / Myocardial revascularization in the female population

OBJECTIVES: To analyze the factors that influence outcomes of surgical myocardial revascularization in the female population. PATIENTS AND METHOD: This is a retrospective study in which 128 woman, subjected to GABC[IBM1] from January to September 2004, were enrolled in an univariate and multivariate analysis of risk factors associated with morbidity and mortality. Results: The mean age was 69.19 +/- 9.05 [IBM2] years, the most frequent pathologies, comorbilities, were dyslipemia, hypertension, and myocardial infarction. Unestable angina was found in 63.28% patients and stenosis in the left main coronary artery 42.96%; NYHA III-IV in 23.43%. The EuroSCORE mean preoperative risk was [IBM3] 5.57. Twelve surgeries were emergencies. Mean of grafts was 2.57. Mortality corresponded to 5.4% in programmed surgeries, 7% global. Univariate analysis identified this risk factors releated to mortality (p < 0.05): age older than 67 years, NYHA III-IV and emergency surgery, complicated in 25.2%. Follow-up was kept in 90.8% of patients, mean follow-up time was 17.11 (+/- 14.94) months; 115 patients did not present angina. The risk factor for angina during follow-up, in the univariate analysis (p < 0.05) was not having used the left internal thoracic artery as graft for the anastomosis of the anterior descending artery. CONCLUSIONS: Emergency surgery, age older than 67 years, and NYHA III-IV, were independent risk factors associated with mortality in this group. The use of artery grafts associated to reduced angina during follow-up.

Clinical and prognostic profile of patients with infective endocarditis who need urgent surgery.

AIMS: Surgery in patients with infective endocarditis (IE) can be elective (upon completion of antibiotic treatment) or urgent (before antibiotic treatment has ended) when the clinical course is unfavourable. However, urgent surgery for left-sided endocarditis is associated with high mortality. The aims of this study were to describe the profile of patients with left-sided endocarditis who underwent urgent surgery and to analyse the factors that predicted mortality. METHODS AND RESULTS: Among 508 consecutive episodes of IE, 391 were left-sided and 89 required urgent surgery. The main reasons for urgent surgery were heart failure that did not respond to medication (72%) and persistent infection despite appropriate antibiotic treatment (31%). Thirty-two patients (36%) died during their hospital stay. Univariate analysis identified renal failure, septic shock, Gram-negative bacteria, persistent infection, and surgery for persistent infection as factors associated with mortality. Multivariate analysis confirmed only persistent infection and renal insufficiency as factors independently associated with a poor prognosis. CONCLUSION: Patients with IE who need urgent surgery have a poor clinical course. Heart failure, the main cause of urgent surgery, was not associated with higher mortality. However, persistent infection and renal failure were factors associated with higher post-surgical mortality.

Disección espontánea de la arteria coronaria descendente anterior tratada mediante cirugía sin circulación extracorpórea / Surgical treatment of a spontaneous dissection of the left anterior descending coronary artery without the use of cardiopulmonary bypass

Se presenta un caso de disección espontánea de la arteria coronaria descendente anterior en una mujer de 51 años, sin relación con factores desencadenantes conocidos. El inicio clínico fue un IAM no Q anterior, controlado con tratamiento médico y buena evolución clínica. El cateterismo cardíaco evidenció la disección de la arteria descendente anterior, que producía deterioro de la función sistólica. Se realizó revascularización arterial urgente mediante injerto de mamaria interna izquierda a descendente anterior sin CEC. El posoperatorio cursó sin complicaciones y a 25 meses del procedimiento la paciente se encuentra asintomática. Se realiza, además, una exposición de las consideraciones clínicas relacionadas con esta patología.

Disección espontánea de la arteria coronaria descendente anterior tratada mediante cirugía sin circulación extracorpórea / Surgical treatment of a spontaneous dissection of the left anterior descending coronary artery without the use of cardiopulmonary bypass

Se presenta un caso de disección espontánea de la arteria coronaria descendente anterior en una mujer de 51 años, sin relación con factores desencadenantes conocidos. El inicio clínico fue un IAM no Q anterior, controlado con tratamiento médico y buena evolución clínica. El cateterismo cardíaco evidenció la disección de la arteria descendente anterior, que producía deterioro de la función sistólica. Se realizó revascularización arterial urgente mediante injerto de mamaria interna izquierda a descendente anterior sin CEC. El posoperatorio cursó sin complicaciones y a 25 meses del procedimiento la paciente se encuentra asintomática. Se realiza, además, una exposición de las consideraciones clínicas relacionadas con esta patología. (AU)

[Cardiac surgery in octogenarians: current situation and future perspectives]. / Cirugía cardíaca en octogenarios: situación actual y perspectivas de futuro.

BACKGROUND AND OBJECTIVE: Increasing life expectancy makes cardiac surgery in octogenarians not very uncommon. We evaluated the characteristics and outcomes of patients aged over 80 undergoing cardiac surgery in our centre. PATIENTS AND METHOD: We retrospectively analyzed preoperative risk factors, in-hospital morbimortality, and long term survival in 120 patients aged 80 years--mean age (standard deviation): 81.53 (1.83)--who underwent cardiac surgery between 2000 and 2005, in comparison with 2425 younger patients referred to our center during the same period. RESULTS: Preoperatively, octogenarians presented arterial hypertension, renal failure, unstable angina, left main coronary stenosis and New York Heart Association (NYHA) functional class III or IV more frequently than younger patients. Combined cardiac surgery procedures (valvular plus coronary) were also significatively higher (20% vs. 9.85%). Hospital mortality (15.8%) was twice as higher as in the non octogenarian population and postoperative intensive care units and hospital stay was longer. 45% suffered some postoperative complication. In the multivariate analysis, urgent procedure, mitral valve surgery and presentation of any postoperative complication were identified as predictors of mortality, and female sex was identified as a risk factor for postoperative morbidity. Survival at one, 3 and 5 years was 91.20%, 80.73% and 69.20%, respectively. 98.7% of the patients were in I-II NYHA functional class and 92.5% satisfied with overall surgery outcome when they were interviewed. CONCLUSIONS: Despite more preoperative co-morbidity and worse functional class, cardiac surgery in octogenarians can be performed with an acceptable mortality. Our patients have a satisfactory quality of life and would undergo a cardiac surgery procedure again. Specific measurements in preoperative and immediate postoperative periods, in order to reduce higher morbidity rates, are advisable.

Cirugía cardíaca en octogenarios: situación actual y perspectivas de futuro / Cardiac surgery in octogenarians: current situation and future perspectives

Fundamento y objetivo: La mayor esperanza de vida incrementa la probabilidad de la cirugía cardíaca en octogenarios. Evaluamos las características, la evolución temporal, la comorbilidad asociada, los factores de riesgo y los resultados de estas intervenciones. Pacientes y método: Analizamos retrospectivamente los factores de riesgo de morbimortalidad y la supervivencia de 120 pacientes de 80 años de edad o más ­media (desviación estándar) de 81,53 (1,83) años­ intervenidos entre 2000 y 2005, comparando la comorbilidad preoperatoria y la mortalidad hospitalaria con las de un grupo de 2.425 pacientes de edad inferior a 80 años intervenidos en el mismo período. Resultados: Preoperatoriamente los octogenarios presentaron mayor incidencia de hipertensión arterial, insuficiencia renal, angina inestable, afectación de tronco de coronaria izquierda y peor grado funcional. La cirugía combinada (valvular más coronaria) fue significativamente mayor (el 20 frente al 9,85%) y un 45% presentó alguna complicación postoperatoria. La mortalidad (15,8%) se duplicó con respecto a la población de menor edad y las estancias hospitalarias y en la unidad de cuidados intensivos se prolongaron. En el análisis multivariante la cirugía urgente, la cirugía mitral y la presencia de alguna complicación postoperatoria fueron factores de riesgo de mortalidad. El sexo femenino fue factor de riesgo de morbilidad. La supervivencia a 1, 3 y 5 años fue del 91,2, el 80,73 y el 69,2%, respectivamente. Un 98,7% se hallaba en clase funcional I-II de la New York Heart Association (NYHA). El 92,5% de los pacientes se ratificó en su decisión de operarse. Conclusiones: A pesar de una mayor comorbilidad y peor clase funcional, la mortalidad de la cirugía cardíaca en octogenarios es aceptable y la calidad de vida es muy satisfactoria. Son aconsejables medidas para la reducción de la alta morbilidad asociada

Background and objective: Increasing life expectancy makes cardiac surgery in octogenarians not very uncommon. We evaluated the characteristics and outcomes of patients aged over 80 undergoing cardiac surgery in our centre. Patients and method: We retrospectively analyzed preoperative risk factors, in-hospital morbimortality, and long term survival in 120 patients aged 80 years ­mean age (standard deviation): 81.53 (1.83)­ who underwent cardiac surgery between 2000 and 2005, in comparison with 2425 younger patients referred to our center during the same period. Results: Preoperatively, octogenarians presented arterial hypertension, renal failure, unstable angina, left main coronary stenosis and New York Heart Association (NYHA) functional class III or IV more frequently than younger patients. Combined cardiac surgery procedures (valvular plus coronary) were also significatively higher (20% vs. 9.85%). Hospital mortality (15.8%) was twice as higher as in the non octogenarian population and postoperative intensive care units and hospital stay was longer. 45% suffered some postoperative complication. In the multivariate analysis, urgent procedure, mitral valve surgery and presentation of any postoperative complication were identified as predictors of mortality, and female sex was identified as a risk factor for postoperative morbidity. Survival at one, 3 and 5 years was 91.20%, 80.73% and 69.20%, respectively. 98.7% of the patients were in I-II NYHA functional class and 92.5% satisfied with overall surgery outcome when they were interviewed. Conclusions: Despite more preoperative co-morbidity and worse functional class, cardiac surgery in octogenarians can be performed with an acceptable mortality. Our patients have a satisfactory quality of life and would undergo a cardiac surgery procedure again. Specific measurements in preoperative and immediate postoperative periods, in order to reduce higher morbidity rates, are advisable

[Valve replacement with the Omnicarbon valve prosthesis. A 10-year follow-up]. / Troca de valva com a prótese valvar modelo Omnicarbon. Seguimento clínico de 10 anos.

OBJECTIVE: We retrospectively examined the outcomes of 264 patients who underwent consecutive Omnicarbon valve implantation surgery between April 1985 and May 1995. METHODS: At the time of surgery, patients who received this mechanical prosthesis averaged 57+/-11 years of age. Omnicarbon valves were placed in the aortic position in 36% of the cases, in the mitral position in 44%, and in both positions in 20%. Follow-up was carefully performed, with most patients undergoing physical examination at our clinic. While taking the case history, cardiac physicians specifically questioned the patient about valve-related complications. RESULTS: Accumulated total patient-years is 1291, with a mean follow-up time of 5.4 years. Survival at 10 years is 79.4+/-3.9%, including all causes of death and early mortality. Complications recorded during the 11-year study include: thromboembolism (0.1%), hemorrhage (0.4%), endocarditis (0.2%), and nonstructural failure (1.2%). No hemolytic anemia, valve thrombosis, or structural failure was detected during this long-term experience. Functional capability of these patients was subjectively assessed by the NYHA classification system. With follow-up time averaging over 5 years, 97% of our Omnicarbon valve patients are in NYHA I or II. CONCLUSION: The Omnicarbon mechanical prosthesis provides a good clinical performance for up to 10 years in both the aortic and mitral positions. Results indicated a low incidence of thromboembolism and of hemorrhagic complications.

Troca de valva com a prótese valvar modelo Omnicarbon: seguimento clínico de 10 anos / Valve replacement with the Omnicarbon valve prosthesis: a 10-year follow-up

OBJETIVO: Estudar retrospectivamente os resultados de 264 pacientes submetidos à implementação cirúrgica de válvula modelo Omnicarbon entre abril 1985 e maio 1995. MÉTODOS: No momento da cirurgia, a média de idade dos pacientes que receberam essa prótese mecânica era de 57±11 anos. As válvulas modelo Omnicarbon foram colocadas em posição aórtica em 36 por cento dos casos, na posição mitral em 44 por cento dos casos, e nas duas posições em 20 por cento dos casos. O seguimento clínico foi feito cuidadosamente, com a maioria dos pacientes submetidos ao exame físico em nossa clínica. Levando em conta o histórico do caso, os cardiologistas faziam perguntas aos pacientes sobre as complicações relacionadas à válvula. RESULTADOS: O seguimento acumulado dos pacientes foi de 1291 anos, com média de seguimento de 5,4 anos. A sobrevida após 10 anos foi de 79,4±3,9 por cento, incluindo todas as causas de morte e os casos de mortalidade precoce. As complicações relatadas durante os 11 anos de estudo incluem: tromboembolismo (0,1 por cento), hemorragia (0,4 por cento), endocardite (0,2 por cento), e insuficiência não-estrutural (1,2 por cento). Não foram detectadas anemia hemolítica, trombose valvar, ou insuficiência estrutural durante esse longo período de estudo. A capacidade funcional desses pacientes foi avaliada subjetivamente pelo sistema de classificação da NYHA. Com o tempo de seguimento maior do que 5 anos em média, nossos pacientes que receberam a válvula modelo Omnicarbon se encontram na classe I ou II da NYHA. CONCLUSAO: As próteses mecânicas modelo Omnicarbon apresentam um bom desempenho clínico por até 10 anos, tanto em posição aórtica quanto mitral. Os resultados indicam uma baixa incidência de tromboembolismo e complicações hemorrágicas.

Cognitive decline after cardiac surgery: proposal for easy measurement with a new test.

OBJECTIVES: Neuropsychological dysfunction is a recognized complication after cardiac surgery. Attention, concentration, short term memory, and speed of mental processing are commonly involved. We evaluated prospectively the incidence of cognitive impairment in our population using a single test: Paced Auditory Serial Addition Test. METHODS: We analysed 132 patients (mean age 67 years) undergoing elective cardiac surgery (63.6% valvular, 25% coronary artery bypass grafting and rest mixed procedures) between January and June 2003. We did not include patients with previous history of cognitive impairment, major psychiatric disorders or stroke. Paced Auditory Serial Addition Test was performed before and after surgery (mean, 7 days) and in outpatient follow-up (mean, 4 months). RESULTS: None of the patients suffered a major neurological complication. Mean preoperative Paced Auditory Serial Addition Test score was 27.04+/-11.05, 25.81+/-11.83 in immediate postoperative and 27.93+/-13.11 in follow-up. A significant postoperative neuropsychological dysfunction (test scale decline more than 1 S.D.) was shown in 45.5% of the patients. In 48.8%, decline persisted in follow-up. Valvular surgery and low preoperative Paced Auditory Serial Addition Test score were significant risk factors for immediate postoperative neuropsychological dysfunction. Valvular surgery and female sex were significant in multivariable analysis. Considering follow-up, older age is the only significant risk factor for cognitive impairment. CONCLUSIONS: Using a single, quantifiable and easy and quickly applied test such as the Paced Auditory Serial Addition Test, we found an incidence of cognitive decline after cardiac surgery similar to that previously described. Valvular surgery and older age are the main risk factors for neuropsychological dysfunction in our population.

[Results of isolated and combined surgical coronary revascularization in patients over 75]. / Resultados de la cirugía de revascularización coronaria aislada y combinada en pacientes mayores de 75 años.

BACKGROUND: Increase in life expectancy is causing an increase of surgical myocardial revascularization procedures in the elderly. We evaluate the evolution of this type of interventions in people older than 75 years, taking into account the risk factors, results and survival. PATIENTS AND METHOD: Between July 1988 and May 2001, 237 isolated or combined myocardial revascularization procedures were carried out in patients older than 75 years (Group I), while 1177 were performed in younger patients (Group II). We retrospectively analyzed the mortality risk factors, surgical procedures, postoperative complications and survival in Group I patients. RESULTS: Preoperatively, Group I patients showed a more frequent left ventricular dysfunction, left main coronary stenosis, emergency surgery and combined procedures, while Group II patients displayed more common preoperative myocardial infarction and dyslipemia. Mortality in Group I was 20.7% vs 9.09% in Group II. Mortality was higher for mixed procedures (27.1%) than for isolated myocardial revascularization (13.8%). Postoperative complications were present in 48.5% patients. Significant preoperative risk factors of mortality in Group I were: female sex, high-risk ergometry, III-IV NYHA functional class, and atrial arrhythmia. The preoperative NYHA functional class was also a morbidity risk factor. Survival at 1, 3 and 5 years was present in 98.4%, 92.1% and 81% patients, respectively, NYHA functional class I-II being present in 94.18% patients. CONCLUSIONS: Myocardial revascularization surgery in people older than 75 years leads to an increase of morbimortality. Anyway, long-term survivors' quality of life makes us think of surgery as a valid treatment alternative.

Resultados de la cirugía de revascularización coronaria aislada y combinada en pacientes mayores de 75 años / Results of isolated and combined surgical coronary revascularization in patients over 75

FUNDAMENTO: La mayor esperanza de vida de la población ha aumentado las revascularizaciones miocárdicas quirúrgicas en ancianos. Pretendemos evaluar la evolución de este tipo de intervenciones en mayores de 75 años, sus factores de riesgo, resultados y supervivencia. PACIENTES Y MÉTODO: Entre julio de 1988 y mayo de 2001 se realizó revascularización coronaria aislada o combinada con otros procedimientos en 237 pacientes mayores de 75 años (grupo I, edad media de 77,17 años) y 1.177 pacientes de menos de 75 años (grupo II, edad media de 64,19 años). Analizamos retrospectivamente en el grupo I los factores de riesgo de mortalidad, el procedimiento quirúrgico requerido, las complicaciones posquirúrgicas y la supervivencia. RESULTADOS: Preoperatoriamente, el grupo I presentó mayor incidencia de disfunción ventricular izquierda, lesión de tronco de coronaria izquierda, cirugía emergente y procedimientos mixtos, y el grupo II, de infarto preoperatorio y dislipemia. La mortalidad en el grupo I fue del 20,7 per cent, frente al 9,09 per cent en el grupo II, mayor en procedimientos mixtos (27,1 per cent) que en la revascularización coronaria aislada (13,8 per cent). El 48,5 per cent de los enfermos presentó complicaciones en el postoperatorio inmediato. Fueron factores de riesgo preoperatorio significativos de mortalidad en el grupo I: sexo femenino, ergometría positiva de alto riesgo, grado funcional III-IV de la NYHA y arritmia auricular. Fue factor de riesgo de morbilidad el grado de NYHA preoperatorio. La supervivencia a 1, 3 y 5 años fue del 98,4, el 92,1 y el 81 per cent, respectivamente, con clase funcional I-II de la NYHA en el 94,18 per cent de los pacientes; un 96,83 per cent eran asintomáticos para angina. CONCLUSIONES: La cirugía de revascularización miocárdica en mayores de 75 años implica un incremento de la morbimortalidad. La evolución y la calidad de vida a largo plazo de los supervivientes hacen de ella una opción válida de tratamiento (AU)