Consentimiento informado por representación en unidades de cuidados intensivos. ¿Necesitan los familiares instrucciones previas? / Informed consent for representation in intensive care units. Do the relatives need previous instructions?

Introducción. La toma de decisiones en las unidades de cuidados intensivos (UCI) suele revertir gran complejidad, debido a la situación frecuente de invalidez del paciente condicionada por la sedación o el estado clínico crítico. El objetivo del presente estudio fue explorar la calidad del proceso de consentimiento informado (CI) por representación e investigar la opinión de los representantes sobre la utilidad de disponer del documento de instrucciones previas (DIP) al ingreso. Material y método. Estudio observacional y retrospectivo durante 24 meses en la UCI del Hospital San Juan de Dios del Aljarafe (Sevilla, España), mediante entrevista telefónica, a los representantes de los pacientes de la UCI que firmaron un documento de CI. Se analizaron los datos demográficos, el cuestionario sobre conocimientos del CI, la posibilidad de realizar DIP y la utilidad del DIP en los pacientes ingresados en la UCI. Resultados. Se realizaron 90 entrevistas. El 96% de los representantes encuestados sabían qué era un CI, y en el 65% de los casos conocían la posibilidad actual de poder realizar DIP. Refirieron no preferir que el CI lo hubiese firmado otra persona (81,1%) y negaron preferir que la existencia previa de DIP les hubiera evitado actuar como representante (75,5%). Reconocieron que hubiese sido positivo que su familiar hubiese firmado previamente un DIP (47,7%). Conclusiones. El CI por representación es una práctica aceptada, con calidad percibida adecuada. La ausencia de DIP no se percibe como un factor limitante en la asunción por los familiares de la responsabilidad sobre las decisiones en el paciente crítico (AU)

Introduction. Decision making in intensive care units (ICUs) usually returns very complex due to frequent invalidity of conditional patient sedation or critical medical condition. The goal of this study is to explore the quality of the informed consent (IC) for representation and to know their opinion about the availability of the advance directives document at admission. Material and method. Retrospective observational study during 24 months in the ICU of the Hospital San Juan de Dios del Aljarafe (Seville, Spain), by telephone interview, to the representative of ICU patients who signed one surrogated informed consent. We evaluated demographic data and developed a questionnaire about informed consent, their knowledge of advance directives and the usefulness in ICU patients. Results. Ninety interviews were conducted. 96,6% knew the meaning of informed consent. 65,5% of the representatives knew the advance directives document. 81,1% said not to prefer that informed consent was signed by another relative and 75,5% said not to prefer that an advance directive had avoided them to be the representative of the patient. 47,7% said it would be positive to have advance directives signed by the patient. Conclusions. The informed consent for representation is an accepted practice, with adequate perception of quality of information. Absence of advance directives is not perceived as a limiting factor when the relatives assume the decisions in the critically ill patient (AU)

Válvula aórtica cuatricúspide como causa de insuficiencia aórtica / Quadricuspid aortic valve and aortic valve incompetence

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[Permanent His-bundle pacing in patients with infra-Hisian atrioventricular block]. / Estimulación hisiana definitiva en pacientes con bloqueos infrahisianos.

INTRODUCTION AND OBJECTIVES: Permanent His-bundle pacing is effective in patients with supra-Hisian atrioventricular block. We report our experience in patients with infra-Hisian atrioventricular block. METHODS: The study involved selected patients referred for syncope and intraventricular conduction disturbance, infra-Hisian atrioventricular block, with left ventricular dyssynchrony and no coronary sinus access. All patients underwent electrophysiological study to evaluate infra-Hisian atrioventricular conduction, both at baseline and after flecainide administration. We selected patients with an indication for permanent pacing in whom His-bundle pacing produced a narrow QRS complex. Leads were implanted in the right atrium, in the bundle of His, and at the apex of the right ventricle, and connected to the atrial, left ventricular, and right ventricular terminals, respectively, of a biventricular pacemaker generator. All pacemakers were programmed in DDD mode with a left ventricle-right ventricle interval of 80 ms. RESULTS: Between February and December 2004, seven patients met the study's inclusion criteria. The His-bundle lead was implanted successfully in five. The His-bundle pacing threshold remained stable in two patients, whereas it increased in three. During follow-up, at between 2 and 12 months, no lead dislodgement or failure to capture was observed. Echocardiography did not disclose any deterioration in ventricular function, or any worsening of or new valvular incompetence, but showed that ventricular dyssynchrony had disappeared in previously affected patients. CONCLUSIONS: His-bundle pacing is the only pacing mode capable of inducing a physiologically normal ventricular contraction. It can be used in some patients with infra-Hisian atrioventricular block.

Estimulación hisiana definitiva en pacientes con bloqueos infrahisianos / Permanent his-bundle pacing in patients with infra-hisian atrioventricular block

Introducción y objetivos. La estimulación permanente del haz de His es eficaz en los bloqueos auriculoventriculares suprahisianos. Mostramos nuestra experiencia en bloqueos infrahisianos. Métodos. Seleccionamos a pacientes derivados por síncopes y trastornos de la conducción intraventricular, bloqueo auriculoventricular completo y con asincronía intraventricular izquierda con seno coronario no accesible. En todos se practicó un estudio electrofisiológico en el que se evaluó la conducción infrahisiana basal y tras la administración de flecainida. Entre los pacientes con indicación de marcapasos permanente se seleccionó a aquellos en los que la estimulación del haz de His provocaba un complejo QRS estrecho. Implantamos electrodos en la aurícula derecha, el haz de His y el ápex de ventrículo derecho, conectándolos a las salidas auricular, ventricular izquierda y ventricular derecha de un marcapasos biventricular. Se programaron en modo DDD con un intervalo ventrículo izquierdo-ventrículo derecho de 80 ms. Resultados. Desde febrero hasta diciembre de 2004 se estudió a 10 pacientes, de los que 7 cumplieron criterios de inclusión; en 5 pudo implantarse un electrodo hisiano. El umbral de estimulación hisiana permaneció estable en 2 y mostró incrementos en 3. Durante el seguimiento de 2 a 12 meses no se han observado dislocamientos o pérdidas de captura. Ecocardiográficamente no ha habido deterioro de la función ventricular ni incompetencias valvulares, y la asincronía intraventricular mejoró en el caso de que estuviera presente. Conclusiones. La estimulación hisiana constituye el único modo de provocar una contracción ventricular más fisiológica y su utilización es posible en algunos casos de bloqueo infrahisiano

Introduction and objectives. Permanent His-bundle pacing is effective in patients with supra-Hisian atrioventricular block. We report our experience in patients with infra-Hisian atrioventricular block. Methods. The study involved selected patients referred for syncope and intraventricular conduction disturbance, infra-Hisian atrioventricular block, with left ventricular dyssynchrony and no coronary sinus access. All patients underwent electrophysiological study to evaluate infra-Hisian atrioventricular conduction, both at baseline and after flecainide administration. We selected patients with an indication for permanent pacing in whom His-bundle pacing produced a narrow QRS complex. Leads were implanted in the right atrium, in the bundle of His, and at the apex of the right ventricle, and connected to the atrial, left ventricular, and right ventricular terminals, respectively, of a biventricular pacemaker generator. All pacemakers were programmed in DDD mode with a left ventricle-right ventricle interval of 80 ms. Results. Between February and December 2004, seven patients met the study's inclusion criteria. The His-bundle lead was implanted successfully in five. The His-bundle pacing threshold remained stable in two patients, whereas it increased in three. During follow-up, at between 2 and 12 months, no lead dislodgement or failure to capture was observed. Echocardiography did not disclose any deterioration in ventricular function, or any worsening of or new valvular incompetence, but showed that ventricular dyssynchrony had disappeared in previously affected patients. Conclusions. His-bundle pacing is the only pacing mode capable of inducing a physiologically normal ventricular contraction. It can be used in some patients with infra-Hisian atrioventricular block