Cirugía de Bentall: supervivencia a medio y largo plazo de 109 pacientes / Bentall procedure: long and midterm results in 109 patients

INTRODUCCIÓN: La cirugía de sustitución de raíz de aorta con implante de prótesis mecánica o biológica es un procedimiento ampliamente utilizado. El objetivo de nuestro estudio es evaluar los resultados de morbimortalidad a corto y largo plazo de la cirugía de Bentall, e identificar predictores de mortalidad durante el seguimiento. MATERIAL Y MÉTODOS: Entre 1983 y 2020 un total de 109 pacientes (edad media 56,8 ± 7,1) fueron sometidos a procedimiento de Bentall en nuestro centro de forma programada, con seguimiento medio de 12 ± 5,1 años. En el 88% de los casos se implantó un conducto valvulado mecánico y en el 12% se realizó procedimiento de Biobentall. En 22 pacientes (20,2%) se realizaron procedimientos concomitantes, siendo los más frecuentes la cirugía coronaria y mitral. RESULTADOS: La mortalidad intrahospitalaria fue del 1,83%, y la supervivencia fue del 88,9% a los 5 años y del 77,9% a los 15 años. Cuatro pacientes (3,7%) precisaron reintervención, la tasa de accidente cerebrovascular fue del 5,5% y tres pacientes (2,8%) desarrollaron endocarditis. El análisis de regresión multivariante de Cox reveló la presencia de procedimientos concomitantes como predictor independiente de mortalidad a largo plazo. CONCLUSIÓN: Nuestro estudio muestra que el procedimiento de Bentall presenta excelentes resultados a largo plazo, siendo una técnica segura con bajas tasas de morbilidad y mortalidad. La presencia de procedimientos concomitantes es el factor de riesgo de mayor impacto de cara a disminución de la supervivencia durante el seguimiento de estos enfermos

INTRODUCCIÓN: Aortic root replacement with a mechanical or biological valve prosthesis is a a classical technique used worldwide. The study aim was to evaluate short-term and long-term clinical outcomes of the modified Bentall procedure and to identify predictors of long-term mortality. METHODS: Between 1983 and 2020, a total of 109 patients (mean age 56,8 ± 7,1 years) underwent a Bentall procedure at the authors' institution. Concomitant procedures were performed in 22 patients (20,2%). The mean follow up was 11 ± 6.2 years and was 100% complete. Eighty-eight percent had a mechanical valve Bentall prosthesis and in 12% a biologic valve was implanted. Only data from scheduled procedures were collected. RESULTS: Operative mortality was 1,83% and long-term survival was 88,9% after 5 years and 77,9% after 10 years. Actuarial freedom from thromboembolism was 94,5% at 15 years. Four patients (3,7%) required reoperation, stroke rate was 5,5% and three patients (2,8%) developed endocarditis . Multivariate analysis revealed concomitant procedures (OR 2,58; CI 95%, [1,12- 5,9], p = 0,025 ) as independent predictors of long-term mortality. CONCLUSION: Our study shows that the Bentall procedure has excellent long-term results and can be performed safely with low mortality and acceptable morbidity. The presence of concomitant procedures is the strongest independent risk factor of long-term mortality

Three-dimensional image analytical detection of intussusceptive pillars in murine lung.

A variety of diseases can lead to loss of lung tissue. Currently, this can be treated only symptomatically. In mice, a complete compensatory lung growth within 21 days after resection of the left lung can be observed. Understanding and transferring this concept of compensatory lung growth to humans would greatly improve therapeutic options. Lung growth is always accompanied by a process called angiogenesis forming new capillary blood vessels from preexisting ones. Among the processes during lung growth, the formation of transluminal tissue pillars within the capillary vessels (intussusceptive pillars) is observed. Therefore, pillars can be understood as an indicator for active angiogenesis and microvascular remodelling. Thus, their detection is very valuable when aiming at characterization of compensatory lung growth. In a vascular corrosion cast, these pillars appear as small holes that pierce the vessels. So far, pillars were detected visually only based on 2D images. Our approach relies on high-resolution synchrotron microcomputed tomographic images. With a voxel size of 370 nm we exploit the spatial information provided by this imaging technique and present the first algorithm to semiautomatically detect intussusceptive pillars. An at least semiautomatic detection is essential in lung research, as manual pillar detection is not feasible due to the complexity and size of the 3D structure. Using our algorithm, several thousands of pillars can be detected and subsequently analysed, e.g. regarding their spatial arrangement, size and shape with an acceptable amount of human interaction. In this paper, we apply our novel pillar detection algorithm to compute pillar densities of different specimens. These are prepared such that they show different growing states. Comparing the corresponding pillar densities allows to investigate lung growth over time.

Efecto de dosis bajas de ketamina en la analgesia postoperatoria y consumo de morfina tras cirugía de revascularización miocárdica / Efficacy of low doses of ketamine in postoperative analgesia and the use of morphine after myocardial revascularisation surgery

Objetivos. Valorar la eficacia de la ketamina administrada intraoperatoriamente a dosis bajas en infusión continua (8mg/kg/min) en la analgesia postoperatoria y en reducir el consumo de morfina en las primeras 24h del postoperatorio de cirugía de derivación coronaria tras anestesia basada en remifentanilo. Material y método. Estudio prospectivo, aleatorio y doble ciego en 60 pacientes, ASA III–IV, programados para ser sometidos a cirugía de revascularización miocárdica sin circulación extracorporea. Técnica anestésica estándar con propofol y remifentanilo entre 0,5–1mg/kg/min, tras la inducción anestésica, el grupo K (n=30) recibió una infusión de ketamina constante de 8mg/kg/min y el grupo P (n=30) suero salino 0,9% al mismo ritmo de infusión por vía intravenosa. Antes de finalizar la cirugía se administró 0,15mg/kg de morfina vía intravenosa. La analgesia postoperatoria se realizó con morfina 3mg cada 5min cuando la escala verbal simple (1). Valoramos el consumo de remifentanilo propofol intraoperatorio, tiempo hasta administrarse el primer analgésico, consumo de morfina en las primeras 24h, intensidad del dolor mediante escala verbal simple y escala visual analógica, parámetros hemodinámicos, respiratorios, nivel de sedación y efectos adversos. Resultados. No hemos encontrado diferencias estadísticamente significativas en las características demográficas, así como en el consumo e infusiones medias de remifentanilo y propofol de ambos grupos. Los pacientes del grupo K retrasaron significativamente el momento de solicitar la primera dosis de analgésico con respecto al grupo P (p<0,03), el consumo de morfina en la reanimación y el consumo total en las primeras 24h no mostró diferencias significativas entre ambos grupos de estudio. Resultados. Los parámetros hemodinámicos, respiratorios y nivel de sedación permanecieron estables durante todo el periodo de estudio sin diferencias estadísticamente significativas entre ambos grupos. El control del dolor postoperatorio fue adecuado en ambos grupos (escala visual analógica <30, escala verbal simple <2) sin diferencias significativas durante las 24h de estudio. En la incidencia de efectos adversos no hubo diferencias significativas entre ambos grupos, la incidencia de nauseas y vómitos postoperatorios fue del 20% en el grupo K y del 30% en el grupo P. Ningún paciente presentó alucinaciones o disforia. Conclusiones. Dosis bajas de ketamina en infusión continua durante el periodo intraoperatorio de cirugía coronaria prolongan el tiempo de demanda de la primera dosis de morfina, sin reducir el consumo de remifentanilo intraoperatorio, ni el consumo total de morfina durante en las primeras 24h de postoperatorio (AU)

Objectives. To assess the efficacy of ketamine in low doses by continuous infusion (8mg/kg/min) given during surgery and the reduction in morphine use in the first 24h after coronary bypass surgery with remifentanil based anaesthesia. Material and method. Randomised, prospective, double blind study on 60 patients, ASA III–IV, scheduled to have off-pump myocardial revascularisation surgery. A standard anaesthetic technique with propofol and remifentanil between 0.5−1mg/kg/min, after induction of anaesthesia, the ketamine (K) group (n=30) received a continuous infusion of 8mg/kg/min and the propofol and remifentanil (P) group (n=30) received 0.9% physiological saline intravenously at the same infusion rate. Before the end of the surgery 0.15mg/kg of morphine was given intravenously. Post-operative analgesia consisted of 3mg of morphine every 5min when the simple verbal scale was <1 (SVS<1). The intra-operative use of remifentanil–propofol was determined, as well as, the time to giving the first analgesic, pain intensity using the SVS and visual analogue scale (VAS), haemodynamic and respiratory parameters, level of sedation and adverse effects. Results. No statistically significant differences were found between the demographic parameters, or in the mean use and infusions of remifentanil and propofol by both groups. The patients from the K group significantly delayed the time of requesting the first analgesic dose compared to the P group (P<0.03). There were no significant differences between both study groups in the use of morphine in recovery and the total use in the first 24h. Results. The haemodynamic and respiratory parameters, and the sedation level remained stable during the whole period of the study, with no statistically significant differences between both groups. Post-operative pain control was adequate in both groups VAS<30, SVS<2), with no significant differences during the 24h of the study. There no significant differences between groups, in the incidence of adverse effects. The incidence of nausea and post-operative vomiting was 20% in group K and 30% in group P. None of the patients had hallucinations or dysphoria. Conclusions. Low doses of ketamine in continuous infusion during the intra-operative period of coronary surgery prolongs the time of demanding the first morphine dose, without reducing the use of intra-operative remifentanil, or the total use of morphine in the first 24h after surgery (AU)

[Epidural anesthesia for coronary revascularization in the conscious patient]. / Revascularización coronaria en el paciente despierto bajo anestesia epidural.

Thoracic epidural anesthesia has been widely used to complement general anesthesia in coronary artery bypass grafting. The main advantages of the combination are excellent pain control and a less pronounced stress response to surgery. The invasiveness of surgery to treat ischemic heart disease has been attenuated thanks to the use of the mini-sternotomy and coronary anastomosis without extracorporeal circulation. In 4 patients, coronary artery revascularization was carried out via a mini-sternotomy, grafting the anterior descending artery to the left internal thoracic artery under high thoracic epidural anesthesia (block of segments T1-T8) with a perfusion of 0.75% ropivacaine and fentanyl in a conscious patient. There were no hemodynamic or respiratory complications during surgery. The mean duration of stay in the intensive care unit was less than 18 hours and the mean hospital stay was less than 5 days. Postoperative coronary arteriograms demonstrated the patency of all grafts and all patients were asymptomatic at 1 month. Our initial experience suggests that the use of only high thoracic epidural anesthesia is feasible in coronary revascularization in selected, cooperative patients who require a single coronary bypass graft.

Revascularización coronaria en el paciente despierto bajo anestesia epidural / Epidural anesthesia for coronary revascularization in the conscious patient

La anestesia epidural torácica ha sido ampliamenteutilizada en cirugía cardiaca como coadyuvante a laanestesia general en pacientes intervenidos de revascularizacióncoronaria. Sus principales ventajas son el excelentecontrol del dolor postoperatorio y la disminuciónde la respuesta al estrés quirúrgico. En el tratamientoquirúrgico de la cardiopatía isquémica la agresión quirúrgicase ha atenuado al reducir del tamaño de la esternotomíay a la realización de las anastomosis coronariassin circuito de circulación extracorpórea.Se han intervenido 4 pacientes de revascularizacióncoronaria a través de mini-esternotomía, revascularizandola arteria descendente anterior con la arteria mamariaizquierda, bajo anestesia epidural torácica alta (bloqueosegmentario T1-T8) con perfusión de ropivacaína0,75% y fentanilo y con el paciente consciente. No hubocomplicaciones hemodinámicas, ni respiratorias durantela cirugía. El tiempo medio de estancia en CuidadosIntensivos fue menor de 18 horas y la estancia mediahospitalaria menor de 5 días. La coronariografía postoperatoriamostró permeabilidad de los injertos en todoslos casos y los 4 pacientes permanecieron asintomáticosal mes.CONCLUSIÓN: Nuestra experiencia inicial indica que eluso exclusivo de la epidural torácica alta para la revascularizacióncoronaria sin circuito de circulación extracorpórea,supone una opción en pacientes seleccionados,colaboradores y que precisen revascularización coronariade un solo vaso

Thoracic epidural anesthesia has been widely used to complement general anesthesia in coronary artery bypass grafting. The main advantages of the combination are excellent pain control and a less pronounced stress response to surgery. The invasiveness of surgery to treat ischemic heart disease has been attenuated thanks to the use of the mini-sternotomy and coronary anastomosis without extracorporeal circulation. In 4 patients, coronary artery revascularization was carried out via a mini-sternotomy, grafting the anterior descending artery to the left internal thoracic artery under high thoracic epidural anesthesia (block of segments T1-T8) with a perfusion of 0.75% ropivacaine and fentanyl in a conscious patient. There were no hemodynamic or respiratory complications during surgery. The mean duration of stay in the intensive care unit was less than 18 hours and the mean hospital stay was less than 5 days. Postoperative coronary arteriograms demonstrated the patency of all grafts and all patients were asymptomatic at 1 month. Our initial experience suggests that the use of only high thoracic epidural anesthesia is feasible in coronary revascularization in selected, cooperative patients who require a single coronary bypass graft

[Cell saver devices in coronary revascularization surgery without extracorporeal circulation reduce transfusion requirements]. / El Recuperador Celular (Cell Saver) en cirugía de revascularización coronaria sin circulación extracorpóea reduce necesidades transfusionales.

OBJECTIVES: To analyze the effectiveness of a cell saver device in reducing transfusion requirements in patients undergoing off-pump coronary artery bypass surgery. PATIENTS AND METHODS: Fifty-six consecutive ASA class 4-5 patients who underwent coronary surgery without extracorporeal circulation in our cardiac surgery department between June 2004 and January 2005 were included in this retrospective study; the series comprised 28 patients who received conventional management (control group) without use of the cell saver device and 28 who received cell saver treatment. Variables analyzed were preoperative and discharge hemoglobin levels and hematocrit values, age, weight, height, ejection fraction, packed red blood cells transfused, exitus, and adverse events. RESULTS: The groups were similar with respect to preoperative characteristics. Fewer patients in the cell saver group required transfusions (6 vs 18 in the control group; relative risk 0.33, 95% confidence interval, 0.16-0.71). The mean amount of packed red cells transfused was greater in the control group than in the cell saver group (2.5 L vs 1.2 L, P = 0.03). No deaths or adverse events occurred in either group. CONCLUSIONS: The routine use of a cell saver device during off-pump coronary artery bypass surgery reduces the need for postoperative transfusions and is not associated with adverse events. Cell saver devices should be used routinely, especially in situations where the ability to provide blood transfusions may be compromised.

El Recuperador Celular (Cell Saver) en cirugía de revascularización coronaria sin circulación extracorpórea reduce necesidades transfusionales / Cell saver devices in coronary revascularization surgery without extracorporeal circulation reduce transfusión requirements

OBJETIVOS: Comprobar la eficacia en la reducción detransfusiones del recuperador celular en cirugía coronariaen pacientes que no se someten a circulación extracorpórea.PACIENTES Y MÉTODOS: 56 pacientes consecutivos conriesgo ASA III-IV operados desde junio de 2004 hastaenero de 2005 de cirugía coronaria sin circulación extracorpóreaen un Servicio de Cirugía Cardiaca. Estudioobservacional de cohortes retrospectivo. 28 pacientes(Grupo Control) fueron intervenidos de forma convencionalsin recuperador celular, y en 28 pacientes (GrupoEstudio) se empleó el recuperador celular (Cell Saver).Se determinó: Hemoglobina y Hematocrito preoperatoriosy al alta, edad, peso, talla, fracción de eyección, concentradosde hematíes trasfundidos, exitus y resultadosadversos.RESULTADOS: Las dos poblaciones han resultadohomogéneas en cuanto a criterios demográficos preoperatorios.En el grupo II (con recuperador) precisarontransfusiones menos pacientes (6 vs. 18, RR 0,33 IC 95%0,16-0,71). Se transfundieron más concentrados dehematíes de media en el grupo sin recuperador (2,5 vs1,2, p=0,03). No hubo exitus ni resultados adversos enninguno de los dos grupos.CONCLUSIONES: El uso rutinario de recuperador celularen cirugía coronaria sin bomba reduce las necesidadestransfusionales postoperatorias y no está asociadocon efectos adversos. Su empleo debe considerarse comoprocedimiento habitual de actuación, especialmente enmedios o situaciones en los que la disponibilidad de sangrepuede estar comprometida

OBJECTIVES: To analyze the effectiveness of a cellsaver device in reducing transfusion requirements inpatients undergoing off-pump coronary artery bypasssurgery.PATIENTS AND METHODS: Fifty-six consecutive ASAclass 4-5 patients who underwent coronary surgery withoutextracorporeal circulation in our cardiac surgerydepartment between June 2004 and January 2005 wereincluded in this retrospective study; the series comprised28 patients who received conventional management(control group) without use of the cell saver deviceand 28 who received cell saver treatment. Variablesanalyzed were preoperative and discharge hemoglobinlevels and hematocrit values, age, weight, height, ejectionfraction, packed red blood cells transfused, exitus,and adverse events.RESULTS: The groups were similar with respect topreoperative characteristics. Fewer patients in the cellsaver group required transfusions (6 vs 18 in the controlgroup; relative risk 0.33, 95% confidence interval,0.16-0.71). The mean amount of packed red cells transfusedwas greater in the control group than in the cellsaver group (2.5 L vs 1.2 L, P=0.03). No deaths oradverse events occurred in either group.CONCLUSIONS: The routine use of a cell saver deviceduring off-pump coronary artery bypass surgery reducesthe need for postoperative transfusions and is notassociated with adverse events. Cell saver devicesshould be used routinely, especially in situations wherethe ability to provide blood transfusions may be compromised

Remifentanilo como alternativa a la analgesia neuroaxial en una parturienta con plaquetopenia / Remifentanyl as an alternative to neuroaxial analgesia in a parturient with thrombocytopenia

Describimos el caso de una parturienta con plaquetopenia secundaria a una púrpura trombótica trombocitopénica en la que se utilizó remifentanilo para aliviar el dolor del trabajo de parto mediante analgesia controlada por la paciente (PCA), aunque actualmente no es una indicación, sus características farmacocinéticas la constituyen en una alternativa en obstetricia en situaciones en las que la analgesia neuroaxial está contraindicada. Utilizamos remifentanilo con una infusión basal de 0,03 µg.kg-1.min-1, asociado a bolos de 0,10 µg.kg-1 con un intervalo de cierre de 1 minuto. Remifentanilo permitió reducir la intensidad del dolor al menos en un 60 por ciento con escasos efectos adversos sobre la parturienta, náuseas y prurito, y nulos sobre el recién nacido. Remifentanilo PCA fue una alternativa a otras modalidades de analgesia, epidural o intravenosa, en el alivio del dolor en el trabajo de parto en una paciente con trombopenia secundaria a púrpura trombótica trombocitopénica (AU)

[Acute selective tolerance to remifentanil after prolonged infusion]. / Tolerancia aguda selectiva a remifentanilo tras infusiones prolongadas.

We describe the cases of 3 patients who received anesthesia with remifentanil continuously infused at rates of 0.8 to 1.25 micrograms.kg-1.min-1 for at least 3 hours. Upon emergence from anesthesia, after withdrawal of the anesthetic gas, satisfactory levels of consciousness, spontaneous breathing and absence of pain were achieved under maintenance doses of remifentanil greater than 0.8 microgram.kg-1.min-1; such doses are related to the development of ventilatory depression, apnea and significant sedation. Acute tolerance to remifentanil is under debate at present. Such tolerance involves decreased efficacy of an opiate or the need for higher doses to maintain an effect after exposure. The development of tolerance is related mainly to the pharmacokinetics of an opiate, a short half-life and infusion periods exceeding 3 hours, and in the case of remifentanil, to the use of high doses. The most likely explanation for de phenomena described would be the development of selective acute tolerance to ventilatory depression and to sedation, with no effect on the antinociceptive effects of remifentanil. Clinical trials should be carried out to assess the development of acute tolerance to remifentanil and its possible perioperative repercussions.

Tolerancia aguda selectiva a remifentanilo tras infusiones prolongadas / Selective acute tolerance to remifentanil after prolonged infusion

Describimos 3 casos de pacientes no adictos a opiáceos sometidos a técnicas anestésicas basadas en remifentanilo, en las que se administró infusiones constantes entre 0,81,25 µg.Kg-1.min-1 durante al menos 3 horas, los pacientes presentaron en la educción de la anestesia, tras suprimir la administración del anestésico inhalatorio, un adecuado nivel de conciencia, respiración espontánea y ausencia de dolor manteniendo dosificaciones de remifentanilo superiores a 0,8 µg.Kg-1.min-1, dosis relacionadas con la aparición de depresión respiratoria, apnea y sedación significativa. La tolerancia aguda a remifentanilo es actualmente un tema de controversia; esto implica una disminución de un efecto, o de la necesidad de una dosis más elevada para mantener dicho efecto tras la exposición a un opiáceo. El desarrollo de la tolerancia depende esencialmente de las características farmacocinéticas del remifentanilo, de su corta vida media y de la utilización en infusión durante más de 3 horas, así como del empleo de dosificaciones elevadas. La explicación más probable para estos fenómenos sería el desarrollo de tolerancia aguda selectiva a la depresión respiratoria y a la sedación sin afectar a los efectos antinociceptivos del remifentanilo (AU)

[Effects of the chronic administration of midazolam on the rat hippocampus]. / Efectos de la administración crónica de midazolam sobre el hipocampo de ratas.

The effects of midazolam (MDZ) treatment during 120 days have been studied in 2 groups of young and old Wistar rats: (50 animals two months, 50 aged 24 months). 20 rats of both groups got 1 mg/kg of MDZ daily, 20 3 mg/kg, and finally 10, animals 1 ml saline all administered by gastric intubation. The general effects of MDZ (mortality, weight changes and memory of an aversive stimuli showed no significant differences with the controls either in young or old rats. In the hippocampus, the total count of neurons gave no significant differences compared to controls. However, in the group of old rats a higher number of dark and pycnotic cells, principally in those rats treated with 3 mg/kg of MDZ was observed. The global area of the CA1, CA4 fields and of the GD was significant reduced in comparison with the controls. These results favour the conclusion that the MDZ has a minimal neurotoxicity: only the group of old rats treated with 3 mg/kg showed weak signs of hippocampal effects.