Alejandro Machain

Valve operations through a minimally invasive approach

BACKGROUND We analyzed in-hospital results of 87 patients undergoing minimally invasive valvular operations (right parasternal incision through third and fourth cartilages). METHODS Age was 21 to 84 years (mean, 56.2 +/- 16); 45 patients (51.7%) were female. Five (5.7%) had a previous valvular operation and 8 (9.2%) had severe left ventricular dysfunction. Valve diseases were as follows: aortic in 35 patients (40.2%), mitral in 44 (50.5%), double in 5 (5.7%), tricuspid regurgitation in 2 (2.2%), and mitral periprosthetic leak in 1 (1.1%). RESULTS Nineteen mitral repairs (21.9%), 22 replacements (25.3%), 1 leak closure (1.1%), 1 tricuspid repair (1.1%), and 1 replacement (1.1%) were performed. Thirty-one patients (35.7%) underwent aortic replacement, 2 (2.3%) aortic decalcification, 1 (1.1%) subaortic membrane resection, 4 (4.6%) a double-valve procedure, and 5 (5.7%) a single-valve operation combined with myocardial revascularization. In-hospital mortality was 5.7% (5 patients). Univariate analysis was significant for previous operation, New York Heart Association class IV and severe ventricular dysfunction. Multivariate analysis was significant for previous operation and severe ventricular dysfunction. Atrial fibrillation (12.6%) was the most frequent complication. Postoperative stay was 6.5 +/- 6 days. CONCLUSIONS The minimally invasive approach is a useful technique in valvular surgery. Patients with a previous valvular operation, severe ventricular dysfunction, and New York Heart Association class IV dyspnea have higher in-hospital mortality.

Cirugía coronaria en pacientes ancianos. Resultados hospitalarios y a largo plazo

Introduccion y objetivos Actualmente es cada vez mayor el numero de pacientes ancianos que son sometidos a cirugia de revascularizacion miocardica. Los objetivos de este trabajo fueron estudiar la evolucion hospitalaria y a largo plazo de pacientes mayores de 75 anos sometidos a cirugia coronaria pura e identificar predictores clinicos de mortalidad y sintomas largo plazo. Metodos Entre abril de 1996 y febrero de 2000 se analizaron, en forma prospectiva y consecutiva, 207 pacientes mayores de 75 anos sometidos a cirugia coronaria pura. La edad media fue de 78,4 ± 2,7 anos. Resultados Se realizo un promedio de 2,6 puentes/ paciente. La arteria mamaria izquierda fue empleada en el 93% de los pacientes. La incidencia intrahospitalaria de insuficiencia cardiaca, fibrilacion auricular, infarto perioperatorio y accidente cerebrovascular fue del 38, 29, 4,8 y 2,8%, respectivamente. Fallecieron durante el periodo hospitalario el 5,8% de los pacientes. La mediana de seguimiento fue de 18 meses (intervalo intercuartil, 9-29). Ocho pacientes (4,1%) fallecieron durante el seguimiento tardio. Excluyendo a los fallecidos en el hospital, la probablidad estimada (Kaplan-Meier) de estar vivo y de sobrevivir libre de sintomas en clase funcional III-IV a 3 anos fue del 94 y del 86%, respectivamente. El analisis multivariado mostro que solo la edad fue predictora de mortalidad hospitalaria (OR, 1,26; p = 0,009). La presencia de enfermedad vascular periferica resulto la unica predictora de sintomas en el seguimiento a largo plazo (p = 0,001). Conclusiones En esta serie de pacientes seniles sometidos a cirugia coronaria se demuestra que los de edad mas avanzada (> 80 anos) presentan un riesgo de mortalidad hospitalaria mayor. La presencia de enfermedad vascular periferica resulta util en la valoracion pronostica del grupo.

Left anterior descending coronary artery bypass grafting through minimal thoracotomy

BACKGROUND In recent years, minimally invasive direct coronary artery bypass grafting has emerged as a valid tool for revascularization in a select group of patients with severe lesions of the left anterior descending coronary artery. Here we report the clinical results using two devices designed by us to facilitate the harvesting of the left internal mammary artery up to its origin and to occlude and stabilize the left anterior descending coronary artery while placing the anastomosis. METHODS From January 1996 to January 1998, 122 patients underwent minimally invasive direct coronary artery bypass grafting in the Department of Cardiac Surgery, Favaloro Foundation. One hundred twelve patients received a single left internal mammary artery-left anterior descending coronary artery bypass graft, and in 10 patients, an additional bypass graft was performed. RESULTS Most patients were discharged on day 2 or 3 after the procedure. Three patients (2.5%) had a perioperative myocardial infarction. The overall hospital mortality rate was 3.3% (4 patients). CONCLUSIONS The combination of team experience, more careful dissection of the left internal mammary artery up to its origin, and use of the stabilizer-occluder and interrupted suture technique for the anastomosis has markedly improved our results.

Seudoaneurisma de aorta ascendente

Varon de 67 anos, hipertenso, diabetico, con historia de reemplazo valvular aortico con protesis mecanica en 1991 por estenosis valvular, complicada en el postoperatorio inmediato con diseccion aortica tipo A que determina cirugia de urgencia. Se realiza reemplazo de aorta ascendente con tubo protesico (preservando la raiz aortica y la protesis valvular), con buena evolucion postoperatoria. En enero de 1999 presenta de forma subita disnea y dolor retrosternal irradiado a dorso. En el momento de la consulta el paciente se encuentra palido, sudoroso e hipotenso. El electrocardiograma no revela alteraciones agudas. La radiografia de torax demuestra un significativo ensanchamiento mediastinico. Sin disponer de los detalles de la cirugia previa y ante la sospecha de diseccion aortica tipo A, se decide