Álvaro González Rocafort

Chimney Technique for Mitral Valve Replacement in Children

Severe mitral stenosis is unusual in children, but it represents an important challenge for surgeons because of the scarcity of solutions. Several mitral percutaneous and surgical valvuloplasties are performed repetitively to delay mitral valve replacement. Most of the time these procedures show discouraging results. When mitral valve replacement is performed, the annulus may not be large enough to fit a substitute. We present, to our best knowledge, a new technique to implant a large prosthesis in a small annulus without negatively affecting the opening of the leaflets.

Resultados de la cirugía coronaria sin circulación extracopórea tras angioplastia con stent

Introduccion y objetivos. Evaluar el impacto de la implantacion de stents coronarios previa a la cirugia de revascularizacion miocardica en los resultados postoperatorios de esta. Metodos. Desde enero de 2005 hasta abril de 2008, se evaluo retrospectivamente el impacto de la implantacion de stents coronarios previa a la cirugia coronaria sin circulacion extracorporea en la incidencia de eventos cardiovasculares mayores en el postoperatorio (30 dias o ingreso hospitalario postoperatorios). Resultados. Se sometio a 796 pacientes consecutivos a revascularizacion miocardica quirurgica; 116 (14,6%) portaban algun stent coronario en el momento de la cirugia. Los grupos con stent y sin stent tenian un perfil de riesgo similar (EuroSCORE). En el analisis multivariable, ajustando el riesgo por las variables de confusion detectadas (fraccion de eyeccion del ventriculo izquierdo preoperatoria < 40%, estado critico preoperatorio, edad, antecedentes de accidente cerebrovascular agudo, infarto miocardico agudo previo reciente, numero de vasos coronarios enfermos, revascularizacion quirurgica incompleta y conversion a circulacion extracorporea) se detecto que el ser portador de stent se asociaba de forma significativa a un mayor riesgo de infarto miocardico postoperatorio (RR = 3,13; intervalo de confianza [IC] del 95%, 1,75-5,96), mortalidad cardiaca hospitalaria (RR = 4,62; IC del 95%, 1,76-12,11) y mortalidad hospitalaria por todas las causas (RR = 3,65; IC del 95%, 1,6-8,34). Conclusiones. En nuestra experiencia, la implantacion previa de stents coronarios se asocia a un mayor riesgo de infarto miocardico y mortalidad cardiaca y por todas las causas en el postoperatorio de la cirugia coronaria.

Clinical Outcomes With Off-Pump Coronary Surgery After Angioplasty With Stent

INTRODUCTION AND OBJECTIVES The aim was to determine whether prior coronary stent implantation affects postoperative outcomes in patients undergoing coronary artery bypass grafting. METHODS Between January 2005 and April 2008, a retrospective analysis was carried out to evaluate the effect of prior coronary stent implantation in patients undergoing off-pump coronary surgery on the incidence of major cardiovascular events in the postoperative period (i.e. at 30 days or during postoperative hospitalization). RESULTS In total, 796 consecutive patients underwent coronary artery bypass grafting. Of these, 116 (14.6%) had a coronary stent at the time of surgery. Patients with and without stents had similar levels of risk (i.e. EuroSCORE). Multivariate analysis, adjusted for the presence of confounding variables (i.e. preoperative left ventricular ejection fraction <40%, critical preoperative state, age, history of cerebrovascular accident, recent acute myocardial infarction, number of diseased coronary vessels, incomplete revascularization and on-pump conversion), showed that the presence of a stent was significantly associated with increased risks of postoperative myocardial infarction (relative risk [RR]=3.13; 95% confidence interval [CI], 1.75-5.96), in-hospital cardiac mortality (RR=4.62; 95% CI, 1.76-12.11) and in-hospital all-cause mortality (RR=3.65; 95% CI, 1.60-8.34). CONCLUSIONS In our experience, coronary artery stent implantation prior to coronary surgery was associated with increased risks of postoperative myocardial infarction, cardiac mortality and all-cause mortality in the postoperative period.

Persistent embryonic right venous valve giving a cor triatriatum dexter appearance in a cyanotic neonate.

Embryonic right venous valve may persist after birth as a membrane seen inside the right atrium and give a cor triatriatum dexter appearance in echographic imaging. The finding is usually asymptomatic, but may rarely cause cyanosis when flow from the inferior vena cava is redirected into the left atrium and be misdiagnosed with a tricuspid valve anomaly. We report the case of a cyanotic newborn who underwent a successful resection of a cor triatriatum dexter membrane.

Stented Bovine Jugular Vein Graft (Melody Valve) in Mitral Position. Could Be an Alternative for Mechanical Valve Replacement in the Pediatric Population

Congenital mitral valve disease is an uncommon condition. Medical treatment can be very complicated in some cases, leaving surgery as the only option. Surgical valvuloplasty often fails in children, especially in neonates and young infants, due to the presence of dysplastic valves with a small annulus and special anatomic features. In such cases, valve replacement is generally the only solution. We present 3 cases of Melody valve implantation in the mitral position. Patient 1 was a 4-month-old infant weighing 4.6 kg with severe mitral regurgitation (MR) (valve with thickened leaflets, reduced mobility, and absence of central coaptation; annulus of 15 mm) that was refractory to medical treatment. Following Kay-Wooler annuloplasty, the boy showed moderate residual MR and was extubated, but he developed severe MR 14 days later and required ventilatory support. We decided to implant a Melody valve in the mitral position using the Boston technique with some modifications. Before initiation of extracorporeal circulation, the valve was expanded to 18 mm and a 3-mm pericardial sewing cuff was added

A coarctation on the wrong aortic arch side.

A 3-month-old male infant, with diagnosis of a complex, cyanotic, congenital heart disease (double-outlet right ventricle, pulmonary stenosis, and hypoplastic pulmonary arteries, among other defects) and a double aortic arch (Fig. 1, [L, left; LCA, left carotid artery; LSA, left subclavian artery; R, right; RCA, right carotid artery; RSA, right subclavian artery]), had required a shunt from ascending aorta to main pulmonary trunk (Fig. 2A, *), plus a section of the aortic arch distal to right subclavian artery (Fig. 2B, y). During admission, the infant experienced low systemic cardiac output, with arterial pressure gradient between upper and lower extremities, and an echo suspicion of aortic coarctation. A thorax computed tomography scan showed a stenotic area in the native, left aortic arch (Figs. 2A, 2B, arrow), bizarrely located between the left carotid artery and the left subclavian artery. Due to the atypical location of the coarctation, and the complexity and risk of the patient, after agreement with cardiac surgeons we accordingly performed a balloon catheter angioplasty to resolve the coarctation (Fig. 3A), which was effective and uneventful (Fig. 3B). Angio computed tomography scan and 3D reconstructions provide fast, high-resolution images of congenital heart disease, with minimum radiation doses and use of intravenous contrasts. In infants with congenital heart disease, computed tomography scan is better than magnetic resonance imaging, especially in large-vessel anomalies. Findings may be later confirmed in the operation theater or the cath-lab. In our patient with double aortic arch intervention, computed tomography scan provided accurate images of an atypical coarctation, and allowed an individualized approach. Figure 1.