Aurelio Sarralde

Surgery for rheumatic tricuspid valve disease: a 30-year experience.

OBJECTIVE This study was undertaken to assess factors influencing short- and long-term outcomes of surgery for rheumatic disease of the tricuspid valve. METHODS Between 1974 and 2005, a total of 328 consecutive patients (mean age 51.3 +/- 13.6 years) underwent tricuspid valve surgery for rheumatic disease. There were 12 cases of isolated tricuspid lesion, 199 of triple-valve disease, 114 of tricuspid and mitral valve disease, and 3 of aortic and tricuspid valve disease. Most patients (72%) had predominantly tricuspid regurgitation. Tricuspid valve prosthetic replacement was performed in 31 cases and valve repair in 297. RESULTS In-hospital mortality was 7.6%. Late mortality was 52.1%, whereas the expected mortality of the Spanish population of the same age was 24.2%. Predictors of in-hospital mortality were male sex, isolated tricuspid lesion, moderate aortic insufficiency, postclamping time, and tricuspid valve replacement. Mean follow-up was 8.7 years (range 1-31 years). Follow-up was 98.9% complete. Predictors of late mortality were age, New York Heart Association functional class IV, postclamping time, and mitral valve replacement. In total, 114 patients required valve reoperation, but only 4 (3.5%) for isolated tricuspid valve dysfunction. At 30 years, actuarial survival was 12.1% +/- 4.4%, actuarial freedom from reoperation was 27.5% +/- 5.8%, and actuarial freedom from valve-related complications was 2.0% +/- 1.3%. CONCLUSION Organic tricuspid valve disease associated with rheumatic mitral or aortic lesions increases hospital and late mortality, but valve repair compared favorably with valve replacement. Long-term results may be considered acceptable for otherwise incurable valve disease.

Repeat Mitral Valve Replacement: 30-Years Experience

Prosthetic heart valve dysfunction is an acquired condition that carries a significant risk of emergency surgery. However, the long-term natural history of the condition is not well understood. Between 1974 and 2006, 1535 isolated mitral valve replacements were performed at our hospital (in-hospital mortality 5%). In total, 369 patients needed a second operation (in-hospital mortality 8.1%), while 80 (age 59.8+/-11.4 years) needed a third. The reasons for the third intervention were structural deterioration (67.5%), paravalvular leak (20%) and endocarditis (6.3%). Some 15 patients died in hospital (18.8%). After a mean follow-up period of 17.8 years, 21 patients needed another intervention (i.e., a fourth intervention). The actuarial reoperation-free rate at 20 years was 40.1+/-13.8%. The late mortality rate was 58.5% (18-year survival rate 15.4+/-5.4%). Indications for repeat mitral valve replacement must be judged on an individual basis given the high risk associated with surgery.

Cirugía cardiaca en testigos de Jehová. Experiencia en Santander

Los testigos de Jehova constituyen una poblacion de dificil tratamiento para las intervenciones de cirugia cardiaca. Entre 1998 y 2004, todos los pacientes testigos de Jehova con indicacion de cirugia cardiaca (n = 10) fueron intervenidos por un mismo equipo. El descenso medio del hematocrito fue, durante la circulacion extracorporea, del 30%, durante el postoperatorio, del 35% y en el alta, del 22%. Un paciente preciso una reintervencion precoz por sangrado importante de origen esternal. Todos los pacientes fueron dados de alta y durante el seguimiento un enfermo fallecio de causa respiratoria. Las medidas para disminuir y recuperar la perdida de sangre permiten realizar intervenciones de riesgo hemorragico en pacientes testigos de Jehova.

Regeneración celular cardíaca

La terapia celular con celulas madre, como estrategia para regenerar tejidos danados, es una de las areas mas prometedoras en el tratamiento de enfermedades con escasas o nulas expectativas de curacion. La insuficiencia cardiaca, principalmente de origen isquemico, es una de las enfermedades que mas se pueden beneficiar de esta estrategia. El objetivo es regenerar el musculo, reducir la apoptosis, aumentar la expresion del colageno intersticial e inducir la generacion de nuevos vasos. la terapia celular cardiaca ha sido propuesta con una gran variedad de celulas angiogenicas y miogenicas: mioblastos esqueleticos, celulas mononucleares y mesenquimales de medula osea, progenitores endoteliales circulantes, celulas derivadas del estroma de la grasa o del endometrio, celulas mesoteliales y pluripotenciales (induced pluripotent stem cells [iPS]). las indicaciones incluyen a pacientes con miocardiopatia isquemica o dilatada, enfermedad de Chagas, insuficiencia mitral isquemica y miocardiopatia diabetica. Los abordajes son quirurgicos, con inyeccion periinfarto, intracoronario y endoventricular percutaneo. Los mecanismos de accion propuestos son la reduccion del tamano de la cicatriz del infarto, el aumento de la viabilidad miocardica, la limitacion del remodelado ventricular y los efectos paracrinos. Sin embargo, los resultados clinicos muestran solo mejoras muy limitadas de la funcion sistolica y del remodelado ventricular. El desarrollo de estrategias que mejoren la supervivencia y la diferenciacion celular deben ser prioritarias, tales como el preacondicionamiento con electroestimulacion o la ingenieria tisular con el objetivo de desarrollar un miocardio bioartificial.

Cardiac Surgery in Jehovah's Witnesses. Experience in Santander, Spain

As patients who are Jehovahs Witnesses are against blood transfusion, they are difficult to manage when a cardiac intervention is required. Between 1998 and 2004, all Jehovahs Witness patients with an indication for cardiac surgery (n=10) were operated on by the same multidisciplinary team. The mean fall in hematocrit was 30% during cardiopulmonary bypass, 35% during the postoperative period, and 22% at discharge. One patient required cardiac re-exploration because of sternal bleeding. All patients survived operation and were discharged. At follow-up, 1 patient died due to respiratory failure. Technological developments that reduce bleeding and enable lost blood to be recovered have made it possible to perform operations involving a risk of hemorrhage in Jehovahs Witnesses.

Iliac Artery Aneurysm Repair with Preservation of a Single Ectopic Pelvic Kidney

An ultrasonographic study in a 60-year-old man incidentally detected an iliac artery aneurysm that gave rise to the renal artery of a single ectopic pelvic kidney. Renal-preservation solution could not be used during surgery, because the unclamped renal vein would have enabled the solution to enter the systemic circulation. Therefore, cold saline solution was infused through the renal ostium, and the kidney was maintained under cold saline immersion. We performed aortoiliac bypass and then implanted the renal artery into the bypass graft. Postoperatively, the patients serum creatinine level increased; after one year, his renal function was normal. We discuss our use of cold saline solution for renal preservation.