Eduardo Gabe

Total myocardial revascularization with arterial conduits: Radial artery combined with internal thoracic arteries

OBJECTIVE We prospectively tested the feasibility of achieving total arterial revascularization with the use of the radial artery to revascularize the circumflex, diagonal, and right coronary arteries combined with a left internal thoracic artery graft to the left anterior descending artery and, in some cases, a right internal thoracic artery graft to the right coronary artery. METHODS In 164 patients, the radial artery was used as a free Y or T graft from the left internal thoracic artery. Of 568 grafts (3.5 +/- 1 [standard deviation] per patient), 296 (1.8 +/- 0.8 per patient) were constructed with the radial artery as single grafts or as double, triple, or quadruple sequential anastomoses to the circumflex, diagonal, and posterior descending arteries. Diltiazem was administered to prevent spasm. Forty-six patients underwent coronary angiography before discharge from the hospital. Follow-up time was 1 to 19 (9.5 +/- 6.1) months. RESULTS Total arterial revascularization was achieved in 137 patients (83.5%). Three (1.8%) died postoperatively of sepsis, ventricular fibrillation, and heart failure, respectively. Three (1.8%) had postoperative myocardial infarction. No hand ischemia occurred. Angiography showed patency of all arterial conduits. Radial artery spasm appeared in 3 (6.5%) of 46 angiograms. Two patients (1.2%) died during the follow-up period of pneumonia and gastrointestinal tract bleeding, respectively. No other events or reoperations occurred, and 95.1% of the patients are free of symptoms. CONCLUSIONS The radial artery, as a free Y or T graft from the left internal thoracic artery to the circumflex, diagonal, and right coronary arteries, permits total arterial revascularization with excellent patency rates, minimal morbidity and mortality, and no need for reoperation. Longer follow-up times are necessary to draw definitive conclusions.

Myocardial revascularization with radial and mammary arteries: initial and mid-term results.

BACKGROUND The radial artery is being used with increasing frequency instead of the saphenous vein in coronary artery bypass grafts. We analyzed the in-hospital and midterm results in patients undergoing coronary artery bypass surgery in whom a combination of arterial grafts was used, including radial artery and one or both internal mammary arteries. METHODS Between 1995 and 1998, 1,023 patients underwent coronary artery bypass surgery using arterial conduits. The left internal mammary artery and the right internal mammary artery were employed in combination with the radial artery. RESULTS An average of 3.2 grafts per patient were done. The left internal mammary artery and radial artery were used in 100% of patients, the right internal mammary artery in 21.7%, and a venous graft in 31%. The operative mortality rate was 2.5%. On repeat angiography performed in 62 patients before their discharge, the arterial conduits were patent in 98.4%. Mean follow-up was 25.0 +/- 9.6 months (1 to 48 months). The probability of survival was 92.8%. CONCLUSIONS Revascularization using mammary and radial artery grafts is safe. Complications are not higher than those observed with saphenous vein grafting. It was possible to use arterial conduits in all the patients, even in those with impaired left ventricular function.

Mixomas cardíacos: correlaciÓn anatomoclínica

Introduction and objectives. Myxomas are the most common type of primary cardiac tumors. The aim of this study was to analyze the clinical forms of presentation of cardiac myxoma, the postoperative evolution, and the possibility of recurrence and tumoral embolism. Patients and method. From July 1992 to March 1999, 31 patients with myxoma were studied. Cell cycles (ploidy pattern of the tumoral DNA) were studied in 12 patients to evaluate the risk of recurrence and tumoral embolism. Results. The most frequent clinical manifestations were constitutional symptoms (74%), dyspnea (45%), and embolism (41%). Smaller-diameter myxomas correlated independently with tumoral embolism (45%). The inhospital mortality was 3.2%, no deaths were observed during follow-up (mean: 4.8 years). No patients had clinical or echocardiographic signs of tumoral recurrence. Patients with tumoral embolism (n = 8) were compared with patients without embolism (n = 4). Patients who suffered embolism had higher S phase > 7 and/or DNA index > 1.2 (4/4 patients [100%], p= 0.061) than patients without embolism (2/8 patients [25%]). Cytometry of the only recurrent tumor (second operation) revealed a diploid tumor with a significantly more frequent S phase (10%) than in sporadic myxomas (4.27 ± 2.32%, p = 0.039). Conclusions. Constitutional symptoms, dyspnea, and tumor embolism were the most frequent clinical manifestations. Clinical and anatomopathologic characteristics and the cell cycle were not significantly related to tumoral embolism, but there was a tendency toward a higher proportion of cells in S phase and a higher DNA index in tumors associated with embolism. The S phase was significantly more frequent in the only case of recurrent myxoma and could be a potential marker of recurrence.

Radial artery graft vasospasm.

We report an unusual case of vasospasm of a grafted radial artery complicated with ventricular fibrillation during the postoperative course of coronary artery bypass graft surgery. To our knowledge this is the first documented case of a radial artery graft spasm leading to a severe arrhythmia. The arrhythmia resolved spontaneously. Radial artery graft spasm was demonstrated by angiography and was successfully resolved by intravenous nitroglycerin administration.

Cirugía de revascularización coronaria con conductos arteriales. Técnica, resultados y seguimiento a cuatro años en 1.023 pacientes consecutivos

Objetivo El proposito del presente trabajo fue analizarlos resultados intrahospitalarios y tras 4 anos en 1.023 pacientesconsecutivos sometidos a cirugia de revascularizacioncoronaria en los que se emplearon conductos arteriales:arteria radial y una o dos arterias mamarias internas. Metodo Entre mayo de 1995 y mayo de 1998, 1.023 pacientes consecutivos fueron operados utilizando conductosarteriales, una o dos arterias mamarias y arteria radial. Lamamaria izquierda fue empleada in situ, y la mamaria derechacomo injerto libre o in situ, ambas en combinacion con laarteria radial. Esta ultima fue conectada a la mamaria izquierdaa traves de una anastomosis en «T» o «Y» o, en menorproporcion, emergiendo de la porcion ascendente de la aorta. Resultados Se realizaron un promedio de 3,2 puentes/paciente. La mamaria izquierda se utilizo en el 100%de los casos. La mamaria derecha se empleo en el 21,7% yla radial en el 100% de los pacientes. La mortalidad hospitalariafue de 2,5% (26 pacientes) y 32 (3,1%) sufrieron infartoperioperatorio. Los primeros 62 pacientes fueron angiograficamenteestudiados antes del alta y se obtuvo un 98,4% depermeabilidad en los conductos empleados. La media de seguimientofue 25,0 ± 9,6 meses (rango, 1-48 meses). Conclusiones a) la cirugia de revascularizacion miocardica empleando una combinacion de arterias mamarias y radial es segura; b) los resultados intrahospitalarios y a mediano plazo (4 anos) en terminos de morbilidad y mortalidad no son mayores que los observados en la cirugia con puentes venosos de safena; c) es posible realizar una revascularizacion coronaria completa con conductos arteriales, aun en pacientes con funcion ventricular deprimida, y d) se pueden emplear conductos arteriales en pacientes anosos.

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.

Manual debridement of the aortic valve in elderly patients with degenerative aortic stenosis

OBJECTIVE We prospectively analyzed the short- and long-term results of manual debridement of the aortic valve in elderly patients with severe degenerative aortic stenosis. METHODS Between September 1988 and January 1997, 103 patients aged 73.7 +/- 6 years with degenerative aortic stenosis underwent the manual debridement technique. All had symptoms (angina or dyspnea, or both). Peak systolic gradient was 89 +/- 28 mm Hg. Forty-one patients (39.8%) had associated coronary artery disease necessitating revascularization. RESULTS Follow-up time was 42 +/- 21 months (range 3-98 months). The Kaplan-Meier estimated survival at 98 months was 50% (95% CI: 30%-70%). In-hospital mortality was 5.8% (6 patients), and late mortality was 21% (21 patients). No predictors of in-hospital mortality or of late mortality were detected. Nonfatal postoperative complications appeared in 25 patients (24%). At 8 years, freedom from endocarditis was 98% (95% CI: 95%-100%) and freedom from thromboembolic events was 99% (95% CI: 96%-100%). No patient required long-term anticoagulation as a result of the procedure. Fourteen patients (14%) required reoperation for aortic insufficiency (n = 5), restenosis (n = 8), and mitral regurgitation (n = 1). The probability of reoperation at 98 months was 23% (95% CI: 12%-35%). CONCLUSION Manual aortic valve debridement has low rates of in-hospital mortality, perioperative complications, and thromboembolic and infectious events and it offers freedom from anticoagulation. However, the incidence of restenosis and reoperation is high in the long term. It may therefore be regarded as an alternative in aged patients with favorable valve anatomy (no distortion and calcium deposits only on the aortic surface of the cusps), especially in those with a small aortic anulus, associated coronary artery disease, and/or contraindication for anticoagulation.

Azygos vein diverticulum

A 47-year-old woman, diagnosed with a diverticulum of the arch of the azygos vein, underwent surgical treatment. With nonspecific symptomatology, she presented one of the most uncommon anomalies of the large veins.

Association Between Nonalcoholic Fatty Liver Disease and Aortic Atherosclerosis in a Healthy Population Older Than 40 Years

Synopsis: The safety and tolerability profiles of statin monotherapy and statin+ezetimibe combination therapy have been established in clinical trials that were not powered to identify small between-treatment differences or very rare adverse experiences. Moreover, conclusions drawn about differences in subpopulations have been limited due to group size. Purpose: To assess the safety and tolerability profiles of various statins+ezetimibe versus statin monotherapy using a pooled analysis of data in more than 21,000 patients. Methods: Data were combined from 27 double-blind, placebo-controlled or active-comparator studies that randomized adult hypercholesterolemic patients to statin or statin+ezetimibe for 6–24 weeks. In the full cohort, percent patients with adverse events (AEs) within treatment groups (statin: n 5 10,517; statin+ezetimibe n 5 11,714) was assessed by a logistic regression model with terms for first-/second-line therapy (statin-na€ive/ongoing statin at study entry), trial within first-/second-line therapy, and treatment. The same model was fitted for age (,65,

CLINICA Y SEGUIMIENTO DE LA PERICARDITIS CONSTRICTIVA CRONICA

65 years), gender, and race (white, black, other) subgroups with additional terms for subgroup and subgroup-by-treatment interaction. Results: In the full cohort, the only significant difference between treatments was in consecutive AST or ALT elevations