Elena Sandoval

Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST): A 2-Center Randomized Clinical Trial

Background— Catheter ablation (CA) and minimally invasive surgical ablation (SA) have become accepted therapy for antiarrhythmic drug–refractory atrial fibrillation. This study describes the first randomized clinical trial comparing their efficacy and safety during a 12-month follow-up. Methods and Results— One hundred twenty-four patients with antiarrhythmic drug–refractory atrial fibrillation with left atrial dilatation and hypertension (42 patients, 33%) or failed prior CA (82 patients, 67%) were randomized to CA (63 patients) or SA (61 patients). CA consisted of linear antral pulmonary vein isolation and optional additional lines. SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein, ganglionated plexi ablation, and left atrial appendage excision with optional additional lines. Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording. The primary end point, freedom from left atrial arrhythmia >30 seconds without antiarrhythmic drugs after 12 months, was 36.5% for CA and 65.6% for SA (P=0.0022). There was no difference in effect for subgroups, which was consistent at both sites. The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA (n=21 [34.4%] versus n=10 [15.9%]; P=0.027), driven mainly by procedural complications such as pneumothorax, major bleeding, and the need for pacemaker. In the CA group, 1 patient died at 1 month of subarachnoid hemorrhage. Conclusion— In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA, SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up, although the procedural adverse event rate is significantly higher for SA than for CA. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique identifier: NCT00662701.

2017 EACTS Guidelines on perioperative medication in adult cardiac surgery

Authors/Task Force Members: Miguel Sousa-Uva* (Chairperson) (Portugal), Stuart J. Head (Netherlands), Milan Milojevic (Netherlands), Jean-Philippe Collet (France), Giovanni Landoni (Italy), Manuel Castella (Spain), Joel Dunning (UK), T omas Gudbjartsson (Iceland), Nick J. Linker (UK), Elena Sandoval (Spain), Matthias Thielmann (Germany), Anders Jeppsson (Sweden) and Ulf Landmesser* (Chairperson) (Germany)

Current State of the Surgical Treatment of Atrial Fibrillation

Surgery of atrial fibrillation (AF) was first described in 1991 by James Cox in what was named the Cox-Maze procedure, and over the years it has been considered the gold-standard treatment, with best results in maintaining sinus rhythm in the long term. Nevertheless, the complexity and aggressivity of the first techniques of cut-and-sew limited the application of this procedure, and few centers were dedicated to AF surgery. In the past years, however, new devices able to ablate atrial tissue with cryotherapy, radiofrequency, or ultrasounds have facilitated this operation. In the mid-term, other energy devices with laser or microwave have been abandoned due to a lack of consistency in getting transmural lesions in a consistent and reproducible manner. Additionally, better knowledge of the physiopathology of AF, with the importance of triggering zones around the pulmonary veins, has started new minimally invasive techniques to approach paroxysmal and persistent AF patients through thoracoscopy.

Myxoid liposarcoma: an unusual primary cardiac tumour

Figure 1: (a and b) Magnetic resonance and computed tomography studies display the left ventricle mass, protruding into the pericardial space and infiltrating epicardial fat; 18 months after surgery, a new mass presented with similar characteristics and size. (c) Jelly tumour from the surgeon’s view. (d) Haematoxilin–eosin stain showing a myxoid pattern with a reticulated matrix and elongated cells, with minimum pleomorphism, no mitotic activity and lipidic differentiation.

Mechanical Thrombectomy for Acute Ischemic Stroke Secondary to Infective Endocarditis

Intravenous thrombolysis is contraindicated in acute ischemic stroke secondary to infective endocarditis. We report our initial experience in 6 cases of proximal vessel occlusion treated with mechanical thrombectomy, which was safe (no bleeding) and effective (significant early neurological improvement) and might be useful in this clinical setting.

La Directiva Europea sobre el Horario de Trabajo y su impacto sobre la formación quirúrgica. Resultados de una encuesta entre los residentes de Cirugía Cardiovascular en España

Objetivos La Directiva Europea del Horario de Trabajo (European Working time Directive [EWTD]) de 1993 deberia estar en funcionamiento para cirujanos cardiovasculares y residentes en agosto de 2009, como respuesta a las dudas sobre la calidad del cuidado del paciente y la calidad de vida de los profesionales causadas por el trabajo excesivo y la fatiga laboral. Hay temor al impacto negativo de la fatiga en la calidad de la atencion al paciente y de las residencias quirurgicas, en especial en Cirugia Cardiovascular. Evaluamos el nivel de conocimiento de los residentes espanoles sobre la EWTD. Metodos Encuesta individual a los residentes asistentes al XIII Curso de Residentes de la Sociedad Espanola de Cirugia Toracica y Cardiovascular de mayo de 2008. Incluye un resumen de los objetivos principales de la EWTD. Resultados Asistieron 58 de 70 residentes posibles. La encuesta fue completada por 26. El 92,3% no habia leido la EWTD y el 26,9% no tenia el minimo conocimiento. El 54,2% estaba de acuerdo con su contenido; 53,8% la considera incompatible con su modelo ideal de formacion; 68% cree que tendra impacto negativo en la misma; 87% cree que discrimina a los residentes quirurgicos; 65,2% cree que reducira sus ingresos anuales; 84,6% cree que parte de la plantilla de sus servicios se opondra. Conclusiones Existe un desconocimiento muy importante sobre la EWTD por los residentes espanoles de Cirugia Cardiovascular. Sorprendentemente, la mayoria esta de acuerdo con la EWTD a pesar de que pueda tener impacto negativo en su formacion y retribucion economica. Se requiere una profunda reflexion por parte de las sociedades profesionales sobre este tema para promover y proteger la formacion en nuestra especialidad.

HACEK infective endocarditis: Epidemiology, clinical features, and outcome: A case–control study

OBJECTIVES The study aimed to describe the epidemiological, microbiological, and clinical features of a population sample of 17 patients with HACEK infective endocarditis (HACEK-IE) and to compare them with matched control patients with IE caused by viridans group streptococci (VGS-IE). METHODS Cases of definite (n=14, 82.2%) and possible (n=3, 17.6%) HACEK-IE included in the Infective Endocarditis Hospital Clinic of Barcelona (IE-HCB) database between 1979 and 2016 were identified and described. Furthermore, a retrospective case-control analysis was performed, matching each case to three control subjects with VGS-IE registered in the same database during the same time period. RESULTS Seventeen out of 1209 IE cases (1.3%, 95% confidence interval 0.69-1.91%) were due to HACEK group organisms. The most frequently isolated HACEK species were Aggregatibacter spp (n=11, 64.7%). Intracardiac vegetations were present in 70.6% of cases. Left heart failure (LHF) was present in 29.4% of cases. Ten patients (58.8%) required in-hospital surgery and none died during hospitalization. In the case-control analysis, there was a trend towards larger vegetations in the HACEK-IE group (median (interquartile range) size 11.5 (10.0-20.0) mm vs. 9.0 (7.0-13.0) mm; p=0.068). Clinical manifestations, echocardiographic findings, LHF rate, systemic emboli, and other complications were all comparable (p>0.05). In-hospital surgery and mortality were similar in the two groups. One-year mortality was lower for HACEK-IE (1/17 vs. to 6/48; p=0.006). CONCLUSIONS HACEK-IE represented 1.3% of all IE cases. Clinical features and outcomes were comparable to those of the VGS-IE control group. Despite the trend towards a larger vegetation size, the embolic event rate was not higher and the 1-year mortality was significantly lower for HACEK-IE.

Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular

BACKGROUND To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

Reparación de prolapso mitral y miocardiopatía hipertrófica obstructiva

Resumen La mayoria de pacientes con miocardiopatia hipertrof ica presenta insuf iciencia mitral por el desplazamiento sistolico anterior del velo mitral anterior. En la mayoria de casos, la miectomia septal aislada soluciona tanto la obstruccion del tracto de salida del ventriculo izquierdo, como la insuficiencia mitral por movimiento sistolico anterior. Sin embargo, algunos pacientes presentan lesiones intrinsecas de la valvula que requieren reparacion concomitante. Presentamos el caso de un paciente joven con miocardiopatia hipertrofica obstructiva y prolapso del velo posterior mitral por rotura de cuerdas.

279. El derrame pericárdico postoperatorio en cirugía cardíaca: Incidencia e impacto en los resultados quirúrgicos

Objetivos El derrame pericardico (DP) es una complicacion (40–65%) que puede determinar taponamiento diferido letal. Determinamos la incidencia de DP grave en el postoperatorio de cirugia cardiaca. Material y metodos Estudio prospectivo de cohorte de pacientes consecutivos no seleccionados con intervenciones mayores de cirugia cardiaca. Se practico estudio ecocardiografico prealta. Se diagnostico DP por criterios de Horowitz en modo M. Para la ecocardiografia-2D se consideraron diagnosticos de taponamiento cardiaco: colapso diastolico precoz del ventriculo derecho, compresion de cavidades cardiacas, pletora de vena cava inferior y variaciones superiores al 30% del flujo mitral. Con independencia de los estudios intraoperatorios o en cuidados intensivos, se programo estudio prealta a partir del septimo dia postoperatorio. Las ecocardiografias se practicaron en el laboratorio de ecocardiografia. Si la condicion del paciente no lo permitio, el estudio se realizo en las unidades de hospitalizacion en los casos urgentes. Se usaron los ecografos Vivid i/Vivid 7 (General Electric, Fairfield, CT). Todos los estudios fueron supervisados por los ecocardiografistas expertos del servicio de cardiologia. Resultados De noviembre de 2009 – noviembre de 2011 se intervinieron 1.186 pacientes; 125 fueron trasladados precozmente a su hospital; 88 fallecieron sin estudio. De 973 pacientes, 53 (5,4%) presentaron DP grave o taponamiento por criterios clinicos/ecocardiograficos; 31/53 (58%) estaban asintomaticos. En 22/53 (42%) hubo sospecha clinica. Fueron reintervenidos 21 (40%). En 16 (30%) se administraron antiinflamatorios no esteroideos (AINE) y corticoides. La mortalidad fue 3,8% (2/53). Conclusion La ecocardiografia es una exploracion inocua que permite el diagnostico rapido de DP potencialmente letal, que tiene un componente medicolegal. Debe realizarse a todo postoperado de cirugia cardiaca.