Enrique Pérez de la Sota

Comentarios a la guía de práctica clínica de la ESC sobre diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica 2012. Un informe del Grupo de Trabajo del Comité de Guías de Práctica Clínica de la Sociedad Española de Cardiología

El Comite de Guias de Practica Clinica de la SEC formo un grupo de trabajo integrado por cardiologos clinicos, electrofisiologos, cirujanos cardiacos y personal de enfermeria, expertos en los diversos aparta-dos de la IC que cubre la guia de la ESC, propuestos por la Seccion de Insuficiencia Cardiaca y Trasplante y el Grupo de Trabajo sobre Resin-cronizacion Cardiaca de la SEC y por la Asociacion Espanola de Enfer-meria Cardiovascular, con el objetivo general de revisar las evidencias y recomendaciones aportadas por la guia europea sobre IC antes citada

Cirugía de preservación valvular en 120 pacientes con aneurismas de la raíz aórtica

INTRODUCTION AND OBJECTIVES Several aortic valve sparing techniques have been described for the treatment of aortic root aneurysms. We report our experience using the reimplantation technique in 120 patients. METHODS Between March 2004 and October 2010, 120 patients with aortic root aneurysms underwent David operations. Of these, 51 were diagnosed with Marfan syndrome. Mean patient age was 31 ± 12 years. The mean diameter of the sinuses of Valsalva was 51 ± 5 mm and moderate/severe aortic regurgitation was present in 16% of these patients. In the other 69 patients mean age was 56 ± 14 years, the mean diameter of the sinuses of Valsalva was 53 ± 7 mm and moderate/severe aortic regurgitation was present in 66%. A bicuspid aortic valve was presented in 14 cases. RESULTS Hospital mortality was 1.7%. Mean follow-up was 37 ± 21 months; 94% of the patients survived and 96% had an aortic regurgitation below grade II during 5 years of follow-up. One patient required re-operation because of severe aortic regurgitation. No endocarditis or thromboembolic complications have been documented, and 96% of the patients did not receive any anticoagulation therapy. CONCLUSIONS Short- and mid-term results with the reimplantation technique for aortic root aneurysms are excellent. This technique prevents the need for chronic anticoagulation treatment as well as the complications arising from mechanical prostheses, and it should be the treatment of choice for young patients.

Registro de Asistencia Circulatoria y Respiratoria: 1.er informe (2007–2010) del Grupo de Trabajo de Asistencia Mecánica Circulatoria de la Sociedad Española de Cirugía Torácica-Cardiovascular

Se presenta el Registro de Asistencia Circulatoria y Respiratoria de la SECTCV. Desde su inicio en 2007 y hasta diciembre de 2010 se han recogido los datos de forma anual y prospectiva, habiendo participado 15 centros con un total de 246 casos. Los objetivos mayoritarios fueron la recuperacion ventricular (54%) y el puente a trasplante (44%), y las principales indicaciones clinicas han sido poscardiotomia (59 casos), pretrasplante (57 casos) y postinfarto agudo (46 casos). La oxigenacion de membrana extracorporea (ECMO) ha sido el modo de asistencia mas frecuente, y las bombas centrifugas el tipo de dispositivo mas habitual. El 56% de dispositivos pudieron retirarse por mejoria ventricular o trasplante. La morbilidad quirurgica (hemorragia, taponamiento) fue la mas frecuente, y un 35% de pacientes desarrollaron algun grado de insuficiencia renal durante la asistencia. La mortalidad hospitalaria fue del 57% (140 pacientes, 108 de ellos con el dispositivo); la tasa de altas tras recuperacion ventricular fue del 71% y la de alta despues del trasplante del 80%.

Experiencia inicial con la preservación de la válvula aórtica en el síndrome de Marfan

Introduccion y objetivos La preservacion de la valvula aortica nativa descrita por David ha demostrado ser igual de eficaz que la tecnica de Bentall-Bono, pero ademas evita la anticoagulacion cronica y las complicaciones de las protesis mecanicas. Presentamos nuestra experiencia inicial con esta tecnica en pacientes con sindrome de Marfan. Metodos Desde abril de 2004 hasta abril de 2006 se ha realizado la tecnica de David en 40 pacientes con aneurisma de raiz de aorta. Dieciocho pacientes tenian sindrome de Marfan, con una mediana de edad de 29 anos (intervalo, 13-55 anos). En el estudio ecocardiografico, la mediana del diametro de los senos de Valsalva fue de 53 mm (intervalo, 46-59 mm). Resultados En 17 pacientes se pudo preservar la valvula aortica. No hubo mortalidad hospitalaria ni ninguna complicacion resenable. En el estudio ecocardiografico previo al alta ningun paciente mostro una insuficiencia aortica mayor de grado II. La mediana de seguimiento es de 8 meses (intervalo, 1-24 meses) y se ha producido una muerte por rotura de un aneurisma abdominal. El resto de los pacientes estan en clase funcional I. Conclusiones La preservacion de la valvula aortica mediante reimplante valvular ha mostrado unos resultados excelentes. Evita las complicaciones tromboembolicas y hemorragicas derivadas de las protesis y de la anticoagulacion cronica. Si la valvula aortica reimplantada mantiene una funcionalidad adecuada a largo plazo, deberia convertirse en la tecnica de eleccion en la cirugia de los aneurismas de aorta ascendente en el sindrome de Marfan.

Off-pump surgery in preventing perioperative stroke after coronary artery bypass grafting: a retrospective multicentre study

OBJECTIVES To determine the effect of the off-pump technique in preventing stroke development during the early perioperative period after coronary artery bypass graft surgery (CABG). METHODS Patients undergoing isolated CABG surgery were enrolled from 21 Spanish cardiac-surgery centres. Baseline variables related to perioperative stroke risk were recorded in the preoperative (age, gender, diabetes mellitus, arterial hypertension, prior stroke, cardiac failure: preoperative New York Heart Association class III-IV and/or left ventricular ejection fraction <40%, non-elective priority of surgery, peripheral arteriopathy, chronic renal failure) and intraoperative periods (on/off-pump performance). The Northern New England Cardiovascular Disease Study Group (NNECDSG) stroke risk schema was used to stratify stroke risk and compare observed neurological outcomes in this study. RESULTS A total of 26 347 patients were included in the study. Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (OR = 2.37), peripheral arteriopathy (OR = 1.62), cardiac failure (OR = 2.98), prior stroke (OR = 1.57) and chronic renal failure (OR = 6.16) were found to be independent risk factors for perioperative stroke in uni- and multivariate models; Hosmer-Lemeshow test: χ(2) = 4.62, P = 0.59. Perioperative stroke incidence increased whenever NNECDSG score or the number of preoperative risk factors increased. However, on- vs off-pump surgery did not show statistical differences in NNECDSG strata. For patients with two or more preoperative independent risk factors, off-pump surgery showed a significant reduction in perioperative stroke incidence (4.29 vs 6.76%, P < 0.05), particularly when one of these factors was chronic renal failure or preoperative cardiac failure. However, when both factors were present concomitantly there was no difference between on and off-pump techniques, P < 0.0001. CONCLUSIONS Off-pump surgery has a lower perioperative stroke incidence than on-pump only in cases associated with cardiovascular stroke-risk factors, in particular, with chronic renal failure and preoperative cardiac failure, but also with peripheral arteriopathy, prior stroke and non-elective surgery. The perioperative stroke rate remains high in cases with two or more preoperative stroke risk factors, even when using the off-pump technique, particularly when chronic renal failure is present.

Insuficiencia cardiaca y trasplante

The mission of the Heart Failure and Heart Transplantation Section of the Spanish Society of Cardiology is to study, promote interest in, and disseminate information about all aspects of myocardial dysfunction and heart transplantation. Heart failure is a highly prevalent disorder that consumes a substantial proportion of healthcare resources. Consequently, there is a very high level of interest in the condition and a wide range of preclinical and clinical research is being carried out, including research into new ways of looking at the disease that will increase our understanding. The aim of this article was to describe current developments concerning this disease and its treatment. Firstly, the latest publications on heart failure are summarized. Then, the most recent studies on advanced heart failure and ventricular assist devices are reviewed. Finally, the latest findings on heart transplantation are reported.

A multicentre Spanish study for multivariate prediction of perioperative in-hospital cerebrovascular accident after coronary bypass surgery: the PACK2 score

OBJECTIVES To develop a multivariate predictive risk score of perioperative in-hospital stroke after coronary artery bypass grafting (CABG) surgery. METHOD A total of 26 347 patients were enrolled from 21 Spanish hospital databases. Logistic regression analysis was used to predict the risk of perioperative stroke (ictus or transient ischaemic attack). The predictive scale was developed from a training set of data and validated by an independent test set, both selected randomly. The assessment of the accuracy of prediction was related to the area under the ROC curve. The variables considered were: preoperative (age, gender, diabetes mellitus, arterial hypertension, previous stroke, cardiac failure and/or left ventricular ejection fraction<40%, non-elective priority of surgery, extracardiac arteriopathy, chronic kidney failure and/or creatininemia≥2 mg/dl and atrial fibrillation) and intraoperative (on/off-pump). RESULTS Global perioperative stroke incidence was 1.38%. Non-elective priority of surgery (priority; OR=2.32), vascular disease (arteriopathy; OR=1.37), cardiac failure (cardiac; OR=3.64) and chronic kidney failure (kidney; OR=6.78) were found to be independent risk factors for perioperative stroke in uni- and multivariate models in the training set of data; P<0.0001; AUC=0.77, 95% CI 0.73-0.82. The PACK2 stroke CABG score was established with 1 point for each item, except for chronic kidney failure with 2 points (range 0-5 points); AUC=0.76, 95% CI 0.72-0.80. In patients with PACK2 score≥2 points, off-pump reduced perioperative stoke incidence by 2.3% when compared with on-pump CABG. CONCLUSIONS PACK2 risk scale shows good predictive accuracy in the data analysed and could be useful in clinical practice for decision making and patient selection.

Concepto, historia y métodos de asistencia ventricular

Los dispositivos de asistencia ventricular se han disenado para el tratamiento de diversas situaciones que comprometen la vida del paciente siempre en el contexto de una disfuncion ventricular grave, bien sea de forma aguda en el shock cardiogenico o de forma cronica en la insuficiencia cardiaca refractaria. Se trata de aparatos muy diferentes entre si en cuanto al diseno, modo de funcionamiento, durabilidad, tecnica y lugar de implantacion o coste, por lo que su analisis aqui sera necesariamente parcial y esquematico y se dara simplemente una vision global. En el presente trabajo se abordan aspectos generales de la asistencia ventricular como su definicion, la fisiopatologia o los distintos metodos posibles asi como un breve recuerdo historico sobre la asistencia circulatoria.

Left ventricular–coronary sinus/right ventricular fistula late after mitral valve replacement

Development of an intracardiac fistula is a rare complication after mitral valve replacement. In the literature we have found six cases of left ventricular-coronary sinus fistula and another one of left ventricular-coronary sinus and right atrial fistula. We report the history and course of a patient in whom a left ventricular-coronary sinus and right ventricular fistula developed late after mitral valve replacement. The current study examines this type of intracardiac shunt, and presents our report on a left ventricular-coronary sinus and right ventricular fistula complication.

Resultados precoces de la ventriculectomía parcial izquierda (operación de Batista)

Introduccion y objetivos La escasez de donantes asi como la morbimortalidad asociada al trasplante han motivado el planteamiento de otras opciones quirurgicas para la miocardiopatia dilatada en fase terminal. Entre ellas se encuentra la ventriculectomia parcial izquierda, que implica la reduccion del diametro y la masa ventricular. Presentamos en este trabajo la experiencia inicial (no limitada a la alternativa al trasplante) y los resultados inmediatos de esta tecnica en nuestro centro. Metodos Hemos intervenido a 6 pacientes con miocardiopatia dilatada: cuatro de etiologia idiopatica y con motivos de exclusion para trasplante cardiaco y dos de origen valvular. Se practico reseccion de la pared lateral de ventriculo izquierdo entre los musculos papilares y cierre directo con sutura continua, asociandose anuloplastia mitral en 5 casos, tricuspidea en uno y sustitucion valvular aortica en los dos ultimos. Resultados Dos pacientes precisaron balon de contrapulsacion; uno fallecio por shock cardiogenico refractario y el otro a los 15 dias tras episodios de arritmia ventricular. Los estudios ecocardiograficos intraoperatorios pusieron de manifiesto una reduccion significativa del diametro diastolico (de 8,7 a 6,8 cm; p = 0,02) y de la insuficiencia mitral, con una mejoria en la fraccion de eyeccion (del 17 al 27%; p = 0,09) mantenidos en el ecocardiograma previo al alta. Conclusiones La tecnica es reproducible y adecuada como posibilidad terapeutica en la insuficiencia cardiaca en fase terminal. Quedan por precisar el grupo y tipo de paciente ideal, el manejo perioperatorio y el soporte a largo plazo.