Guillermina Fita

Adverse reactions to vancomycin prophylaxis in cardiac surgery

Several adverse effects of vancomycin have been reported. The aim of this study was to assess the incidence of adverse responses to antibiotic prophylaxis with vancomycin in cardiac surgical patients. Prospectively, 116 consecutive patients (106 adults and 10 children) undergoing cardiac surgical procedures in this institution from January to June 1990 were studied. After the anesthetic induction, vancomycin, 1 g in adults and 10 mg/kg in children, was intravenously administered over 30 minutes. The infusion rate was slowed if any adverse effect was observed. As a control group, 10 similar patients were evaluated during the same period of 30 minutes after anesthetic induction but prior to vancomycin administration and surgical stimulation. Thirty-one patients (26.72%) developed an adverse effect, mainly hypotension (29 patients, 25%), which was considered severe in 15 patients (12.93%). Seven patients (6.03%) developed a maculopapular erythema that was associated with hypotension (Red-Mans syndrome) in 5 patients and with bronchospasm in 1 patient. The incidence of adverse reactions in children (20%) was similar to the overall incidence. Only 1 patient in the control group (10%) developed hypotension during the period studied. The incidence of adverse reactions was not related to age, body weight, vancomycin dose administered per kilogram body weight, type of surgical procedure, or associated disease. Mean duration of the infusion was similar in patients with and without adverse responses (34.60 +/- 12.41 minutes and 37.38 +/- 14.55 minutes, respectively). It is concluded that perioperative prophylaxis with vancomycin in cardiac surgery produces a high and unpredictable risk of significant hypotension.

Infarct transmurality as a criterion for first-line endo-epicardial substrate–guided ventricular tachycardia ablation in ischemic cardiomyopathy

BACKGROUND There is no consensus on the appropriate indications for the epicardial approach in substrate ablation of post-myocardial infarction (MI) ventricular tachycardia (VT). OBJECTIVE The purpose of this study was to investigate whether infarct transmurality (IT) could identify patients who would benefit from a combined first-line endo-epicardial approach. METHODS Before ablation, IT was assessed by contrast-enhanced cardiac magnetic resonance imaging (hyperenhancement ≥75% of the wall thickness in ≥1 segment), echocardiography (dyskinesia/akinesia + hyperrefringency + wall thinning), computed tomography (wall thinning), or scintigraphy (transmural necrosis). Prospectively from January 2011, an endocardial approach was used in patients with subendocardial MI (group 1) and a combined endo-epicardial approach in patients with transmural MI (group 2). Outcomes in both groups were compared with those in patients with transmural MI and only endocardial approach due to previous cardiac surgery or procedure performed before January 2011 (group 3). The primary end point was VT/ventricular fibrillation recurrence-free survival. RESULTS Ninety patients (92.2% men; mean age 67.4 ± 9.8 years) undergoing VT substrate ablation were included: group 1, n = 34; group 2, n = 24; group 3, n = 32. During a mean follow-up duration of 22.5 ± 13.7 months, 5 patients in group 1 (14.7%), 3 patients in group 2 (12.5%), and 13 patients in group 3 (40.6%) had VT recurrences (P = .011). Time to recurrence was the shortest in group 3 (log-rank, P = .018). The endocardial approach in patients with transmural MI was associated with an increased risk of recurrence (hazard ratio 4.01; 95% confidence interval 1.41-11.3; P = .009). CONCLUSION The endocardial approach in patients with transmural MI undergoing VT substrate ablation is associated with an increased risk of recurrence. IT may be a useful criterion for the selection of a first-line combined endo-epicardial approach.

Transoesophageal echocardiography accurately detects cardiac output variation: a prospective comparison with thermodilution in cardiac surgery

Background and objective: Intraoperative Doppler ultrasound can be used to measure cardiac output by transoesophageal echocardiography. Recently, its reliability, when compared to the thermodilution technique, has been questioned. The purpose of this study was to compare intraoperative changes in cardiac output measured by echo‐Doppler and by thermodilution in cardiac surgery. We also assessed the agreement between the techniques. Methods: Fifty cardiac surgical patients (38 male, 12 female, mean age of 63.4 ± 14.3 yr) were prospectively included after approval by the Ethics Committee of the Institution. Cardiac output was assessed by thermodilution, with 10 mL saline at 12°C, and simultaneously and blindly by echo‐Doppler in deep transgastric view with pulsed wave Doppler at the level of the left ventricular outflow tract. Matched thermodilution cardiac output and echo‐Doppler cardiac output measurements were taken three times at the end of expiration, both pre‐ and post‐cardiopulmonary bypass. Results: Echo‐Doppler measurements were obtained in 44 patients (88%). In three patients, Doppler recordings could not be obtained adequately, and three developed left ventricular outflow tract obstruction after bypass. Bland‐Altman analysis revealed a bias of 0.015 L min−1, with narrow limits of agreement (−1.21 to 1.22 L min−1) and 29.1% error. Echo‐Doppler was accurate (92% sensitivity and 71% specificity, P = 0.008 by receiver operating characteristic curves) for detecting more than 10% of change in thermodilution cardiac output. There were no complications related to the study. Conclusions: The agreement between cardiac output by echo‐Doppler and by thermodilution is clinically acceptable and transoesophageal echocardiography is a reliable tool to assess significant cardiac output changes in a population of selected patients.

Complicaciones graves de tipo mecánico asociadas al catéter de arteria pulmonar en cirugía cardiovascular y torácica

Resumen Objetivos A pesar de la discusion sobre la utilidad del cateter de arteria pulmonar (CAP) en el manejo del paciente critico, se sigue utilizando frecuentemente y es conveniente tener en cuenta tambien sus posibles complicaciones. El objetivo del estudio es revisar las complicaciones mecanicas graves o potencialmente graves asociadas a CAP ocurridos en nuestro centro en los ultimos 15 anos. Pacientes y metodos Se ha realizado un estudio observacional retrospectivo sobre los pacientes sometidos a cirugia vascular, cardiaca y toracica en los que se coloco un CAP, considerandose las complicaciones graves de origen mecanico. Resultados Se incluyeron 7.540 pacientes, detectandose nueve casos de complicaciones graves entre los que se incluyen cinco rupturas de arteria pulmonar, tres de ellas con resultado de muerte; una perforacion de vena mamaria interna; un nudo; un acodamiento y un atrapamiento del cateter en la sutura quirurgica. Conclusiones Esto supone una incidencia de 0,12%, menor a la publicada. Aunque la frecuencia de estas complicaciones es baja, su aparicion inesperada obliga a estar alerta ante su posible aparicion, con una cuidadosa seleccion de los pacientes en que se emplea el CAP y especial vigilancia de los signos clinicos y radiologicos caracteristicos de complicaciones.

Platelet function during cardiac surgery and cardiopulmonary bypass with low-dose aprotinin☆

OBJECTIVE To determine whether two low-dose regimens of aprotinin influence platelet function. DESIGN Prospective, randomized, single-blinded trial. SETTING University teaching hospital performing 600 cardiac operations per year. PARTICIPANTS Fifty-nine patients scheduled for cardiac surgery undergoing cardiopulmonary bypass (CPB) of expected duration of 60 minutes or more. INTERVENTIONS Patients were randomized into three groups. Group C (control) included 21 patients who did not receive aprotinin. In group A2, 17 patients received 14,286 kallikrein inhibitor units (KIU)/kg (2 mg/kg) of aprotinin before surgery, followed by a continuous infusion of 7,143 KIU/kg/h (1 mg/kg/h) until the end of surgery. In group A4, 19 patients received 28,572 KIU/kg (4 mg/kg) of aprotinin before surgery, followed by the same infusion. MEASUREMENTS AND MAIN RESULTS Postoperative bleeding and transfusion requirements were significantly less in group A4. Changes in platelet number and function were similar in the three groups. Platelet aggregation was assessed in four periods: before CPB (T1), post-CPB (T2), and 2 hours (T3) and 4 hours (T4) after CPB. Platelet aggregation induced by adenosine diphosphate, 1 and 2 micromol/L; ristocetin, 1 mg/mL; and arachadonic acid (AA), 1.4 mmol/L, decreased at T2 (p < 0.001) in all groups, and for the ristocetin and AA groups, remained at less than baseline values at T3 and T4. In five patients from each group, platelet receptors for glycoprotein IIb-IIIa (GPIIb-IIIa) and expression of platelet activation markers, guanosine monophosphate 140 (GMP-140) and lysosomal protein, were measured by flow cytometry before and after CPB. Modifications in the expression of GPIIb-IIIa were always modest and without statistical significance. Platelet activation markers, GMP-140 or lysosomal protein, nearly doubled from baseline to post-CPB only in the A4 group, whereas they remained stable in both other groups (statistically not significant). CONCLUSION The two regimens of aprotinin, both considered low dosage, did not exert a protective effect on platelet function. Neither dose produced changes in platelet GPIIb-IIIa or platelet activation markers. However, bleeding and transfusion needs were decreased.

Epidemiology, Clinical Features, and Outcome of Infective Endocarditis due to Abiotrophia Species and Granulicatella Species: Report of 76 Cases, 2000–2015

Background Infective endocarditis (IE) caused by Abiotrophia (ABI) and Granulicatella (GRA) species is poorly studied. This work aims to describe and compare the main features of ABI and GRA IE. Methods We performed a retrospective study of 12 IE institutional cases of GRA or ABI and of 64 cases published in the literature (overall, 38 ABI and 38 GRA IE cases). Results ABI/GRA IE represented 1.51% of IE cases in our institution between 2000 and 2015, compared to 0.88% of HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella)-related IE and 16.62% of Viridans group streptococci (VGS) IE. Institutional ABI/GRA IE case characteristics were comparable to that of VGS, but periannular complications were more frequent (P = .008). Congenital heart disease was reported in 4 (10.5%) ABI and in 11 (28.9%) GRA cases (P = .04). Mitral valve was more frequently involved in ABI than in GRA (P < .001). Patient sex, prosthetic IE, aortic involvement, penicillin susceptibility, and surgical treatment were comparable between the genera. New-onset heart failure was the most frequent complication without genera differences (P = .21). Five (13.2%) ABI patients and 2 (5.3%) GRA patients died (P = .23). Factors associated with higher mortality were age (P = .02) and new-onset heart failure (P = .02). The genus (GRA vs ABI) was not associated with higher mortality (P = .23). Conclusions GRA/ABI IE was more prevalent than HACEK IE and approximately one-tenth as prevalent as VGS; periannular complications were more frequent. GRA and ABI genera IE presented similar clinical features and outcomes. Overall mortality was low, and related to age and development of heart failure.

Role of Echocardiogram in Decision Making for Surgery in Endocarditis

Infective endocarditis is a serious disease that carries significant morbidity and mortality. Adequate treatment is based on a high degree of clinical suspicion, accurate microbiologic diagnosis, and high-quality imaging. Echocardiography has been shown to be a fundamental tool for diagnosis and management. Currently accepted Duke criteria include blood cultures and echocardiography. Transthoracic and transesophageal echocardiography play a critical role in the decision-making process, especially when surgical treatment is contemplated. Because infective endocarditis is considered a medical and surgical disease, and considering that the current rate of surgery is about 50%, echocardiography has definite value in preoperative diagnosis and surgical planning, intraoperative confirmation of lesions and quality of repair or replacement before and after cardiopulmonary bypass, and postoperative assessment.

Disfunción cognitiva después de cirugía cardiaca: Saturación cerebral e índice biespectral: estudio longitudinal

: Prospective study in patients undergoing elective cardiac surgery with cardiopulmonary bypass. A comprehensive neuropsychological assessment was applied preoperatively and 3 months after surgery. Postoperative dysfunction was defi ned as a decrease of at least one standard deviation in two or more neuropsychological tests. Cerebral oxygenation and bispectral index were continuously recorded and corrected throughout surgery. Cerebral oxygenation data were analyzed by the mean value and at three thresholds: 50%, 40% and < 25% of the basal value. Bispectral index was analyzed at threshold of 45.

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.

Twenty-year experience with cryopreserved arterial allografts for vascular infections†

OBJECTIVES The aim of this study was to analyse outcomes over 2 decades using cryopreserved vascular allografts to treat vascular infection. METHODS We conducted a retrospective study of patients identified from our institutional database who were treated for primary or secondary vascular infection using implanted allografts. RESULTS Between October 1992 and May 2014, 54 patients underwent surgery for vascular infection out of 118 patients implanted with cryopreserved vascular allografts. The 52 patients for whom we had full information form the basis of the study with a 96% follow-up. The average age was 64 ± 11 years; 87% were men; 65% had previous vascular surgery; 19% had emergency operations. A total of 75% of the patients had aortoiliofemoral infections. Five patients underwent surgery with cardiopulmonary bypass. Fifty percent required more than 1 allograft and 15% had concomitant procedures. Seventy-three percent (38/52) of specimen cultures yielded positive results with polymicrobial flora in 29%. Surgical specimens most frequently grew coagulase-negative staphylococci. The early postoperative reoperation rate was 15% for allograft-related complications. There were 20 (38%) early deaths, including deaths of acute myocardial infarction, anastomosis rupture and persistent sepsis and shock. Uncontrolled infection leading to septic shock and multiple organ failure was the cause of death in 50% of the cases. The mean duration of freedom from allograft reintervention was 12.2 years. The mean duration of freedom from allograft occlusion or limb loss was 12.1 years [95% confidence interval (CI) 9.9-14.4]. Of the 32 surviving patients, we had patency information for 66% obtained by angiography or computed tomography. The mean survival for the cohort was 5.9 years (95% CI 3.9-7.8). Mean freedom from cardiovascular infection-related death was 9.3 years (95% CI 7.2-11.4). CONCLUSIONS Allografts can be indicated for treatment of primary/secondary infection and have remarkable results in multimorbid patients. Patients with vascular infection have a high-risk profile, around 40% mortality during the first 6 months, with reduction in overall mortality thereafter. We believe that allografts may play a role in the surgical treatment of vascular infection.