Irarrázaval Mj

Revascularización miocárdica de la arteria descendente anterior con anastomosis mamaria con técnica clásica

Introduccion y objetivos Establecer los resultados obtenidos con la tecnica clasica de anastomosis de la arteria descendente anterior. Material y metodos Entre enero de 1982 y julio de 1997, 154 pacientes fueron sometidos a cirugia de revascularizacion de la arteria descendente anterior con mamaria usando tecnica clasica (esternotomia y circulacion extracorporea). Resultados En nuestro grupo no hubo mortalidad, infarto perioperatorio ni accidente vascular encefalico. Un paciente (0,6%) tuvo infeccion de la herida esternal y otro (0,6%) presento sangrado postoperatorio que requirio reoperacion. Se obtuvo un 100% de seguimiento entre 3 y 183 meses (promedio, 64,4 meses). La supervivencia actuarial global a los 5, 10 y 15 anos fue del 95,6 ± 2,1%; 92,1 ± 4% y 85,5 ± 7,5%, respectivamente, y la probabilidad actuarial de estar libre de muerte cardiaca fue de 99 ± 0,9%; 99% y 99%. La probabilidad actuarial de estar libre de infarto a los 5, 10 y 15 anos fue de 99 ± 0,9%, 99% ± 0,9% y 99%, y la de estar libre de angina del 95 ± 2,2%; 86,9 ± 4,9% y 74,5 ± 12,2%. Finalmente, la probabilidad actuarial de estar libre de reoperacion y de angioplastia a los 5, 10 y 15 anos fue del 99 ± 0,9%, 99%, 99% y 96,9 ± 1,7%, 91,4 ± 4.1% y 91,4 ± 4,1%, respectivamente. La cuenta hospitalaria promedio en el ultimo 10% de este grupo fue 199,8 UF (6.200 dolares). Conclusion La revascularizacion miocardica a la descendente anterior con arteria mamaria unica, con tecnica clasica, es un procedimiento seguro, de minimo riesgo, de bajo coste y de excelentes resultados a los 10 y 15 anos

Morbimortalidad precoz y alejada del reemplazo valvular aórtico con prótesis mecánica y biológica durante la última década: El estándar de oro

BACKGROUND There is a growing interest in alternative techniques for aortic valve replacement (AVR). Therefore it is important to have updated results of conventional AYR as a valid comparative standard. AIM To evaluate both perioperative and late morbidity and mortality in patients undergoing conventional AVR, with either mechanical (RVAm) or biological (RVAb) prostheses. PATIENTS AND METHODS Retrospective review of medical records and operative protocols of patients undergoing AVR between January 1995 and December 2005. Patients with previous cardiac surgery, aortic balloonplasty or simultaneous cardiovascular procedures were excluded. RESULTS During the study period, 788 patients underwent AVR and 317 met the inclusion criteria. Of the latter, 175 patients aged 13 to 83 years (63% males) were subjected to AVRm and 142 patients aged 49 to 87 years (64% males), were subjected to AVRb. Five (1.6%) patients died during the perioperative period (one AVRm and four AVRb). All were older than 65 years. Perioperative complications were recorded in 29 and 25% of patients in AVRm and AVRb groups, respectively (NS). During a median follow-up of six years, complications were recorded in 12 and 4% of patients in AVRm and AVRb groups, respectively (p <0.05). The actuarial survival for AVRm group at 1, 5 and 10 years, was 96, 92 and 87%, respectively. The figures for AVRb group were 95, 86 and 83%, respectively (NS). The 10 year reintervention free survival was 97% for the AVRm group and 84% for the AVRb (p <0.05). CONCLUSIONS Perioperative mortality and rates of complications of AVR in this series of patients are low, which compares favorably with other series.

Cirugía coronaria en el infarto de miocardio de menos de 24 horas de evolución

Background. Thrombolysis and angioplasty in the first hours after myocardial infarction minimize necrosis, leading to better early and late survival, but these therapies have limited effect in patients with three-vessel disease and cardiogenic shock. Emergency coronary surgery is an alternative treatment in some cases. Aim. To assess perioperative complications, mortality and long-term survival in patients undergoing coronary surgery within 24 h of myocardial infarction. Patients and methods. We retrospectively studied 57 patients undergoing surgery within 24 h of the onset of symptoms of myocardial infarction between 1982 and 1998. Multiple vessel disease was present in 31 patients (54%), shock or cardiac arrest in 19 (33%) and coronary angiography complications in 7 (12%). The mean time between onset of symptoms and surgery was 6.32 h. At the beginning of surgery 32 patients (56%) were hemodynamically stable, 15 (26%) were in shock and 10 (17%) were in cardiac arrest. Results. The operative mortality was 0% for those who were hemodynamically stable at the start of surgery and 44% (11 of 25 patients) for those in shock or cardiac arrest. Shock or prior cardiac arrest were associated with higher rates of sternal infection and heart failure and longer hospital stays. Follow-up (mean 67 months) was possible for all remaining patients. The 5- and 10-year survival rates were 89 and 82%, respectively, for patients who were hemodynamically stable at the time of surgery. Five-year survival was 55%, however, for those who underwent surgery in shock or cardiac arrest. The overall rate of freedom from myocardial infarction, angioplasty or reoperation was over 95% at 5 years and over 85% at 10 years of follow-up. Age and shock or cardiac arrest were risk factors for a poor long-term outcome. Conclusion. The early and long-term outcome of coronary surgery within 24 h of myocardial infarction is good for patients who are hemodynamically stable when surgery begins. Shock and cardiac arrest are important risk factors for complication and death. Coronary artery bypass grafting is a good treatment option in the first hours after myocardial infarction.

Cirugía de la comunicación interventricular post infarto: análisis de los últimos 22 años

Operamos 43 pacientes, edad prome-dio de 66,6 ± 10,2 anos. El 58% eran hombres, de menor edad que las mujeres (63,1 ± 10,8 vs 71,5 ± 6,9 anos, p=0,006). El tiempo promedio entre el diagnostico de infarto y de CIVPI fue 10 ± 15 dias. El 74% fueron in-tervenidos de urgencia. La CIVPI fue anterior en 58%. Se realizo revascularizacion miocardica concomitante en el 58%. Trece pacientes fallecieron (30%) en el posope-ratorio. Factores de riesgo de mortalidad operatoria fue-ron: cirugia de urgencia ( p = 0,019]) y uso de balon intra aortico (p = 0,006). La cirugia realizada despues de las 24 horas del diagnostico tuvo una mortalidad significa-tivamente menor (7,7%, p=0,033). El seguimiento pro-medio fue de 8,36 ± 5,3 anos. La supervivencia alejada, excluida la mortalidad operatoria, a 5 y 10 anos, fue 93% y 71%, respectivamente.

Influencia del Sistema de Salud de procedencia y otros factores en el resultado del reemplazo valvular mitral.

BACKGROUND There is no consensus regarding which risk factors influence the outcome of mitral valve replacement. AIM To study the effects of the referring health care system and other factors on the results of mitral replacement. PATIENTS AND METHODS We included 632 patients operated between 1990 and 2010 receiving the St Jude prosthesis. Patients were divided into three groups, group 1 composed by 180 patients coming from the Public System, group 2 composed by 182 patients coming from the University System and group 3 composed by 270 patients coming from the Private System. RESULTS Overall operative mortality was 4.3%. There was no difference between groups in mortality. Factors responsible for operative mortality were: emergency operation (Odds Patio (OR): 5.6 P < 0.01) and left ventricular function (according to ejection fraction) grade III to IV (OR: 2.5 p = 0.048). Actuarial survival rates at 1, 5, 10, 15 and 20 years were 95%, 87%, 76%, 61% and 41%, respectively. Risk factors for long-term mortality were diabetes (OR: 3.3 p < 0.01), left ventricular function grades III-IV (OR: 2.6 p < 0.01), New York Heart Association functional class III to PV (OR: 2.1 p < 0.005) and male sex (OR: 1.5 p < 0.032). CONCLUSIONS Referring health care system and type of surgery do not constitute a risk factor for mitral replacement. Risk factors were: emergency surgery, ventricular function grades III-IV, diabetes, functional capacity class III-IV and male sex. Integration of public and private health care systems in a university hospital setting achieves excellent outcomes for complex pathology.

Reducción de incidencia de neumonía asociada a ventilación mecánica post cirugía cardíaca: experiencia de 13 años de vigilancia epidemiológica en un hospital universitario

OBJECTIVES To report the results of 13 years worth of epidemiologic surveillance of ventilator-associated pneumonia (VAP) following heart surgery and the main interventions applied in order to reduce VAP incidence. METHODS This is a retrospective and descriptive study of active epidemiologic surveillance of VAP. National diagnostic criteria were used. Interventions associated with a decrease in VAlP incidence in adults who underwent heart surgery are described. RESULTS A significant and sustained reduction was observed in the rate of VAP; being 56.7 per 1,000 ventilator-days in 1998 vs 4.7 per 1,000 ventilator-days in 2010 (p < 0.001). The strongest reduction was observed following 2003 (34.4 to 14.8 per 1,000 ventilator-days in 2004, p < 0.001). The interventions with greatest impact were the implementation of an early-weaning protocol, the introduction of trained nurses to perform the mechanical ventilator equipment management and the routine use of alcohol-based hand rubs. CONCLUSION Epidemiologic surveillance associated with the establishment of a multifactorial intervention program applied in collaboration with the attending team, have demonstrated a significant reduction of VAP incidence after heart surgery.