J.R. Echevarría

Impact of preoperative anemia on cardiac surgery in octogenarians

OBJECTIVES Preoperative anemia has been related with adverse outcomes in elective valve replacement and CABG surgery. Impact of preoperative anemia on outcome in octogenarians submitted to cardiopulmonary bypass (CPB) has not yet been precisely described. METHODS We analyzed association between preoperative hemoglobin level, minimum intraoperative and immediate postoperative hematocrit (HCT), and other co-morbidities and occurrence of adverse outcomes in 227 octogenarians who underwent cardiac surgery. RESULTS Frequency of preoperative anemia was 41.9% (40.4% in male and 43.5% in female patients). Postoperative mortality was 13.2% (9% in non-anemic patients vs. 18.9% in anemic). 44.5% of patients suffered at least one postoperative adverse outcome (43.1% non-anemic vs. 46.3% anemic). In multivariate analysis (after adjusting independent preoperative risk factors for operative mortality and EuroSCORE) preoperative creatinine level [odds ratio (OR), 2.29; 95% confidence interval (CI), 1.06-4.98; P=0.035], immediate postoperative HCT <24% (OR, 2.78; 95% CI, 1.04-7.38; P=0.039), perioperative red blood cell (RBC) transfusion (OR, 1.58; 95% CI, 1.24-2.00; P=0.0001), peripheral vascular disease (OR, 4.92; 95% CI, 1.45-16.69; P=0.012) and urgent surgery (OR, 10.57; 95% CI, 2.54-43.91; P=0.0001) were identified as independent predictors for in-hospital mortality. CONCLUSIONS Mortality and adverse postoperative outcome increase in anemic octogenarians undergoing cardiac surgery. Although mortality is directly related to immediate postoperative anemia, adverse outcomes mainly depend on associated co-morbidities.

Cardiac Surgery With Extracorporeal Circulation in Cancer Patients: Influence on Surgical Morbidity and Mortality, and on Survival

INTRODUCTION AND OBJECTIVES Morbimortality related to cardiac surgery may be superior in patients with malignant neoplastic disease. Inflammatory phenomena and immunologic changes secondary to extracorporeal circulation use can also increase tumor recurrence. We evaluate characteristics and results of cardiac surgery in our neoplastic patients. METHODS Out of 2146 consecutive patients who underwent cardiac surgery with extracorporeal circulation, 89 (4.2%) had been previously affected by cancer. Cancer was active (recent diagnosis or under treatment) in 33 patients (group A) and 56 (group B) were in remission. Both groups were matched with 165 patients with no tumor, according to age, gender, type of surgery, and comorbidity (group C). We retrospectively evaluated incremental risk factors for surgical morbimortality, survival and tumor recurrence. RESULTS Median interval between cancer diagnosis and surgery was 60 months and mortality and morbidity were 4.5% and 36%, respectively, vs 5,4% and 32,7% in group C. During follow-up, 12 patients died (8 due to cancer), 16 suffered cancer recurrence and 2 new tumors were diagnosed. Statistical analysis did not permit us to identify any incremental risk factor for mortality. Postoperative morbidity was increased in case of preoperative renal failure. During follow-up, survival was significantly decreased in group A, in case of preoperative left ventricular dysfunction or pulmonary obstructive disease, and when interval between cancer diagnosis and cardiac surgery was under 2 years. CONCLUSIONS We have not observed an increase in cardiac surgery morbimortality in cancer patients. Anyway, survival is decreased in case of active or recently diagnosed cancer.

Cirugía cardiaca con circulación extracorpórea en pacientes oncológicos: influencia en la morbimortalidad quirúrgica y la supervivencia

Introduccion y objetivos La morbimortalidad de la cirugia cardiaca parece ser mayor en los pacientes neoplasicos. Los fenomenos inflamatorios y las reacciones inmunitarias secundarias a la circulacion extracorporea pueden favorecer la recidiva tumoral. Evaluamos las caracteristicas y los resultados de la cirugia cardiaca en nuestros pacientes oncologicos. Metodos De 2.146 pacientes consecutivos sometidos a circulacion extracorporea, 89 (4,2%) presentaban una neoplasia. El cancer estaba activo (recientemente diagnosticado o en tratamiento) en 33 pacientes (grupo A) y en remision completa en 56 (grupo B). Se pareo ambos grupos con 165 pacientes sin tumor similares en edad, sexo, tipo de cirugia y comorbilidad (grupo C). Evaluamos retrospectivamente los factores de riesgo de morbimortalidad quirurgica, supervivencia y recidiva tumoral. Resultados La mediana del intervalo entre diagnostico del cancer y cirugia fue de 60 meses, con mortalidad y morbilidad hospitalarias del 4,5 y el 36%, respectivamente, frente al 5,4 y el 32,7% en el grupo C. Durante el seguimiento, fallecieron 12 pacientes (8 por causa tumoral), 16 sufrieron recidiva y 2, tumores nuevos. El analisis estadistico no permitio identificar ningun factor de riesgo de mortalidad. La morbilidad postoperatoria aumento en pacientes con insuficiencia renal. Durante el seguimiento, la supervivencia disminuyo significativamente en el grupo A en caso de disfuncion ventricular izquierda preoperatoria y enfermedad pulmonar obstructiva cronica y cuando el intervalo entre diagnostico de cancer y cirugia fue Conclusiones No hemos observado un incremento en la morbimortalidad de la cirugia cardiaca en pacientes oncologicos. No obstante, la supervivencia disminuye en neoplasias activas o de diagnostico reciente.

Post-Traumatic Ventricular Septal Defect: From Clinical Suspicion to Treatment

Ventricular septal defect (VSD) following closed thoracic trauma is an unusual complication,1,2 that generally has a delayed diagnosis. We present the case of an 18-year-old male who suffered severe thoracic trauma with bilateral pleural effusion, lacerations of abdominal viscera and bone fractures following a road traffic accident. He was intubated for hypovolaemic shock and had multiple transfusions, required splenectomy, repair of liver lacerations and surgical re-exploration due to haemorrhage. Upon admission, no heart murmurs were detected, the electrocardiogram revealed sinus tachycardia with Q-waves in II, III, and aVF and the maximum troponin-T was 2.33 ng/mL. The initial creatine kinase (CK) (1017 U/L; CK-MB, 79 U/L) increased to a maximum of 2510 U/L (CK-MB, 65 U/L) 24 hours later. The transthoracic echocardiogram (TTE) revealed a contusion of the interventricular septum (IVS), slightly thickened from the middle third to the apex and a reduction in movement, a slightly dilated right ventricle, and a pulmonary artery pressure of 50 mm Hg. At 24 hours, a proto-mesosystolic murmur was heard at the left sternal border and haemodynamic instability, tachycardia, and the need for vasoactive drugs persisted. High oxygen saturation in the pulmonary artery (PA) led to the suspicion of a VSD, which was confirmed by TTE. Severe dilation of the right ventricle was seen with mild systolic dysfunction, the appearance of an apical pseudoaneurysm and a large irregular longitudinal VSD in the mid-distal portion of the IVS (Figure 1). He underwent urgent intervention, the mid-inferior apical septum had a linear VSD with irregular borders measuring 435 cm, which was closed with a Dacron patch (Figure 2). No other lesions were found except for the contusion of the apex of the heart. Subsequent progress was satisfactory. Only 5% of closed thoracic traumas are complicated with a VSD. Asymptomatic myocardial contusion with an increase in cardiac enzymes is more common.1,2 Two mechanisms cause rupture of the IVS: the increase in intrathoracic pressure that compresses the heart and the myocardial contusion, with direct cellular damage or a change in coronary blood-flow and a secondary myocardial infarction.1,3 Both mechanisms complement each other in our patient, in whom ischaemia was seen at admission and the apical myocardial contusion was seen during surgery. VSD following closed trauma usually affects the muscular septum,1,4,5 is located in the apex and is linear; occasionally there can be several.3,4 The diagnosis is usually delayed (between 12 h and 12 days)1,3,5 (in this case, it evolved in 2 phases: initially, from the myocardial contusion seen on the echocardiogram, and delayed, at 24 hours, due LETTERS TO THE EDITOR

Estudio de la reserva de perfusión miocárdica mediante tomografía de emisión de fotón único con talio-201 y estrés farmacológico con adenosina trifosfato en pacientes con factores de riesgo cardiovascular

Introduccion y objetivo Recientes estudios hansugerido que la valoracion de la reserva coronariade flujo es un metodo sensible de detectar precozmenteanomalias vasculares antes de la aparicionde lesiones arterioscleroticas angiograficamentevisibles. La tomografia de emision de foton unico(SPECT) con talio-201 (201Tl) permite la evaluacionno invasiva de la reserva de perfusion miocardica.El objetivo de este trabajo fue la utilizacionde este metodo para estudiar la reserva miocardicade dos grupos de sujetos sin cardiopatia isquemicaconocida, con y sin factores de riesgo cardiovasculary la de un grupo de pacientes con enfermedadcoronaria demostrada. Metodos El estudio se llevo a cabo en 74 individuosseleccionados de forma prospectiva y divididosen tres grupos: grupo control, formado por 11sujetos asintomaticos sin factores de riesgo cardiovascular;grupo con factores de riesgo cardiovascular,constituido por 49 pacientes, y grupo con enfermedadcoronaria, integrado por 14 pacientes. Elestudio de perfusion miocardica se realizo con201Tl, utilizando como test de provocacion farmacologicala adenosina trifosfato (ATP) en infusion.Se adquirio un estudio tomografico en reposo yotro tras 7 min de infusion con ATP (140mg/kg/min). Posteriormente se efectuo el procesadode estas imagenes y la cuantificacion de la perfusionmiocardica, calculandose la reserva de perfusionmiocardica, obtenida como el cociente entrelos valores de perfusion en estres y en reposo. Resultados Tanto la reserva de perfusion decada region como la global, como la de los territoriosde la arteria descendente anterior (DA), circunfleja(Cx) y coronaria derecha (CD) fueron significativamentemas bajas en los individuos confactores de riesgo cardiovascular que en los sujetosdel grupo control (global: 1,48 ± 0,19 frente a1,81 ± 0,08; DA: 1,52 ± 0,21 frente a 1,85 ± 0,09; Cx:1,45 ± 0,2 frente a 1,79 ± 0,86; CD: 1,47 ± 0,2 frentea 1,79 ± 0,86), y significativamente superiores a lasde los pacientes con enfermedad coronaria (global:1,48 ± 0,19 frente a 1,31 ± 0,14; DA: 1,52 ± 0,21frente a 1,35 ± 0,15; Cx: 1,45 ± 0,2 frente a 1,2 ±0,24). De todos los sujetos pertenecientes al grupo de factores de riesgo, 40 presentaban un perfil lipidicode alto riesgo. Dentro de este subgrupo, el analisisunivariado revelo una correlacion negativa, debilpero significativa, entre los valores de reservade perfusion miocardica y los valores de colesteroltotal (r = –0,35; p = 0,01), colesterol LDL (r =–0,38; p = 0,036) y cociente LDL/HDL (r = –0,39; p =0,029). Conclusion La determinacion de la reserva de perfusion miocardica mediante SPECT con 201Tl posibilitala deteccion de la disminucion de la respuestavasodilatadora al ATP en pacientes con factoresde riesgo cardiovascular. Dichos pacientespresentan, no obstante, una reserva superior aaquellos con enfermedad coronaria, lo que puedesugerir que se encuentran en una etapa precoz de aterosclerosis.