Jaime Mulet

Large-caliber cryopreserved arterial allografts in vascular reconstructive operations: Early experience

Between October 1992 and June 1994, 16 patients (mean age, 55.6 years) underwent vascular reconstruction using cryopreserved arterial allografts. Aortoiliac aneurysms, vascular infections, and trauma accounted for the majority of case diagnoses. Twenty allografts were implanted. Two patients died in the hospital (12.5%) and 1 patient died 9 months after the operation. Early patency rate on angiography is 92.9%. Follow-up averages 8.2 months. Large-caliber cryopreserved arterial vascular allografts seem to provide satisfactory clinical results.

Hybrid Procedures for Complex Aortic Pathology: Initial Single Center Experience

Introduction and objectives To review experience at our center with the use of hybrid techniques for treating complex aneurysms of the thoracic aorta. Methods The medical records of 41 patients (40 male) with complex aortic aneurysms affecting supra-aortic or visceral vessels who underwent hybrid procedures between 1998 and 2007 were reviewed retrospectively. All patients were in American Society of Anesthesiologists category IV. They were divided in 2 groups: group A comprised 32 patients with aneurysms involving the aortic arch and its branches (2 ascending aorta replacements, 1 arch repair, 13 carotid-carotid bypasses, 12 carotid-subclavian bypasses, and 4 with total arch debranching); and group B comprised 9 patients with thoracoabdominal aneurysms and visceral vessel transpositions (4 partial and 5 total debranching). The mean age in group A was 69.3 (1.3) (range, 62–73) years and in group B, 71.5 (5.0) (range, 68-74) years. Results The mean hospital stay was 18 (7.1) days (range, 5-35) and 12 (8.2) days (range, 2-15) in groups A and B, respectively. Overall mortality was 12.2% (3.4% and 44.4% in groups A and B, respectively) and neurological morbidity was 3.4% and 11.1% in the 2 groups, respectively. Conclusions The results obtained with hybrid treatment of the aortic arch area were comparable with those of conventional surgery. However, thoracoabdominal repair with complete revascularization of the visceral branches was associated with high mortality. Consequently, hybrid treatment is a valid option for high-risk patients who do not require complete revascularization in the visceral area.

Anatomic aspects of the atrioventricular junction influencing radiofrequency Cox maze IV procedures

OBJECTIVE This study analyzes the anatomic structure of the mitral and tricuspid annuli, their relationship with the coronary arteries and veins, and how this anatomic distribution may affect atrial ablation with bipolar radiofrequency clamps, the only technology that ensures transmurality. METHODS Nine explanted fresh human hearts were studied, two of them with left coronary dominance. Two types of bipolar radiofrequency clamps were positioned to reach the mitral and tricuspid annuli, and relationships within the atrioventricular junction were analyzed, including coronary sinus and coronary arteries. RESULTS In all hearts studied, the coronary arteries and veins within the adipose tissue of the right or left atrioventricular groove lay in the atrial side, 3 to 18 mm away from the mitral or tricuspid annuli. When the bipolar radiofrequency clamp was closed toward the mitral annulus, the coronary sinus was always included between the jaws, and in left coronary-dominant hearts, the circumflex artery was also included. Nevertheless, the clamp never reached the annulus owing to the increase in thickness of the adipose tissue around the groove and the ventricular mass, leaving 5 to 10 mm of atrial myocardium free from the radiofrequency electrodes. In the right atrium, clamp placement toward the tricuspid annulus excluding the right coronary left 8 to 18 mm of atrial muscle free from the bipolar electrodes. CONCLUSIONS Bipolar radiofrequency clamps are not sufficient to complete a Cox maze IV procedure. Moreover, they may compromise coronary arteries in patients with left coronary dominance. Lines to the atrioventricular annuli need to be completed with the cut-and-sew technique or with alternative monopolar energy devices.

True knot in a Swan-Ganz catheter on a central venous catheter: A simple trick for percutaneous removal

Sir: A true knot in a thermodilut ion catheter around an other central venous catheter is a rare occurrence [1]. Most of the cases described have occurred when X-ray imaging was not being used, and inadequate persistence was used to get the catheter into place. In many cases the knot consists of a loop that loosens and slides through the catheter as it is pulled out. In a small number of cases it is a true knot that does not loosen by a gentle pulling but rather becomes tightened. We present a case of a knot of a Swan-Ganz catheter on a previously inserted central venous catheter in the right atr ium which proved impossible to loosen in the usual manner. An easy trick was enough to avoid surgery. A 35-year-old white woman diagnosed 4 years earlier with Buschkes scleredema, was receiving treatment with thalidomide. Fig. ] See text

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.

How does an apico-aortic conduit look after death?

A65-year-old man, with insulin dependency, peripheral vascular disease, hypertension, a body mass index of 37.1, and ischemic heart disease, underwent on-pump left internal mammary-to-left anterior descending coronary artery and saphenous vein to posterior descending coronary artery bypass grafting in March 2004. Methycillin-sensitive Staphylococcus aureus mediastinitis required debridement and antibiotics. The patient was discharged 68 days later. The patient had aortic stenosis that was diagnosed in 2008, with a transaortic gradient of 83/46 mm Hg and a 0.7-cm valve area. An apico-aortic conduit containing a 22-mm porcine Hancock xenobioprosthesis (Medtronic Inc, Minneapolis, MN) was implanted on January 12, 2009. The need for a patent conduit was confirmed by computed tomography. Nine months later, the patient was seen because of angina, and his troponin I was 7.76 ng/dL. Emergency catheterization confirmed patent coronary grafts. Eight hours later, he suddenly collapsed and eventually died. Postmortem examination showed a patent apico-aortic conduit (Fig 1). Partial loss of ventricular apical tissue was seen (Fig 2) with no leak on a pressure water test. A midventricular view confirmed healing of the apical connector (Fig 3) and signs of recent infarction. Apico-aortic conduits have been

Empleo de las prótesis compuestas en el tratamiento del arco aórtico distal

La cirugia de la aorta intratoracica sigue siendo un reto quirurgico. La diseccion aguda y los aneurismas del cayado aortico y la aorta toracoab-dominal tienen riesgos relacionados con la presentacion clinica y la tecnica quirurgica, la cual exige tiempos prolongados y la necesidad de modificar temporalmente la circulacion cerebral y medular. El tratamiento del arco aortico exige con frecuencia un abordaje en dos tiempos con las ventajas e inconvenientes que ello representa. La introduccion en clinica de endoprotesis integradas que persiguen el tratamiento simultaneo en un solo tiempo de la aorta intratoracica puede representar un cambio conceptual en ciertas situaciones, como la diseccion aguda de aorta. La acumulacion de experiencia clinica y el analisis cuidadoso de los datos disponibles pueden aportar informacion critica en un futuro no lejano.

Ascending Aorta to Femoral Bypass with Cryopreserved Vascular Homografts

Homograft vascular replacement is almost as old as vascular surgery itself. Gross and Dubost are credited as the first authors who clinically attempted vascular reconstruction using biological tissue of human origin. The advent of synthetic vascular prostheses together with the complexity of logistics in procuring, preserving, and storing vascular homografts made the routine use of vascular homografts impractical. Cryopreservation techniques have strongly influenced the use of biological tissue. The tireless work of a few authors has enabled us to better understand the behavior of homograft tissues in cardiovascular surgery. Homograft replacement of the aortic and pulmonary valves is now a recognized way to treat a number of conditions of the aortic root and the right ventricular outflow tract. Renewed interest in the use of cryopreserved homografts in cardiac surgery has led us to expand our own indications for their use. As our Cryopreservation Unit is fully operative, we also have vascular homografts available for implantation. Here we describe the extended use of vascular homografts in extraanatomic aortic bifurcation bypass in a patient with previous multiple vascular operations. To use the ascending aorta as the inflow source in cardiovascular reconstruction has been previously described; however, it has not been popular among surgeons. Robicsek termed this type of bypass graft “very long” aortic grafts, and we recently had the chance to use fully biological tissue of human origin for this type of reconstruction.