Jaume Mulet

Coronary artery revascularization in patients with sustained ventricular arrhythmias in the chronic phase of a myocardial infarction : Effects on the electrophysiologic substrate and outcome

OBJECTIVES The objective of this study was to analyze the influence of coronary artery revascularization in patients with ventricular arrhythmias. BACKGROUND Coronary artery revascularization is an effective treatment for myocardial ischemia; however, its effect on ventricular arrhythmias not related to an acute ischemic event has not been carefully studied. METHODS Sixty-four patients (58 men, mean age 65 +/- 8 years old) with prior myocardial infarction, spontaneous ventricular arrhythmias not related to an acute ischemic event (55 ventricular tachycardia, 9 ventricular fibrillation) and coronary lesions requiring revascularization were studied prospectively. Electrophysiological study was performed before and after revascularization, and events during follow-up were analyzed. RESULTS At initial study 61 patients were inducible into sustained ventricular arrhythmias. After revascularization, in 62 survivors, 52 out of 59 patients previously inducible were still inducible (group A), and 10 patients were noninducible (group B). No differences were found in clinical, hemodynamic, therapeutic and electrophysiological characteristics between both groups. During 32 +/- 26 months follow-up, 28/52 patients in group A (54%) and 4/10 patients in group B (40%) had arrhythmic events (p = 0.46). An ejection fraction <30% predicted recurrent arrhythmic events (p = 0.02), but not the presence of demonstrable ischemia before revascularization (p = 0.42), amiodarone (p = 0.69) or beta-adrenergic blocking agent therapy (p = 0.53). Total mortality was 10% in both groups. CONCLUSIONS In patients with ventricular arrhythmias in the chronic phase of myocardial infarction, probability of recurrence is high despite coronary artery revascularization, but mortality is low if combined with appropriate antiarrhythmic therapy. Recurrences are related to the presence of a low ejection fraction but not to demonstrable ischemia before revascularization, amiodarone or beta-blocker therapy nor are they the results of electrophysiological testing after revascularization.

Delayed sternal closure for life-threatening complications in cardiac operations: An update

Over a 7-year-period, 25 patients had delayed sternal closure after open heart operations out of 34 patients whose sternum was not closed. The indications were extreme cardiac dilatation and uncontrollable mediastinal hemorrhage. This represented a 1.79% incidence in the overall open heart surgical experience at our unit. Sternal closure was performed at a mean of 2.64 days after the initial operation. Eighteen patients (52.9%) left the hospital alive and well, representing a 72% survival rate among patients undergoing delayed sternal closure. No mediastinal or fatal infection developed and only 1 patient had late superficial wound infection after delayed sternal closure. We conclude that delayed sternal closure is an effective method to treat severe complications after cardiac operations.

Thoracoscopic pulmonary vein isolation in patients with atrial fibrillation and failed percutaneous ablation.

OBJECTIVE Pulmonary vein isolation is indicated in patients with symptomatic isolated atrial fibrillation not controlled with antiarrhythmic therapy. We describe our surgical experience with thoracoscopic pulmonary vein isolation in patients in whom percutaneous ablation has failed. METHODS Thirty-four adult patients with unsuccessful catheter ablations (range 1-4, mean 2 +/- 1) underwent thoracoscopic bipolar-radiofrequency pulmonary vein isolation. Seventeen patients had paroxysmal atrial fibrillation, 12 with persistent and 5 with long-standing persistent fibrillation, for a mean of 6 years (range 3-10 years), 13 years (5-25 years), and 9 years (3-15 years), respectively. RESULTS There was no mortality during the procedure or follow-up (mean 16 +/- 11 months). Two patients needed conversion to thoracotomy owing to hemorrhage, and ablation could not be completed. Antiarrhythmic therapy was withdrawn 3 months postoperatively. Postoperative sinus rhythm was maintained in 82% of those with paroxysmal atrial fibrillation (13/15 at 6 months, 9/11 at 12 months), 60% had persistent atrial fibrillation (8/12 at 6 months and 6/10 at 12 months), and 20% had long-standing persistent atrial fibrillation (1/5 at 6 and 12 months). Preoperative left atrial diameter significantly differed between patients with paroxysmal fibrillation (mean 42 +/- 6 mm) and those with persistent and long-standing persistent fibrillation (means 50 +/- 4 and 47 +/- 2 mm). Left atrial size greater than 45 mm and atrial fibrillation type were preoperative factors that significantly influenced outcome in the univariate logistic regression analysis. CONCLUSIONS Thoracoscopic pulmonary vein isolation in patients with previously unsuccessful catheter ablations demonstrates satisfactory sinus rhythm maintenance rates in paroxysmal and persistent atrial fibrillation, but not in long-standing persistent atrial fibrillation. As with other minimally invasive surgical techniques, there is an important learning curve.

[Mortality and morbidity in HIV-infected patients undergoing coronary artery bypass surgery: a case control study].

The use of highly active antiretroviral therapy (HAART) in patients with HIV infection has improved survival. This improvement combined with the metabolic effects of treatment has increased cardiovascular risk and the need for cardiac surgery in these patients. We compared morbidity and mortality in HIV-infected patients (cases, n=7) and non-HIV-infected patients (controls, n=21) who underwent isolated coronary artery surgery between 1997 and 2004. The durations of extracorporeal circulation and aortic cross-clamping were shorter in HIV-infected patients (P=.002 and P=.014, respectively). The percentage of patients who experienced complications was similar, at 57.1% in both groups, but there was a slightly higher number of complications per patient in non-HIV-infected individuals. The mean length of total hospitalization was greater in HIV-infected patients (27.1 [13.3] versus 8.8 [5.3] days; P=.003), as was that of postoperative hospitalization (18.2 [15.4] vs 7.9 [4.2] days; P=.08). No HIV-infected patient died or needed a repeat cardiac operation. No progression of the HIV infection was observed. Isolated coronary artery surgery in HIV-infected patients produces good results, and there is no increase in morbidity or mortality. Extracorporeal circulation did not influence disease progression.

Morbimortalidad en pacientes con infección por el virus de la inmunodeficiencia humana que reciben cirugía de revascularización miocárdica: estudio de casos y controles

Paciente varón de 64 años al que se realiza coronariografía por angina de esfuerzo con pruebas de isquemia severamente positivas. El estudio mostró una lesión severa focal y calcificada en la coronaria derecha (fig. 1-1). Se intentó evaluarlo con IVUS, pero el catéter no la cruzó, llegándose a visualizar una calcificación superficial de la placa, con extensión angular de unos 300°. Tras dilatar con balón de 3 mm a 18 atm, se logró dilatar la lesión (fig. 1-2), pero en las angiografías de comprobación inmediatamente posteriores se apreciaba una progresiva oclusión del vaso justo distal a la lesión original (fig. 1-3). Se evaluó con IVUS y se obserIMÁGENES EN CARDIOLOGÍA

Estudio prospectivo, comparativo entre implantes de marcapasos realizados en el laboratorio de electrofisiología y en el quirófano

Introduccion y objetivos El implante de marcapasos permanentes es realizado por diversos especialistas con entrenamiento quirurgico o clinico. El objetivo del estudio fue analizar si existian diferencias en los parametros de implante y complicaciones entre los implantes realizados por cardiologos en el laboratorio de electrofisiologia y cirujanos cardiacos en el quirofano. Material y metodos Se recogieron prospectivamente datos de los primoimplantes de marcapasos realizados durante 1998 por cirugia cardiovascular y electrofisiologia. Se recolectaron datos demograficos, diagnostico que motivo el implante, tiempo de procedimiento, complicaciones del mismo, umbrales de estimulacion y deteccion y tipo de estimulacion. Resultados Se implantaron 216 marcapasos, 101 por cirugia cardiovascular y 115 por electrofisiologia. El 56% de los pacientes eran varones. La edad promedio del grupo de cirugia cardiovascular fue 74 ± 9 anos y 72 ± 12,3 anos para el de electrofisiologia (p = NS). Los principales diagnosticos fueron bloqueos AV completos en el 32,9% de los pacientes, bloqueos AV de segundo grado en el 16,4%, disfuncion sinusal en el 12,2%, ablacion del nodo AV en el 12,2%. La tasa de complicaciones del procedimiento fue del 4% para cirugia cardiovascular y 1,7% para electrofisiologia (p = NS). Hubo mas implantes de marcapasos bicamerales en electrofisiologia, y minimas diferencias sin significacion clinica en los parametros de implante. Conclusiones El implante de marcapasos por cardiologos en el laboratorio de electrofisiologia se puede realizar de manera segura y sin mas complicaciones que en los implantes realizados por cirujanos. Esto permite optimizar los recursos hospitalarios y disminuir los dias de estancia.

Eyes wide shut - unusual two stage repair of pectus excavatum and annuloaortic ectasia in a 37 year old marfan patient: case report

We report about a 37 year old male patient with a pectus excavatum. The patient was in NYHA functional class III. After performed computed tomography the symptoms were thought to be related to the severity of chest deformation. A Ravitch-procedure had been accomplished in a district hospital in 2009. The crack of a metal bar led to a reevaluation 2010, in which surprisingly the presence of an annuloaortic ectasia (root 73 × 74 mm) in direct neighborhood of the formerly implanted metal-bars was diagnosed. Echocardiography revealed a severe aortic valve regurgitation, the left ventricle was massively dilated presenting a reduced ejection fraction of 45%. A marfan syndrome was suspected and the patient underwent a valve sparing aortic root replacement (David procedure) in our institution with an uneventful postoperative course. A review of the literature in combination with discussion of our case suggests the application of stronger recommendations towards preoperative cardiovascular assessment in patients with pectus excavatum.

A cluster of fever and hypotension on a surgical intensive care unit related to the contamination of plasma expanders by cell wall products of Bacillus stearothermophilus.

OBJECTIVE To evaluate an outbreak of fever and hypotension after cardiac surgical procedures and the role of polygeline, a plasma expander. DESIGN Unmatched case-control study. SETTING A six-bed cardiac surgery intensive care unit (SICU) of the Hospital Clinic of Barcelona (Spain), a 940-bed public teaching hospital. PATIENTS Eight cases and 25 control patients admitted to the SICU over a 4-week epidemic period. MAIN OUTCOME MEASURES Development of hypotension (systolic blood pressure < or = 90 mm Hg or a drop of 40 mm Hg from baseline systolic blood pressure) and fever (axillary temperature > 38.5 degrees C) within 24 hours of a cardiac surgical procedure. RESULTS The single risk factor significantly different between cases and controls was the total volume of polygeline used throughout the surgical procedure for extracorporeal circulation: a median of 1,250 mL (mean, 1,312.5 +/- 842.5 mL) in cases versus 500 mL (mean, 566.0 +/- 159.9 mL) in controls (P = .0029). By multiple logistic regression analysis, polygeline use was the single risk factor significantly related to the outcome (odds ratio, 8.75; CI95, 1.36 to 56.2; P = .01). Neither blood cultures from patients nor cultures of the polygeline used yielded growth of any microorganism. Stopping use of the implicated polygeline lot controlled the outbreak. CONCLUSIONS Use of polygeline was associated with an outbreak of fever and hypotension in a SICU. Information from the manufacturer indicated the likelihood of contamination of the product with Bacillus stearothermophilus components. The manufacturer has since changed the production and control processes, and no further adverse events have been seen.

279. El derrame pericárdico postoperatorio en cirugía cardíaca: Incidencia e impacto en los resultados quirúrgicos

Objetivos El derrame pericardico (DP) es una complicacion (40–65%) que puede determinar taponamiento diferido letal. Determinamos la incidencia de DP grave en el postoperatorio de cirugia cardiaca. Material y metodos Estudio prospectivo de cohorte de pacientes consecutivos no seleccionados con intervenciones mayores de cirugia cardiaca. Se practico estudio ecocardiografico prealta. Se diagnostico DP por criterios de Horowitz en modo M. Para la ecocardiografia-2D se consideraron diagnosticos de taponamiento cardiaco: colapso diastolico precoz del ventriculo derecho, compresion de cavidades cardiacas, pletora de vena cava inferior y variaciones superiores al 30% del flujo mitral. Con independencia de los estudios intraoperatorios o en cuidados intensivos, se programo estudio prealta a partir del septimo dia postoperatorio. Las ecocardiografias se practicaron en el laboratorio de ecocardiografia. Si la condicion del paciente no lo permitio, el estudio se realizo en las unidades de hospitalizacion en los casos urgentes. Se usaron los ecografos Vivid i/Vivid 7 (General Electric, Fairfield, CT). Todos los estudios fueron supervisados por los ecocardiografistas expertos del servicio de cardiologia. Resultados De noviembre de 2009 – noviembre de 2011 se intervinieron 1.186 pacientes; 125 fueron trasladados precozmente a su hospital; 88 fallecieron sin estudio. De 973 pacientes, 53 (5,4%) presentaron DP grave o taponamiento por criterios clinicos/ecocardiograficos; 31/53 (58%) estaban asintomaticos. En 22/53 (42%) hubo sospecha clinica. Fueron reintervenidos 21 (40%). En 16 (30%) se administraron antiinflamatorios no esteroideos (AINE) y corticoides. La mortalidad fue 3,8% (2/53). Conclusion La ecocardiografia es una exploracion inocua que permite el diagnostico rapido de DP potencialmente letal, que tiene un componente medicolegal. Debe realizarse a todo postoperado de cirugia cardiaca.

The Gore-Tex Surgical Membrane for Temporary Skin Closure after Complicated Cardiac Operations

Between April 1986 and March 1989, 12 patients, 7 male and 5 female with a mean age of 50.0 years underwent temporary skin closure after complicated cardiac operations with the Gore-Tex Surgical Membrane and the indications to delay primary closure of the sternume were myocardial edema, uncontrollable hemorrhage and additional cannulations needed for mechanical circulatory support. Seven patients (58%) finally underwent sternal closure. Five patients survived and left the hospital (42%). No superficial nor deep infection developed in survivors. The analysis of 3 explanted membranes showed no bacterial growth.