José J. Cuenca

Conferencia de Consenso de los Grupos Españoles de Trasplante Cardiaco

La Seccion de Insuficiencia Cardiaca, Trasplante Cardiaco y otras Alternativas Terapeuticas de la Sociedad Espanola de Cardiologia desarrollo en Sevilla, en junio de 2005, una Conferencia de Consenso sobre trasplante cardiaco (TC) a la que fueron invitados a participar todos los grupos espanoles de TC. El objetivo fue determinar, discutir y consensuar los aspectos mas relevantes y/o controvertidos de diferentes areas del TC en la actualidad: organizacion, seleccion del receptor, donantes, rechazo, inmunosupresion, enfermedad vascular del injerto, complicaciones a largo plazo y TC pediatrico. Este documento reune las recomendaciones del grupo de trabajo incluyendo el grado de evidencia con que se respalda cada una.

Role of conservative management in traumatic aortic injury: comparison of long-term results of conservative, surgical, and endovascular treatment

OBJECTIVE The purpose of this study is to compare early and long-term results in terms of survival and cardiovascular complications of patients with acute traumatic aortic injury who were conservatively managed with patients who underwent surgical or endovascular repair. METHODS From January 1980 to December 2009, 66 patients with acute traumatic aortic injury were divided into 3 groups according to treatment intention at admission: 37 patients in a conservative group, 22 patients in a surgical group, and 7 patients in an endovascular group. Groups were similar with regard to gender, age, Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. RESULTS In-hospital mortality was 21.6% in the conservative group, 22.7% in the surgical group, and 14.3% in the endovascular group (P = .57). In-hospital aortic-related complications occurred only in the conservative group. Median follow-up time was 75 months (range, 5-327 months). Conservative group survival was 75.6% at 1 year, 72.3% at 5 years, and 66.7% at 10 years. Surgical group survival remained at 77.2% at 1, 5, and 10 years, whereas survival in the endovascular group was 85.7% at 1 and 5 years (P = .18). No patient in the surgical or endovascular group required reintervention because of aortic-related complications, whereas 37.9% of the conservative group had an aortic-related complication that required surgery or caused the patients death during the follow-up period. Cumulative survival free from aortic-related complications in the conservative group was 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. Cox regression confirmed the initial type of aortic lesion (hazard ratio, 2.94; P = .002) and a Trauma Score-Injury Severity Score greater than 50% on admission (hazard ratio, 1.49; P = .042) as risk factors for the appearance of aortic-related complications. Two peaks in the complication rate of the conservative group were detected in the first week and between the first and third months after blunt thoracic trauma. CONCLUSIONS The advent of thoracic aortic endografting has enabled a revolution in the management of acute traumatic aortic injury in patients with multisystem trauma with a low in-hospital morbimortality. Nonoperative management may be only a therapeutic option with acceptable survival in carefully selected patients. The natural history of these patients has revealed a marked trend of late aortic-related complications developing, which may justify an endovascular repair even in some low-risk patients.

Off-pump total arterial revascularization: our experience.

Abstract  Background and Aim: Off‐pump coronary artery bypass grafting with both the internal thoracic arteries, such as the Tector technique, can reduce the morbidity associated with extracorporeal circulation and aortic cross‐clamp. The aim of the present study is to describe our experience and the results obtained. Methods: From April 1998 to December 2003, the off‐pump Tector technique was performed on 743 patients, of whom 621 were male (83.5%), with a mean age of 65.3 ± 9.5 years (23–90). Preoperative risk factors were diabetes mellitus in 29.5% and peripheral vasculopathy in 14.7% of the patients. Angiography showed left main disease in 25.6% and triple‐vessel disease in 50.3% of the patients, with a mean ejection fraction of 60%± 13% (23–88). Both the internal thoracic arteries were harvested using the skeletonization technique and were anastomosed as “Y” or “T” grafts. Intraoperative graft patency was checked using a Doppler flowmeter. Results: A total of 2028 distal anastomoses were performed, the average being 2.7 (1 to 5) per patient. At least three distal anastomoses were undertaken in 62% of the patients. Postoperative complications included atrial fibrillation in 40 patients (5.4%), myocardial infarction in 24 (3.2%), mediastinitis and reoperation for bleeding in 7 (0.9%) and stroke in 3 (0.4%). Twenty‐four patients (3.2%) died in the first month postoperatively. Conclusions: The off‐pump Tector technique appears to be safe, showing a low surgical morbidity.

Evaluación preoperatoria del riesgo en la cirugía coronaria sin circulación extracorpórea

Introduccion y objetivos Los modelos de estratificacion del riesgo quirurgico en cirugia cardiaca han sido elaborados a partir de pacientes intervenidos con circulacion extracorporea. El objetivo del presente estudio es valorar como se comportan 6 modelos de riesgo preoperatorio en pacientes intervenidos sin circulacion extracorporea, asi como conocer cuales son los factores de riesgo predictores de complicaciones mayores y mortalidad en nuestros pacientes revascularizados mediante dicha tecnica. Pacientes y metodo Entre enero de 1997 y diciembre de 2002 se realizo cirugia de revascularizacion miocardica sin el uso de circulacion extracorporea en un total de 762 pacientes consecutivos; de ellos, 61 (8%) presentaron complicaciones mayores y 25 (3,3%) murieron. A partir de variables recogidas de forma prospectiva, se calcularon mediante un analisis de regresion logistica los factores predictores para complicaciones mayores y mortalidad. En cada uno de los pacientes se calcularon las escalas de riesgo Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario y Francesa. Mediante curvas ROC se comparo la capacidad de cada una de las escalas para predecir la mortalidad y la presencia de complicaciones mayores. Resultados En nuestra serie, las variables preoperatorias que aumentan significativamente el riesgo fueron: la resucitacion cardiopulmonar, la presencia de insuficiencia renal, la arteriopatia periferica, la presencia de enfermedad coronaria severa de tronco izquierdo en mas de 3 vasos y la fraccion de eyeccion deprimida. Conclusiones Las escalas de riesgo que mejor predicen la mortalidad y la presencia de complicaciones mayores fueron Parsonnet 95 y Euroscore.

Revascularización miocárdica arterial completa con ambas arterias mamarias sin circulación extracorpórea

Introduccion. Tector ha descrito la tecnica de revascularizacion arterial completa usando multiples anastomosis con ambas arterias mamarias internas. Para reducir la morbimortalidad quirurgica nos hemos propuesto realizar esta tecnica sin circulacion extracorporea. Pacientes y metodos. Desde abril de 1998 hemos realizado revascularizacion «tipo Tector» sin circulacion extracorporea en 92 pacientes, 74 varones (80%) y 18 mujeres (20%), con una edad media de 64,9 ± 8,1 anos (rango, 42-78). La angiografia preoperativa puso de manifiesto que diecinueve (20,5%) pacientes tenian lesion significativa de tronco comun y 58 (63%) triple vaso. Cuarenta pacientes (43,5%) presentaban angina inestable, 24 (26%) enfermedad vascular periferica significativa y 26 (28%) diabetes. Ambas mamarias fueron disecadas sin pediculo, y anastomosadas como injerto en «Y» o «T». La permeabilidad de las anastomosis se evaluo con Doppler intraoperatorio en 24 (26%) pacientes mediante

Mid-term results of thoracic endovascular aortic repair in surgical high-risk patients.

Between May 2001 and June 2008, the outcome and morphological changes in thoracic aortic lesions of 20 surgical high-risk patients who underwent TEVAR were evaluated. Aortic lesions included 8 (40%) type B dissections, 5 (25%) atherosclerotic aneurysms, 4 (20%) penetrating ulcers and 3 (15%) traumatic aortic ruptures. All patients were classified as American Society of Anaesthesiologists class IV and obtained high scores in both the logistic European System for Cardiac Operative Risk Evaluation, median of 14.5% (range 8.1-65.7%), and the STS Parsonet 95 scoring system, median of 14 (range 10-52). Endovascular stent-graft deployment was technically successful in all cases. No surgical conversion occurred. Early mortality was observed in two patients. Clinical and imaging follow-up was available in all patients at a median time of 28 months (range 4-89 months). Overall actuarial survival was 90% at one and five years and 60% at seven years. Mean diameter of the descending aorta decreased from 51.1+/-13 mm to 45.3+/-8 mm (P=0.032). Mean reduction in dimension of aneurysms was 10.7+/-8 mm. Endovascular thoracic aorta repair will probably benefit more patients with multiple comorbidities that limit their life expectancy than patients with a lower profile.

Cirugía coronaria sin circulación extracorpórea: 5 años de experiencia

Introduccion La cirugia coronaria sin circulacionextracorporea se considera actualmente una alternativavalida para la revascularizacion miocardicay su empleo esta aumentando progresivamente. Objetivos Presentar nuestra experiencia conesta tecnica y comparar los resultados con los dela tecnica convencional con circulacion extracorporea. Pacientes y metodos Entre diciembre de 1991 yjulio de 1996 fueron intervenidos en nuestro centro30 pacientes, realizandose pontaje coronariosin circulacion extracorporea. Este grupo fue comparadoretrospectivamente con los pacientes intervenidosdurante el mismo periodo para la realizacionde 1 puente coronario con circulacion extracorporea(excluyendo reintervenciones), 22 casosen total. Resultados En el grupo de cirugia coronaria sincirculacion extracorpora hubo 2 muertes hospitalariasy un caso de infarto de miocardio durante elpostoperatorio inmediato que requirio reintervencionurgente. En la comparacion retrospectiva unicamente dosvariables presentaron diferencias estadisticamentesignificativa, el grupo sin circulacion extracorporeapresento una mayor incidencia de infarto preoperatorio(53 frente al 23%) y un menor tiempo deventilacion asistida (7 ± 5 frente a 14 ± 9 h). El seguimiento fue completo con una media de 29meses (rango, 1-55 meses). No existio ningun casode muerte relacionado con el procedimiento, recurrenciade la angina, infarto de miocardio o necesidadde nueva revascularizacion. Conclusiones El procedimiento consiguio unosresultados semejantes a los de la tecnica convencionaly con un coste inferior.

Off-Pump Coronary Artery Bypass Grafting and Other Minimally Invasive Techniques

Although coronary surgery was first carried out without the use of extracorporeal circulation more than 40 years ago, it was not until the second half of the 1990s and thanks to an important technological development that it became a standardized reproducible technique. There is significant terminological confusion between the different forms of so-called minimally invasive technique. There are even important technical variations in off-pump coronary surgery involving median sternotomy. The present article reviews the reasons for this renaissance, the terminology used, current progress, key technical requirements, and new developments in anesthesia and postoperative management. Our approach to the technique has resulted in us carrying out full arterial revascularization in the beating heart using both internal mammary arteries. Part of this article is devoted to the specific technical details of this form of revascularization and to the results obtained in our first 1000 patients. Finally, we comment on the scientific evidence concerning coronary surgery without extracorporeal circulation that was reviewed at the ISMICS Consensus Conference in Paris in 2004: in expert hands, coronary surgery without extracorporeal circulation is just as safe and effective as conventional surgery, reduces some forms of morbidity, and, according to nonrandomized but adjusted studies, decreases mortality in high-risk patients.

No hay relación entre el volumen quirúrgico y la mortalidad en los servicios de cirugía cardiaca en España

Introduccion y objetivos. La relacion entre el numero de intervenciones cardiacas anuales (volumen) de un centro y sus resultados es controvertido. Varios estudios occidentales hallan una relacion inversa volumen/mortalidad. Analizamos el numero de intervenciones de algunos centros cardioquirurgicos nacionales y su mortalidad bruta y ajustada a riesgo. Metodos Estudio observacional prospectivo de 6.054 pacientes intervenidos en 16 hospitales, correspondientes al 34% del total de la actividad cardioquirurgica que se realizo en Espana durante el ano 2004. Se analizaron los factores de riesgo y los resultados de cada paciente intervenido en los centros participantes. Los datos de cada centro fueron verificados por auditoria independiente. Se estimo el riesgo quirurgico de cada paciente intervenido por los metodos de Parsonnet y EuroSCORE, con objeto de evaluar la mortalidad ajustada a riesgo. Resultados La mortalidad total fue del 7,7% (intervalo de confianza del 95%, 7%-8,4%). El indice de mortalidad ajustada a riesgo fue 0,81 por el metodo de Parsonnet y 1,12 por EuroSCORE. La correlacion entre numero de cirugias de un centro y mortalidad por el metodo de Pearson fue 0,065 para la mortalidad bruta, 0,092 para la mortalidad ajustada a riesgo por Parsonnet y 0,111 para la mortalidad ajustada por EuroSCORE. Descartando los centros con mortalidades mas alta y mas baja, los resultados fueron –0,464, –0,420 y –0,267 respectivamente. Conclusiones En Espana no hay relacion estadisticamente significativa entre el numero de intervenciones cardiacas de un centro y su mortalidad hospitalaria.

Early results of off-pump coronary artery bypass graft surgery using bilateral internal thoracic artery grafts in octogenarian patients during ten years

OBJECTIVES The aim of this study is to review the outcome of OP-CABG using bilateral internal thoracic artery (BITA) grafts in these patients in terms of morbidity and mortality. PATIENTS AND METHOD Retrospective data from consecutive 64 octogenarian patients who underwent this surgery in the period between April 1998 and December 2007 were taken. Demographic data, risk factors, and details of surgical intervention and postoperative complications were analysed. RESULTS The mean age was 81.8+/-1.8 years (males=78.1%). Expected mortality calculated by additive EuroSCORE was 7.1+/-1.9%. The mean of left ventricular ejection fraction was 57.3+/-12.3%. Unstable angina was the main presenting symptom in 70.3% of patients and 18.7% had recent acute myocardial infarction. Hospital morbidity and mortality rates were 60.9 and 6.2%, respectively. The most frequent complications were: respiratory (25%) and atrial fibrillation (17.2%). The means of stay in intensive care unit and total hospital stay were 2.4+/-1.9 and 7.6+/-3.7 days, respectively. CONCLUSION Realizing OP-CABG using BITA grafts had a high rate of postoperative morbidity, however, the mortality rate was low.