José L. Vallejo

Eight years' experience with the Medtronic-Hall valve prosthesis

During the period January 1981 to September 1986, 444 Medtronic-Hall heart valve prostheses were implanted in 351 patients (mean age, 45 +/- 10 years) mainly for rheumatic valve disease (63.2%). Most of the patients were in New York Heart Association functional class III. Concomitant surgical procedures, mainly conservative tricuspid or mitral procedures or coronary artery bypass grafting, were performed in 101 patients (28.7%). Single-valve replacement was performed in 262 patients (74.6%) (aortic in 117 patients, mitral in 143, and tricuspid in 2), double-valve replacement in 85 (24.2%) (mitral and aortic in 83 and mitral and tricuspid in 2), and triple-valve replacement in 4 (1.1%). Hospital mortality was 6.2%. Follow-up was 97.7% complete. The overall actuarial 8-year survival rate was 77.2%. The linearized incidence of valve-related complications was as follows: thromboembolism, 1.5%/patient-year; reoperation, 1.5%/patient-year; endocarditis, 1.25%/patient-year; hemolysis, 0.52%/patient-year; anticoagulant-related hemorrhage, 0.39%/patient-year; and noninfection-related paraprosthetic leak, 0.33%/patient-year. There were no instances of structural failure. We conclude that after 8 years of follow-up, the Medtronic-Hall valve prosthesis has an excellent clinical performance and a low range of valve-related complications.

The spanish monostrut study group: A ten-year experience with 8,599 implants

BACKGROUND The Monostrut valve is a pyrolytic carbon, tilting-disc prosthesis with no welds. After the first implantation in Spain in May 1983, the Spanish Monostrut Study Group was established to evaluate prospectively the performance of the valve using uniform protocols. METHODS During a 10-year period, 8,599 Monostrut valves were implanted in 7,317 patients in 22 centers. Mean age was 53.3 +/- 11 years. Of the total group, 3,229 underwent aortic valve replacement, 2,806 had mitral valve replacement, and 1,282 had double valve replacement. Follow-up was 96% complete, with a mean period of 4.3 years and a total of 29,155 patient-years. RESULTS The operative mortality rate was 7.2%. The 10-year probability of freedom from valve-related complications and linearized rates (event/100 patient-years in parentheses) were as follows: structural deterioration, 100% (0); nonstructural dysfunction, 96% +/- 0.5% (0.51); thromboembolism, 82.9% +/- 1.5% (1.32); anticoagulant-related hemorrhage, 87.6% +/- 1.4% (0.98); and prosthetic valve endocarditis, 96.1% +/- 0.5% (0.48). There were five obstructive valve thromboses (0.017/100 patient-years). Actuarial freedom from reoperation was 95% +/- 0.5% at 10 years. Actuarial freedom from all valve-related morbidity was 70.2% +/- 1.6%; freedom from all valve-related morbidity and mortality (including operative and sudden deaths) was 62.6% +/- 2% (70.1% +/- 2% for aortic valve replacement, 56.9% +/- 2% for mitral valve replacement, and 59.8% +/- 3% for double valve replacement; p < 0.0001). Clinically, 5,988 patients (94%) are in New York Heart Association class I-II. CONCLUSIONS The Monostrut valve has shown no structural failures and a low rate of valve-related complications over a 10-year period in a large patient population.

Iatrogenic mammary arteriovenous fistula caused by sternal wire

Internal mammary arteriovenous fistulas are a rare complication of sternotomy. We present a case of a 64-year-old woman with a poststernotomy fistula between the left mammary vein and artery with formation of a pseudoaneurysm with subcutaneous extension. We describe the different imaging techniques that led to the diagnosis and the resolution of the fistula via endovascular embolization.

Thoracic aneurysm as a cause of chyluria: resolution by surgical treatment.

A 37-year-old man who had suffered a thoracic trauma presented night release of whitish urine 2 years later. Thoracic computed tomography and aortography demonstrated an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. After surgical repair the patient has remained asymptomatic.

Resultados clínicos de la revascularización miocárdica con doble arteria mamaria frente a única: 15 años de seguimiento

Introduccion Mediante la revascularizacion de la descendente anterior con la arteria mamaria se consigue una mayor supervivencia y reduccion de acontecimientos cardiologicos. Existen, sin embargo, resultados discrepantes sobre los beneficios de ambas mamarias. Objetivos Comparar los resultados del empleo de ambas mamarias frente a una. Pacientes y metodo Estudio de cohortes retrospectivo, con un seguimiento medio de 9,0 ± 4,2 anos, en el que se han incluido 108 pacientes consecutivos en los que se emplearon ambas mamarias (II), y 108 elegidos aleatoriamente de aquellos en los que se empleo una mamaria (I). Resultados Ambos grupos fueron homogeneos. No hubo diferencias en la morbimortalidad operatoria. La supervivencia a los 10 anos fue similar (II: 84,61 ± 4%; I: 85,18 ± 3,8%), mientras que la recurrencia de angina (II: 29,63 ± 5,3; I: 47,55 ± 5,6%) (p = 0,012), la necesidad de angioplastia percutanea (II: 3,98 ± 2%; I: 12,99 ± 4,1%) (p = 0,009) y el acontecimiento cardiologico (II: 33,48 ± 5,5%; I: 48,48 ± 5,5%) (p = 0,022) fueron inferiores en el grupo de dos mamarias. En el analisis multivariante, el empleo de ambas mamarias resulto ser un factor protector independiente para la recurrencia de angina (RR = 0,54), angioplastia (RR = 0,18) y acontecimiento cardiologico (RR = 0,60). Conclusiones El empleo de ambas mamarias no incrementa la morbimortalidad operatoria y reduce la recurrencia de angina, la necesidad de angioplastia y los acontecimientos cardiologicos en el seguimiento, por lo que su uso parece justificado.

Detección mediante Doppler color de los puentes de arteria mamaria interna y valoración funcional de su permeabilidad

Introduccion. La permeabilidad de los puentes coronarios de arteria mamaria interna se evalua habitualmente de forma invasiva mediante cateterismo cardiaco. El objetivo de este estudio fue investigar la capacidad de un sistema Doppler de alta frecuencia en la evaluacion funcional de los cambios de flujo en puentes coronarios de arteria mamaria interna mediante abordaje transtoracico. Metodos. Veintidos pacientes (63 ± 9 anos, 17 varones) con puentes coronarios de arteria mamaria interna fueron evaluados mediante ecocardiografia transtoracica, con un equipo Acuson Sequoia C256 (Acuson, Mountain view, EE.UU.), colocando el transductor (sonda de 5 MHz) en posicion paraesternal en el segundo o tercer espacios intercostales izquierdos. Se considero haber detectado el flujo del puente de mamaria en presencia de un flujo bifasico sistolico/diastolico. En ausencia de contraindicaciones, se administro dipiridamol 0,5 mg/kg i.v. para la evaluacion funcional del flujo coronario. Resultados. En 16 pacientes (73%), se visualizo el flujo correspondiente al puente de mamaria interna. La velocidad maxima de las ondas sistolica y diastolica fueron 38 ± 13 y 37 ± 15 cm/s, respectivamente. Se administro dipiridamol a 11 pacientes. Tras la administracion de dipiridamol, las velocidades sistolica y diastolica se incrementaron de 32 ± 8 a 43 ± 14 cm/s (p = 0,0429) y de 25 ± 8 a 50 ± 17 cm/s (p = 0,0002), respectivamente (incremento del 33 ± 22% y del 103 ± 46% sobre los valores basales, respectivamente). Conclusion. En este estudio descriptivo se observa que la evaluacion funcional no invasiva de los puentes coronarios de arteria mamaria interna mediante abordaje transtoracico es posible mediante un sistema de ecocardiografia de alta frecuencia.

Internal thoracic artery atherosclerosis after coarctation repair in an adult

We report a rare case of a patient with an unsuitable grossly atherosclerotic and extensively calcified right internal thoracic artery found during a coronary bypass grafting operation. He had undergone an aortic coarctation repair 35 years before, with long-term systemic hypertension previous to the operation and sustained after it. It is advisable to be alert to the possibility of atherosclerotic degeneration of the internal thoracic artery in these patients.

Selective and adjustable pericardial flap to protect internal mammary artery grafts.

We describe the surgical technique of a localized and adjustable pericardial flap to protect internal mammary artery grafts. This flap allows selective pulmonary retraction, maintains pleural integrity, and saves most of the pericardium for later closure. This technique has proved to be simple and highly effective. We have used it in 80 patients and have not had any related complications.

The Value of an Intervention for Improving Secondary Prevention in Patients Undergoing Cardiac Surgery

Given that treatment for secondary prevention in patients undergoing cardiac surgery is underused, we devised a hospital intervention to increase its implementation. The intervention involved all physicians in the department of cardiac surgery agreeing to complete a report on each patient before hospital discharge. The document recorded the indications for the recommended treatments, and prompted for details of the drugs prescribed, the doses used, the reasons for not prescribing the recommended drugs, if that was the case, and the use of alternative medicines. The efficacy of the intervention was evaluated by comparing the rate of drug use in the year in which it was introduced (2003, n=341) with retrospective data on the rate in the previous year (n=369). The rates of use of aspirin, statins, angiotensin-converting enzyme inhibitors, and beta-blockers by patients who required them all showed an absolute increase, of 13.4%, 38.3%, 21.8%, and 21.5%, respectively. In conclusion, the introduction of a simple and inexpensive intervention was able to significantly increase the use of drugs for secondary prevention in patients undergoing cardiac surgery.