José M. Herrera

Off-pump total arterial revascularization: our experience.

Abstractu2003 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.

Is the femoral cannulation for minimally invasive aortic valve replacement necessary

INTRODUCTIONnMinimally invasive cardiac surgery through a small transverse sternotomy is a new promising technique that can be considered an alternative in most cases to aortic valve replacement thus reducing surgical trauma and subsequent time of hospitalization. The need to avoid the risks associated with femoro-femoral bypass has lead to the interest in aortic valve replacement (AVR) operations without femoral vessels cannulation. We want to emphasize a few important points of our technique, which differs somewhat from the one applied by Cosgrove and associates.nnnOBJECTIVEnThis study details the approach to the minimally invasive AVR as first described by. Cosgrove et al. without standard femoral cannulation and points out our preliminary clinical experience.nnnPATIENTS AND METHODSnFrom October 1996 to May 1997 we have operated on 25 patients using minimally invasive AVR (MI-AVR) In 23 cases, access through transverse sternotomy as described by Cosgrove et al., was performed. In two additional cases the chest is opened via a mini-median sternotomy with an L-shape extending from the sternal notch to the superior edge of the third interspace. Twenty-three patients underwent AVR through transverse sternotomy. The male/female ratio was 13:10. The mean age was 67 years (range 45-78 years). Seventy-four percent of the patients were over 65. Predominantly, in 43% of cases aortic valve stenosis and in 25% of cases aortic valve regurgitation isolated is presented. In 19 cases, a 10-cm transverse incision is performed over the second interspace. Likewise, in four cases over the third interspace according to the thorax morphology and length of the ascending aorta assessed by chest X-ray films. By convention, cannulation of the ascending aorta and right atrial appendage was performed as usual. In contrast, in one patient (5.5%), cannulation was placed in the superior vena cava and right common femoral vein into the inferior vena cava. In the present series, 15 mechanical prostheses and eight bioprostheses whose used sizes were 19, 21,23, and 25 mm in diameter were placed in four, nine, nine, and one of the cases, respectively. All patients underwent AVR electively and a transesophageal echocardiography probe is made.nnnRESULTSnDuring surgery, conversion to median sternotomy was not required in any patient. Mean aortic cross-clamp time was 68 min (range 38-90 min). Mean total bypass time was 87 min (range 50-120 min). Mean postoperative bleeding was 434 ml. (range 200-850 ml). Perioperative blood transfusion was required in 17% of the patients. Mean mechanical ventilation time was 7.3 h (range 3-24 h), with a mean ICU stay of 18 h. Mean postoperative hospital stay was 4.5 days (range 3-10 days). In all cases, transthoracic and transesophageal echocardiography were performed postoperatively Prosthetic valve dysfunction was not observed. On the other hand, just one patient (4%) died 5 days after operation due to sudden cardiac death. Further, in two patients (8%), during follow-up, pericardial effusion is detected. In one case, cardiac tamponade with hemodynamic instability required a pericardial window procedure. In addition, in two patients (8%), non-infectious sternal dehiscence required reinforced sternal closure.nnnCONCLUSIONSnMinimally invasive AVR surgery without femoral vessel cannulation is a safe procedure with less surgical aggression. After a learning curve, benefits on fast-track programs will be accomplished.

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.

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study

OBJECTIVEnTo report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries.nnnMETHODSnHistoric cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011.nnnRESULTSnThe most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years.nnnCONCLUSIONSnTraumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis.

Preoperative Risk Evaluation in Beating-Heart Coronary Artery Bypass Surgery

INTRODUCTION AND OBJECTIVESnOperative risk stratification scales for use in cardiac surgery have been developed for patients who undergo procedures using extracorporeal circulation. The aims of the present study were to investigate the use of six preoperative risk stratification scales in patients undergoing beating-heart surgery and to identify risk factors for major complications and mortality in our group of patients who underwent revascularization using this approach.nnnPATIENTS AND METHODnBetween January 1997 and December 2002, we performed 762 coronary artery bypass operations on the beating heart; 61 patients suffered major complications (8%) and 25 died (3.3%). Risk factors for major complications and death were identified using logistic regression analysis of prospectively collected data. The following risk scores were calculated for each patient: Parsonnet 95, Parsonnet 97, Euroscore, Cleveland, Ontario, and French. Receiver operating characteristic curves were used to compare the ability of each scale to predict mortality and major complications.nnnRESULTSnIn our patient group, the preoperative variables associated with increased risk were: need for cardiopulmonary resuscitation, renal dysfunction, peripheral vasculopathy, and the presence of severe left main coronary artery disease, three-vessel disease, or an impaired ejection fraction.nnnCONCLUSIONSnMortality and major complications were best predicted by the Parsonnet 95 and Euroscore scales.

Reemplazo valvular aórtico con bioprótesis no soportada de Cryolife O'Brien

Introduccion y objetivos El xenoinjerto de Cryolife O’Brien es una bioprotesis no soportada, construida por valvas no coronarias de 3 valvulas aorticas porcinas. El objetivo de este estudio es investigar los resultados precoces despues del reemplazo valvular aortico con este xenoinjerto compuesto. Metodos Desde octubre de 1993, la bioprotesis Cryolife O’Brien ha sido implantada en 210 pacientes. La edad media fue de 70,9 ± 7,5 anos (intervalo, 23 y 83 anos). La indicacion fue estenosis aortica en 132 casos, insuficiencia aortica en 25 casos y doble lesion en 53 casos. Se ha estudiado la funcion valvular, mediante ecocardiografia preoperatoria, en el momento del alta y a los 6 y 12 meses del postoperatorio. Resultados La mortalidad a 30 dias fue del 5,2% (11/210). Los gradientes medios se reducen y el indice de area efectiva aortica aumenta con el tiempo. El indice de masa ventricular izquierda, el grosor de la pared y el espesor del septo tambien se reducen de forma precoz en el postoperatorio. Conclusiones El uso de la bioprotesis no soportada de Cryolife O’Brien ha mostrado unos resultados satisfactorios en el seguimiento a un ano. Sera necesario realizar seguimientos futuros para analizar el comportamiento de esta bioprotesis a largo plazo.

Aortic Valve Replacement With a Cryolife O'Brien Stentless Bioprosthesis

INTRODUCTION AND OBJECTIVESnThe Cryolife OBrien xenograft is a stentless bioprosthesis constructed from noncoronary leaflets from three porcine aortic valves. The aim of this study was to investigate short-term results after aortic valve replacement with this composite xenograft.nnnMETHODSnSince October 1993, Cryolife OBrien bioprostheses have been implanted in 210 patients. The patients mean age was 70.9 (7.5) years (range 23-83 years). The indication was aortic stenosis in 132 cases, aortic insufficiency in 25 cases, and both lesions in 53 cases. Valve function was studied by echocardiography preoperatively, at discharge, and 6 and 12 months postoperatively.nnnRESULTSnThe 30-day mortality rate was 5.2% (11/210). Over time, the mean gradients decreased and the effective area index increased. In addition, the left ventricular mass index, wall thickness, and septum thickness also decreased shortly after surgery.nnnCONCLUSIONSnUse of the Cryolife OBrien stentless bioprosthesis demonstrated satisfactory results at 1-year follow-up. Additional follow-up is required to assess the performance of this bioprosthesis over the long term.