José María Arribas

Endovascular repair of concomitant celiac trunk and abdominal aortic aneurysms in a patient with Behçet's disease.

Purpose: To report endovascular repair of dual aneurysms in a patient with Behçets disease. Case Report: A 37-year-old man diagnosed 6 months prior with Behçets disease presented with a pulsating abdominal mass. Computed tomography revealed a 70-mm-diameter pseudoaneurysm in the abdominal aorta and another (20 mm) in the celiac trunk 5 mm from the aorta. Staged endovascular repair began with the aortic aneurysm, which was excluded with a bifurcated 23×140-mm Excluder stent-graft. Three days later, 2 Jostent stent-grafts were placed in the celiac trunk, successfully excluding the lesion. Fifteen days later, the patient was discharged on a regimen of clopidogrel, cyclosporine, and warfarin. At 6 months, the CT scan showed good perfusion of the stent-grafts. Conclusions: Aneurysmal involvement of the celiac trunk in a patient with Behçets disease is a rare pathology that appears amenable to stent-graft repair.

High-sensitivity troponin T as a biomarker for the development of atrial fibrillation after cardiac surgery.

OBJECTIVES Atrial fibrillation (AF) occurs in ∼ 30% of patients undergoing coronary artery bypass grafting (CABG) and in 40% of patients after valve surgery. High-sensitivity cardiac troponin T (hsTnT) is a specific and high-sensitivity marker of myocardial injury, while N-terminal proB-type natriuretic peptide (NT-proBNP) is an established biomarker for wall remodelling. We investigated whether hsTnT and NT-proBNP levels could be used as valuable biomarkers for AF occurrence after cardiac surgery. METHODS We included consecutive haemodynamically stable patients undergoing programmed cardiac surgery with cardiopulmonary bypass pump. We determined hsTnT and NT-proBNP levels before and after cardiac surgery and recorded AF development by prolonged electrocardiogram monitoring. RESULTS We included 100 patients with predominantly aortic valve (n = 42) or ischaemic heart (n = 58) diseases. Twenty-nine patients (29%) developed post-surgical AF. Patients developing AF had a longer hospital stay (P = 0.005). hsTnT levels increased after surgery [P < 0.001], indicating perioperative myocardial injury, with higher presurgery levels in patients who developed AF [P = 0.015]. Body mass index and EuroSCORE risk scale were independently associated with higher hsTnT levels presurgery. On univariate analysis, age (P = 0.048), male sex (P = 0.031), indexed left atrial volume (P = 0.042), β-blockers treatment (P = 0.024), type of surgery (valve surgery vs CABG; P = 0.034), EuroSCORE risk scale (P = 0.025) and higher preoperative hsTnT levels (P = 0.009) were predictors of AF development, but NT-proBNP did not reach statistical significance (P = 0.060). hsTnT levels in blood samples obtained the day after surgery were not associated with post-surgical AF development (P = 0.165). In a multivariate model, only higher hsTnT levels before cardiac surgery (>11.87 ng/l) [Odds Ratio, OR; (95% Confidence interval, CI) 4.27 (1.43-12.77), P = 0.009] and male sex [OR 5.10 (1.72-15.13), P = 0.003)] were independently associated with the occurrence of post-surgical AF. CONCLUSION High presurgical hsTnT levels were independently predictive of patients developing AF after cardiac surgery. hsTnT levels determined post-surgery suggest that cardiac perioperative myocardial injury is not associated with postoperative AF development. NT-proBNP did not reach statistical significance as a biomarker for AF prediction.

Experiencia inicial con la asistencia ventricular izquierda tipo «Impella» para el shock cardiogénico poscardiotomía y la angioplastia de tronco coronario izquierdo no protegido con baja fracción de eyección ventricular izquierda

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty.

Constrictive pericarditis due to Coxiella burnetii

Q fever is characterized by its clinical polymorphism. Cardiac involvement in acute Q fever is rare. We report a case of pleuro-pericarditis that rapidly evolved to pericardial constriction during an acute episode of Coxiella burnetii infection. Constrictive pericarditis was confirmed by hemodynamic measurements, echocardiography, and magnetic resonance. Indirect immunofluorescence assay revealed positive serology for acute Q fever. The patient underwent a successful pericardiectomy and was given antibiotics. The histopathologic study of the excised pericardium showed C. burnetii in a large cluster of organisms. After a 6-month follow-up period, the individual was asymptomatic.

Radiotherapeutic management of the chyloperitoneum following abdominal aortic aneurysm repair

Chyloperitoneum is a rare but life-threatening complication with no uniformity concerning the treatment. We present a 77-year-old male with chylous ascites after open abdominal aneurysmectomy refractory to conservative and surgical strategies. After failure of re-exploration with periaortic lymphatic cauterization and drainage, he was treated with five cycles of retroperitoneal radiotherapy. At 12 months of follow-up, the patient remains asymptomatic without any objective evidence of chyloperitoneum relapse. Periaortic radiotherapy may be a feasible alternative in the management of the chylous ascites following abdominal aortic aneurysm surgery.

Canulación de la arteria axilar extratorácica en cirugía cardíaca

Presentamos la experiencia inicial con la canulacion de la arteria axilar en su tercera porcion extratoracica en la raiz del brazo derecho o hueco axilar. De diciembre de 2003 a mayo de 2004, hemos intervenido cuatro pacientes con enfermedad de aorta ascendente en los cuales hemos colocado la canula de retorno arterial de la circulacion extracorporea a traves de la arteria axilar derecha. Desde el punto de vista tecnico el paciente se coloca en decubito supino y brazo derecho en extension de 90°, incision a nivel del hueco axilar. Tras exponer la arteria se introduce canula 20F iniciando asi la circulacion extracorporea sin problemas de resistencia, pudiendo alcanzar flujos maximos adecuados a la superficie corporal de cada paciente. Permite proteccion cerebral directa si es necesaria la parada circulatoria. No ha habido complicaciones neurologica, isquemica o infecciosa en la extremidad superior derecha. Se describe via de acceso arterial alternativa valida para la circulacion extracorporea. Una serie mas amplia de pacientes aportara datos comparativos.

Von Willebrand factor is associated with atrial fibrillation development in ischaemic patients after cardiac surgery

AIMS Atrial fibrillation (AF) is associated with an increased morbidity and mortality after cardiac surgery. Von Willebrand factor (vWF) has been proposed as a biomarker of endothelial damage/dysfunction. We hypothesized that vWF levels could be used as valuable biomarker for AF occurrence after cardiac surgery. Moreover, we explored the potential association between vWF and tissue remodelling as possible implication in post-surgical AF. METHODS AND RESULTS We prospectively recruited 100 consecutive patients who undergoing programmed cardiac surgery with cardiopulmonary bypass and with no previous history of AF. Plasma vWF levels were determined from citrated plasma samples. Right atrial appendage tissue was obtained during cardiac surgery, and vWF expression as well as interstitial fibrosis was analysed by immunostaining and Massons trichrome, respectively. We found raised vWF plasma levels in ischaemic vs. valvular patients (200.2 ± 66.3 vs. 157.2 ± 84.3 IU/dL; P = 0.015). Fibrosis degree was associated with plasma vWF levels. Plasma vWF was an independent prognostic marker for AF development in ischaemic patients [odds ratio, OR 6.44 (95% confidence interval, CI 1.40-36.57), P = 0.035]. CONCLUSION Plasma vWF levels are associated with tissue fibrosis in patients undergoing cardiac surgery and with post-surgical AF development in ischaemic patients. These findings suggest an association among vWF levels, atrial remodelling, and AF development. It is supported by higher vWF expression in right atrial tissue in ischaemic patients, who developed post-surgical AF.

Ellis-van Creveld syndrome in adulthood: extending the clinical spectrum.

Ellis-van Creveld (EvC) syndrome is a rare autosomal recessive malformation disorder. Cardiac defects are observed in about 50% of EvC cases. Surgical data is lacking on the prognosis and life expectancy of EvC patients. Herein, we report the case of a 38-year-old man with EvC syndrome who underwent two surgical corrections for cardiac anomalies. This report supplements the available information on the clinical course of EvC syndrome in older patients.

Tratamiento de enfermedad de aorta torácica con afectación de troncos supraaórticos usando técnica combinada de cirugía convencional y tratamiento endovascular

Introduccion La combinacion de cirugia convencional y tratamiento endovascular podria ser una alternativa valida en el manejo de la enfermedad de aorta toracica con implicacion de troncos supraaorticos (TSA). Material y metodos Presentamos dos casos con estrategia quirurgica similar, basada en revascularizacion de TSA y colocacion de endoprotesis toracica ocluyendo dos de los troncos, y embolizacion posterior de estos. Resultados El paciente 1, diagnosticado de aneurismas en aorta abdominal (AAA), toracica descendente (AATD) y en arteria subclavia derecha aberrante, fue intervenido previamente del AAA realizandose endoaneurismorrafia. A este se le practico una derivacion aortobiaxilar previa a la colocacion de la endoprotesis y posterior embolizacion de arteria subclavia derecha. En el postoperatorio desarrollo paraparesia transitoria. El paciente 2, con historia de seudoaneurisma postraumatico distal al istmo tratado con cirugia convencional 20 anos antes, presentaba dilatacion de aorta toracica a nivel del istmo y afectacion de arteria subclavia izquierda. En este se realizo derivacion aortocarotideosubclavia izquierda tras la que se implanto la endoprotesis toracica, con embolizacion posterior de arteria subclavia y vertebral izquierda. El paciente no presento ninguna complicacion. En seguimiento a 1 ano no hubo complicaciones. Conclusiones El abordaje del arco aortico usando tecnicas endovasculares presenta el problema de la oclusion de TSA. El uso de derivaciones quirurgicas hace posible esto. El abordaje combinado es aun una tecnica nueva pero que podria ser una alternativa valida a la cirugia abierta de arco y aorta toracica descendente. Nuestra experiencia es satisfactoria, aunque no concluyente por tratarse solo de dos casos.