Juan Ugarte

Pulmonary hydatidosis: surgical treatment and follow-up of 240 cases

OBJECTIVE We review a series of 240 patients treated surgically for pulmonary hydatid cyst in our center between 1966 and 1988, assessing the results with our surgical technique, which involves a novel needle aspiration device designed by Professor D. Figuera, and postoperative treatment protocol. PATIENTS AND METHODS The majority (60.4%) of the patients were from areas endemic for hydatid disease. The mean age of the patients at the time of the surgical procedure was 31.5 +/- 7.2 years (range: 4-70 years). A trocar-suction device was used for the needle aspiration of 276 (92%) of the 300 cysts encountered in the 240 patients. The remaining 24 cysts were removed integrally by means of different surgical techniques such as cyst enucleation, lobectomy, segmentectomy and atypical pulmonary resection. The residual cavity was treated by pericystectomy and eversion to the pleural surface in 238 cases (86.2%) and by capitonnage in 38 (13.7%). High vacuum suction (-30 cm H2O) was employed in every case. Depending on when the procedure was performed, the patients were treated with mebendazole or albendazole according to the protocol designed by Bekhti. RESULTS Clinical assessment of the symptoms and plain chest X-ray led to the correct diagnosis in 228 cases (95%). In six (2.5%), imaging studies such as ultrasonography, computed tomography and nuclear magnetic resonance were required, and in the remaining six cases (2.5%), the diagnosis was established intraoperatively or in the subsequent histopathological study. One hundred and seventy patients (70.8%) presented a solitary lung cyst, while the remaining 70 (29.2%) were found to have multiple cysts in one or more lobes of one or both lungs. In addition, 45 patients (18.7%) presented hepatic cysts and 25 (10.4%) had cysts in other locations. After 18 years of follow-up, the survival rate was 94.6%. Of the surviving patients, 98.3% were free of pulmonary hydatid disease and 95.1% were free of hydatid disease. CONCLUSIONS The trocar-suction device employed here for needle aspiration of hydatid cysts has demonstrated its efficacy in preventing the rupture of the cyst and its possible dissemination. With its use, the parasite is eradicated and the residual cavity can be excised.

RADIAL: A novel primary graft failure risk score in heart transplantation

BACKGROUND Primary graft failure (PGF) is the leading cause of early mortality after heart transplantation (HT). Our aim is to propose a working definition of PGF and to develop a predictive risk score. METHODS PGF was defined by four criteria reflecting significant myocardial dysfunction, severe hemodynamic impairment, early onset after HT, and absence of secondary causes of graft dysfunction. We identified independent risk factors for PGF in a derivation series of 621 HTs and constructed a predictive model. After proving its internal consistency we tested the model in a prospective validation series. RESULTS The incidence and lethality of PGF in our series were 9% and 80%, respectively. We identified 6 multivariate risk factors for PGF (Right atrial pressure ≥ 10 mm Hg, recipient Age ≥ 60 years, Diabetes mellitus, Inotrope dependence, donor Age ≥ 30 years, Length of ischemic time ≥ 240 minutes--i.e., RADIAL). Analysis of isolated right ventricular failure showed similar predictors. The RADIAL score was obtained by adding 1 point for each of these factors present in a given HT. PGF incidence increased significantly as the RADIAL score increased (p < 0.001 for trend). Rates of actual and predicted PGF incidence for RADIAL subgroups showed a good correlation (C-statistic = 0.74). In a prospective validation cohort, RADIAL score kept its predictive ability. CONCLUSIONS PGF as defined by these criteria showed a high impact on early post-HT mortality in our series. The RADIAL score showed good ability to predict the development of PGF, and could be useful in the prevention and early treatment of this complication.

Clinical experience with retrograde lung preservation

Abstract  Previous reports and our own experimental work suggest increased vascularity of the tracheo‐bronchial wall when retrograde lung preservation is used. This principle was clinically applied in 21 consecutive lung transplant recipients (10 single and 11 bilateral). Lung preservation was achieved via the left atrial appendage and drainage was obtained through the pulmonary artery. Pneumoplegic preservation was achieved with modified Euro‐Collins solution. Cardioplegia was induced by the standard method and the heart, harvested by different teams, did not exhibit left ventricular dilatation. Thirty‐two bronchial anastomoses without wrapping were performed. No primary lung graft failure was documented. Cardiopul‐monary bypass was instituted in three cases of pulmonary hypertension; however, this was deemed unnecessary in the remainder of the cases of bilateral transplantation while the second organ was being implanted. All bronchial anastomoses were followed between 2 and 28 months. A single instance of bronchial anastomosis dehiscence was observed on the 30th postoperative day. However, no stents were employed in this series, and no strictures or anastomotic granulomas have been reported so far. All the hearts could be used satisfactorily except for one primary graft failure. In conclusion, retrograde lung preservation is feasible in clinical lung transplantation, with simultaneous harvesting of the heart. The impact of retrograde lung preservation on the late clinical outcome remains to be seen.

Ischemia-Reperfusion Injury During Experimental Heart Transplantation. Evaluation of Trimetazidine¿s Cytoprotective Effect

INTRODUCTION AND OBJECTIVES The objectives of this study were to analyze the ischemia-reperfusion injury due to free radicals that occurs during heart transplantation and to determine the potential cytoprotective effect of trimetazidine. MATERIAL AND METHOD A total of 21 orthotopic heart transplantations were performed in pigs. We divided the experimental animals into 2 groups: in group A (n=11),standard myocardial protection was used; in group B (n=10), trimetazidine was added to the cardioplegic solution used to protect the donor heart and to the solution administered to the recipient prior to release of the aortic clamp (trimetazidine, 10(-5) mol/L), and recipients were pretreated with trimetazidine, 2.5 mg/kg. Blood samples were taken from the recipients coronary sinus at three times: at baseline, during ischemia, and during reperfusion. We measured the levels of malondialdehyde, a marker of lipid peroxidation, and of several antioxidants: glutathione peroxidase, glutathione reductase, superoxide dismutase, alpha-tocopherol, and retinol. The total antioxidant status was also determined. RESULTS Malondialdehyde production and enzymatic antioxidant activity rose during ischemia and reperfusion, while the retinol level decreased. The increases in malondialdehyde level and glutathione peroxidase activity that occurred between baseline and reperfusion were significantly higher in group A. CONCLUSIONS. The degree of lipid peroxidation and the level of activity of intracellular antioxidant mechanisms increased progressively throughout transplantation. Trimetazidine had a cytoprotective effect. It ameliorated free radical-induced reperfusion injury and modified the response pattern of several defense mechanisms.

Daño por isquemia-reperfusión durante el trasplante cardíaco experimental. Evaluación del papel citoprotector de la trimetazidina

Introduccion y objetivos. El objetivo de este trabajo fueanalizar el dano por isquemia-reperfusion mediado por radicales libres que se produce durante el trasplante cardiaco y eva-luar el posible efecto citoprotector de la trimetazidina (TMZ). Material y metodo. Se realizaron 21 trasplantes cardiacos ortotopicos en cerdos. Dividimos los experimentos en 2 grupos: A (n = 11), en el que se realizo una proteccion miocardica estandar, y B (n = 10), en el que se administro TMZ en la cardioplejia empleada para parar el corazon donante (TMZ, 10?5 mol/l), como pretratamiento intravenosodel receptor (TMZ, 2,5 mg/kg) y como parte de la cardio-plejia infundida en el receptor antes de despinzar la aorta(TMZ, 10?5 mol/l). Se tomaron muestras de sangre del senocoronario del receptor en 3 momentos: basal, isquemia y reperfusion. Se determino la concentracion de malonildial-dehido como marcador de peroxidacion lipidica y de variosantioxidantes: glutation peroxidasa, glutation reductasa,superoxido dismutasa, a-tocoferol, retinol y estado de antioxidantes totales. Resultados. Durante la isquemia-reperfusion aumentola produccion de malonildialdehido y la actividad de losantioxidantes enzimaticos, mientras que el retinol disminuyo. El incremento de malonildialdehido y de la actividad de la glutation peroxidasa entre el momento basal y la reperfusion fue significativamente mayor en el grupo A. Conclusiones. Durante el trasplante se incremento progresivamente el nivel de peroxidacion lipidica y se activaronlos sistemas antioxidantes intracelulares. La TMZ ejercio un efecto citoprotector y limito el dano por isquemia-reperfusion generado por los radicales libres, ademas de modificar el patron de reaccion de parte de los sistemas de defensa.

Long-Term Results of Cardiac Valve Replacement with the Delrin-Disc Model of the Björk-Shiley Valve Prosthesis

One hundred two Björk-Shiley valve prostheses with the Delrin-disc occluder were implanted in 83 patients between January, 1971, and July, 1972. Fifty-eight were in the mitral position, 42 in the aortic, and 2 in the tricuspid. Complete follow-up until 1981 was obtained in 93% of the patients (mean follow-up, 66.8 months). Hospital mortality was 18% and late mortality, 19%. Survival according to actuarial methods was 84.8% at 5 years and 78.1% at 9 years after operation. Thromboembolism was detected in 8.8% of patients but caused no deaths. The incidence was 1.2% and 1.5% per year in those patients treated with Coumadin and antiplatelet agents, respectively. Reoperation was necessary in 13% of the patients. Most survivors (72%) are in New York Heart Association Functional Class I, despite a preoperative status of Class III or IV in 57% of the patients. Hospital mortality may be due to poorer understanding of patient management and less refined techniques of myocardial protection. Long-term survival with this prosthesis is similar to that in more recent studies, and rates of thromboembolism and malfunction compare favorably with other prosthetic valves.

Coronary Artery Fistula as a Bypass of a Left Anterior Descending Coronary Artery Stenosis

We present a case of coronary artery fistula originating from the proximal left anterior descending coronary artery anterior to a critical atheromatous stenosis, draining into the main trunk of the pulmonary artery and with a third branch draining into the coronary vessel itself, distal to the lesion. The diagnosis was made when we were performing a diagnostic coronary arteriography on a patient with unstable angina. The possible association of the fistula and coronary atherosclerosis is discussed.

Characteristics of Patients With Survival Longer Than 20 Years Following Heart Transplantation

INTRODUCTION AND OBJECTIVES The number of heart-transplant recipients exceeding 20 years of follow-up is steadily increasing. However, little is known about their functional status, comorbidities, and mortality. Identifying the predictors of prolonged survival could guide the selection of candidates for the low number of available donors. METHODS Functional status, morbidities, and mortality of heart-transplant patients between 1984 and 1992 were analyzed. To identify predictors of 20-year survival, a logistic regression model was constructed using the covariates associated with survival in the univariate analysis. RESULTS A total of 39 patients who survived 20 years (26% of patients transplanted before 1992) were compared to 90 recipients from the same period who died between 1 and 20 years post-transplantation. Major complications were hypertension, renal dysfunction, infections, and cancer. After a mean follow-up of 30 months, 6 survivors had died, yielding a mortality rate of 6% per year (vs 2.5%-3% in years 1-19). Causes of mortality were infection (50%), malignancy (33%), and allograft vasculopathy (17%). Long-term survivors were younger and leaner, and had nonischemic cardiomyopathy and lower ischemic time. Logistic regression identified recipient age <45 years (odds ratio=3.9; 95% confidence interval, 1.6-9.7; P=.002) and idiopathic cardiomyopathy (odds ratio=3; 95% confidence interval, 1.4-7.8; P=.012) as independent predictors for 20-year survival. CONCLUSIONS One fourth of all heart-transplant patients in our series survived >20 years with the same graft, and most enjoy independent lives despite significant comorbidities. Recipient age <45 years and idiopathic cardiomyopathy were associated with survival beyond 2 decades. These data may help decide donor allocation.

Influence of hypothermia on right atrial cardiomyocyte apoptosis in patients undergoing aortic valve replacement

BackgroundThere is increasing evidence that programmed cell death can be triggered during cardiopulmonary bypass (CPB) and may be involved in postoperative complications. The purpose of this study was to investigate whether apoptosis occurs during aortic valve surgery and whether modifying temperature during CPB has any influence on cardiomyocyte apoptotic death rate.Methods20 patients undergoing elective aortic valve replacement for aortic stenosis were randomly assigned to either moderate hypothermic (ModHT group, n = 10, 28°C) or mild hypothermic (MiHT group, n = 10, 34°C) CPB. Myocardial samples were obtained from the right atrium before and after weaning from CPB. Specimens were examined for apoptosis by flow cytometry analysis of annexin V-propidium iodide (PI) and Fas death receptor staining.ResultsIn the ModHT group, non apoptotic non necrotic cells (annexin negative, PI negative) decreased after CPB, while early apoptotic (annexin positive, PI negative) and late apoptotic or necrotic (PI positive) cells increased. In contrast, no change in the different cell populations was observed over time in the MiHT group. Fas expression rose after reperfusion in the ModHT group but not in MiHT patients, in which there was even a trend for a lower Fas staining after CPB (p = 0.08). In ModHT patients, a prolonged ischemic time tended to induce a higher increase of Fas (p = 0.061).ConclusionOur data suggest that apoptosis signal cascade is activated at early stages during aortic valve replacement under ModHT CPB. This apoptosis induction can effectively be attenuated by a more normothermic procedure.

Failure of Percutaneous Closure of Prosthetic, Aortic Paravalvular Leak

We report the progression of aortic insufficiency after percutaneous closure of an aortic prosthesis paravalvular leak with the Amplatzer vascular plug (AGA Inc, Golden Valley, MN). Removal of the device and replacement of the aortic prosthesis was successfully performed. Based on operative findings, we hypothesize that shape mismatch between the occluder system and the leak might promote tearing at the end of slanted defects further enhancing the regurgitant area.