Paula Campelos

Association of Myocardial T1-Mapping CMR With Hemodynamics and RV Performance in Pulmonary Hypertension

Early detection of right ventricular (RV) involvement in chronic pulmonary hypertension (PH) is essential due to prognostic implications. T1 mapping by cardiac magnetic resonance (CMR) has emerged as a noninvasive technique for extracellular volume fraction (ECV) quantification. We assessed the association of myocardial native T1 time and equilibrium contrast ECV (Eq-ECV) at the RV insertion points with pulmonary hemodynamics and RV performance in an experimental model of chronic PH. Right heart catheterization followed by immediate CMR was performed on 38 pigs with chronic PH (generated by surgical pulmonary vein banding) and 6 sham-operated controls. Native T1 and Eq-ECV values at the RV insertion points were both significantly higher in banded animals than in controls and showed significant correlation with pulmonary hemodynamics, RV arterial coupling, and RV performance. Eq-ECV values also increased before overt RV systolic dysfunction, offering potential for the early detection of myocardial involvement in chronic PH.

Intra-operative factors predicting 1-month arteriovenous fistula thrombosis

Purpose The aim of this study is to determine clinical and ultrasound intra-operative factors related to 1-month autogenous arteriovenous fistula (AVF) thrombosis in end-stage renal failure patients. Methods A prospective study was designed, including AVF performed between October 2009 and May 2010. Patient characteristics and intra-operative measurements (clinical and ultrasound findings in both artery and vein: diameters, peak-systolic, end-diastolic and mean velocities, flow and resistance index) were recorded. At 1-month follow-up, AVF primary patency was analyzed. Stepwise logistic regression and ROC curves of the resulting test were used. Results 111 autogenous end-to-side AVF (44 radiocephalic, 45 brachiocephalic, 22 brachiobasilic) in 101 patients were performed. One-month primary patency rate was 84.7%. Intra-operative absence of bruit following skin closure could predict 1-month AVF thrombosis (70.6% sensitivity and 80.9% specificity, better than absence of thrill: 35.3% and 87.2%). However, logistic regression identified intra-operative end-diastolic velocity in the proximal feeding artery after AVF creation (EDV) as the best independent predictor of 1-month AVF thrombosis (OR=1.072, 95%CI 1.036–1.109; 76.5% sensitivity and 84.0% specificity for EDV<24.5 cm/s). This is a slight improvement on isolated clinical findings, but nevertheless a low positive predictive value (46.4%) is attained. Conclusions Prediction of AVF thrombosis with intra-operative ultrasound measurements (proximal artery EDV under 24.5 cm/s) can slightly improve isolated clinical findings, helping to establish an intra-operative criterion to review AVF and increase surgical efficiency, assuming a relatively low positive predictive value.

Eyes wide shut - unusual two stage repair of pectus excavatum and annuloaortic ectasia in a 37 year old marfan patient: case report

We report about a 37 year old male patient with a pectus excavatum. The patient was in NYHA functional class III. After performed computed tomography the symptoms were thought to be related to the severity of chest deformation. A Ravitch-procedure had been accomplished in a district hospital in 2009. The crack of a metal bar led to a reevaluation 2010, in which surprisingly the presence of an annuloaortic ectasia (root 73 × 74 mm) in direct neighborhood of the formerly implanted metal-bars was diagnosed. Echocardiography revealed a severe aortic valve regurgitation, the left ventricle was massively dilated presenting a reduced ejection fraction of 45%. A marfan syndrome was suspected and the patient underwent a valve sparing aortic root replacement (David procedure) in our institution with an uneventful postoperative course. A review of the literature in combination with discussion of our case suggests the application of stronger recommendations towards preoperative cardiovascular assessment in patients with pectus excavatum.

Reintervenciones en una Unidad de Cuidados Intensivos de Cirugía Cardiovascular

BACKGROUND To analyze the indications, actions and results of the operations performed in the Cardiovascular Surgery Intensive Care Unit. METHODS Retrospective analysis of consecutive non-selected adult patients operated in the ICU. All operations were included. Descriptive statistics were used. RESULTS Between 2008 and 2013, 3379 consecutive adult patients were operated upon. A total of 124 operations were performed in the ICU in 109 patients, 70 male (64.2%) and 39 female (35.8%) with a mean age of 61.6 years (12-80). This represented 3.2% of all operations. During the study period, 185 patients (5.5%) were reoperated for postoperative bleeding/tamponade in the operating room. The index interventions were for valvular heart disease (34.9%), aortic disease (22.9%), ischemic heart disease (15.6%), combined valvular/ischemic (12%), valvular/aorta (11%) and miscellaneous (3.6%). The indications for reoperation were persistent bleeding 54 (43.5%), pericardial tamponade 41 (33%), low cardiac output 13 (10.5%), cardiac arrest/arrhythmia 8 (6.5%), respiratory insufficiency 6 (4.8%) and acute ischemic limb 2 (1.7%). Operations performed were: mediastinal exploration 73 (58.9%), implant/removal of ECMO 17 (13.7%), sternal closure 16 (12.9%), open resuscitation 9 (7.3%), subxyphoid drainage 7 (5.6%) and femoral embolectomy 2 (1.6%). Overall mortality was 33%. There was one case of mediastinitis (0,9%), with no difference from patients operated in the regular operating room. CONCLUSIONS Operations in the ICU represent a safe, life-saving alternative in specific subgroups of patients. The risk of wound infection is not increased, unstable patients are not transferred and there is time savings.

279. El derrame pericárdico postoperatorio en cirugía cardíaca: Incidencia e impacto en los resultados quirúrgicos

Objetivos El derrame pericardico (DP) es una complicacion (40–65%) que puede determinar taponamiento diferido letal. Determinamos la incidencia de DP grave en el postoperatorio de cirugia cardiaca. Material y metodos Estudio prospectivo de cohorte de pacientes consecutivos no seleccionados con intervenciones mayores de cirugia cardiaca. Se practico estudio ecocardiografico prealta. Se diagnostico DP por criterios de Horowitz en modo M. Para la ecocardiografia-2D se consideraron diagnosticos de taponamiento cardiaco: colapso diastolico precoz del ventriculo derecho, compresion de cavidades cardiacas, pletora de vena cava inferior y variaciones superiores al 30% del flujo mitral. Con independencia de los estudios intraoperatorios o en cuidados intensivos, se programo estudio prealta a partir del septimo dia postoperatorio. Las ecocardiografias se practicaron en el laboratorio de ecocardiografia. Si la condicion del paciente no lo permitio, el estudio se realizo en las unidades de hospitalizacion en los casos urgentes. Se usaron los ecografos Vivid i/Vivid 7 (General Electric, Fairfield, CT). Todos los estudios fueron supervisados por los ecocardiografistas expertos del servicio de cardiologia. Resultados De noviembre de 2009 – noviembre de 2011 se intervinieron 1.186 pacientes; 125 fueron trasladados precozmente a su hospital; 88 fallecieron sin estudio. De 973 pacientes, 53 (5,4%) presentaron DP grave o taponamiento por criterios clinicos/ecocardiograficos; 31/53 (58%) estaban asintomaticos. En 22/53 (42%) hubo sospecha clinica. Fueron reintervenidos 21 (40%). En 16 (30%) se administraron antiinflamatorios no esteroideos (AINE) y corticoides. La mortalidad fue 3,8% (2/53). Conclusion La ecocardiografia es una exploracion inocua que permite el diagnostico rapido de DP potencialmente letal, que tiene un componente medicolegal. Debe realizarse a todo postoperado de cirugia cardiaca.