Rafael Castillo

Cirugía mínimamente invasiva en niños. Corrección de la comunicación interauricular por vía axilar y submamaria

INTRODUCTION AND OBJECTIVES Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal circulation. METHODS 20 patients are included: 10 in the submammary group (7 ostium secundum, 2 sinus venosus, 1 ostium primum) and 10 in the axillary group (7 ostium secundum, 3 sinus venosus). Mean age and weight are 6.4±3.62 years (range 3-13) and 23.5±8.74 Kg (range 12-38) in the submammary group, and 5.5±2.04 years (range 3-9) and 19.7±5.88 Kg (range 14-29) in the axillary one, respectively. Muscles are spared (pectoralis in submammary and latissimus in axillary). The whole procedure (cannulation and correction) is performed through a single incision, with no side ports. RESULTS No residual defects were found at discharge. Surgical approach maneuvers are more cumbersome through the axillary than the submammary approach. In a peer comparison, extracorporeal circulation and cross-clamp time were similar in both groups (P>.05). CONCLUSIONS 1. Axillary approach is as safe as submammary access in selected patients and for defects approached through the atrium. 2. Cosmetic result is excellent.

Comparación de la sensibilidad y especificidad de los criterios electrocardiográficos para la hipertrofia ventricular izquierda según métodos de Romhilt-Estes, Sokolow-Lyon, Cornell y Rodríguez Padial

Introduccion y objetivos Debido a que la masaventricular izquierda esta asociada con un aumentoen el riesgo de morbilidad y mortalidad de las enfermedadescardiovasculares en la poblacion general ysiendo el electrocardiograma un metodo accesible yeconomico para el diagnostico de la hipertrofia ventricularizquierda, decidimos calcular la sensibilidady la especificidad de 5 criterios electrocardiograficospara el diagnostico de la hipertrofiaventricular izquierda y comparar los resultados denuestro estudio con los de los autores originales. Pacientes y metodo Fueron evaluados 135 pacientesy de ellos 46 fueron excluidos por los siguientescriterios enfermedad broncopulmonarobstructiva cronica, bloqueo completo de rama derechao izquierda, cardiopatia isquemica o sindromede Wolff-Parkinson-White. Quedaron 89 pacientesy se les realizo un electrocardiograma con lossiguientes criterios: el sistema de puntuacion deRomhilt-Estes, el criterio de Sokolow-Lyon en dosversiones (S en V1 + R en V5 o V6 > 3,5 mV; R enaVL > 1,1 mV), el de Cornell y el de Rodriguez Padial.La hipertrofia ventricular izquierda fue definidapor los criterios de la convencion de Penn. Resultados En nuestro estudio obtuvimos los siguientesresultados: a) la puntuacion de Romhilt-Estes tiene una sensibilidad del 12% y una especificidaddel 87%; b) el criterio de Sokolow-Lyon (SV1+ RV5 o V6) tiene una sensibilidad del 22% y unaespecificidad del 79%; c) el criterio de Sokolow-Lyon (RaVL) tiene una sensibilidad del 18% y unaespecificidad del 92%; d) el criterio de Cornell tieneuna sensibilidad del 31% y una especificidad del87%, y e) el criterio de Rodriguez Padial tiene unasensibilidad del 82% y una especificidad del 8%.Hay una tendencia similar entre los resultados denuestro estudio y el de los autores originales aunqueexiste una diferencia estadisticamente significativaentre ambos (p ≤ 0,01). Conclusion Estos criterios tienen poco valordiagnostico en la interpretacion aislada de un pacientecon hipertrofia ventricular izquierda, por loque se debe tener en cuenta toda la historia medicay el examen fisico.

Neoválvula pulmonar en la corrección del Fallot con parche transanular

Introduccion y objetivos Presentamos nuestra experiencia inicial en la implantacion de valvula pulmonar segun tecnica de Nunn, asociada al parche transanular, en la correccion completa de la tetralogia de Fallot. Metodos Se intervino a 21 pacientes entre septiembre de 2008 y febrero de 2010. Intervalo de edad, 7 meses- 15 anos (mediana, 12 meses). Peso de 6,8-44 kg (mediana, 10 kg). Cuatro pacientes presentaban fistula paliativa; en dos se asociaba el diagnostico de canal completo. El parche transanular (pericardio autologo curtido) se acompano de implantacion previa de valvula monocuspide de PTFE de 0,1 mm de grosor, mediante fijacion posterior. Se realizo ecografia transesofagica, presiones intraoperatorias y ecografia antes del alta. Resultados No hubo mortalidad. Un paciente presento CIV residual que preciso reintervencion. Por ecografia, el gradiente maximo atribuible a la valvula de PTFE es de 25 mmHg, y la insuficiencia es ligera en 19 casos y moderada en 2 (primero y segundo de la serie). Conclusiones Los resultados iniciales del parche transanular con valvula monocuspide modificada en reconstruccion del tracto de salida de Fallot son prometedores (regurgitacion ligera, gradiente escaso). Es preciso un seguimiento a medio-largo plazo para confirmar estos resultados y compararlos con otras tecnicas.

15 años de cirugía cardiaca infantil miniinvasiva; evolución y tendencias

INTRODUCTION The minimally invasive approach is seldom reported in paediatric cardiac surgery. Teams gathering experience are scarce, with programs focused on simple cases. The experience is presented on a series of over 200 cases operated on in the past 15 years. MATERIAL AND METHODS A sub-mammary approach program was started in 2000, which was gradually extended to include more complex and younger patients. The axillary incision was adopted in 2009, following the same steps. In 2013, the mini-sternotomy incision was introduced, increasing our armamentarium. From July 2000 until December 2014, 203 patients were operated on. The sub-mammary approach was used in 102 cases, axillary in 50 patients, mini-sternotomy in 44, postero-lateral thoracotomy in 4 cases, and upper mini-sternotomy in 3. RESULTS By diagnosis, ostium secundum atrial septal defect was the most common (128), followed by sinus venosus (20), ventricular septal defect (20), ostium primum (16), and others (19). One patient was converted to sternotomy. No neurological events were detected. The mean age was 7.8/3.7 and 1.8 years, and the mean weight was 28.1/16.1 and 9.4 Kg. in the sub-mammary, axillary and mini-sternotomy approaches, respectively. The aesthetic results were excellent. CONCLUSIONS Based on our 15 years of experience, minimally invasive surgery is safe and yields excellent cosmetic results. The gradual introduction of alternative approaches (sub-mammary, axillary, mini-sternotomy) allowed us to set-up guidelines and learning curves. The wide range of incisions enables the most appropriate one to be selected depending on age/weight and cardiac condition.

Complete muscle-sparing technique in axillary closure of atrial septal defects

Minimally invasive cardiac surgery is gaining wide acceptance. The midaxillary approach hides the incision under the right arm. Concerns may arise regarding functional recovery should the latissimus dorsi and serratus anterior muscles be affected by this maneuver. A modified technique that spares both muscles, without splitting their fibers, is described. Six patients have been operated on, with excellent functional and cosmetic results, and no side-effects.

Intrapericardial pacemaker in a 2-kilogram newborn.

A 2-kilogram child had a pacemaker implanted by a subxyphoid approach with the generator located under the rectus sheath. Days later, the battery eroded the abdominal wall and the peritoneum. The whole system was removed and a new one was implanted inside the pericardium on an emergent basis.

Use of a Pulmonary Neovalve With a Transannular Patch for Repair of Tetralogy of Fallot

INTRODUCTION AND OBJECTIVES To report on our initial experience with the implantation of a pulmonary valve using Nunns technique in association with a transannular patch for the complete repair of the tetralogy of Fallot. METHODS In total, 21 patients were treated between September 2008 and February 2010. Their ages ranged from 7 months to 15 years (median 12 months) and weights from 6.8 kg to 44 kg (median 10 kg). Four patients had previously undergone palliative shunt placement; in two, it was associated with the diagnosis of a complete atrioventricular septal defect. Use of the transannular patch (treated autologous pericardium) was preceded by implantation of a 0.1-mm polytetrafluoroethylene (PTFE) monocusp valve using posterior fixation. Intraoperative transesophageal echocardiography and pressure gradient measurement were carried out, and echocardiography was repeated before discharge. RESULTS No deaths were recorded. One patient had a residual ventricular septal defect that required reintervention. Echocardiography showed that the maximum gradient across the PTFE valve was 25 mmHg. Regurgitation was mild in 19 cases and moderate in 2 (the first and second in the series). CONCLUSIONS Initial results using a transannular patch with a modified monocusp valve to repair the outflow tract in the tetralogy of Fallot were promising: there was only a slight pressure gradient and mild regurgitation. A medium-or long-term follow-up study is required to confirm these findings and to compare them with results obtained using other techniques.

Right thoracotomy, off-pump, scimitar syndrome repair in infants

Two cases of scimitar syndrome in children under one-year old are presented. Both were repaired through a right thoracotomy, off-pump, reimplanting the venous collector in the left atrium. Tips and advantages are discussed.

Azygos Approach for Pacemaker Placement in an Infant

A pacemaker insertion through the azygos vein in a child is presented. When both the low weight of the child and mediastinitis precluded standard approaches, the azygos approach proved to be an alternative and a straightforward bailout solution.

Switch arterial tardío, sin preparación previa ni oxigenador de membrana extracorpórea de soporte

is 6. J izquierdo del 45%. Es caracterı́stico de este sı́ndrome que la función ventricular se normalice al cabo de varias semanas. Nuestra paciente residı́a en otra comunidad autónoma, por lo que no disponemos de ese dato. El pronóstico del sı́ndrome de Kounis es en general bueno, aunque durante la fase aguda se han descrito como complicaciones edema pulmonar, arritmias y formación de trombos. La presentación como shock cardiogénico es extraordinariamente poco frecuente, y previamente sólo se habı́a publicado un caso similar. Actualmente, no hay establecidas guı́as clı́nicas para el tratamiento del sı́ndrome de Kounis. El número de casos es demasiado pequeño para alcanzar conclusiones definitivas sobre el tratamiento de este sı́ndrome, pero en general estos pacientes necesitan tratamiento con corticoides, antihistamı́nicos y antitrombóticos. El tratamiento con adrenalina es controvertido, ya que puede agravar la isquemia, prolongar el intervalo QT, inducir vasospasmo coronario y arritmias, pero en general se debe administrar en caso de gran hipotensión o parada cardiaca. Se deberı́a considerar los agentes vasodilatadores, incluidos nitratos y antagonistas del calcio, como terapia de primera lı́nea para sujetos jóvenes y previamente sanos. Se deberı́a seguir el protocolo del sı́ndrome coronario agudo para los pacientes con la variante tipo II. El sı́ndrome de Kounis es un cuadro que probablemente esté infradiagnosticado, y habrı́a que considerarlo dentro del diagnóstico diferencial del shock cardiogénico.