Rafael Hernández-Estefanía

Left atrial appendage occlusion by invagination and double suture technique

Left atrial appendage (LAA) plays a crucial role as a source of atrial thrombus in patients with atrial fibrillation (AF). Thus, the need to close LAA becomes evident in patients with AF who undergo concomitant mitral valve surgery. Unfortunately, it has been reported a high rate of unsuccessful LAA occlusion, regardless of the technique employed.We propose a safe and simple method for LAA occlusion consisting in invagination of the appendage into the left atrium, followed by two sutures (purse string suture around the base of the LAA and a reinforce running suture).

Lipomatous hypertrophy of the interatrial septum: report of two cases where histological examination and surgical intervention were unavoidable.

Lipomatous hypertrophy of the interatrial septum (LHIS) is an increasingly recognized heart condition characterized by fatty deposits in the interatrial septum with sparing of the fossa ovalis. Its distinctive characteristic features by imaging techniques, benign nature, and the fact that most patients remain asymptomatic, has limited the need for histological confirmation and operative intervention in most cases. In this report, we describe two cases of LHIS where cardiac surgical intervention was indispensable: in the first patient, due to the presence of an additional left atrial tumour found out as mixoma and in the second, to relief a superior vena cava obstruction together with bypass grafts for severe coronary artery disease. Histological samples of the interatrial septal lesion were obtained in both cases either because of uncertainty of the diagnosis (Case 1) or to confirm the diagnosis (Case 2).

Assessment of left ventricular parameters in orthotopic heart transplant recipients using dual-source CT and contrast-enhanced echocardiography: Comparison with MRI

OBJECTIVES To establish the accuracy and reliability of cardiac dual-source CT (DSCT) and two-dimensional contrast-enhanced echocardiography (CE-Echo) in estimating left ventricular (LV) parameters with respect to cardiac magnetic resonance imaging (CMR) as the reference standard. METHODS Twenty-five consecutive heart transplant recipients (20 male, mean age 62.7±10.4 years, mean time since transplantation 8.1±5.9 years) were prospectively recruited. Two blinded readers independently assessed LV ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), and stroke volume (SV) for each patient after manual tracing of the endo- and epicardial contours in DSCT, CE-Echo and CMR cine images. Students t-test for paired samples for differences, and Bland and Altman plots and Lins concordance-correlation coefficients (CCC) for agreement were calculated. RESULTS There was no statistical difference between left ventricular parameters determined by DSCT and CMR. CE-Echo resulted in significant underestimation of left ventricular volumes (mean difference EDV: 15.94±14.19 ml and 17.1±17.06 ml, ESV: 8.5±9.3 and 7.32±9.14 ml with respect to DSCT and CMR), and overestimation of EF compared with the cross-sectional imaging modalities (3.78±8.47% and 2.14±8.35% with respect to DSCT and CMR). Concordance correlation coefficients for LV parameters using DSCT and CMR were higher (CCC≥0.75) than CCC values observed between CE-Echo and DSCT- or CMR-derived data (CCC≥0.54 and CCC≥0.49, respectively). Interobserver agreement was higher for DSCT and CMR values (CCC≥0.72 and CCC≥0.87, respectively). CONCLUSION In orthotopic heart transplantation cardiac DSCT allows accurate and reliable estimation of LV parameters compared with CMR, whereas CE-Echo seems to be insufficient to obtain precise measurements.

Prophylactic treatment with coenzyme Q10 in patients undergoing cardiac surgery: could an antioxidant reduce complications? A systematic review and meta-analysis

Coenzyme Q10 (CoQ10) is a lipid-soluble antioxidant that could have beneficial effects in patients undergoing cardiac surgery with cardiopulmonary bypass. There is no clear evidence about its clinical effects or a systematic review published yet. We aimed to conduct a systematic review and meta-analysis of the literature to elucidate the role of coenzyme Q10 in preventing complications in patients undergoing cardiac surgery with cardiopulmonary bypass. We searched the PubMed Database using the following keywords: Coenzyme Q10, ubiquinone, ubiquinol, CoQ10, Heart Surgery, Cardiac surgery. Articles were systematically retrieved, selected, assessed and summarized for this review. We performed separate meta-analyses for different outcomes (inotropic drug requirements after surgery, incidence of ventricular arrhythmias and atrial fibrillation, cardiac index 24 h after surgery and hospital stay), estimating pooled odds ratios (ORs) or mean differences of the association of CoQ10 administration with the risk of these outcomes. Eight clinical trials met our inclusion criteria. Patients with CoQ10 treatment were significantly less likely to require inotropic drugs after surgery {OR [95% confidence interval (CI) 0.47 (0.27-0.81)]}, and to develop ventricular arrhythmias after surgery [OR (95% CI) 0.05 (0.01-0.31)]. However, CoQ10 treatment was not associated with Cardiac index 24 h after surgery [mean difference (95% CI) 0.06 (-0.30 to 0.43)], hospital stay (days) [mean difference (95% CI) -0.61 (-4.61 to 3.39)] and incidence of atrial fibrillation [OR (95% CI) 1.06 (0.19-6.04)]. Since none of the clinical trials included in this review report any adverse effects associated to CoQ10 administration, and coenzyme Q10 has been demonstrated to be safe even at much higher doses in other studies, we conclude that CoQ10 should be considered as a prophylactic treatment for preventing complications in patients undergoing cardiac surgery with cardiopulmonary bypass. However, better quality randomized, controlled trials are needed to clarify the role of CoQ10 in patients undergoing cardiac surgery with cardiopulmonary bypass.

Tratamiento percutáneo de la estenosis aórtica grave

La estenosis aórtica grave (EAS) es la patologı́a valvular más frecuente en adultos en nuestros dı́as, aumentando conforme avanza la esperanza de vida de la población. Es un trastorno que presenta una rápida evolución una vez instaurados los sı́ntomas, de manera que aproximadamente tres de cada cuatro pacientes morirán en los tres primeros años después del inicio de la sintomatologı́a. Aunque la cirugı́a de substitución valvular por prótesis presenta buenos resultados en aquellos pacientes que no tienen enfermedades asociadas graves, se sabe que al menos uno de cada tres pacientes con EAS no son operados debido a su elevado riesgo quirúrgico consecuencia de la edad y otras comorbilidades. El tratamiento percutáneo de la EAS es una técnica muy reciente. La primera implantación de una prótesis aórtica percutánea (IPAP) fue realizada por Cribier et al en 2002 en un paciente con EAS y shock cardiogénico rechazado para cirugı́a convencional por sus múltiples comorbilidades, en el que fue implantada una bioprótesis a través del septo interauricular mediante acceso por la vı́a venosa femoral. Poco tiempo después se estandariza la implantación de válvulas percutáneas a través de la arteria femoral (implantación retrógrada), y comienzan a realizarse diversos estudios en modelos animales para obtener una vı́a de abordaje diferente en pacientes con enfermedad arterial periférica, cuyos resultados fructifican en 2006 con la implantación de la primera válvula percutánea transapical (TA). Al año siguiente la técnica ya se realiza en muchos centros quirúrgicos europeos y algunos grupos ya acumulan una importante experiencia. Por otro lado, estos buenos resultados iniciales han favorecido su utilización en el tratamiento de pacientes portadores

Intramural hemangioma of the left ventricle: accurate noninvasive diagnosis and surgical treatment.

A 38-year-old man was admitted to the hospital because of bronchitis and self-limited hemoptysis. He was heterozygous for factor V Leiden and had hyperhomocysteinemia. A thoracic computed tomographic (CT) scan, to screen for pulmonary emboli, instead revealed a 20-mm-diameter mass in the left ventricular myocardium. A CT angiogram showed that the mass was fed by a marginal branch of the left circumflex coronary artery and had no well-defined capsule (Fig. 1). A coronary angiogram showed a marginal branch that ended in a rounded stain or “tumor blush,” a typical sign of benign vascular tumors (Fig. 2). On cardiac magnetic resonance images, the T2-weighted signal was hyperintense (Fig. 3A), whereas the T1-weighted signal was isointense (Fig. 3B). When gadolinium contrast medium was administered, rapid enhancement during first-pass infusion and late homogeneous enhancement of the lesion indicated its vascular nature (Fig. 3C). Fig. 1. Computed tomographic coronary angiogram (3-dimensional reconstruction) shows that a marginal branch of the left circumflex coronary artery ends in the tumor (encircled), which is in the inferolateral wall of the left ventricle. Fig. 2. Coronary angiogram shows tumor blush (arrow). Fig. 3. Cardiac magnetic resonance images. A) The T2-weighted fast-spin echo sequence shows that the tumor has higher signal intensity than does the myocardium. B) The T1-weighted fast-spin echo sequence shows an isointense signal in comparison with the surrounding ... We concluded that the patient had a benign intramural hemangioma of the left ventricle, with no apparent complications. After a risk–benefit analysis, we surgically exposed the tumor (Fig. 4), carefully resected it, ligated its small nutritional vessels, and closed the defect with use of interrupted sutures. The patient recovered uneventfully. Fig. 4. Intraoperative photograph shows the exposed mass upon its removal. Macroscopic examination revealed a solid mass that had a smooth, bright, whitish surface of fibrous appearance and areas of muscle (Fig. 5A). Microscopic sections revealed a benign tumor with irregular capillary vascular structures and some cavernous patterns (Fig. 5B). There was no atypical proliferation of endothelial cells. Compressed myocardial fibers were found in the tumors periphery. Immunohistochemical analysis confirmed the vascular nature of the cells. The final diagnosis was benign myocardial hemangioma. Fig. 5. A) Photograph shows a solid, fibrous tumor with surrounding cardiac muscle. B) Photomicrograph shows irregular capillary and cavernous patterns, lined endothelium, and a collagenous matrix (H & E, orig. ×100).

Disección de la aurícula izquierda por rotura de ventrículo izquierdo después de cirugía mitral

Varón de 69 años, sin antecedentes relevantes, que ingresa con edema agudo de pulmón y choque cardiogénico, por rotura del músculo papilar posterior secundario a infarto agudo de miocardio inferior. Es operado de emergencia, se implanta una bioprótesis mitral y se realiza un bypass para la arteria descendente anterior con la arteria mamaria izquierda. Durante el postoperatorio inmediato se objetiva inestabilidad hemodinámica y dificultad para el destete del balón intraaórtico de contrapulsación. El ecocardiograma transtorácico revela prótesis mitral sin alteraciones y función sistólica del ventrículo izquierdo conservada. Al no haber correlación entre el ecocardiograma transtorácico y la situación clínica, se realiza un ecocardiograma transesofágico que revela una falsa cámara en el interior de la aurícula izquierda formada por la pared auricular posterior disecada, y que ocupa casi la totalidad del verdadero lumen (fig. 1). Se observa también flujo sistólico retrógrado en su interior provenienDisección de la aurícula izquierda por rotura de ventrículo izquierdo después de cirugía mitral IMÁGEN EN CARDIOLOGÍA

La orejuela izquierda como fuente de accidentes cerebrovasculares: cerrar (y cómo), o no cerrar (y por qué)

The left atrial appendage is considered the main source of emboli in strokes in patients with atrial fibrillation. Oral anticoagulant therapy significantly reduces the risk of cerebral embolic events compared to aspirin, but it is associated with bleeding complications, and is not always used. Closure of the left atrial appendage reduces the rate of thromboembolic events, and it is currently recommended in patients with atrial fibrillation submitted to mitral valve surgery. However, the formation of emboli in these patients may be due to other causes, as the role of the atrial appendage could be less important than is assumed. Moreover, not all patients are candidates for oral anticoagulation, and not all are kept in a proper therapeutic range, which could justify the formation of atrial thrombi. There are several methods for performing the closure of the appendage: direct suture in concomitant mitral surgery, epicardial exclusion by stapling or clips, or endovascular occlusion by percutaneous application. However, the results seem inconclusive with regards to their effectiveness for complete occlusion of the appendage, safety, and efficacy in preventing cerebral embolic events. To add to the confusion, some authors reveal no clear benefit in suture closure, and even describe an increased risk of thromboembolism. We present a review of left atrial appendage closure for the prevention of strokes, as well as the different procedures described above.

Úlcera penetrante de aorta ascendente en un paciente asintomático

Penetrating aortic ulcer (PAU) has been defined as an atherosclerotic plaque ulceration that breaks the internal elastic lamina of the aorta, which may progress to a wall hematoma or aortic dissection in the case of blood seeping into the middle layer. Although PAU is commonly located in the descending aorta, the involvement of the ascending aorta can be fatal. Therefore, surgery is indicated even in asymptomatic patients presenting an ascending PAU. We report on an asymptomatic patient with ascending PAU referred for replacement of the ascending aorta with a composite prosthetic graft.

[Emergency thoracotomy. Indications, surgical technique and results].

Emergency thoracotomy is a surgical technique that has been extended in the last few years, and is currently included in advanced cardiopulmonary resuscitation protocols. Despite its proven use in patients with penetrating heart wounds, it is often not used due to lack of knowledge of the technique. Currently, the increase in chest wounds due to violence, traffic accidents, crashes or suicides, and advances in extra-hospital medical care systems, has currently awakened new interest in this technique. A review of emergency thoracotomy is presented in this article: indications, surgical technique, results, and its usefulness in the extra-hospital setting.