Ramón Arcas

Eight years' experience with the Medtronic-Hall valve prosthesis

During the period January 1981 to September 1986, 444 Medtronic-Hall heart valve prostheses were implanted in 351 patients (mean age, 45 +/- 10 years) mainly for rheumatic valve disease (63.2%). Most of the patients were in New York Heart Association functional class III. Concomitant surgical procedures, mainly conservative tricuspid or mitral procedures or coronary artery bypass grafting, were performed in 101 patients (28.7%). Single-valve replacement was performed in 262 patients (74.6%) (aortic in 117 patients, mitral in 143, and tricuspid in 2), double-valve replacement in 85 (24.2%) (mitral and aortic in 83 and mitral and tricuspid in 2), and triple-valve replacement in 4 (1.1%). Hospital mortality was 6.2%. Follow-up was 97.7% complete. The overall actuarial 8-year survival rate was 77.2%. The linearized incidence of valve-related complications was as follows: thromboembolism, 1.5%/patient-year; reoperation, 1.5%/patient-year; endocarditis, 1.25%/patient-year; hemolysis, 0.52%/patient-year; anticoagulant-related hemorrhage, 0.39%/patient-year; and noninfection-related paraprosthetic leak, 0.33%/patient-year. There were no instances of structural failure. We conclude that after 8 years of follow-up, the Medtronic-Hall valve prosthesis has an excellent clinical performance and a low range of valve-related complications.

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.

Thoracic aneurysm as a cause of chyluria: resolution by surgical treatment.

A 37-year-old man who had suffered a thoracic trauma presented night release of whitish urine 2 years later. Thoracic computed tomography and aortography demonstrated an aneurysm of the thoracic aorta. Lymphography confirmed the compression of the thoracic duct by the aneurysm. After surgical repair the patient has remained asymptomatic.

Flow capacity of the human retrograde internal mammary artery: Surgical considerations

The diastolic flow of the retrograde internal mammary artery (IMA) was calculated in 30 patients and compared with the expected coronary flow of the left ventricle and that of specific branches. Arterial pressure and free flow were measured in the proximal and distal IMA as well as in the superior epigastric and musculophrenic arteries. Systolic and mean arterial pressure were significantly higher in the proximal IMA than in any other site, but diastolic pressure was comparable. Overall and diastolic antegrade IMA flows (77 +/- 6 and 44 +/- 3 mL/min) were significantly greater than the retrograde flows through the distal IMA (18.5 +/- 2 and 11.5 +/- 1 mL/min), musculophrenic artery (13.3 +/- 1 and 7.9 +/- 1 mL/min), and superior epigastric artery (5.3 +/- 0.4 and 3.1 +/- 0.2 mL/min). Only patient-size-related variables correlated significantly with retrograde IMA flow. Diastolic retrograde IMA flow represented 8.5% +/- 0.6% of the expected left ventricle coronary flow and in 12 patients (40%) was greater than the expected flow of at least one posteroinferior coronary artery. Based on these data, the retrograde IMA may adequately perfuse the posterior descending or other posterolateral coronary branches in select patients. Previous measuring of the retrograde flow is mandatory.

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.

Selective and adjustable pericardial flap to protect internal mammary artery grafts.

We describe the surgical technique of a localized and adjustable pericardial flap to protect internal mammary artery grafts. This flap allows selective pulmonary retraction, maintains pleural integrity, and saves most of the pericardium for later closure. This technique has proved to be simple and highly effective. We have used it in 80 patients and have not had any related complications.

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.

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.