Raúl A. Borracci

Prospective validation of EuroSCORE II in patients undergoing cardiac surgery in Argentinean centres

OBJECTIVES The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) is an updated version of the original EuroSCORE that must be extensively validated. The objective was to prospectively evaluate the efficacy of EuroSCORE II in predicting the immediate results of cardiac surgery in Argentinean centres. METHODS A prospective consecutive series of 503 adults who underwent cardiac surgery between January 2012 and April 2013 was studied. EuroSCORE II discrimination and accuracy were assessed in the overall cohort and in two surgically defined subgroups: isolated coronary artery bypass graft (CABG) surgery and non-CABG surgery. Additionally, a risk-adjusted cumulative sum control chart analysis was performed. RESULTS In-hospital overall mortality rate was 4.17%, while the mortality rate predicted by the EuroSCORE II was 3.18% (P = 0.402). Receiver operating characteristic curve analysis demonstrated a good overall (area 0.856) and non-CABG subgroup (area 0.857) discrimination (P = 0.0001), while discrimination in the CABG subgroup was poorer (area 0.794, P = 0.014). The model showed good calibration in predicting in-hospital mortality, both overall (Hosmer-Lemeshow, P = 0.082) and for each subgroup (non-CABG, P = 0.308, and CABG, P = 0.150). CONCLUSIONS EuroSCORE II reflects a better current surgical performance and offers a new quality standard to evaluate local outcomes. EuroSCORE showed an overall good discriminative capacity and calibration in this local population; nevertheless, the model performed optimally in non-CABG surgery and in highest-risk patients, underestimating in-hospital mortality in lowest-risk cases. The latter finding may be interpreted as an inadequate behaviour of the model, as a poor performance of surgeons or both. Larger prospective studies will elucidate this hypothesis.

Eating habits, physical activity, smoking and alcohol consumption in adolescents attending school in the province of Buenos Aires

INTRODUCTION Knowledge on dietary habits, tobacco and alcohol consumption in adolescents is crucial to plan early preventive programs. The objective was to assess the eating habits, physical activity and tobacco and alcohol consumption in adolescents of Buenos Aires, in order to get information on cardiovascular risk factors. MATERIAL AND METHODS Cross-sectional observational study in adolescents aged 11-16 years of 12 urban and rural, public and private schools of the province of Buenos Aires. An anonymous survey was carried out including demographical data, eating habits, physical activity, smoking and alcohol consumption. RESULTS 1230 adolescents were surveyed, 46% of rural zones. Of them, 42.5% restrained food intake to control weight; 92% performed physical activity at least 1 h a week; 29.3% were smokers and 38.4% drank alcoholic beverages. Females restrained more food intake (46.3% vs. 37.7%; p=0.003) and were heavier smokers (32.6% vs. 25.2%; p=0.005). Alcohol consumption and smoking were associated (OR 8.27; p<0.001). Having a smoker friend increased almost 4 times the chance of smoking. Alcohol consumption by the best friend (OR 10.0; p<0.001), father o brother also increased chance in the adolescent. Adolescents of rural zones performed less physical activity (89.6% vs. 94.2%; p=0.003) and smoked more cigarettes (32.1% vs. 26.8%; p=0.04). CONCLUSIONS 42% restrained food intake to control weight, and almost all performed physical activity. Rates of smoking and alcohol consumption were 29.3% and 38.4%, and were strongly associated. Smoking was more common in females and in rural zones, and more associated to alcohol and a smoker friend.

Revisão ética e termo de consentimento livre e esclarecido nas publicações de pesquisas cardiovasculares na Argentina

BACKGROUND Requirements for Institutional Review Board approval and informed consent for research involving human subjects have existed for more than 2 decades. However, evidence of fulfillment of these requirements is sometimes lacking in cardiovascular research reports in Argentina. Since ethical standards vary between committees, there may be some confusion among researchers regarding the need for an ethical review when conducting low risk research. OBJECTIVE To examine the frequency of obtaining an ethical review and informed consent in cardiovascular research in Argentina. METHODS Through a questionnaire, we contacted authors of 100 reports submitted to our annual scientific meeting during 2006. RESULTS Thirty six per cent of questionnaires were resubmitted with confirmation of ethical review, 34% responded that ethical review was not obtained, 23% reported as being exempt and 7% were never resubmitted. Most articles obtaining ethical review were pharmacological trials or research involving assessment of new devices. On the other hand, most articles reporting lack of or exemption from ethical review come from epidemiological research or studies evaluating non-invasive methods. Sixty percent of phase IV pharmacological trials, research on cellular implantation or assessment of new devices met federal regulations requirements. CONCLUSION The rate of ethical review and use of informed consent in cardiovascular reports in Argentina vary among articles. Most research involving prospective observational studies and nearly 50% of protocols including intervention or invasive procedures do not report ethical review. This high proportion of articles lacking ethical review suggests the presence of legal and ethical flaws which should be discussed and overcome.

Routine operation theatre extubation after cardiac surgery in the elderly

OBJECTIVES The aim was to analyse in-hospital outcomes of patients over 70 years of age undergoing routine immediate operation theatre (OT) extubation after on-pump or off-pump cardiac surgery. METHODS A retrospective analysis was performed of prospectively collected data over a 4-year period (2011-14) from elderly patients undergoing early extubation after cardiac surgery at a single institution. All patients over 70 years were considered eligible for immediate OT or intensive care unit (ICU) early extubation after meeting specific criteria. All types of non-emergency cardiac surgery were included. Cardiac surgical risk stratification was assessed with EuroSCORE II and age, creatinine level and left ventricular ejection fraction (ACEF) score. RESULTS Among the 415 patients operated on during the period, 275 (66.3%) were ≥70 years old. One hundred and forty patients (50.9%) of the elderly group were extubated successfully in the OT. Excluding off-pump coronary surgery, OT extubation was achieved in 51.5% of cases. The rate of risk of reintubation within 24 h of surgery after OT extubation was 2.1%. The in-hospital mortality rate was 4.7%, and the complication rate was 11.6%, independently of extubation timing. Elderly patients extubated in the OT had a significantly lower median EuroSCORE II risk level and ACEF score, more isolated valve surgeries, reduced cardiopulmonary bypass time, less complications and shorter length of stay than ICU-extubated patients. In the multivariate analysis, only the ACEF score remained as an independent variable associated with OT extubation in the elderly (odds ratio 25.0, 95% CI 2.74-228.8, P = 0.004), and had good discriminating power [receiver operating characteristics (ROC) area 0.713]. On the other hand, the EuroSCORE ROC area used to predict OT extubation was 0.694, and the cut-off analysis showed that a risk value under 2.11 was associated with 72.1% OT extubation versus 37.3% when the risk value was over 2.11 (P = 0.0002). CONCLUSIONS OT extubation in the elderly can be safely performed in nearly 50% of patients, without apparently worsening their outcomes. A key point of this success was the use of a short-acting volatile agent to maintain anaesthesia throughout the procedure. Low- or moderate-risk cardiac surgery assessed with a preoperative EuroSCORE II <2.11 will help to better predict successful OT extubation in the elderly.

Giant Pedunculated Thrombus with Normal Left Ventricular Systolic Function Mimicking Myxoma

A 74‐year‐old woman with a history of essential thrombocythemia was admitted to the Coronary Care Unit because of atypical chest pain. The transthoracic echocardiogram showed normal left ventricular (LV) diameter and preserved regional and global systolic function. A pedunculated mobile mass measuring 25 mm × 14 mm was visualized in the LV cavity, attached to the midanterior wall. Because of the typical echocardiographic appearance, a myxoma was suspected. The patient evolved with left hemiparesis and negative T‐waves in the electrocardiogram. Left ventriculotomy with excision of the ventricular mass was performed. Histopathological examination revealed an organized thrombus. (Echocardiography 2011;28:E31‐E33)

Tobacco use during adolescence may predict smoking during adulthood: simulation-based research

INTRODUCTION There is little information about the age of onset of smoking among adolescents and its continuation into adulthood. The objective of this study was to assess the influence of tobacco use during adolescence to predict the prevalence of adult smoking using simulation models. MATERIAL AND METHODS Five models were examined based on initiation and tobacco use rates among 421 adolescents. After simulating different scenarios, expected adult tobacco use rates were obtained and compared to those observed in a validation sample made up of 1218 adults. RESULTS Models adequately predicted adult smoking rates by comparing them to data obtained using the validation sample (Markov: 37.6% versus 34.5%, p=0.109; dynamic simulation: 32.0% versus 34.5%, p=0.197). The simulation demonstrated that smoking, at least, one cigarette per month during adolescence sufficed to predict adult tobacco use rates. Eliminating tobacco use during adolescence may reduce the rate of tobacco use among adults by 12.2-16.2%. CONCLUSIONS Adolescent tobacco use models adequately predicted the proportion of smokers among adults. Scenarios of restriction regarding the age of onset of tobacco use showed the expected reductions in the rates of tobacco use among adults. Although it was not evaluated in this study, restricting tobacco use among adolescents may help to protect their health and would probably have an impact on the reduction of tobacco-associated mortality among adults.

Incidence of prosthesis-patient mismatch in patients receiving mitral Biocor® porcine prosthetic valves

BACKGROUND The aim was to assess the incidence of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) in patients receiving Biocor® porcine or mechanical valves, and to evaluate the effect of PPM on long-term survival. METHODS All patients undergoing MVR between 2009 and 2013 received either mechanical or bioprosthetic valves (Biocor® porcine). PPM was defined as severe when the indexed effective ori-fice area was < 0.9 cm2/m2, moderate between 0.9 cm2/m2 and 1.2 cm2/m2 or absent > 1.2 cm2/m2. The primary endpoint was all-cause long-term mortality. RESULTS Among a total of 136 MVR, PPM was severe in 27%, moderate in 44% and absent in 29% of patients. Implanted valves were 57% mechanical and 43% bioprosthetic. Only 3% of patients with mechanical valves had severe PPM vs. 59% with bioprostheses (p < 0.0001). Sixty-month survival with severe mismatch was 0.559 (SE 0.149) and with no mismatch 0.895 (SE 0.058) (p = 0.043). Survival of patients suffering from severe mismatch, or moderate mismatch with pulmonary hypertension (PH) was 0.749 (SE 0.101); while for patients with no mismatch or with moderate mismatch without PH, survival was 0.951 (SE 0.028) (p = 0.016). CONCLUSIONS About one-fourth of patients had severe PPM and almost all of them had received a bioprosthesis. Sixty-month survival was significantly lower in patients with severe mismatch, or moderate mismatch with PH. Specifically, when a bioprothesis is chosen and while further evidence on the impact of PPM on clinical outcomes appears, surgeons are recommended to follow a preoperative strategy to implant a mitral prosthesis of adequate size in order to prevent PPM.

Intracardiac sewing needle in a women with autoaggressive behavior

Heart lesions produced by the introduction of sewing needles into the thorax by people with autoagressive behavior patterns are very rare.1-4 Such patients usually suffer psychiatric disorders and present at hospital manifesting that they have introduced a foreign object into their chest, or with chest pain, dyspnea and sometimes pneumothorax. We recently treated a female drug addict with psychiatric problems who had managed to introduce a sewing needle into the myocardium. The migration of such objects into the heart chambers can cause intramural hematomas, tamponade, infection, embolism, valve dysfunction and death, and their extraction is recommended.3,4 The present patient was 44 years old, had a background of schizophrenia and drug abuse, and had been institutionalized after a suicide attempt. She was admitted to our hospital after having inserted a sewing needle into the precordium. She complained of pain in the fifth midclavicular intercostal space, where an area of ecchymosis was visible. A physical examination showed several scars on the left arm. Radioscopy revealed a metallic object that moved with the cardiac silhouette. Echocardiography and computed tomography showed a needle to be lodged in the heart (Figure 1). Since the patient was hemodynamically stable, videothoracoscopic exploration and extraction of the object was attempted, but this proved fruitless. Given the risk of migration and tamponade it was decided to undertake direct surgery. Following sternotomy, a hematoma was noticed on the back side of the left hemithorax and in the pericardial fat. Following pericardiotomy, a small serohematic hemorrhage and granuloma were seen on the anterior face of the left ventricle close to the left descending coronary artery. The remainder of the heart and the pericardial cavity were normal. Intraoperative radioscopy showed the needle to be in the left ventricle. The granuloma was explored, positioning the heart with a stabilizer (Octopus®). The dissection of the beating heart proved unfruitful, and given the danger of perforating the left ventricle the decision was made to continue with extracorporeal circulation and cardioplegic arrest. Figure 2 shows the dissection of the granuloma and the extraction of a 7 cm long sewing needle (this needle was completely within the myocardium; the figure shows it partially extracted). Ventricular closure was performed with 2 Teflon patches. The patient progressed satisfactorily with no complications. Heart lesions caused by the introduction of pins or needles in an attempt to inflict self-injury have been described only on very few occasions. Such self-mutilatory behavior has been observed in patients with schizophrenia, depression, and in the mentally disabled. As in the present case, drug or alcohol abuse increases the probability of such behavior. In published cases, these needles have been found free in the pericardial cavity or in the left ventricle, extraction being performed with or without extracorporeal circulation as required.1,5 Although some authors have suggested that these objects might be removed by performing a small anterior thoracotomy without the help of extracorporeal circulation,5 in the present case, conventional midline sternotomy was decided upon following the failure of thoracoscopy. Intraoperative radioscopy was successful in finding the end of the needle, thus showing where ventriculotomy was required.

Diferencias en los estilos de aprendizaje desde la escuela primaria hasta el posgrado en medicina

espanolObjetivos. Describir los estilos de aprendizaje de estudiantes de medicina al ingreso y en el posgrado inmediato, de acuerdo con las modalidades preferidas para usar la informacion, y comparar estos resultados con los estilos de alumnos de la escuela primaria, a fin de hallar diferencias generacionales. Sujetos y metodos. Se administro el cuestionario VARK a 73 alumnos de septimo grado de una escuela primaria, 113 estudiantes de primer ano de medicina y 141 residentes. Se realizo un analisis exploratorio para determinar conjuntos con caracteristicas afines (analisis de conglomerados). El conteo y suma de los resultados de cada individuo represento el estilo preponderante de cada grupo, definiendose como dominante cuando se elegia en mas del 50% de las respuestas. Resultados. Los estilos preponderantes en los tres grupos fueron cinestesico (27,5%) y bimodal (37,3%), mientras que el lectoescritor crecio desde la escuela primaria hasta el posgrado (1,4% a 10,7%; p = 0.037), con una tendencia de la caida del estilo auditivo desde la primaria hasta la universidad y posgrado (19,2% a 12,2%; p = 0.269). Para el estilo bimodal, la combinacion preponderante fue auditivo-cinestesica, que disminuyo desde la primaria hasta el posgrado (65% a 31%; p = 0,002). Conclusiones. El analisis de correspondencia mostro que los alumnos de la escuela primaria preferian el estilo auditivo, los universitarios se acercaban al cinestesico y los de posgrado tenian una preferencia intermedia entre el visual y el lectoescritor. Este ultimo perfil crecio significativamente desde la escuela primaria hasta el posgrado, con una tendencia inversa del estilo auditivo y del bimodal auditivo-cinestesico entre los mismos grupos. EnglishAims. To describe learning styles observed in first-year medical students and in postgraduates, regarding sensory preferences to use information, and to compare the results with the learning styles of last-year elementary school pupils, in order to find out generational differences. Subjects and methods. The VARK questionnaire was administered to 73 last-year elementary school pupils, 113 first-year medical students and 141 residents of cardiology (postgraduate). The questionnaire consists of 16 questions and each answer was associated to a particular learning style, corresponding to visual, aural, reading/writing or kinaesthetic. Results. Most common styles were kinaesthetic (27.5%) and bimodal (37.3%) in the three groups, with some differences in reading/writing profile that increased from elementary school up to postgraduate (1.4% to 10.7%; p = 0.037), and a slight tendency to decrease aural style from that educational level to the university and the postgraduate (19.2% to 12.2%; p =0.269). Within bimodal styles, the most common combination was aural-kinaesthetic, that decreased from the elementary school to the postgraduate (65% to 31%; p = 0.002). Conclusions. Correspondence analysis showed last-year elementary school pupils preferred aural style, medical students were nearer to kinaesthetic mode, and postgraduates had an intermediate preference between visual and reading/writing styles. The last profile significantly increased from elementary school to postgraduate, with an inverse tendency of aural and aural-kinaesthetic bimodal styles among the two same levels.

Agrandamiento del anillo aórtico pequeño con la técnica de Nicks en la cirugía de la estenosis valvular aórtica

La siguiente presentacion es una aproximacion a los Modos Ventilatorios durante la Ventilacion Mecanica Invasiva. Repasaremos sucesivamente las variables de control y de fase de los modos mas utilizados en las Unidades de Cuidados Intensivos. Haremos un repaso de la programacion basica, revision de las alarmas mas importantes, y por ultimo daremos un vistazo al monitoreo de variables mecanicas en cada uno de los modos.