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Resumen Introduccion y objetivos El numero de pacientes ancianos con insuficiencia cardiaca terminal ha crecido espectacularmente. Considerando que el numero de trasplantes cardiacos se ha estancado, se requiere una alternativa terapeutica. Desde hace poco se estan aplicando como terapia de destino (TD) dispositivos de asistencia ventricular izquierda (DAVI). Asumiendo que los pacientes de mas edad tienen mayor riesgo quirurgico, es presumible que la cirugia menos invasiva (CMI) para el DAVI contribuya a mejorar los resultados operatorios en pacientes en TD. Metodos Se realizo un estudio prospectivo con un seguimiento de 2 anos de 46 pacientes en TD (edad mayor de 60 anos) consecutivos a los que se trato con DAVI (HVAD, HeartWare) en nuestra institucion entre 2011 y 2013. Se formaron 2 grupos segun el metodo quirurgico de implante: CMI (n = 20) o cirugia convencional (n = 26). Resultados A pesar de que no se hallaron diferencias estadisticas significativas respecto a la supervivencia a 2 anos, si se observo una tendencia a mayor supervivencia en el grupo CMI (el 85,0 frente al 69,2%; p = 0,302). Asimismo, los pacientes del grupo de CMI presentaron menor incidencia de hemorragias tras la cirugia (0 frente al 26,9%; p Conclusiones Los datos indican que los pacientes sometidos a CMI para implante de DAVI como TD muestran tras la cirugia menor incidencia de hemorragias, menor necesidad de apoyo con inotropicos y una tendencia a menor mortalidad que los pacientes operados de manera convencional.

The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients.We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26).There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P.05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P.05).Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique.

ResumenObjetivosDurante los últimos años el número de pacientes de avanzada edad que presentan insuficiencia cardíaca congestiva se ha incrementado de manera dramática. En el contexto del estancamiento global del trasplante cardíaco nace la necesidad de una terapia definitiva alternativa para estos pacientes. Recientemente, los dispositivos de asistencia ventricular izquierda (DAVI) han experimentado un auge, sobrepasando incluso el número de pacientes trasplantados mundialmente. El desarrollo tecnológico de los nuevos dispositivos y el surgimiento de nuevas técnicas quirúrgicas derivados de la cirugía cardíaca mínimamente invasiva han formado parte de este desarrollo. El propósito del presente estudio fue revisar la primera serie de implantes de DAVI mínimamente invasivo en pacientes septuagenarios.MétodosEl diseño del ensayo clínico es monocéntrico prospectivo. Se incluyó a todos los pacientes mayores o iguales a 70 años que requirieron un implante de DAVI (HVAD, HeartWare Inc.) como terapia de destino durante los años 2013 y 2015 en la Medizinische Hochschule Hannover. El seguimiento concluyó luego de 2 años. Todos los pacientes fueron operados por una técnica mínimamente invasiva compuesta por una miniesternotomía en «J» y una toracotomía lateral izquierda.ResultadosUn total de 14 pacientes fueron incluidos (edad 71,8±1,5 años, 100% hombres, miocardiopatía isquémica 64,3%). El 50% de los casos correspondía a una reoperación, un 7,1% recibió soporte mecánico circulatorio previo. Todos los pacientes fueron operados utilizando circulación extracorpórea (CEC) (tiempo medio de CEC 51±8min). El tiempo promedio de permanencia en la Unidad de Cuidados Intensivos fue de 6,4±5,2 días. Eventos adversos en el transcurso postoperatorio temprano fueron: reintervención quirúrgica por sangrado 7,1%, falla ventricular derecha 14,3% y diálisis 14,3%. Los niveles de supervivencia fueron: 30 días: 85,7%, un año: 78,6%, y 2 años: 70,7%.ConclusionesNuestros resultados iniciales demuestran que el implante mínimamente invasivo de DAVI puede ser realizado de manera eficaz, segura y con buenos resultados en pacientes septuagenarios terapia de destino. Los bajos niveles de eventos adversos durante el seguimiento por 2 años demuestran que la terapia de destino puede ser realizada incluso en pacientes septuagenarios.AbstractObjectivesThe number of elderly patients suffering from congestive heart failure has increased dramatically in recent years. In the context of global stagnation of heart transplantation, comes the need for an alternative definitive therapy for these patients. Recently left ventricular assist devices (LVAD) have increased significantly, surpassing even the number of transplants worldwide. The technological development of new devices and the emergence of new surgical techniques arising from minimally invasive cardiac surgery have been part of this development. The purpose of this study was to review the first series of minimally invasive LVAD implants in septuagenarian patients.MethodsA prospective single-centre clinical trial was conducted on all patients greater than or equal to 70 years that required an LVAD implant (HVAD, HeartWare Inc.) as destination therapy for the years 2013 to 2015 in the Medizinische Hochschule Clinic in Hannover. The monitoring ended after two years. All patients were operated by a minimally invasive technique consisting of a “J” mini-sternotomy and a left lateral thoracotomy.ResultsA total of 14 patients were included (age 71.8 ± 1.5 years, all (100%) males, and 64.3% with ischaemic heart disease). It was a second operation for 50% of the cases, and 7.1% received a prior mechanical circulatory assist device (MCAD). All patients were operated on using extracorporeal circulation (ECC) for a mean time of 51 ± 8 min). The mean length of stay in ICU was 6.4 ± 5.2 days. Adverse events during the early post-operative period included, surgical re-intervention due to bleeding (7.1%), right ventricular failure (14.3%), and dialysis (14.3%). Survival rates were: 30 days: 85.7% 1 year: 78.6% 2 years: 70.7%.ConclusionsThe initial results show that minimally invasive implantation of LVAD can be performed effectively, safely, and with good results in septuagenarian patients as destination therapy. There were low levels of adverse events during a two year follow-up, showing that destination therapy can be performed even in patients in their seventies.

A patient was submitted to mitral valve replacement and tricuspid ring annuloplasty. During immediate postoperative course, signs of inferior myocardial ischemia appeared. Acute entrapment of the right coronary artery due to tricuspid ring sutures was confirmed by coronary angiography. The patient was reoperated and a right coronary bypass graft was successfully performed. Tricuspid procedures have shown to be effective and secure with a low rate of complication. Few cases of right coronary artery occlusion have been described and the majority not treated. Exceptional cases of right coronary occlusion related to tricuspid ring annuloplasty have been reported with a favorable outcome, as the case described herein.

Resumen Los puntos de Campbell de Morgan, o angiomas seniles, son la forma mas frecuente de todos los tipos de angiomas que existen. Tambien denominados puntos rubi, hemangiomas cereza o cherry angiomas, son un motivo de consulta altamente frecuente en la practica clinica. De origen vascular, consisten en unas pequenas lesiones rojizas puntiformes cutaneas de pequeno tamano y naturaleza benigna. De aparicion espontanea predominantemente, existe un cierto caracter hereditario en su aparicion. Su tratamiento es simple y efectivo, aunque requiere tecnicas dermatologicas especificas para lograr su resolucion.

La disfuncion de la valvula tricuspide (VT) es frecuente en los pacientes con enfermedad de otras valvulas y otras afecciones cardiacas. La insuficiencia tricuspidea (IT) es habitual entre los pacientes con valvulopatias izquierdas, especialmente cuando hay hipertension pulmonar; mas de un 30% de los candidatos a cirugia mitral tienen IT moderada o grave. En la mayoria de los casos se trata de un hecho funcional, consecuencia del remodelado del ventriculo derecho (VD). Mas raramente la propia VT resulta afectada por diferentes procesos que alteran su morfologia y comprometen su funcion. A pesar de que se tolera bien durante anos, la IT tiene evidente repercusion clinica; en pacientes con valvulopatias izquierdas, la IT moderada o grave reduce la supervivencia, limita la capacidad de ejercicio y condiciona peor clase funcional. A pesar de la elevada prevalencia de esta afeccion valvular, la VT ha merecido poca atencion en la literatura medica en nuestro pais. En el articulo publicado en REVISTA ESPANOLA DE CARDIOLOGIA, RodriguezCapitan et al presentan los resultados de mas de una decada de tratamiento de esta valvulopatia. Los autores analizan la epidemiologia y los resultados clinicos y funcionales de la cirugia de la IT grave relacionandolos con el tipo de procedimiento quirurgico practicado.

ResuménLa cirugía cardiovascular (CCV) es una especialidad de la medicina que se ocupa de los trastornos y enfermedades del sistema cardiocirculatorio que requieren una terapéutica quirúrgica. El presente documento está dedicado a los aspectos definitorios de la especialidad y a los organizativos de la actividad profesional incluyendo la acreditación y homologación. se define asimismo la sociedad profesional, la sociedad Española de Cirugía Torácica-Cardiovascular (SECTCV) en sus aspectos relacionados con la profesión, con la formación continuada así como la comunicación en el seno y fuera de la misma al igual que la necesidad y existencia de la fundación Cirugía y Corazón (FCC). También se focaliza en la actividad en CCV y los requerimientos estructurales mínimos para llevar a cabo el componente de intervención de la CCV. Por último, se confirman las recomendaciones para su práctica y se presentan los requerimientos de calidad y del programa docente de la especialidad. Este documento de la junta directiva de la SECTCV y asesores externos de la misma confirma la realidad de la especialidad y sus contenidos como señas de identidad inalienables.AbstractCardiovascular surgery (CVS) is a branch of medicine related to the diseases of the cardio-circulatory system requiring surgical treatment. this current document is dedicated to all aspects defining the specialty and the organization of the professional activity including accreditation and credentialing. The professional society, the spanish society of thoracic-Cardiovascular surgery (SECTCV) is also defined and insights on its professional, continuing education and communication given as well as the background for the Cirugía y Corazón foundation. Attention is also given to the activity in CVS and the core requirements for practice. The recommendations for practice and quality requirements and the postgraduate teaching programme are also presented. This document of the Council of the SECTCV and its external advisors confirms the reality of the specialty and its contents as sound signs of identity.

Introduccion y objetivos La edad de los pacientes sometidos a cirugia cardiaca se ha incrementado en los ultimos anos. Pretendemos conocer los resultados a medio plazo de la cirugia en octogenarios, comparandolos con los de otros ancianos de menos edad. Metodos Analizamos la mortalidad precoz, la incidencia de complicaciones postoperatorias, la supervivencia a medio plazo y los factores asociados a estas de 589 ancianos consecutivos sometidos a cirugia: 140 octogenarios entre 80 y 87 anos (grupo I) y 449 entre 75 y 70 anos (grupo II). Resultados Ambos grupos fueron homogeneos. No hubo diferencias en la mortalidad (I, 10%; II, 10,9%) e incidencia de complicaciones postoperatorias (I, 22%; II, 30%). La cirugia de emergencia, la combinada y la hipertension pulmonar se asociaron de manera independiente a la mortalidad y al desarrollo de complicaciones mayores. La supervivencia a 5 anos fue del 79% (I) y el 65% (II) (p = 0,832) y la supervivencia libre de evento cardiaco fue del 75% (I) y el 64% (II) respectivamente (p = 0,959). El 97% de los pacientes de ambos grupos se encontraban en clase funcional I-II. El EuroSCORE aditivo y la fibrilacion auricular preoperatoria se asociaron a una mayor mortalidad en el seguimiento. Ser octogenario no fue predictor (hazard ratio = 0,78; intervalo de confianza del 95%, 0,51-1,21; p = 0,373). Conclusiones La cirugia cardiaca en octogenarios seleccionados ofrece resultados similares a los de otros ancianos mas jovenes, con una buena supervivencia y calidad de vida a medio plazo. La hipertension pulmonar, la cirugia de emergencia y la combinada conllevan un riesgo elevado en estos pacientes.

Introduction and objectives. The age of patients undergoing cardiac surgery has increased in recent years. Our aims were to investigate the medium-term clinical outcomes of surgery in octogenarians and to compare them with outcomes in other elderly individuals of a less advanced age. Methods. We investigated early mortality, the incidence of postoperative complications, medium-term survival and factors associated with these parameters in 589 consecutive elderly patients undergoing surgery: 140 were octogenarians aged 80-87 years (group I) while 449 were aged between 75 and 79 years (group II). Results. The 2 groups were similar. There was no difference in mortality (10.0% in group I vs 10.9% in group II) or in the incidence of postoperative complications (22% in group I vs 30% in group II). Emergency surgery, combined surgery, and pulmonary hypertension were all independent predictors of mortality and of major postoperative complications. The 5-year survival rate was 79% in group I and 65% in group II (P=.832) and the cardiac event-free survival rate was 75% in group I and 64% in group II (P=.959). Overall, 97% of patients in both groups were in functional class I or II. The additive EuroSCORE and preoperative atrial fibrillation were both associated with increased mortality during follow-up. Being an octogenarian was not a predictor (hazard ratio=0.78; 95% confidence interval, 0.51-1.21; P=.373). Conclusions. In selected octogenarians, cardiac surgery gives similar results to those obtained in other elderly individuals of a less advanced age. The mediumterm survival rate and quality of life are good. Pulmonary hypertension, emergency surgery and combined surgery all increased risk in these patients.

ObjectiveTo determine the feasibility and safety of skeletal myoblast transplantation in patients with chronic myocardial infarction undergoing coronary artery bypass grafting.MethodsTwelve patients with a previous myocardial infarction and ischemic coronary artery disease underwent treatment with coronary artery bypass grafting surgery and intramyocardial injection of autologous skeletal myoblasts cultured with autologous serum. Global and regional cardiac function was assessed by echocardiogram. Fluorine 18 fluorodeoxyglucose and nitrogen 13–ammonia positron emission tomography studies were used to determine cardiac viability and perfusion. A group of historical control patients (n = 14) treated with coronary artery bypass grafting surgery without myoblast transplantation was analyzed.ResultsThe left ventricular ejection fraction improved from 35.5% ± 2.3% (mean ± SEM) before surgery to 55.1% ± 8.2% at 12 months (P < .01) in the myoblast group and from 33.6% ± 9.3% to 38.6% ± 11% in the control group. Regional contractility also improved in the myoblast group, particularly in cardiac segments treated with skeletal myoblasts (wall motion score index: 3.02 ± 0.17 at baseline vs 1.36 ± 0.14 at 12 months; P < .0001). Quantitative fluorine 18–fluorodeoxyglucose and nitrogen 13–ammonia positron emission tomography showed an increase in viability and perfusion 12 months after surgery both globally and in segments treated with myoblasts (P = .012 and P = .004). Skeletal myoblast implantation was not associated with adverse events or an increased incidence of cardiac arrhythmias.ConclusionsIn patients with previous myocardial infarction, treatment with skeletal myoblasts in conjunction with coronary artery bypass is safe and feasible and is associated with an increased global and regional left ventricular function, improvement in viability, and perfusion of cardiac tissue and no significant incidence of arrhythmias.

Background. Massive calcification of the atrial walls ("porcelain atrium") is a rare condition that usually has been reported as an incidental radiologic finding. Methods. Between January 1988 and June 1993, 971 patients underwent valvular operation at our institution; 21 patients showed extensive calcification of the left atrium. In 8 patients the calcification was massive, involving almost all the atrial surface. The diagnoses were established by radiology and were confirmed at operation. The mean age of these patients (4 men, 4 women) was 55 ± 9.6 years. All had rheumatic valve disease, were on atrial fibrillation, and had undergone at least one operation previously. Pulmonary artery pressure was severely increased, even up to systemic levels, in all patients except 1. Total endoatriectomy of the left atrium and mitral valve replacement were performed. No patient was lost during the follow-up. Results. Hospital mortality rate was 12.5% (1 patient) and 2 patients died in the late postoperative period. None of these deaths are attributable to the surgical procedure. Conclusions. In toto endoatriectomy of a massively calcified atrium is an easy to perform technique that helps to replace the mitral valve and close the atrial wall.

Progressive dyspnea after myocardial infarction can suggests the presence of left ventricular (LV) dysfunction or a left ventricular aneurysm (LVA). Surgical treatment of LVA aims to reduce its volume and to restore the ventricle. Recurrence of LVA after previous repair is extremely rare and the occurrence of concomitant postoperative true and false aneurysms is extraordinary. Surgery is usually challenging because of LV dysfunction and cardiac adherences in reoperations. We describe the simultaneous occurrence in a patient of a recurrent true and false LVA after surgical repair of a postinfarction LVA. Five years postoperatively, the patient remains alive and healthy. Resumo: A dispneia progressiva após o enfarte do miocárdio pode sugerir a presença de disfunção ventricular esquerda (VE) ou a formação de aneurisma ventricular esquerdo (AVE). Os procedimentos cirúrgicos concebidos para o seu tratamento visam reduzir o volume e a reparação do VE. A recidiva de AVE após a reparação anterior é extremamente rara e a concomitância de aneurismas verdadeiros e falsos pós-operatórios não é vulgar. A cirurgia é geralmente um desafio por causa da disfunção VE e das aderências cardíacas em reoperações. Apresentamos a concomitância num doente de um AVE verdadeiro e falso recorrente após reparação cirúrgica de um AVE pós-enfarte do miocárdio. Cinco anos após a cirurgia, o doente mantém-se vivo e saudável. Keywords: Postoperative, Recurrence, Post-infarction, Left ventricular, Aneurysm, Palavras-chave: Pós-operatório, Recidiva, Pós-enfarte, Ventrículo esquerdo, Aneurisma

We describe a curious congenital variation of human aortic arch (AA) branching pattern termed the “bovine aortic arch”. Rather than arising directly from the AA as a separate branch as occurs in the most common AA branching pattern, the left common carotid artery moves to the right and merges from the brachiocephalic trunk. It is the normal AA branching pattern presented in a number of animals (canines, felines or Macaque monkeys) but it has nothing to do with anatomy of AA in ruminant animals, including cattle and buffalo. That is why it is one of the most widely misnomers used in medical literature whose origin is nowadays unknown.

A 78-year-old woman was admitted to our institution with progressive dyspnea. She had previously been diagnosed with rheumatic heart disease and had undergone cardiac surgery for mechanical mitral valve replacement ten years previously. Transesophageal echocardiography revealed blockage of the mechanical prosthesis and the patient was scheduled for surgery, in which a thrombus was removed from the left atrial appendage. A partial thrombosis of the mechanical prosthesis and circumferential pannus overgrowth were concomitantly detected. Prosthetic heart valve blockage is a rare but life-threatening complication, the main causes of which are thrombosis and pannus formation. The two conditions are different but both are usually misdiagnosed. Two concurrent mechanisms of prosthesis blockage were found in this patient. Resumo: Uma mulher de 78 anos de idade, foi admitida na nossa instituição com dispneia progressiva. Foi-lhe previamente diagnosticada doença reumática, tendo sido submetida a cirurgia cardíaca de substituição de válvula mitral por prótese mecânica há dez anos. O ecocardiograma transesofágico revelou um bloqueio da prótese mecânica. A paciente foi referida para a cirurgia, tendo sido removido um trombo do apêndice atrial esquerdo. A trombose parcial de prótese mecânica e o crescimento circunferencial de pannus ocorreram concomitantemente. O bloqueio das válvulas cardíacas protésicas é uma complicação rara mas potencialmente fatal. As principais causas são a trombose ou formação de pannus. As duas condições são diferentes, mas em regra erradamente diagnosticadas. Nesta paciente foi detetado um duplo mecanismo de bloqueio de prótese. Keywords: Mitral, Prosthesis, Thrombosis, Pannus, Mechanical valve dysfunction, Palavras-chave: Mitral, Prótese, Trombose, Pannus, Disfunção valvar mecânica

Atherosclerotic changes are often noted in vein grafts at angiography 8 to 10 years after coronary artery grafting. Reoperation in these patients is hazardous, as manipulation of the grafts may loosen atheromatous debris and cause coronary embolization and myocardial infarction. A technique is described to avoid embolization of atheromatous material during reoperation in patients with patent atherosclerotic coronary vein grafts. This technique was carried out in six patients and compared to the standard technique of reoperation in similar patients. The incidence of complicated perioperative myocardial infarction (0/6 versus 5/12) and perioperative death (zero versus three) was lower when our new technique was used. This approach consists of minimal dissection for access to the right atrium and ascending aorta for cannulation, prompt ligation of all patent grafts at the start of cardiopulmonary bypass, cardioplegic infusion through the ascending aorta and subsequently also through newly inserted grafts using larger infusions until myocardial temperatures reach 15° C, and single aortic clamping for distal and proximal anastomoses.