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The outcomes of heart-lung transplant (HLT) are worse than those of heart transplant (HT) and lung transplant alone; this and the availability of mechanical assistance have meant that the indications for HLT have been changing. This study aims to analyze the evolution of indications for HLT in a country of 47 million inhabitants.We performed a retrospective observational study of all HLTs performed in Spain (performed in 2 centers) from 1990 to 2020. The total number of patients included was 1751 (HT 1673 and HLT 78). After clinical adjustment, overall survival was compared between the 2 groups. Seven etiological subgroups were considered within the HLT group: (1) cardiomyopathy with pulmonary hypertension (CM + PH);, (2) Eisenmenger syndrome, (3) congenital heart disease without Eisenmenger syndrome, (4) idiopathic pulmonary arterial hypertension (IPAH), (5) cystic fibrosis, (6) chronic obstructive pulmonary disease (COPD) and/or emphysema), and (7) diffuse interstitial lung disease.There were a large number of differences between patients with HLT vs HT. HLT had a 2.69-fold increased probability of death in the first year compared with HT. The indications for HLT have changed over the years. In the recent period the indications are mainly congenital heart disease and Eisenmenger syndrome, with some cases of CM + PH. Other indications for HLT have virtually disappeared, mainly lung diseases (IPAH, COPD, cystic fibrosis). Median survival was low in CM + PH (18 days), diffuse interstitial lung disease (29 days), and ischemic heart disease (114 days); intermediate in Eisenmenger syndrome (600 days); and longer in IPAH, COPD and/or emphysema, and cystic fibrosis.HLT is a procedure with high mortality. This and mechanical assists mean that the indications have changed over the years. Etiological analysis is of utmost interest to take advantage of organs and improve survival.

A giant coronary artery aneurysm is an infrequent anomaly encountered as an incidental finding. An even more rare condition is its association with a coronary artery fistula. We report the case of a 61-year-old woman that combines two of the rarest coronary anomalies: a 70-mm giant circumflex aneurysm with an arteriovenous fistula tract draining to the superior vena cava. Considering the unique display of anatomy, the surgery was guided with 3-dimensional printing technology. Direct fistula occlusion near its outflow union, orifice source closure, aneurysmal sac exclusion, and two coronary artery bypass grafts were surgically performed. The postoperative course was satisfactory.

OBJECTIVES: In recent years, the percentage of heart transplantation (HT) with short/medium-term assistance devices has increased. This study aims at analyzing primary graft failure and in-hospital mortality according to the type of care. MATERIAL AND METHODS: From January 2013 to December 2017 all patients undergoing urgent HT with circulatory/ventricular assistance were retrospectively and consecutively recruited. Combined transplants, retransplantations and pediatric transplants were excluded. The sample was divided in 10 groups according to the type of shot/medium term assistance devices. RESULTS: A total of 53 patients were recruited, 79% men, average age 49 ± 13 years. 26 patients (51%) had mechanical ventilation at the time of the HT. Primary graft failure occurred in 20 patients (38.5%), whilst it was more frequent in patients assisted with ECMO (8 patients in group 1 (45%) and 7 in group 2 (54%), p 0.5). 14 deaths (27%) were registered, whereas a higher mortality was observed in the group assisted with ECMO (6 patients in group 1 (34%) and 4 in group 2 (31%), p 0.6). Mortality was 17% in the group of non-urgent Levitronix. CONCLUSIONS: Despite not showing statistical significance due to the low number of patients in some subgroups, hospital mortality was high in HT patients with circulatory assistance. A trend towards a higher incidence of primary graft failure and mortality in patients assisted with ECMO was observed. The direct implantation of a centrifugal pump as a bridge to urgent transplantation could identify a subgroup with a better prognosis.

BACKGROUND The purpose of the study was to analyze postcardiac transplant complications in patients who received transplants with short-term mechanical ventricular assist devices and to compare complications according to the type of device. METHODS Ambispective and consecutive study of urgent heart transplants from 2015 to 2019. Pediatric transplants, retransplants, and combined transplants were excluded. A total of 45 patients were analyzed in 4 groups: (1) venoarterial extracorporeal membrane oxygenation (ECMO) implanted

BACKGROUND The purpose of this study was to compare early and late survival among patients who have undergone heart transplantation (HTx) with a short-term mechanical assist device. METHODS This was an ambispective, single-center, consecutive study of patients undergoing urgent HTx for 5 years. Pediatric transplants, retransplants, and combined transplants were excluded. Forty-five patients were included. Four groups were analyzed: those with venoarterial extracorporeal membrane oxygenation (ECMO) implanted 10 days; patients classified as INTERMACS 2 to 3 with Levitronix Centrimag implanted; and those classified as INTERMACS 2 with Levitronix Centrimag implanted. Survival and the influence of orotracheal intubation (OI) at the time of transplantation were compared. RESULTS There were differences in in-hospital mortality (P = .03) and total mortality (P = .06). The groups with the highest risk for mortality were those who carried ECMO for >10 days before transplantation or those classified as INTERMACS 2 with Levitronix Centrimag implanted. In these groups, the need for posttransplant circulatory support was also greater (P = .04) as was the length of stay in critical care (P = .02). The need for OI during the days of care and until transplantation had a negative effect on survival in all groups (P < .1). CONCLUSIONS There are different risk subgroups among patients who are transplanted with a circulatory/ventricular assist device. The lowest mortality occurs when the days of ECMO implantation are

Resumen: La enfermedad cardiaca carcinoide es una causa importante de morbimortalidad para estos pacientes. El pronóstico de esta enfermedad ha mejorado en las últimas décadas, recomendándose un enfoque multidisciplinario en centros de experiencia. No hay guías clínicas establecidas sobre el tratamiento de esta enfermedad, pero el tratamiento quirúrgico de sustitución valvular aumenta considerablemente la supervivencia y la calidad de vida. Se presenta un caso clínico de una mujer de 56 años con síndrome carcinoide de origen primario desconocido. A pesar de una buena respuesta al tratamiento médico con análogo de la somatostatina, desarrolló durante la evolución polivalvulopatía severa decidiéndose tratamiento quirúrgico. El resultado postoperatorio fue óptimo. Abstract: Carcinoid heart disease is a significant cause of morbidity and mortality in the patients that suffer from it. The prognosis of this disease has improved in the last decades, with a multidisciplinary approach in being recommended in centres of experience. There are no established clinical guidelines on the treatment of this disease, but the surgical treatment by valve replacement considerably increases survival and quality of life. The clinical case is presented of a 56-year-old woman with carcinoid syndrome of unknown primary cause. Despite a good response to medical treatment with a somatostatin analogue, she developed severe multiple valve disease during its course, and it was decided to perform surgical treatment. The post-operative outcome was optimal. Palabras clave: Enfermedad cardiaca carcinoide, Válvulas cardiacas, Cirugía torácica, Keywords: Carcinoid heart disease, Heart valves, Thoracic surgery

ResumenEl manejo conservador con inotrópicos y vasopresores en el shock cardiogénico ha mostrado ser insuficiente en muchos pacientes para mantener una perfusión adecuada y prevenir el fallo multiorgánico irreversible, lo que ha llevado a la mejora y a la utilización cada vez mayor de diferentes dispositivos de asistencia mecánica circulatoria de corta duración (balón intraaórtico de contrapulsación, TandemHeart, Impella, oxigenación de membrana extracorpórea [ECMO] y CentriMag Levitronix). Por ser la ECMO el dispositivo más versátil —capaz de proporcionar soporte a pacientes con fallo cardíaco, fallo respiratorio o fallo combinado cardiopulmonar durante días a semanas—, sus indicaciones se han ido diversificando, con un uso e interés en adultos creciente durante los últimos años, gracias también al progreso tecnológico y a la mejora en sus resultados. Es por ello esencial familiarizarse con la fisiología, las indicaciones, las estrategias de canulación, los principios de manejo y la evidencia sobre esta terapia, en la que enfatizaremos especialmente en esta revisión.AbstractMedical therapy with inotropes and vasopresors in the treatment of cardiogenic shock has failed in many patients to maintain adequate perfusion and to prevent irreversible end-organ failure, leading to improvement and increasing utilization of temporary mechanical circulatory support devices (intra-aortic balloon pump, TandemHeart, Impella, extracorporeal membrane oxygenation [ECMO] and CentriMag Levitronix). ECMO provides days to weeks of support for patients with respiratory, cardiac, or combined cardiopulmonary failure, and its use in adults is increasing as well as indications have expanded, due to advances in technology and improved outcomes. In this article specific emphasis is placed on physiology, clinical indications, cannulation techniques, management and evidence for ECMO, as it is essential to become familiar with this device.

ResumenIntroducciónLa elección la solución cardiopléjica óptima sigue siendo motivo de debate en la actualidad. La cardioplejía Del Nido (diseñada originariamente para la población pediátrica) está ganando popularidad en el campo de la cirugía cardiaca del adulto.MétodosSerie consecutiva de 30 pacientes que recibieron cardioplejía Del Nido como estrategia de protección miocárdica. Se registraron parámetros demográficos y de perfil de riesgo quirúrgico, tipo de procedimiento realizado, supervivencia perioperatoria; así como los principales parámetros de perfusión, variación de hematocrito intraoperatorio y liberación de enzimas de daño miocárdico durante el postoperatorio. Se determinaron los costes de elaboración de la formulación con respecto a los preparados comerciales convencionales.ResultadosLa serie presentó una supervivencia hospitalaria del 100%. La parada electromecánica del corazón fue efectiva en todos los casos. Los grupos de procedimientos realizados fueron cirugía combinada valvular/coronaria (43,34%), cirugía valvular simple (30%), cirugía coronaria aislada (13,34%) e intervenciones de más de 2 procedimientos (13,34%). Tras la reperfusión del miocardio se observó una tasa de desfibrilación espontánea del corazón del 83,34%. El destete de circulación extracorpórea se realizó con éxito en el 100%, sin necesidad de soporte circulatorio mecánico y con dosis bajas de soporte inotrópico con dobutamina. El coste estimado de elaboración se situó en 7,39 euros por cada unidad.ConclusionesLa cardioplejía Del Nido es de uso habitual en la práctica clínica tanto en la población pediátrica como en la adulta en centros de elevado volumen quirúrgico. Podría constituir una estrategia de protección miocárdica segura, eficaz y económica de aplicación universal en cirugía cardiaca. Son necesarios estudios adicionales de corte prospectivo para corroborar estos datos.AbstractIntroductionThe choice of the optimal cardioplegic solution is still under debate. Del Nido cardioplegia (originally designed for the paediatric population) is gaining popularity in the field of adult cardiac surgery.MethodsA study was conducted on a consecutive series of 30 patients who received Del Nido cardioplegia as myocardial protection strategy. Demographic and risk profile parameters, procedure performed, and surgical survival were registered, as well as main the perfusion variables, intraoperative haematocrit variation, and myocardial injury enzymatic release during the postoperative period. Formulation costs compared with conventional commercial solutions were determined.ResultsSurvival of the series was 100%. Electromechanical arrest of the heart was achieved in all cases. The group of procedures performed were combined valvular/coronary surgery (43.34%), isolated valve surgery (30.00%), coronary artery bypass graft surgery (13.34%), and interventions with more than 2 procedures (13.34%). After myocardial reperfusion, spontaneous defibrillation of the heart occurred in 83.34%. Weaning from cardiopulmonary bypass was successful in 100% with no mechanical circulatory support, and low-dose inotropic support with dobutamine. The estimated preparation costs were set at 7.39 euros per unit.ConclusionsDel Nido cardioplegia is routinely used in clinical practice both in paediatric and adult population in high volume centres. It could be a safe, effective and cheap myocardial protection strategy of universal implementation in cardiac surgery. Additional prospective studies are needed to confirm these data.

ResumenIntroducciónLa naturaleza heterogénea de la válvula aórtica bicúspide (VAB) y su asociación con la dilatación de la aorta ascendente ha sido reconocida en muchos estudios observacionales. El objetivo de nuestro estudio es valorar la asociación que tiene el patrón de aortopatía con la morfología y lesión valvular primaria de esta valvulopatía.MétodosDesde febrero del 2007 hasta noviembre del 2013, 107 pacientes con VAB y aneurisma de aorta ascendente fueron derivados a cirugía. Identificamos la morfología valvular intraoperatoriamente y la lesión valvular primaria por ecocardiografia. Con la tomografía preoperatoria realizamos mediciones en varios sectores de la aorta ascendente.ResultadosLa edad media al momento de la cirugía fue significativamente menor en enfermos con insuficiencia frente a estenosis aórtica (51 vs. 64 años, p

ResumenIntroducción y objetivosLos modelos predictivos de mortalidad hospitalaria, EuroSCORE logístico y EuroSCORE II, ofrecen un rendimiento razonable en cirugía cardíaca. Sin embargo, su aplicación en la cirugía de aorta es motivo de controversia. El objeto del presente estudio es el diseño de un modelo de estimación de riesgo específico ajustado a pacientes con cirugía de aorta torácica.MétodosSe recogieron retrospectivamente 310 pacientes consecutivos con cirugía de aorta proximal (raíz, aorta ascendente y/o arco) entre 2006 y 2013. Se elaboró un modelo predictivo mediante regresión logística múltiple con las variables que resultaron significativas en el análisis univariado. La capacidad discriminatoria se calculó mediante el área bajo la curva ROC y se comparó con las obtenidas aplicando el EuroSCORE logístico y el EuroSCORE II.ResultadosLa mortalidad hospitalaria observada fue de un 8,1%. Las variables relacionadas con muerte hospitalaria fueron la clase NYHA, el aclaramiento de creatinina, el estado crítico preoperatorio y la endocarditis activa. La mortalidad predicha por el EuroSCORE logístico, el EuroSCORE II y el modelo elaborado fueron de 14,98, 8,12 y 8,06%, respectivamente. El área bajo la curva ROC fue de 0,665 (0,541-0,789) para el EuroSCORE logístico, de 0,718 (0,588-0,848) para el EuroSCORE II y de 0,775 (0,675-0,876) para el modelo elaborado (Hosmer-Lemeshow, p=0,405).ConclusionesEl modelo predictivo elaborado predice la mortalidad hospitalaria de manera más ajustada, y con mayor discriminación que el EuroSCORE logístico y el EuroSCORE II para pacientes sometidos a cirugía de aorta torácica, aportando además una mayor sencillez de cálculo al basarse únicamente en 4 parámetros preoperatorios.AbstractIntroduction and objectivesPredictive stratification scores of hospital mortality, logistic EuroSCORE and EuroSCORE II are reasonable tools in cardiac surgery. However, its utility in aortic procedures is controversial. The aim of this study is to design a new specific mortality risk model adjusted to patients undergoing thoracic aortic surgery.MethodsWe analyzed retrospectively 310 consecutive patients who underwent surgery of proximal aorta (root, ascending and/or arch) between 2006 and 2013. A predictive model was developed using multiple logistic regression, entering variables that were significant in univariate analysis. Discriminatory performance was calculated by area under ROC curve and was compared with those of the logistic EuroSCORE and EuroSCORE II.ResultsThe observed death in-hospital mortality was 8.1%. Hospital mortality related variables were NYHA class, creatinine clearance, critical preoperative status, and active endocarditis. Logistic EuroSCORE, EuroSCORE II and new model predicted mortality were 14.98, 8.12, and 8.06, respectively. Area under ROC curve was 0.665 (0.541-0.789) for logistic EuroSCORE, 0.718 (0.588-0.848) for EuroSCORE II and 0.775 (0.675-0.876) for the new developed model (Hosmer-Lemeshow P=.405).ConclusionsThe new developed model predicts hospital mortality more accurate and with more discriminatory power than logistic EuroSCORE and EuroSCORE II in thoracic aortic surgery, also offering an easier method for the calculation based on only 4 preoperative parameters.

La técnica quirúrgica óptima para el tratamiento de la enfermedad aneurismática extensa de la aorta torácica no está claramente establecida. Las opciones incluyen un procedimiento en estadios, por esternotomía media, habitualmente incorporando una trompa de elefante, en el primero, seguido por toracotomía izquierda para completar el procedimiento. Una segunda opción es un procedimiento en un estadio realizado mediante ester-notomía media exclusivamente, o bien, esternotomía media extendida mediante incisión a través de un espacio intercostal, o bien, toracotomía anterior bilateral (incisión clamshell).The optimal surgical technique for the treatment of extensive aneurysmal disease of the thoracic aorta is not clearly established. Options include a staged approach, commonly incorporating an elephant trunk in the first stage performed through a median sternotomy, followed by a left thoracotomy to complete the procedure. A second option is a one-stage procedure performed through a median sternotomy alone, a median sternotomy with an extension through a left intercostal space, or a bilateral anterior thoracotomy (clamshell incision). The surgical techniques are described.

ResuménLa oxigenación de membrana extracorpórea (ECMO) es un sistema de asistencia mecánica circulatoria y respiratoria extracorpórea de corta duración. Está indicado en el shock cardiogénico e insuficiencia respiratoria con compromiso vital de cualquier causa, cuando las medidas terapéuticas médicas o quirúrgicas convencionales, incluyendo el empleo del balón intraaórtico de contrapulsación, han fracasado. Sus ventajas respecto a otros sistemas de asistencia mecánica circulatoria son: 1) inicio rápido de la asistencia mediante canulación periférica; 2) es una técnica poco agresiva, por lo que es mejor tolerada en estos pacientes críticos; 3) al no necesitar toracotomía, permite continuar con las medidas de resucitación cardiopulmonar en los pacientes con parada cardíaca; 4) proporciona soporte pulmonar, univentricular o biventricular; 5) se ha mostrado eficaz como puente a una asistencia ventricular de larga duración o como puente a trasplante cardíaco, y 6) es mucho más económico que otros dispositivos de asistencia ventricular.AbstractExtracorporeal membrane oxygenation (ECMO) is a short-term mechanical circulatory and respiratory assistance. It is indicated in life-threatening cardiogenic shock and respiratory insufficiency of any cause, when conventional medical and surgical therapeutic measures, including intraaortic balloon pump have failed. its advantages regarding other mechanical circulatory assistance are: 1) quick start of assistance trough peripheral cannulation; 2) it is a less aggressive technique, therefore it is better tolerated; 3) there is no need of thoracotomy, allowing cardiopulmonary resuscitation in patients with cardiac arrest; 4) it provides lung, univentricular or biventricular support; 5) it has been shown efficient as bridge to bridge or bridge to transplantation, and 6) it is cheaper than other ventricular assist devices.

El aneurisma de arco aórtico (AAA) es la dilatación patológica que afecta a la porción horizontal de la aorta intratorácica. En el presente capítulo se analizan los principales aspectos relacionados con la historia natural y las complicaciones de esta enfermedad, fundamentalmente la rotura, así como los métodos diagnósticos, las indicaciones actuales de tratamiento quirúrgico según la evidencia disponible, la valoración del riesgo quirúrgico y el estudio preoperatorio necesario y las principale s variantes técnicas de tratamiento, tanto en cirugía abierta como híbrida.Aortic arch aneurysm (AAA) is the pathological dilation affecting the horizontal portion of the intrathoracic aorta. In this chapter we discuss the natural history an key aspects of the complications of this disease, mainly rupture, as well as diagnostic tests, current indications for surgical treatment according to the available evidence, surgical risk assessment, preoperative study and major technical variations of treatment, both in open and hybrid surgery.

Se presenta el caso de un paciente de 32 años que presentó síntomas de fibrilación ventricular mientras estaba practicando una maratón. El estudio diagnóstico puso de manifiesto la existencia de un origen anómalo de la arteria coronaria derecha en el seno coronario izquierdo, con trayecto no intramural entre la aorta y la arteria pulmonar. La reparación quirúrgica consistió en la realización de una anastomosis laterolateral de la coronaria derecha al seno aórtico derecho. El postoperatorio del paciente transcurrió con normalidad. El origen aórtico anómalo de las coronarias es una alteración congénita rara asociada a un mayor riesgo de muerte súbita. En muchos casos la enfermedad es asintomática hasta producirse el infarto o la arritmia ventricular. Cuando la coronaria sigue un trayecto intramural la corrección mediante el unroofing es la técnica más empleada. Si no hay trayecto intramural y la translocación no es posible, la técnica descrita constituye una alternativa válida.We report the case of a 32-year-old patient with ventricular fibrillation while running marathon. Diagnostic tests showed the existence of an anomalous origin of the right coronary artery from the left aortic sinus, with a non intramural course between aorta and pulmonary artery. Surgical repair was performed using a side-to-side anastomosis between the right coronary artery and the right aortic sinus. The patient recovered uneventfully. Anomalous aortic origin of coronary arteries is a rare congenital defect associated with increased risk of sudden death. Often myocardial infarction or ventricular arrhythmia are the first manifestations of the disease. Unroofing procedure is the commonest technique if the coronary has an intramural course. If there is not an intramural course and coronary reimplantation cannot be performed, this technique may be an acceptable therapy.

Objetivo El proposito de este estudio fue analizarvariables del donante, receptor y quirurgicaspara descubrir factores que pudieran predecir mortalidaddurante la fase precoz ( Material y metodo Se analizaron 125 trasplantescardiacos ortotopicos consecutivos de adultos. Laedad media fue de 51 ± 11 anos (rango, 12-67), 109fueron varones (87%) y 16 mujeres (13%). Se compararondos grupos segun los pacientes hubieranfallecido o no durante los primeros 30 dias tras eltrasplante cardiaco (15 y 110 pacientes, respectivamente). Protocolo inmunosupresor: en el preoperatorio,ciclosporina mas azatioprina. En el intraoperatorio,metilprednisolona. En el postoperatorio, metilprednisolona(primeras 24 h), anticuerpos monoclonalesantilinfociticos (7-10 dias posterioresal trasplante), ciclosporina, azatioprina y corticoides. Se analizaron los siguientes parametros del receptor:sexo, edad, peso, talla, perimetro toracico,cardiopatia de base, intervenciones toracicas previas,estadio funcional o necesidad de catecolaminaslos dias previos al trasplante, presiones y resistenciaspulmonares, historia de hipertensionarterial sistemica, elevacion de creatinina, gruposanguineo, trasplante realizado de forma urgente yrelacion de peso receptor/donante. Se analizaronlos siguientes parametros del donante y la intervencion:sexo, edad, peso, perimetro toracico, diasde estancia en cuidados criticos, dosis de dopaminay dobutamina, grupo sanguineo, procedencia delorgano, causa de muerte, tiempo de isquemia y circulacionextracorporea y tipo de cardioplejia. Resultados La tasa de mortalidad precoz ennuestra serie fue del 12%. En el analisis univariantese observaron diferencias en cuanto a los antecedentesde cirugia cardiovascular, grupo sanguineodel receptor, necesidad de realizar eltrasplante de una forma urgente, resistencias vascularespulmonares superiores a 2,5 UW, tiempo decirculacion extracorporea y la relacion de pesosentre el receptor y el donante. Se aproximo a lasignificacion la causa de muerte del donante. Elanalisis multivariante senalo, como parametros convalor predictivo independiente de mortalidad precoz,los antecedentes de intervencion con circulacionextracorporea, las resistencias vascularespulmonares elevadas, el trasplante urgente, la relacionde pesos receptor/donante y el tiempo de circulacionextracorporea. Conclusiones Pensamos que los resultados denuestra experiencia pueden ayudar a estratificar elriesgo ante un receptor de trasplante cardiaco ortotopico,e incluso contraindicar el procedimientoen determinados casos con acumulacion de factoresde mal pronostico en receptores «limite».

Introduccion y objetivo La mediastinitis poscirugia cardia-ca, aunque infrecuente, continua siendo una patologia con una elevada mortalidad pese a su manejo de forma agresiva. Segun algunas series publicadas previamente, la mortalidad se situa en torno al 30–40% de los afectados que son tratados de forma convencional. En este estudio queremos mostrar nuestros resultados y experiencia en el manejo de esta patologia con la utilizacion de la terapia vacuum assisted closure (VAC). Material y metodos Desde abril de 2006 - diciembre de 2011 se utilizo la terapia VAC en 63 pacientes con diagnostico establecido de mediastinitis. De forma retrospectiva se recogieron datos pre, intra y postoperatorio que se analizaron en SPSS. Resultados La edad media fue de 64 anos (19–82), siendo el 73% varones. El 58,9% eran diabeticos y el 45% eran obesos. La media de dias con tratamiento VAC fue de 28. La distribucion por etiologias fue: cirugia coronaria (BPAC) 48%, cirugia valvular 18%, combinado 12%, trasplante 10%, congenitos 6%, y aorta ascendente 6%. En el 80% de los pacientes la infeccion fue polimicrobiana, destacando el S. aureus, que se aislo hasta en el 65% de los cultivos. La estancia media hospitalaria fue de 59 dias. La mortalidad hospitalaria fue de 9 pacientes (14,2%). Conclusiones En nuestro estudio evidenciamos que la terapia VAC disminuye significativamente la mortalidad y estancia hospitalaria de las mediastinitis poscirugia cardiaca comparada con las series publicadas con el tratamiento convencional. Estos resultados nos animan a continuar con este tratamiento.

The study aim was to determine whether long-term prognosis was affected by valve replacement with a tilting-disc prosthesis.Surgical data were recorded prospectively for all (n = 153) valve replacement cases with the Omnicarbon prosthesis during the period February 1985 to January 1986. A rheumatic valvular pathology was present in 105 patients (68.6%). There were 78 (51%) aortic (AVR), 51 (33%) mitral (MVR) and 24 (16%) double (DVR) valve replacements. The follow up was 99% complete (n = 151).Mean follow up was 10.2+/-4.4 years (total 1,472 patient-years (pt-yr)). Survival at 10 years was 68+/-4% (71+/-5% AVR, 61+/-7% MVR), and this fell to 57+/-4% at 14 years. No structural failure was observed. Thromboembolic and hemorrhagic events were rare, with actuarial freedom from thromboembolism of 94+/-2% and 91+/-3% at 10 and 14 years, respectively. This low incidence of thromboembolism encouraged an ease in anticoagulation; hence the AVR and MVR cohorts had a median INR of 2.8, but a higher INR (3.4) was maintained in DVR patients. All prostheses had acceptable hemodynamic performance. No cases of hemolytic anemia were detected, and mean blood counts were within normal ranges. Lactate dehydrogenase values indicated minimal hemolysis, and were lowest after AVR (median LDH 93% normal) and highest after DVR (median LDH 136% normal). Functional evaluation showed an improvement in NYHA class that remained stable over 14 years. At follow up, 95% (75/79) of patients were in NYHA class I or II.Survival and quality of life after Omnicarbon valve implantation exceeded the authors' expectations. Functional capacity remains good, and valve-related complication rates are low. The Omnicarbon tilting-disc valve has been shown to provide reliable and satisfactory service in the long term.

Background . From February 1985 to December 1994, 781 Omnicarbon valve prostheses were implanted in 647 patients. These were 357 male and 290 female patients with a mean age of 53.5 ± 10.5 years (range, 4 to 78 years). Before operation, 81% of the patients were in New York Heart Association class III or IV, 16% were in class II, and only 3% were in class I. Methods . There were 227 aortic valve replacements (AVR) (35%), 286 mitral valve replacements (MVR) (44%), and 134 double-valve replacements (DVR) (21%) (AVR + MVR). Follow-up was 96.3% complete and consisted of 2,746 patient-years (mean follow-up, 4.6 years, and maximum follow-up, 10.7 years). Results . Hospital mortality rates were 7.0% for AVR, 8.0% for MVR, and 8.2% for DVR. The annualized rate of anticoagulant-related hemorrhage was 0.8% per patient-year, and thromboembolism occurred at a rate of 0.7% per patient-year. No structural failure was observed during 10-year follow-up. Twenty-one instances of nonstructural dysfunction (two, pannus growth, and 19, dehiscence) of the Omnicarbon valve occurred in 20 patients, an incidence of 0.8% per patient-year. Hemolytic anemia was observed only in the presence of valvular dehiscence (6 of 19). Eight patients (0.3% per patient-year) had development of prosthetic valve endocarditis (4, AVR; 2, MVR; and 2 DVR). At the end of 10 years of follow-up, 91% of the survivors were in New York Heart Association class I or II. The overall survival rate at 10 years was 82.5% ± 2.6% (85.0% ± 3.9%, AVR; 81.0% ± 4.1%, MVR; and 82.5% ± 2.6%, DVR). Considering only valve-related deaths, the survival rate at 10 years was 91.9% ± 2.4% (90.0% ± 2.7%, AVR; 93.1% ± 3.8%, MVR; and 90.0% ± 1.8%, DVR). Conclusions . Clinical results over a 10-year follow-up are excellent with the Omnicarbon prosthesis.

Introduccion y objetivo La mediastinitis es una complicacion devastadora en aquellos pacientes que deben ser sometidos a tratamiento inmunosupresor. El objetivo es presentar nuestra experiencia con el uso de la terapia vacuum assisted closure (VAC) para el manejo de esta patologia en pacientes sometidos a trasplante cardiaco. Material y metodos Desde abril de 2006 - diciembre de 2011, 5 pacientes sometidos a trasplante cardiaco presentaron mediastinitis y se utilizo la terapia VAC como tratamiento de base. Estudio retrospectivo y analisis con software SPSS 17.0. Resultados Se analizaron 5 pacientes (3 varones – 2 mujeres) con edad media de 49 anos. Todos los cultivos fueron positivos para el S. aureus (aislado en el 100%), en el 60% la infeccion fue polimicrobiana. La media de dias con terapia VAC fue de 30 y la estancia hospitalaria media fue 57 dias. El tratamiento definitivo al cual fueron sometidos fue cierre por segunda intencion en 2 casos y plastia de pectorales en 3. Conclusiones No hubo ningun caso de muerte hospitala-ria. En todos los pacientes se evidencio una evolucion satisfactoria con la utilizacion de la terapia VAC que permitio la resolucion definitiva de la herida sin ser necesaria en ningun caso una reduccion en la terapia inmunosupresora.

Evitar la fragmentación del tejido mixoide durante el acto quirúrgico y resecar todo el espesor del septo interauricular con implantación tumoral son las dos claves para evitar las graves complicaciones de embolia peroperatoria y recidiva postoperatoria en el tratamiento quirúrgico del mixoma auricular izquierdo. La vía transeptal superior nos ha permitido, en tres pacientes, la extirpación en bloque de mixomas de gran tamaño con facilidad y sin complicaciones.To avoid fragmentation of the myxomatous tissue during the surgical procedure and to remove the whole thickness of interatrial septum with tumoral implantation, there are the two keys in order to avoid perioperative embolism and postoperative recurrence in the surgical treatment of atrial myxoma. The superior transseptal approach allowed us to perform an “en bloc” resection of large size left atrial myxomas.

ResumenLas fistulas congénitas desde los senos aórticos a las cavidades cardíacas son lesiones infrecuentes, la mayoría provocadas por la rotura de un aneurisma previo. Las fístulas desde senos normales son aún más raras. Tras el diagnóstico, las fístulas grandes deben corregirse pronto, pero el tratamiento en el caso de fístulas pequeñas asintomáticas está peor establecido. Presentamos el caso de un paciente asintomático con fístula de seno aórtico no coronariano no aneurismático a ventrículo derecho. Se describen los hallazgos del diagnóstico así como la técnica quirúrgica usada para su corrección.AbstractCongenital fistulas from aortic sinuses to cardiac chambers are unusual lesions, most of them caused by a rupture of a previous aneurysm. Fistulas from normal sinuses are even rarer. Once diagnosed, large fistulas have to be corrected as soon as possible, but treatment in case of small asymptomatic fistulas is less established. A fistula from a non aneurysmatic non coronary aortic sinus to the right ventricle was diagnosed in an asymptomatic patient. Diagnostic features as well as the surgical technique used in its correction are described.

Clinical Summary A 57-year old man with a history of acute thoracic pain 3 years previously was seen in September 2005 with interscapular pain. Computed tomographic scanning revealed a type B aortic dissection with 7.9-cm dilatation of distal aortic arch and proximal descending aorta. Angiography demonstrated that the aneurysm involved the left subclavian artery (Figure 1, A). The patient refused conventional surgery, so we offered endovascular treatment. To allow enough proximal landing zone for stent-graft placement, a median sternotomy was performed, and the left common carotid and subclavian arteries were dissected free. After administration of 10,000 IU heparin, a partial occlusion clamp was applied to the ascending aorta, and the body of a 16 8-mm Dacron polyester fabric Y-graft was anastomosed to the aorta with 4-0 Prolene (Ethicon, Inc, Somerville, NJ). Subsequently, the left subclavian artery was divided, its proximal stump was sewn with 4-0 Prolene, and its distal part was anastomosed to one of the 8-mm branches of the Y-graft with 5-0 Prolene. A similar procedure was performed with the left common carotid artery (Figure 2, A ). The next day, in the vascular radiology suite, the endovascular procedure was performed with general anesthesia and cerebrospinal fluid monitoring. The right common femoral artery was dissected free. The true lumen was catheterized under fluoroscopy, and the delivery system was advanced through it up to the ascending aorta. Thereafter, a Zenith TX2 40-mm endovascular graft (Cook Group Incorporated, Bloomington, Ind), 10% oversized, was deployed under fluoroscopic control from the brachiocephalic trunk to the descending aorta at the level of T9. Completion aortography confirmed complete aneurysmal exclusion (Figure 1, B ). Four days later, the patient had acute thoracic pain and arterial hypotension. Echocardiography showed severe aortic regurgitation caused by ascending aortic dissection. The patient was immediately transferred to the operating room. Cardiopulmonary bypass was initiated through the right axillary artery and right atrium. During cooling, the ascending aorta was clamped and sectioned, the previous Y-graft was clamped and deanastomosed, and cold blood cardioplegia was administered through coronary ostia (subsequent doses were administered retrograde every 20 minutes). From the Departments of Cardiac Surgery and Vascular Radiology, Hospital Universitari La Fe, Valencia, Spain.