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Resumen Objetivos El acido tranexamico se utiliza para prevenir la hiperfibrinolisis y disminuir el sangrado postoperatorio y el empleo de hemoderivados en cirugia cardiaca con circulacion extracorporea. Este trabajo evalua la eficacia de dosis bajas o altas de acido tranexamico mediante un estudio de cohortes, prospectivo, realizado en 2 hospitales de Valencia. Material y metodos Se seleccionaron 427 pacientes, 207 en el Hospital General Universitario (dosis bajas [DB]) y 220 en el Hospital Universitario y Politecnico La Fe (dosis intermedias [DI] y dosis altas [DA]), entre enero de 2019 y enero de 2020. Se estudio la presencia de hiperfibrinolisis por tromboelastometria rotacional, la administracion de hemoderivados en el intra y postoperatorio, el debito por drenajes en las 12 primeras horas postoperatorias y la aparicion de convulsiones. Se realizo un analisis comparativo univariante y multivariante. El analisis univariante de todas las categorias se llevo a cabo tras realizar un emparejamiento por indice de propension entre DB y DA, y entre DB y DI. Resultados No hubo diferencias estadisticamente significativas en la hiperfibrinolisis, la administracion de concentrados de hematies, el debito por drenajes en las 12 primeras horas ni la aparicion de convulsiones. El grupo DB recibio menos fibrinogeno que el grupo DA (p = 0,014) y DI (p = 0,040). En cambio, la cantidad de plasma fresco congelado administrado al grupo DB fue significativamente superior a la del grupo DI (p = 0,0002). Conclusiones La administracion de dosis bajas de acido tranexamico es tan efectiva como la de dosis mas elevadas en la profilaxis de la hiperfibrinolisis y la prevencion del sangrado postoperatorio en cirugia cardiaca.

Resumen La ecocardiografia transesofagica (ETE) es una herramienta fundamental en el intraoperatorio y postoperatorio de cirugia cardiaca con una gran difusion en los ultimos anos. El objetivo de este trabajo es conocer la situacion actual de la ETE en el ambito de la anestesiologia en cirugia cardiaca en Espana a traves de una encuesta nacional que explora la disponibilidad de equipos, indicacion y utilizacion de dicha tecnica, asi como la formacion y acreditacion de los profesionales responsables. Los hallazgos muestran que en Espana la ETE intraoperatoria es parte integral de los procedimientos cardiovasculares hoy en dia y en la mayor parte de los centros es realizada por anestesiologos altamente involucrados en este tipo de cirugias. A pesar de la ausencia de formacion estructurada en el curriculum formativo de nuestra especialidad, los anestesiologos adquieren las competencias mediante rotaciones especificas de corta duracion y un alto porcentaje de ellos ha obtenido la acreditacion oficial.

Resumen: La ecocardiografía transesfofágica es una técnica semiinvasiva que permite una evaluación de la morfología y función cardiaca a tiempo real y que constituye, a día de hoy, un estándar de calidad en las intervenciones de cirugía cardiovascular. Se ha convertido en una herramienta fundamental tanto de monitorización como de diagnóstico en el perioperatorio que permite la correcta planificación quirúrgica y manejo farmacológico dirigido.El objetivo de este documento es dar respuesta de forma consensuada y avalada por la evidencia científica de cuándo y cómo debe hacerse la ecocardiografía transesfofágica intraoperatoria en cirugía cardiovascular, qué aplicaciones tiene en el intraoperatorio, quién debe realizarla y cómo debe transmitirse la información obtenida durante el estudio. Los autores han hecho una revisión sistemática de las guías internacionales, artículos de revisión y ensayos clínicos para dar respuesta a estas preguntas. Abstract: Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management.The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

Resumen Introduccion La cirugia cardiaca se asocia a un uso significativo de hemoderivados. El objetivo de este estudio fue evaluar el efecto de la transfusion sobre la saturacion regional de oxigeno cerebral (SrO2) en pacientes tratados mediante cirugia cardiaca con EuroSCORE I aditivo > 6. Material y metodos Estudio prospectivo observacional. Se incluyo en el estudio a los pacientes con EuroSCORE I aditivo > 6 tratados mediante cirugia cardiaca con circulacion extracorporea. Se recogieron los valores demograficos, complicaciones perioperatorias, estancias hospitalarias, asi como el valor de SrO2 basal preinduccion, el valor mas bajo de hemoglobina (Hb) registrado durante la cirugia, el valor de la Hb y la SrO2 pre y postransfusional, asi como la existencia de una caida significativa de mas del 20% del valor basal de la SrO2 o por debajo del 50%. Consideramos como respondedores a la transfusion aquellos que presentaron un aumento de la SrO2 postransfusion de al menos el 20% del valor previo, un aumento de la desviacion estandar (DE) (7,9) o un aumento hasta el nivel basal. Resultados Se recogieron los datos de 57 pacientes. El EuroSCORE I aditivo medio ± DE fue de 7,4 ± DE 2,6 y el EuroSCORE II fue de 6,1 ± DE 7,4. El 52% fueron varones. Se trasfundio al menos un concentrado de hematies al 35,1% de la muestra (20 pacientes). La SrO2 pretransfusional fue 59 ± DE 8,6 y aumento de forma no significativa tras la transfusion del primer CH (61,19 ± 7,9; p = 0,1). Un 29,8% de los pacientes presentaron durante la cirugia una disminucion de la SrO2 del 20% con respecto a su basal o un valor inferior al 50%. Los pacientes con una disminucion significativa de la SrO2 presentaron un mayor tasa de complicaciones perioperatorias (p = 0,04). La estancia en la Unidad de Cuidados Intensivos (UCI) fue mayor en los pacientes con una disminucion significativa de la SrO2 respecto a los que la no presentaron (6,8 ± 8,2 dias vs. 4,3 ± 3,6; p = 0,01) al igual que la estancia hospitalaria (14,2 ± 9,4 dias vs. 10,1 ± 3,1; p = 0,01). En nuestra muestra, 6 de los 21 pacientes fueron respondedores. No hubo diferencias significativas en la morbilidad o la mortalidad entre los respondedores y los no respondedores. Discusion En nuestra poblacion, se observo un aumento no significativo en la SrO2 tras la transfusion. Cuando se analizaron los respondedores a la transfusion por incrementos de SrO2, pocos pacientes fueron identificados como respondedores. En conclusion, la SrO2 podria no ser una herramienta que guie la transfusion en pacientes tratados mediante cirugia cardiaca con EuroSCORE I aditivo > 6.

OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politecnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.

Resumen Introduccion El fracaso renal agudo (FRA) tras la cirugia cardiaca es un factor de riesgo asociado a mortalidad y consumo de recursos. Algunos estudios encuentran efectos beneficiosos del flujo pulsatil en la circulacion extracorporea (CEC) sobre la funcion renal. El objetivo de este estudio es describir la morfologia ecografica de la onda arterial renal modificando los parametros de la CEC pulsatil. Material y metodo Estudio descriptivo de 10 pacientes intervenidos mediante cirugia cardiaca con CEC sin FRA previo. Se realizo ecografia renal pre-, intra- y poscirugia. Durante la CEC pulsatil se modificaron la amplitud y el flujo base. Se obtuvieron registros de Doppler pulsado en arterias intrarrenales, se midio la velocidad maxima sistolica y la velocidad minima diastolica, el indice de resistencia (IR) y el tiempo de aceleracion (TAcel). Resultados La ecografia previa a la CEC (pre-CEC) muestra que hay diferencias significativas cuando se compara con los valores obtenidos en la modalidad A50F50 (p = 0,013), A50F30 (p = 0,013) y A60F50 (p = 0,003). No las hay para la modalidad A30F30 (p = 0,125). Conclusiones La disminucion de la amplitud y del flujo base de la pulsatilidad durante la CEC permite obtener una morfologia ecografica renal mas parecida a la fisiologica. Estudios posteriores utilizando estas caracteristicas durante la CEC pulsatil podrian mostrar la repercusion de este modo de perfusion sobre el FRA que se produce tras la cirugia cardiaca.

Resumen Introduccion El objetivo de este estudio es describir nuestra experiencia en la cirugia de revascularizacion coronaria aislada en pacientes mayores de 80 anos e identificar los riesgos especificos y predictores de mortalidad precoz. Material y metodos Entre enero de 1999 y junio de 2013, 3.097 pacientes fueron sometidos a cirugia de revascularizacion coronaria aislada. Se analizaron los pacientes mayores de 80 anos de edad. Se realizo una regresion mutivariante de Cox para predictores de mortalidad. Resultados Se identificaron 99 pacientes mayores de 80 anos (grupo-80; edad media 82 ± 3,5 anos) y 2.957 menores de 80 anos (grupo control; edad media 64,2 ± 9,7 anos). El EuroSCORE aditivo fue 8,4 ± 4,8 y 4,6 ± 4,6 (p 80 anos vs. Conclusion La cirugia de revascularizacion coronaria aislada se realiza preferentemente en pacientes mayores de 80 anos sin CEC. Presentan una mayor incidencia de complicaciones cardiovasculares, reintervenciones por sangrado en el postoperatorio inmediato y una mortalidad mas elevada.

Cardiac surgery (CS) is associated with a significant use of blood products. The aim of this study was to evaluate the effect of red blood cells concentrates (RBC) transfusion on regional cerebral oxygen saturation (SrOThis is a prospective descriptive study. Patients with additive EuroSCORE I6 undergoing CS with extracorporeal circulation were included in the study. The demographic values, perioperative complications, hospital/ICU length of stay (LOS), as well as the preinduction baseline SrOData from 57 patients were collected. The average additive EuroSCORE I was 7.4 (SD 2.6) and the EuroSCORE II was 6.1 (SD 7.4). 52% were male. 35.1% of patients received intraoperative transfusion of at least one unit of RBC. The overall mortality was 8.7% (N = 5). During surgery 29.8% of the overall sample presented a decrease of more than 20% of baseline SrO2 or a value lower than 50%. Patients with a significant decrease in SrO2 presented a higher rate of perioperative complications (P=0.04) and longer ICU-LOS 4.3 (SD 3.6) vs. 6.8 (SD 8.2) days (P=0.01) and hospital LOS 10.1 (SD 3.1) vs. 14.2 (SD 9.4) days (P=0.01). Pretransfusional HB was 7.4 (SD 0.8) mg/dl and postransfusional value was 8.4 (SD 0.8) (P =0.00). Pretransfusional SrO2 was 59 (SD 8.6) and increased non- significantly after RBC transfusion to 61.1 (SD 7.9) (P=0.1). Only 6 patients out of 21 could be considered responders. There were no significant differences in morbidity, mortality or LOS between responders and non-responders.In our population a non statistically significant increase in SrO2 was observed after RBC transfusion. When considering responders few patients were identified by SrO

Acute renal failure (ARF) after cardiac surgery is a risk factor associated with mortality and use of resources. Some studies have reported beneficial effects of pulsatile flow on cardiopulmonary bypass (CPB) on renal function. The aim of this study is to describe the echographic morphology of the renal arterial wave modifying the parameters of pulsatile CPB.Descriptive study was performed on 10 patients without previous AFR and undergoing cardiac surgery with CPB. Pre-, intra- and post-surgery renal ultrasound was performed. During pulsatile CPB, the amplitude and the baseline flow were modified. Recordings of pulsed Doppler in intrarenal arteries were obtained by measuring maximum systolic velocity, minimum diastolic velocity, resistance index (RI) and acceleration time (AT).Statistical differences were found in ultrasounds pre-CPB between A50F50 modality (P=.013), A50F30 (P=.013) and A60F50 (P=.003). No statistically significance was found with A30F30 modality (P=.125).The decrease in the amplitude and the baseline flow of pulsatility during CPB shows a renal ultrasound morphology that is more similar to the physiological one. Subsequent studies using these characteristics during pulsatile CPB could thus show perfusion over the ARF that occurs after cardiac surgery.

Resumen Introduccion La elevacion del lactato serico en el posoperatorio de la cirugia cardiaca es frecuente y su etiopatogenia, multifactorial. Esta elevacion se asocia a hipoxia tisular (hiperlactatemia tipo A) y a alteraciones metabolicas no hipoxicas (hiperlactatemia tipo B). El objetivo de este estudio fue evaluar la evolucion del lactato en el posoperatorio de la ablacion de la fibrilacion auricular durante la cirugia valvular cardiaca y analizar si los niveles de lactato pudieran ser predictores de morbimortalidad. Material y metodos Estudio de casos y controles. Se estudiaron 32 pacientes intervenidos entre 2011 y 2012 de ablacion de la fibrilacion auricular realizada junto a la cirugia de recambio valvular (grupo Maze), y 32 pacientes pareados (grupo Control). Se analizaron los niveles posoperatorios seriados de lactato, la morbimortalidad perioperatoria y la estancia hospitalaria. Se realizo un estudio univariante y multivariante para estancias prolongadas y un suceso compuesto de morbimortalidad con el fin de detectar predictores independientes. Resultados El lactato estuvo mas elevado a las 6, 12 y 24 h en el grupo Maze. En el analisis univariante resultaron significativos como predictores de complicaciones, mortalidad y estancias prolongadas el hecho de pertenecer al grupo Maze (OR 3,88; IC 95% 1,3-11,1; p = 0,01) y la elevacion de lactato a las 12 h (OR 1,33; IC 95% 1,01-1,7; p = 0,04). En el analisis multivariante la pertenencia al grupo Maze fue predictor independiente de complicaciones mayores (OR 4,13; IC 95% 1,3-12,9; p = 0,015), para el suceso compuesto de morbimortalidad (OR 3,9; IC 95% 1,3-11,6; p = 0,01) y para estancia prolongada en la Unidad de Cuidados Criticos (OR 5,7; IC 95% 2,01-15,7; p = 0,01). Conclusiones La cirugia de ablacion de la fibrilacion auricular podria ser una causa no descrita previamente de hiperlactatemia tipo B con picos entre las 4-24 h tras cirugia cardiaca. El valor predictivo de esta elevacion, su correlacion con la morbimortalidad, su sensibilidad y su especificidad para discriminar los umbrales significativos estan aun por definir.

Resumen Introduccion Una complicacion frecuente tras cirugia cardiaca con circulacion extracorporea es la hemorragia postoperatoria, llegando al 20% de los pacientes. La fibrinolisis es una de las causas de este sangrado excesivo y, por ello, se recomienda la utilizacion de acido tranexamico. El problema de su utilizacion reside en las numerosas pautas y en las diferentes dosis de administracion. Nuestro objetivo fue evaluar si existen diferencias en la hemorragia postoperatoria y la morbilidad tras cirugia cardiaca, con la administracion de diferentes dosis de acido tranexamico en 3 hospitales universitarios. Material y metodos Estudio retrospectivo multicentrico de cohortes. Se estudiaron 146 pacientes, intervenidos con CEC en cirugia programada segun el protocolo anestesico-quirurgico de cada centro. Se revisaron las historias clinicas y se dividieron en 2 grupos segun las dosis de acido tranexamico: Grupo A (dosis altas): dosis inicial de 20 mg/kg y perfusion continua de 4 mg/kg/h hasta el cierre de la esternotomia. Se anadieron 100 mg al cebado de CEC. Grupo B (dosis bajas): dosis inicial de 10 mg/kg seguido de una perfusion continua de 2 mg/kg/h hasta el cierre de la esternotomia. Se anadieron 50 mg al cebado de CEC. Se recogieron edad, sexo, peso, talla, tipo de procedimiento quirurgico (valvular, coronario o mixto), hematocrito, INR y recuento de plaquetas preoperatorio, tiempo y temperatura de CEC y hematocrito al cierre esternal. Entre las variables postoperatorias: debito por drenajes a las 6, 12 y 24 h postoperatorias, numero y tipo de hemoderivados transfundidos en las primeras 24 h, necesidad de reintervencion por hemorragia, ACV, AIT o un nuevo infarto agudo de miocardio, convulsiones y mortalidad. Resultados La incidencia de sangrado aumentado (pacientes en el percentil 90) fue superior en el grupo B en todas los momentos de evaluacion del estudio (p Conclusiones La dosis elevada de acido tranexamico en cirugia cardiaca con CEC parece reducir de forma significativa la hemorragia en las primeras horas del postoperatorio frente a dosis bajas. Sin embargo, esta disminucion no se traduce en una reduccion de las necesidades de hemoderivados.

Resumen Objetivos La cirugia cardiaca de acceso minimo mediante minitoracotomia tiene como objetivo principal una reincorporacion precoz a la actividad diaria. Para ello, el control del dolor postoperatorio es fundamental. Realizamos un estudio para valorar la calidad de la analgesia postoperatoria tras cirugia cardiaca por minitoracotomia, segun la tecnica analgesica. Material y metodos Estudio descriptivo observacional retrospectivo. Se incluyeron los pacientes intervenidos de cirugia cardiaca de acceso minimo en nuestro centro, desde el ano 2009 hasta 2011. Los pacientes se dividieron en 2 grupos dependiendo del tipo de analgesia recibida: analgesia por cateter paravertebral, mediante la infusion de anestesicos locales (grupo BPV), y analgesia intravenosa con opiaceos (grupo AIO). Los objetivos del estudio fueron la comparacion de la calidad analgesica y las complicaciones asociadas a la tecnica analgesica, tiempo de extubacion, complicaciones posquirurgicas y tiempos de estancia hospitalaria, entre ambas tecnicas. Resultados Treinta y siete pacientes fueron intervenidos mediante cirugia cardiaca de acceso minimo tipo «Heart-Port» modificado. Quince pacientes recibieron analgesia mediante bloqueo paravertebral y 22 mediante analgesia con opiaceos. Los datos se muestran como media y desviacion estandar (DE). Se aprecio un tiempo de extubacion traqueal inferior a 4 h en el 60% de los pacientes en el grupo BPV, frente al 22% del grupo AIO (p 0,05). No se observaron complicaciones asociadas al bloqueo paravertebral continuo. Discusion La analgesia mediante bloqueo paravertebral es una tecnica aceptablemente segura en cirugia cardiaca por toracotomia, que permite una extubacion precoz con un control optimo del dolor cuando se compara con analgesia iv con opiaceos.

In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.

Resumen Objetivo Los resultados quirurgicos en las enfermedades de la aorta toracica descendente y toracoabdominal han mejorado significativamente, aunque la morbimortalidad sigue siendo elevada. Como consecuencia de ello las tecnicas terapeuticas endovasculares se presentan como alternativas atractivas. En este trabajo comparamos los resultados de la cirugia abierta sobre ambos segmentos aorticos con el tratamiento endovascular. Material y Metodos Estudio retrospectivo de los pacientes intervenidos de patologia sobre la aorta toracica descendente y toracoabdominal mediante cirugia abierta y tratamiento endovascular en nuestro hospital desde 1995 a 2009. Analizamos las caracteristicas preoperatorias e intraoperatorias y los resultados postoperatorios de ambos grupos. Resultados Se revisaron 22 pacientes, 10 sometidos a cirugia abierta y 12 a tratamiento endovascular. Las etiologias con indicacion quirurgica fueron aneurismas, disecciones y ambos en el 40%, 30% y 30% en el grupo de cirugia abierta y con el 66,7%, 33,3% y 0% en tratamiento endovascular. La patologia de origen traumatico se correspondio con el 20% y 16,7% y la cirugia de urgencia con el 40% y 16,2% en el grupo de cirugia abierta y endovascular respectivamente. No hubo diferencias estadisticamente significativas en las caracteristicas preoperatorios (excepto en la edad de los pacientes) entre ambos grupos. Se observaron diferencias estadisticamente significativas en los tiempos quirurgicos, estancia en unidad de cuidados criticos y estancia hospitalaria, y en el tiempo de intubacion (p Discusion La incidencia de complicaciones postoperatorias en el grupo de cirugia abierta de la aorta toracica descendente es similar a los centros con un volumen reducido de enfermos. Se observa una tendencia hacia una reduccion de la morbimortalidad asi como diferencias estadisticamente significativas en el tiempo de intubacion, la estancia en la unidad de cuidados criticos y hospitalaria en el grupo de tratamiento endovascular.

Resumen Objetivo Analizar los datos clinicos y tratar de identificar los factores asociados que pudieran haber influido en la mortalidad postoperatoria de los pacientes de cirugia cardiaca durante su permanencia en la Unidad de Cuidados Criticos de los hospitales de la sanidad publica de la Comunidad Valenciana durante el 2007. Metodo Estudio retrospectivo desde 1 enero de 2007 hasta 31 diciembre del 2007. Se revisaron todas las historias clinicas de los pacientes operados de cirugia cardiaca con y sin circulacion extracorporea y se aplico un formulario de recogida de datos que permitio obtener la informacion necesaria para determinar edad, sexo, indice de masa corporal, factores de riesgo prequirurgicos, tipo de intervencion quirurgica realizada, tiempo de circulacion extracorporea, tiempo de isquemia, causa de mortalidad y tiempo de estancia en la Unidad de Cuidados Criticos. Resultados En los 5 centros publicos donde se realiza cirugia cardiaca la poblacion estudiada fue de 2.113 pacientes. El numero de pacientes fallecidos fue de 124, de ellos 70 fueron hombres y 54 mujeres. La media de edad fue 70 anos (DE 9,43) oscilando entre 36 y 91 anos. El valor medio del indice de masa corporal fue de 28,19 kg/m2 con un maximo de 42 kg/m2. El valor medio del Euroscore fue de 21,92 con un maximo de 94,29. Entre los factores de riesgo estudiados la hipertension arterial estaba presente en la mayoria de los pacientes (74,2%), dislipemia en el 51,6% de los casos, diabetes mellitus en el 38,7%, accidentes cerebrovasculares previos en el 7,3% e insuficiencia renal previa a la cirugia en el 2,4%. Destaca que el porcentaje mas alto de mortalidad, proxima al 35% de los 124 pacientes fallecidos, correspondio al grupo de pacientes sometidos a cirugia de revascularizacion coronaria, seguida de la cirugia combinada (reparacion/sustitucion valvular mas revascularizacion coronaria) con un 19,4%. En cirugia de valvula aortica la mortalidad fue del 18,5% y en cirugia de la valvula mitral un 11,3%. Los tiempos medios de circulacion extracorporea fueron de 148,63 minutos y el de isquemia miocardica de 94,91 minutos. Las causas de muerte mas frecuentes fueron shock cardiogenico (54,8%), seguido de shock distributivo (29,8%) y el menor grado shock hemorragico (8,9%). La estancia media de estos pacientes en las unidades de cuidados criticos fue de 13,6 dias. La mortalidad global fue de 5,87%. Conclusion Del grupo de pacientes estudiados que fallecieron en las unidades de Cuidados Criticos de la Comunidad Valenciana durante el ano 2007 tras ser intervenidos de cirugia cardiaca, fue la cirugia de revascularizacion coronaria la que presento mayor mortalidad. La hipertension arterial es el factor de comorbilidad preoperatoria con mayor prevalencia. El shock cardiogenico y el distributivo fueron las principales causas de mortalidad postoperatoria. Es necesario desarrollar un sistema de estratificacion de riesgo para la prediccion de mortalidad en las unidad de Cuidados Criticos y mejorar la calidad en el perioperatorio. Mortality following cardiac surgery in the national health service hospitals of the Community of Valencia in 2007: a descriptive analysis

Resumen Los aneurismas congenitos del seno de Valsalva son una afeccion muy rara en nuestro medio. La lesion fundamental consiste en un defecto entre la capa media aortica y el anillo fibroso de la valvula aortica, en un punto que se dilataria por accion de las presiones arteriales. En su evolucion natural existe riesgo de complicarse con una endocarditis bacteriana, con bloqueos de conduccion o con isquemia miocardica. La ruptura del aneurisma a una cavidad, generalmente derecha, origina un cortocircuito izquierda-derecha y da lugar a una insuficiencia cardiaca de pronostico fatal dejada a su evolucion. Presentamos el caso de una paciente de 60 anos, previamente asintomatica que desarrolla un cuadro clinico diagnosticado como hipertiroidismo que coincide con la rotura de un aneurisma congenito del seno de Vasalva. Ponemos de manifiesto la conducta anestesica y la importancia de la ecocardiografia intraoperatoria durante todo el procedimiento de la reseccion del aneurisma.

Postoperative myocardial infarction is a serious and frequent complication of cardiac surgery. Nonetheless, diagnosis in this context it is occasionally challenging. We sought to evaluate the kinetics and diagnostic accuracy of the new biomarker « heart-type fatty acid-binding protein » (h-FABP) in the early detection of myocardial injury in patients undergoing off-pump coronary artery bypass grafting, compared with classical biomarkers.A prospective study was conducted on 17 consecutive patients who underwent off-pump coronary artery bypass grafting during a 2 month period. Blood samples were drawn for measurement of myocardial ischemic injury biomarkers (h-FABP, troponin, creatine kinase [CK] and CK-MB), at baseline (T1), immediate post-coronary artery bypass grafting (T2), on ICU admission (T3), and after 4 (T4), 8 (T5), 24 (T6) and 48 h (T7). Perioperative ischemic complications, defined according to electrocardiographic, echocardiographic and hemodynamic criteria, were recorded.Earlier biomarkers peak plasma values occurred at T4 with troponin (2.9 ± 5.2 ng/mL), and at T5 with h-FABP (37.9 ± 55.5 ng/mL). Maximum values of CK and CK-MB occurred later, both in T6 (741 ± 779 and 37 ± 51 U/L, respectively). The optimized cut-off obtained for h-FABP was 19 ng/mL, providing a sensitivity and specificity of 77 and 75%, respectively, for diagnosis of perioperative ischemic injury, with an area under the ROC curve for h-FABP of 0.83 (95% CI 0.6-1.0) vs. 0.63 (95% CI 0.33-0.83) for troponin. This cut-off value for h-FABP is reached on average at T2 (mean value of h-FABP at T2: 18.9 ± 21.5 ng/mL).This is the first study evaluating the kinetics of h-FABP biomarker in perioperative off-pump coronary artery bypass grafting, and the cut-off value established could help to extend earlier detection of myocardial ischemia in this context.

Increased serum lactate in postoperative cardiac surgery is very common and its pathogenesis is due to multiple factors. The elevation of serum lactate is associated with tissue hypoxia (hyperlactatemia type A) and non-hypoxic (hyperlactatemia type B) metabolic disorders. The aim of the study was to assess the evolution of postoperative lactate in surgical atrial fibrillation ablation during cardiac surgery, and to determine whether lactate levels could be predictors of morbimortality.A case-control study was conducted on 32 patients undergoing surgical atrial fibrillation ablation and cardiac surgery (Maze group) and 32 matched patients (Control group), operated on between 2011 and 2012. An analysis was made of the levels of postoperative lactate, perioperative morbimortality and hospital length of stay. A univariate and multivariate study was performed for a composite endpoint of morbimortality, and prolonged length of stay.Lactate levels were significantly higher at 6, 12 and 24h in the Maze group. The univariate analysis showed that being in the Maze group (OR 3.88; 95% CI 1.3-11.1; P=.01) and an elevated lactate at 12h (OR 1.33; 95% CI 1.01-1.7; P=.04) were significant predictors of major complications, mortality, and longer hospital stays. In the multivariate analysis, surgical atrial fibrillation ablation (Maze group) was an independent predictor of major complications (OR 4.13; 95% CI 1.312.9; P=.015) for the morbimortality composite endpoint (OR 3.9; 95% CI 1.3-11.6; P=.01), and prolonged length of stay in the Intensive Care Unit (OR 5.7; 95% CI 2.01-15.7; P=.01).The atrial fibrillation surgical ablation may be a not-yet-described cause of type B hyperlactatemia, with serum peak values being reached between 4-24h after cardiac surgery. The predictive value of this elevation, its correlation with morbimortality, its sensitivity and specificity to discriminate the significant thresholds needs to be defined.

Minimal access cardiac surgery via minithoracotomy aims faster recovery and shorter hospital length of stay. Pain control is essential in order to achieve this goal. A study was conducted to assess the quality of post-operative analgesia and complications related to the analgesia techniques after cardiac surgery by minithoracotomy.A descriptive, observational and retrospective study was conducted on the patients subjected to minimal access cardiac surgery in our centre between the years 2009 to 2011. The patients were divided into two groups according to the type of analgesia received: analgesia through a paravertebral catheter, with an infusion of local anaesthetics (PVB group), and intravenous analgesia with opioids (IOA group). The aim of the study was to compare the analgesic quality and the complications associated to the analgesic technique, extubation time, post-surgical complications, and length of hospital stay between both techniques.A total of 37 patients underwent to a modified minimally invasive Heart-Port access cardiac surgery. Fifteen patients received analgesia through a paravertebral block and the other 22 IV analgesia with opioids. Data are shown as means and standard deviation (SD). Mean tracheal extubation time less than 4 hours was observed in 60% of the patients in the PVB group, compared to 22% in the IOA group (P.05). Length of stay in ICU for the PVB group was 1.2 (0.7) days compared to 2.2 (0.7) days in the IOA group (P.05). Mean hospital stay was 4.8 (1.2) days for the PVB group, and 5.6 (2.8) for the IOA group (P.05. No complications associated to the continuous paravertebral block were observed.PVB analgesia is an acceptable safe technique in cardiac surgery via thoracotomy which enables early extubation with optimal pain control when compared with IV analgesia with opioids.

In recent decades great advances have been made in surgical procedures for treating thoracic and thoracoabdominal aorta defects. Associated mortality and morbidity rates have dropped considerably, mainly in major reference centers, but nonetheless continue to be significant. The need for new strategies to reduce mortality and morbidity has made endovascular approaches an attractive alternative for high-risk surgical patients. The most feared complications of these procedures include paraparesis and paraplegia, which have devastating consequences on patients' quality of life. We provide an updated review of the pathophysiology of spinal cord ischemia in open and endovascular surgery, as well as perioperative measures designed to protect the spinal cord in both types of procedure.

Outcomes of surgical treatment of the descending thoracic aorta have improved markedly, although high associated morbidity and mortality continue to be a concern. Endovascular treatments are therefore attractive alternatives to open surgery. We compared outcomes of endovascular treatment to outcomes of open surgery on both aortic segments.Retrospective study of patients treated for descending thoracic and thoracoabdominal aorta disease by means of open surgery or endovascular treatment in our hospital between 1995 and 2009. We analyzed preoperative characteristics, intraoperative variables, and postoperative results in both groups.We retrieved the cases of 22 patients, 10 who underwent open surgery and 12 who received endovascular treatment. Surgery was indicated to treat aneurysm (40%), aortic dissection (30%), or both (30%) in the open surgery group. In the endovascular treatment group, 66.7% had aneurysm, 33.3% dissection, and 0% both. Trauma was involved in 20% of the open surgeries and 16.7% of the endovascular procedures. Forty percent of the open surgery cases and 16.2% of the endovascular interventions were emergencies. Patient age was the only statistically significant between-group difference in preoperative characteristics. Postoperative complication rates were similar. Significant differences were observed in duration of surgery, lengths of critical care unit and total hospital stays, and intubation time (P.05).The incidence of postoperative complications in the group of patients undergoing open surgery on the descending thoracic aorta was similar to incidences reported by other hospitals with moderate caseloads. A trend toward reduced morbidity and mortality in the endovascular treatment group was observed, and this group had significantly shorter times of intubation and lengths of critical care unit and hospital stays.

To analyze clinical records of cardiac surgery patients in an attempt to identify factors associated with mortality in the postoperative critical care units of the public health service hospitals in the Community of Valencia, Spain, in 2007.Retrospective study of cases from January 1, 2007 to December 31, 2007. The charts of all patients who underwent cardiac surgery with or without extracorporeal circulation were reviewed. A data collection protocol was followed to obtain information on age, sex, body mass index (BMI), presurgical risk factors, type of surgery, duration of extracorporeal circulation, duration of ischemia, cause of death, and length of stay in the postoperative critical care unit.The study population consisted of 2113 patients at 5 public hospitals; 124 patients (70 men, 54 women) died. The mean (SD) age was 70 (9.43) years (range, 36-91 years). The mean BMI was 28.19 kg/m2 (maximum, 42 kg/m2). The mean Euroscore was 21.92 (maximum, 94.29). Hypertension was present as a preoperative risk factor in most patients (74.2%); dyslipidemia was present in 51.6%, diabetes mellitus in 38.7%, stroke in 73%, and renal failure in 2.4%. It was noteworthy was that the group who underwent coronary revascularization had the highest mortality rate (nearly 35% of the 124 patients). The next highest mortality rate (19.4%) was in patients who had combined procedures (valve repair or substitution plus coronary revascularization). Mortality was 18.5% in the group undergoing aortic valve surgery and 11.3% in those undergoing mitral valve surgery. The mean duration of extracorporeal circulation was 148.63 minutes. The mean duration of myocardial ischemia was 94.91 minutes. The most frequent cause of death was cardiogenic shock (54.8%). This was followed by distributive shock (29.8%) and hemorrhagic shock (8.9%). The mean length of stay in the postoperative critical care unit was 13.6 days. Overall mortality was 5.87%.The highest mortality rate among cardiac surgery patients in postoperative critical care units in hospitals in the Community of Valencia in 2007 was in patients who underwent coronary revascularization. The most prevalent preoperative risk factor was hypertension. Cardiogenic shock and distributive shock were the most frequent causes of death in these patients. A system for classifying risk is needed in order to predict mortality in critical care units and improve perioperative care.

To describe complications and mortality in patients diagnosed of Stanford's type A (Daily) dissection of the ascending aorta requiring circulatory arrest for emergency placement of an aortic graft.Retrospective study of 21 patients treated between December 1992 and November 1997.Hypertension was the disease most often associated with the diagnosis (in 8 of the 21 patients). Preoperative mortality was 9.5% (2 of the 21 patients), no deaths occurred in the operating room and postoperative mortality was 15.8% (3 of the 19 patients who underwent surgery). Durations in mean time (SD) in minutes were as follows: anesthesia-surgery 437.9 (92), extracorporeal circulation 192.5 (47), aortic clamping 82.6 (20), circulatory arrest 30.5 (8). Retrograde cerebral circulation was carried out during circulatory arrest in all cases. Mean temperature during this period was 14.9 degrees C. During the postoperative period we recorded three permanent neurological complications, six cases of acute renal failure and seven respiratory complications, specifically one instance of adult respiratory distress syndrome and six of pneumonia, the most common. Consumption of blood products was high, with great interindividual variation.Anesthesia for and recovery from surgery for acute aortic dissection is complex and associated with a high rate of postoperative complication and high consumption of blood products.

We describe our experience in managing single lung ventilation (SLP) with the Univent bronchial blocker tube from 1993 to the present.Patients were grouped based on the following criteria: use of a double lumen tube as an alternative to SLP (group 1), use of SLP and tracheotomy (group 2), or difficult or dangerous orotracheal intubation (group 3).The mean age of the 32 patients (22 men and 10 women) studied was 45.7 +/- 12.2 years. Mean weight was 67.9 +/- 13.4 kg. Ten patients were physical status ASA I, 10 were ASA II, 10 were ASA III and 2 were ASA IV. Group 1 contained 28 patients (18 receiving right SLP and 10 receiving left SLP; use of SLP failed to collapse the lung in 4 patients [14.3%]). Group 2 consisted of 5 patients and group 3 contained 11. The Univent tube was used in 4 patients in group 3 who did not require use of SLP but whose intubation was considered difficult and in whom laryngoscopic findings were consistent with a Cormack-Lehane group III classification. The Univent bronchial blocker tube was used as a guide, such that intubation was achieved on the first try. The tube was removed from 3 patients (8%) in the intensive care recovery ward. The remaining 29 tracheas were extubated in the operating room. No side effects attributable to the Univent tube were recorded.The advantages and disadvantages of this new tool for the management of SLP mean that it may be useful for specific situations (such as for SLP with difficult intubation or in patients with tracheotomies or aneurysms of the descending thoracic aorta), but that it does not replace conventional methods. We believe that the Univent bronchial blocker tube should be available as part of operating room equipment.

To evaluate the monitoring of intramucosal pH (pHi) and standard pH (pHs) during heart surgery with extracorporeal circulation (ECC) and moderate hypothermia. The correlations of pHi and pHs and the postoperative APACHE III score after surgery were analyzed.Sixteen patients with cardiac output0.4 scheduled for coronary bypass surgery, or aortic or mitral valve replacement were studied. Arterial pH (pHa), pHi and pHs were measured and the difference between pHa and pHi was calculated before starting ECC (T0), during ECC and hypothermia (T1) and after termination of ECC (T2). The APACHE III score was recorded 18 h after surgery.No significant differences between the pHi and pHs were observed in these patients. pHi was significantly higher during ECC with hypothermia (T1) than at baseline (T0). pHi and pHs were significantly correlated during the study period. There was no correlation between the APACHE III score in the immediate postoperative period and either pHi or pHs during surgery.Periods of splanchnic hypoxia (pHi7.32) during heart surgery with moderate hypothermia were not seen in patients with cardiac output0.4. pHs is a reliable measurement of pHi. There is no relation between APACHE III scores in the early postoperative period and pHi or pHs levels during surgery.