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Las lesiones tricuspideas secundarias a traumatismos cerrados del torax son raras y dificiles de diagnosticar. No obstante, han sido descritos mas de 100 casos de insuficiencia tricuspidea postraumatica en los ultimos 35 anos. Presentamos tres casos diagnosticados e intervenidos en nuestro centro en los ultimos 8 anos.

Functional tricuspid regurgitation (TR) occurs as a result of asymmetric dilatation and deformation of the tricuspid anulus owing to right ventricular enlargement. Although TR may spontaneously regress after correction of left-sided valvular lesions, increasing experience shows that in the presence of significant insufficiency, tricuspid annuloplasty (TA) decreases postoperative morbidity and mortality. 2 In the present report we describe a simple technique of TA for patients with significant TR. We evaluated the efficacy of the procedure by clinical and Doppler echocardiography at follow-up. Patients. The study group comprised 34 patients (26 female and 8 male, aged 61 6 36 years) who underwent TA for correction of TR. Isolated TR repair was performed in six patients in whom the valve had previously been repaired by the De Vega annuloplasty. Seventeen patients underwent concomitant mitral replacement, six a mitral-aortic valve replacement, and five an additional coronary bypass grafting. Nine patients had undergone a From the Departments of Cardiac Surgery and Cardiology, Hospital de la Santa Creu i Sant Pau, and Clinica Quiron, Barcelona, Spain.

Background. Aprotinin reduces blood loss in operations done with cardio-pulmonary bypass, whereas the use of desmopressin remains controversial. We compared aprotinin, desmopressin, and placebo in a double-blind, randomized trial to evaluate bleeding and transfusion requirements. Methods and results. One hundred forty-nine patients (48 received aprotinin, 50 desmopressin, 51 placebo) were included. Blood loss and transfusion requirements were recorded and levels of Factor VIII coagulant activity, von Willebrand's factor, thrombin-antithrombin complexes, and D-dimer were measured. Overall blood loss was 195 ± 146 ml/m 2 in the aprotinin group, 400 ± 192 ml/m 2 in the desmopressin group, and 489 ± 361 ml/m 2 in the placebo group (95% confidence intervals: difference between desmopressin and aprotinin 98 to 312 ml/m 2 , p 2 , p p Conclusion. Aprotinin administration reduces blood loss and transfusion requirements in cardiopulmonary bypass. This benefit may be explained by a lower activation of fibrinolysis.

In summary, reference values of Doppler gradients obtained in a large number of patients with normal-functioning mitral and aortic Monostrut Björk-Shiley prostheses are reported. It is shown that the value of the transprosthetic gradient increases with decreasing valve size in patients with aortic prostheses. No individual significant variations of the transprothetic Doppler gradient during a 3-year follow-up were observed.

In 31 patients who had undergone cardiac orthotopic transplantation, valvular regurgitation was studied by echocardiographic and pulsed Doppler over 2 years. The first week after cardiac transplantation, transplant recipients had an increase in the severity of tricuspid, mitral (group II), and aortic regurgitation, as well as a greater number of simultaneously regurgitating valves when compared with those in a group of 60 normal subjects of similar age to heart donors: transplant recipients, trivalvular regurgitation 48% (95% confidence interval [CI] 30 to 66) vs control group, 5% (CI 1 to 13; p0.001). Moderate-severe tricuspid regurgitation (TR) was the most frequent occurrence (55%, CI 36 to 73) followed by pulmonary (PR) (42%, CI 25 to 61), moderate mitral (MR) (32%, CI 15 to 51), and mild aortic (AR) (23%, CI 10 to 43) regurgitation. These regurgitations were asymptomatic at rest except for TR. TR was associated with right-sided heart failure in 76% of patients in the early postoperative period and controlled with diuretic drugs. This regurgitation correlated with persistence of post-transplant pulmonary hypertension (r = 0.6) and was not related to pulmonary hypertension before cardiac transplant. There was also no relation found between donor ischemia time or episodes of cardiac rejection.(ABSTRACT TRUNCATED AT 250 WORDS)

The results of cardiac valve replacement with the Monostrut Bjork-Shiley prosthesis (Shiley, Inc., Irvine, Calif.) during a 7-year period are presented. A total of 984 valves were implanted in 820 patients from May 1983 to April 1990. Aortic valve replacement was performed in 378 patients, mitral replacement in 294, and multiple replacement in 148. In addition, 180 patients (22%) underwent associated procedures. Mean age was 52.6 +/- 11 years. Operative (30 days) mortality was 5.9% (49 patients): 3.9% (15 patients) for aortic, 7.8% (23 patients) for mitral, and 7.4% (11 patients) for multiple valve replacement. All patients were given long-term anticoagulation therapy. Follow-up was 99% complete (eight patients were lost to follow-up), with a closing interval of 3 months, and totaled 2422 patient-years. Valve-related complications, expressed as percentage event-free (+/- standard error) at seven years were as follows: structural deterioration, 100%; nonstructural dysfunction, 98.3% +/- 0.6%; thromboembolism, 90.2% +/- 1.7%; anticoagulant-related hemorrhage, 88.7% +/- 2.8%; and prosthetic valve endocarditis, 98.1% +/- 0.8%. There were no cases of valve thrombosis. Actuarial survival (free from operative, valve-related, and sudden death) was 88.4% +/- 1.2% at 7 years. Freedom from reoperation was 96.8% +/- 0.1%. Probability of being free from all valve-related morbidity and mortality was 70% +/- 3%, and 708 (93%) of the survivors were in New York Heart Association class I or II. Serial Doppler echocardiograms were done prospectively in 243 patients (with 154 aortic and 120 mitral prostheses), both postoperatively and at regular intervals up to 3 years. Mean prosthetic gradients ranged from an average of 20.9 to 7 mm Hg in the aortic prostheses (21 to 29 mm) and from 6.1 to 4.8 mm Hg in the mitral prostheses (25 to 31 mm). The gradients in each patient did not change significantly during the follow-up period. Our 7 year's experience with the Monostrut valve shows a low rate of valve-related complications, a durable design, and good hemodynamic and functional results.

Patients with mitral stenosis and some degree of right ventricular failure may benefit from inotropic or pulmonary vasodilator drugs in the early postoperative period. Thirty patients undergoing an operation for mitral stenosis were randomized into three groups. In group I (n = 10), isoproterenol (5 μg/kg/min) was started in the immediate postoperative period. In group P (n = 10), prostaglandin E1 (0.08 μg/kg/min) was given, and in group C, the control group (n = 10), no drugs were used. After the operation and before drug therapy was begun, basal measurements of cardiac index, mean pulmonary arterial and mean arterial pressures, and pulmonary vascular resistance were taken. Measurements were repeated at 6, 12, and 24 hours. Mean measurements of cardiac index (basal up to 24 hours) were as follows: 1.39 ± 0.3, 1.92 ± 0.4, 2.4 ± 0.5, and 2.34 ± 0.3 L/min/m2 for group C; 1.54 ± 0.5, 2.64 ± 0.4, 2.68 ± 0.7, and 2.2 ± 0.6 L/min/m2 for group I, and 1.57 ± 0.3, 2.2 ± 0.6, 2.72 ± 0.7, and 2.27 ± 0.4 L/min/m2 for group P (p horac C ardiovasc S urg 1992;103:1177-85)

Presentamos cuatro casos de hematoma en aortaascendente. El diagnostico de sospecha inicial fuediseccion aortica en dos de ellos. Todos fueron intervenidoscon caracter de urgencia. Revisamosotras series y concluimos en la conveniencia de tratarlos hematomas en aorta ascendente del mismomodo que las disecciones aorticas.

El diagnostico clinico de los tumores cardiacos es, a menudo, dificil. Presentamos el caso de un paciente de 17 anos en el que se diagnostico un tumor del ventriculo izquierdo a partir del estudio de un sincope. El estudio anatomopatologico confirmo el diagnostico de mixoma. Clinical diagnosis of cardiac tumours is often difficult. We present the case of a 17 year-old boy inwhom a left ventricular tumour was discovered duringon diagnostic work-up for a syncope. The tumourwas removed and histology confirmed thediagnosis of myxoma.

A simple method to obtain a motionless surgical field with excellent exposure and access to perform internal thoracic or radial artery composite grafts for myocardial revascularization is described.

Mitral valve surgery was performed in 88 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure, 94.7 +/- 22 mm Hg; range, 70-180 mm Hg) over a 10-year period. Sixty-four patients (73%) were in New York Heart Association Functional Class III or IV. There were 64 valve replacements and 24 open mitral commissurotomies. Operative mortality was 5.6% (5 patients) and was not related to the degree of pulmonary hypertension, surgical procedure performed, or type of valve lesion. A 100% follow-up was obtained, ranging from nine months to 10 years, with a mean of 44 months. Six late cardiac deaths (7.2%) occurred, 5 in patients with valve replacement and 1 in a patient who underwent a commissurotomy. Actuarial survival was 86 +/- 3% at five years and 83 +/- 4% at 10 years. Fourteen patients underwent right ventricular catheterization a mean of 24 months following operation. Systolic pulmonary artery pressure had decreased from a mean preoperative value of 101 +/- 22 to 40.5 +/- 7 mm Hg (p < 0.001). Cardiac index increased by 55% of the preoperative values. Functional status improved markedly; 71 survivors (93%) were in New York Heart Association Class I or II. These results indicate that, in patients with mitral valve lesions and severe pulmonary hypertension, (1) surgical procedures can be performed with an acceptable operative mortality; (2) excellent long-term survival and functional results can be obtained; and (3) pulmonary hypertension decreases significantly after operation. Patients with mitral valve disease may benefit from surgical treatment regardless of the degree of pulmonary hypertension.

Between May 1983 and April 1986, 318 patients underwent cardiac valve replacement with the Monostrut Bjork-Shiley prosthesis. There were 136 aortic valve replacements, 128 mitral valve replacements, and 54 multiple replacements. A total of 373 valves were implanted. Associated procedures were done in 79 (25%) of the patients. Hospital (30-day) mortality rate was 5.6% (18 patients): 2.9% (n = 4) after aortic, 7.8% (n = 10) after mitrals and 7.4% (n = 4) after multiple valve replacement. Follow-up was obtained in all 300 operative survivors, for a total of 500 patient-years (mean 18 months). Actuarial survival rate, excluding operative deaths, at 4 years was 94.7% ± 1.5% (mean ± standard error of the mean). There were 16 thromboembolic episodes (3.2/100 patient-years). Freedom from all valve-related complications was 87% ± 2.4% at 3½ years. Neither valve thrombosis nor structural failure has been observed. Eighty percent of the patients are in New York Heart Association functional class I. Forty-two patients (26 with aortic and 16 with mitral valve replacement) underwent cardiac catheterization a mean of 6½ months after the operation. In the aortic position, peak gradients were an average of 6.9 ± 1.2 mm Hg. Mean systolic gradients were 12.4 ± 6.3 mm Hg and did not increase with exercise. In the mitral position, end-diastolic gradients were an average of 2.1 ± 2 mm Hg and mean gradients, 5.9 ± 2 mm Hg. Discharge coefficient (estimated orifice area/geometric area) was 0.63 ± 0.2 for the aortic and 0.53 ± 0.2 for the mitral prostheses. Disc opening was maximal in most patients. These results indicate that the Monostrut prosthesis has a low rate of thromboembolic events, no structural failures or thrombotic obstructions and excellent hemodynamic performance, especially in the small aortic sizes (discharge coefficient for 19 and 21 mm valves, 0.77).

Hyperparathyroidism associated with renal failure is due to chronic parathyroid stimulation by hypocalcemia, which, in turn, results from hyperphosphatemia and low circulating 1,25(OH)2D3. If prophylactic measures and medical treatment of hyperparathyroidism fail, parathyroidectomy should be performed to prevent the progression of bone disease. Resolution of renal hyperparathyroidism is often seen after kidney transplantation, but some hypercalcemic patients require prophylactic or therapeutic parathyroidectomy. Hypocalcemia is the most common complication after parathyroidectomy. Our long-term results with subtotal parathyroidectomy are satisfactory. Total parathyroidectomy plus parathyroid autograft should be used in selected cases.

Iatrogenic coronary artery stenosis as a serious complication of aortic valve procedures is a difficult condition to solve. We present a case in which both ostia were involved. As the patient refused reoperation, percutaneous transluminal coronary angioplasty (PTCA) was used.

Beta adrenergic blockade at the time of direct coronary revascularization has theoretical disadvantages and is considered by some to be dangerously depressing to the myocardium in the immediate period after pump oxygenation. A review of 100 consecutive cases of bypass surgery revealed that 25 patients had been taking propranolol to within 24 hours or less before surgery in dosages ranging from 40 to 200 mg. per day. The over-all operative mortality rate was 2 per cent. Neither of the patients who died had been receiving propranolol. Seven of the patients taking the drug required emergency surgery for the preinfarction state. In this group the doses were largest and most proximate to surgery. Nevertheless, none of these patients died. The magnitude of surgery was similar in elective and emergency settings and in those with and without propranolol therapy. We have concluded that coronary revascularization is safe in patients receiving propranolol so long as complete revascularization is done.

Administration of catecholamines can lead to myocyte damage. Dopamine treatment is often used in potential cardiac donors to attain hemodynamic stability. Donor hearts exposed to dopamine are rejected or selected for transplantation without clearly defined criteria. A prospective study was undertaken to analyze the clinical relevance of dopamine-induced myocardial lesions in 25 hearts (21 male, 4 female; 15–40 years, mean: 26 ± 7) that were later used for transplantation. Donors were divided into those who had received dopamine and those who had not. Dopamine doses ranged from 2–12.5 μg/kg/min (mean: 6.3 ± 3). Time of administration was 3–26 hours (mean: 16 ± 8). Use of dopamine was unrelated to donor electrocardiographic findings, intra- or postoperative death, or difficulty coming off by-pass. Postoperatively, filling pressures were similar in both groups of patients at 2 and 10 days postoperatively. Left ventricular ejection fraction was similar in the two groups. Dopamine requirements were significantly higher in the dopamine-treated hearts ( P = 0.05). Histologic findings at first biopsy revealed infiltration and cell damage in a similar proportion of patients in both groups. In conclusion: donor hearts exposed to dopamine can be accepted for transplantation if doses ranging from 2–12.5 μg/kg/min have been administered up to 24 hours.

The case of a 26-year-old woman with cardiac and pulmonary echinococcosis is presented. Surgical treatment of the intrathoracic disease was done in a one-stage operation. Under cardiopulmonary bypass, a left ventricular hydatid cyst and a lower lobe pulmonary cyst were removed. The patient is completely asymptomatic and is leading a normal life two years after operation.

A 21-month-old girl with Marfan’s syndrome developed heart failure due to severe mitral regurgitation, which was controlled with medical therapy for 12 months. The mitral valve was excised and replaced with a No. 21 Bjork-Shiley prosthesis. The child made an uneventful recovery and is doing well 8 months after the operation.

In cases in which renal repair through conventional in situ surgery is not possible, we have proceeded to remove the organ outside of the human body and placed it on a work bench where ec situ repair is aided by microsurgery, x-ray films, and image amplifiers. In most cases the damaged kidney has recovered its function and a grave problem has been solved. Extracorporeal surgery means a new tactical solution to extreme situations.

Between May, 1983, and November, 1984, the new integral monostrut Bjork-Shiley prosthesis was used for aortic valve replacement in 62 patients. The prosthesis is machined from a solid piece of cobalt alloy and has no welded joints. The traditional U-shaped outlet strut has been replaced by a projecting metal finger that holds the disc in place. The disc opens to 70 degrees and is convexoconcave. Successful transseptal heart catheterization was performed in 23 patients an average of 6 months following operation to evaluate the hemodynamic performance of the prosthesis. The mean peak-to-peak gradient was 7.73 ± 7.49 mm Hg (± standard deviation). In five valves it was 0, and in only three was it higher than 15 mm Hg. Significant peak gradients were directly related to the valve index (valve area/body surface area). Mean systolic gradient at rest was 12.7 ± 6.27 mm Hg and did not increase after exercise. Effective orifice areas were adequate, and the discharge coefficient ranged from 0.77 for the 21-mm prosthesis to 0.48 for the 29-mm prosthesis. Minimal regurgitation, which was washed out on the next systole, was observed with all sizes of the prosthesis. Disc opening was maximal (70 degrees) in all but one of the observed instances. Longer clinical follow-up is required, but the new integral monostrut Bjork-Shiley prosthesis, with its important design changes and excellent hemodynamic performance, appears to be a promising aortic valve substitute.

Use of pulsed Doppler to detect and evaluate cardiac valvular regurgitation is an accepted noninvasive diagnostic method.1 Since the cardiac transplantation program started at our institution, 8 consecutive patients have been prospectively studied by pulsed Doppler. This report provides the first description of valvular function in the transplanted heart.

A 23-year-old man who underwent surgical correction of a true pulmonary artery aneurysm is presented. Pathological features and the different surgical alternatives for treatment of this lesion are discussed.

A newly designed temporary pacemaker wire has been tested in 20 patients who underwent open-heart operations. This new device has a small tip that stays securely buried in the myocardium, thus greatly reducing the risk of accidental dislodgment. In addition, the increase in thresholds during the postoperative period is slighter than with the standard electrode.