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Resumen Introduccion y objetivos El posoperatorio de cirugia cardiaca incluye el traslado desde la unidad de cuidados intensivos (UCI) a la sala convencional. Las unidades de cuidados intermedios (UCIn) permiten la optimizacion de recursos hospitalarios. Se ha analizado el impacto de una UCIn en las estancias medias (en la UCI y hospitalaria) y los resultados (mortalidad hospitalaria y reingresos a los 30 dias) tras la cirugia cardiaca (UCIn- CC ). Metodos Desde noviembre de 2012 hasta abril de 2015, ingresaron para cirugia cardiaca 1.324 pacientes consecutivos. Se implemento una UCIn-CC (mayo de 2014). Los pacientes se clasificaron en 2 grupos: pre-UCIn-CC (noviembre de 2012 a abril de 2014; n = 674) y post-UCIn-CC (mayo de 2014 a abril de 2015; n = 650). Resultados No se observaron diferencias significativas en edad, sexo, factores de riesgo, EuroSCORE 2, fraccion de eyeccion o tipo de cirugia (el 53% valvular, el 26% coronaria, el 11,5% valvular y coronaria y el 1,8% de aorta). La estancia en la UCI disminuyo del pre-UCIn-CC al post-UCIn-CC una media ± desviacion estandar de 4,9 ± 11 a 2,9 ± 6 dias (p Conclusiones Tras la implementacion de una UCIn-CC para el cuidado del posoperatorio de cirugia cardiaca, se observo una reduccion de las estancias medias en la UCI y hospitalaria, sin que aumentaran la mortalidad hospitalaria ni los reingresos a los 30 dias.

Resumen Objetivo La introduccion de las nuevas protesis aorticas sin sutura ha supuesto una alternativa para el tratamiento quirurgico de la estenosis aortica severa. Presentamos la experiencia de nuestro grupo tras el inicio de un programa con protesis Perceval S (Livanova, Saluggia, Italia). Pacientes y metodos Entre marzo de 2012 y octubre de 2016 se implanto la protesis Perceval S en 262 pacientes (edad media: 77,97 ± 6,12 anos; 56,49% de mujeres). En 176 casos (67,18%) se realizo sustitucion valvular aortica aislada, con miniesternotomia en un 36,9%. El seguimiento clinico y ecocardiografico se realizo al alta, a los 6 meses y anualmente. Resultados La mortalidad esperada fue del 14,19 ± 1,31% (Euroscore log I ) y del 7,47 ± 1,11% (Euroscore log II ). La mortalidad observada fue del 4,23%. Hubo complicaciones neurologicas en 2 pacientes (0,94%), y fuga periprotesica moderada al alta en 2 pacientes. El seguimiento medio fue de 26 ± 6,2 meses. La mortalidad en el seguimiento fue del 1,9% (4 pacientes); estabilidad de las fugas grado II en el seguimiento; gradiente medio de 10,2 mmHg. El 95% de los pacientes se encontraban en grado funcional I - II . Conclusiones El inicio de un programa de implante de protesis sin sutura Perceval S ha permitido intervenir a pacientes de alto riesgo con buenos resultados y baja morbilidad. La protesis ha demostrado ser muy versatil, tener un excelente comportamiento hemodinamico y favorecer la cirugia de minimo acceso.

Resumen Introduccion y objetivos El empleo de doble mamaria se ha asociado con un aumento de complicaciones esternales, especialmente en pacientes diabeticos y obesos. El objetivo de este trabajo es revisar los factores de riesgo de aquellos pacientes en los que se ha usado doble mamaria y la tasa de complicacion esternal en este grupo. Metodos De nuestra base de datos se ha seleccionado a 526 pacientes revascularizados quirurgicamente con uso de doble arteria mamaria. La edad media de los pacientes fue de 59 anos, con un EuroScore logistico-1 medio de 2,7%. Resultados Presentaron dehiscencia esternal 3 pacientes (0,57%), no se correlaciono con ningun factor de riesgo. Problemas de herida tanto superficial como profunda 31 pacientes (5.9%), (2 mediastinitis-0.38%). Con respecto a los pacientes que presentaron infeccion superficial de la herida quirurgica (29 pacientes, 5,513%), se obtuvo mayor incidencia en mujeres, pacientes con insuficiencia renal y aquellos a los que se les realizo transfusion de concentrado de hematies en quirofano, Siendo estas diferencias estadisticamente significativas (p Tambien hubo mayor incidencia de infeccion superficial en pacientes diabeticos, enfermedad pulmonar obstructiva cronica, obesos, fumadores y a aquellos a los que se les realizo revascularizacion miocardica incompleta, siendo estas diferencias no significativas. Conclusiones En nuestra experiencia, la utilizacion de doble mamaria no se acompano de mayor incidencia de dehiscencia esternal, pero si con problemas de infeccion superficial de la herida, sobre todo en el grupo de pacientes mujeres, con insuficiencia renal y transfundidos en quirofano. Para mantener el beneficio de la doble mamaria en estos pacientes, deberiamos ser especialmente cuidadosos e implementar nuevas estrategias de cierre esternal.

Objective To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement. Methods A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach. Results No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed to-mographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs. Conclusions Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Because of the clinical significance of carotid atherosclerosis, the search for novel biomarkers has become a priority. The aim of the present study was to compare the protein secretion profile of the carotid atherosclerotic plaque (CAP, n = 12) and nonatherosclerotic mammary artery (MA, n = 10) secretomes. We used a nontargeted proteomic approach that incorporated tandem immunoaffinity depletion, iTRAQ labeling, and nanoflow liquid chromatography coupled to high-resolution mass spectrometry. In total, 162 proteins were quantified, of which 25 showed statistically significant differences in secretome levels between carotid atherosclerotic plaque and nondiseased mammary artery. We found increased levels of neutrophil defensin 1, apolipoprotein E, clusterin, and zinc-alpha-2-glycoprotein in CAP secretomes. Results were validated by ELISA assays. Also, differentially secreted proteins are involved in pathways such as focal adhesion and leukocyte transendothelial migration. In conclusion, this study provides a subset of identified proteins that are differently expressed in secretomes of clinical significance.

OBJECTIVES: The development of new percutaneous and surgical techniques has reduced the risk associated with aortic valve replacement procedures. We present the results of a Spanish register after initiating a programme for sutureless prostheses in moderatehigh-risk patients. METHODS: This prospective multicentre study was carried out from November 2013 to November 2016. Data were obtained from 448 patients in whom a Perceval S prosthesis was implanted. RESULTS: The mean age was 79.24 (standard deviation [SD] 4.1) years, and 61.2% were women. The estimated EuroSCORE I log risk was 11.15% (SD 7.6), with an observed mortality of 4.4% (20 patients). Isolated aortic valve replacement was performed on 69.26% of patients, with 64% involving ministernotomy. The incidence of neurological events was 2%, with 2 permanent cerebrovascular accidents, and 41 (9.2%) patients were implanted with a permanent endocavitary pacemaker. At discharge, 12 (2.6%) patients presented minimal periprosthetic leakage, and 4 (0.89%) patients had moderate leakage. There were 3 reinterventions during follow-up (2 endocarditis and 1 dysfunction due to periprosthetic leak progression). The mean gradient at discharge, 6 months and 1 year was 12.94 (SD 5.3) mmHg, 12.19 (SD 4.7) mmHg and 11.77 (SD 4.7) mmHg, respectively; 59.4% of the patients were octogenarians, with a survival rate of 98% at both 6 months and 1 year at discharge. There was neither valve migration nor early structural degeneration. The mean follow-up was 12 ± 3 months. The 6-month and 1-year mortality was 1.4% and 2.1%, respectively. CONCLUSIONS: This is a prospective multicentric study on the largest cohort of patients with sutureless valves conducted in Spain to date. It is a reproducible procedure that has enabled surgery on patients with a moderatehigh risk with low morbidity and mortality, providing good haemodynamic results.

Introduction and objectives Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS). Methods From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n = 674) and post-IMCU-CS (May 2014-April 2015, n = 650). Results There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus coronary in 11.5%, and aorta in 1.8%). The ICU length of stay decreased from 4.9 ± 11 to 2.9 ± 6 days (mean ± standard deviation; P

Resumen Fundamento y objetivo La reparacion valvular mitral es el tratamiento de eleccion de la insuficiencia mitral degenerativa. Sin embargo, no esta tan clara su indicacion en el caso de insuficiencias mitrales (IM) secundarias a endocarditis infecciosas (EI), particularmente cuando se intervienen durante su fase activa. Si bien varios estudios observacionales han mostrado la superioridad de la reparacion con respecto a la sustitucion mitral en pacientes sometidos a cirugia de EI, en la mayoria de los centros se sigue optando por la sustitucion valvular por su facilidad y reproducibilidad tecnica. Exponemos a continuacion la experiencia de nuestro centro. Pacientes y metodo Se trata de 4 pacientes intervenidos recientemente durante la fase activa de una endocarditis infecciosa. Se discuten las caracteristicas epidemiologicas y clinicas de cada paciente. Resultados Los 4 pacientes fueron sometidos a distintas tecnicas de reparacion valvular mitral. No se han descrito recaidas ni reinfecciones, y todos los pacientes presentan IM de grado 0 o i / iv en el seguimiento. Conclusiones La reparacion valvular mitral durante la fase activa de la EI es una tecnica factible y que permite obtener buenos resultados postoperatorios.

ResumenIntroducción y objetivosLa reparación mitral es adecuada cuando en el control ecocardiográfico poscirculación extracorpórea no hay insuficiencia mitral residual o es ligera. Poco se conoce de la evolución clínica y ecocardiográfica de esta insuficiencia mitral ligera residual. El objetivo del estudio era valorar la evolución clínica y ecocardiográfica de los enfermos según la presencia o no de insuficiencia mitral residual ligera poscirugía.MétodosEstudio prospectivo de pacientes con reparación mitral por regurgitación mitral severa degenerativa operados durante el período comprendido entre 2002–2010.ResultadosFueron intervenidos 105 pacientes con afectación de 1 o 2 segmentos según la clasificación de Carpentier (edad media 67±12 años, hombres 61%). En 102 casos (97,1%), la reparación mitral fue adecuada, y en 3 (2,9%) no, sustituyéndose la válvula. La mortalidad hospitalaria fue del 2,9% (EuroSCORE logístico 5±5,5%). En el ecocardiograma transesofágico en quirófano, de los 102 pacientes reparados satisfactoriamente, 69 no presentaban insuficiencia mitral residual (grupo A) y 33 presentaban una regurgitación leve (grupo B). Durante el seguimiento [mediana 37 meses (1–105)], la evolución clínica fue correcta, aunque los pacientes del grupo B evolucionaron peor desde el punto de vista ecocardiográfico por recidiva más precoz de la insuficiencia mitral.ConclusionesLa reparación valvular mitral se ha mostrado como una técnica segura y eficaz. La ausencia de insuficiencia mitral al final de la reparación determina una mejor evolución con mínima recidiva durante un seguimiento a medio plazo.AbstractIntroduction and objectivesA successful mitral valve repair is considered when no or mild residual regurgitation is determined in the echocardiography after weaning from cardiopulmonary bypass. Little is known about the clinical and echocardiographic outcome, in the medium term, of the patients with mild residual regurgitation post-repair. The aim of this study was to evaluate the clinical and echocardiographic outcome depending on the presence or absence of mild residual regurgitation after weaning from cardiopulmonary bypassMethodsA prospective study was conducted on patients with severe degenerative mitral regurgitation, who underwent mitral valve repair in our hospital during the period 2002–2010.ResultsMitral valve repair was performed on 105 patients (66%males, mean age 67±12 years-old) with prolapse of 1 or 2 scallops/segments according to the Carpentier classification. In three patients the repair was not adequate and the valve was replaced. The successful repair rate was 97.1%. After weaning from cardiopulmonary bypass, 69 patients had no residual regurgitation (group A), and in 33 it was mild (group B). The postoperative mortality was 2.9% (logistic EuroSCORE 5±5.5%). During a median follow-up period of 37 months (1–105) both groups had improved their clinical condition, but group B patients suffered an earlier II or III mitral regurgitation recurrence.ConclusionsMitral valve repair proved to be a safe and effective technique. Absence of mitral regurgitation post-repair determines a better outcome with minimal recurrence in the medium term.

Background Novel pro-inflammatory and anti-inflammatory derivatives from adipose tissue, known as adipokines, act as metabolic factors. The aim of this study was to analyse the secreted expression of different adipo/cytokines in secretomes of unstable carotid atherosclerotic plaque versus non-atherosclerotic mammary artery. Methods We evaluated the secretion levels of adiponectin, visfatin, lipocalin-2, resistin, IL-6 and TNFR2 by ELISA in human secretomes from cultured unstable carotid atherosclerotic plaque (n = 18) and non-atherosclerotic mammary artery (n = 13). We also measured visfatin serum levels in patients suffering from atherosclerosis and in a serum cohort of healthy subjects (n = 16). Results We found that visfatin levels were significantly increased in unstable carotid atherosclerotic plaque secretome than in non-atherosclerotic mammary artery secretome. No differences were found with regard the other adipo/cytokines studied. Regarding visfatin circulating levels, there were no differences between unstable carotid atherosclerotic plaque and non-atherosclerotic mammary artery group. However, these visfatin levels were increased in comparison to serum cohort of healthy subjects. Conclusions Of all the adipo/cytokines analysed, only visfatin showed increased levels in secretomes of unstable carotid atherosclerotic plaque. Additional human studies are needed to clarify the possible role of visfatin as prognostic factor of unstable carotid atherosclerotic plaque.

OBJECTIVES In high-risk patients with severe aortic stenosis, aortic valve replacement (AVR) with a sutureless Perceval prosthesis (SU-AVR) can be performed instead of conventional AVR or transcatheter aortic valve implantation. Little data are available regarding postoperative conduction disorders after SU-AVR. We aimed to determine the incidence and predictors of new-onset complete atrioventricular block (NO-AVB) requiring permanent cardiac stimulation following SU-AVR. METHODS We studied consecutive patients who underwent SU-AVR between 2013 and 2015. Early patients underwent partial aortic decalcification and subannular valve implantation (standard technique), while later patients underwent complete/symmetrical decalcification and intra-annular valve deployment (modified technique). Predictive baseline and procedural variables and electrocardiographic parameters were identified using a logistic regression model. RESULTS We included 140 patients (mean age, 78 ± 6.5 years; mean Log EuroSCORE II, 8.9 ± 10%; 28.6% concomitant myocardial revascularization). The most common postoperative conduction disturbances were LBBB (25%), NO-AVB (12.1%) and first-degree atrioventricular block (AVB) (7.9%). The incidence of NO-AVB was 61% lower with the modified versus the standard technique (P= 0.04). NO-AVB predominantly appeared within 24 h post-surgery, occurring >24 h post-surgery in only 2 patients (both with baseline conduction defects). Independent predictors of NO-AVB included baseline left QRS axis deviation (LaQD; P= 0.03), first-degree AVB (P< 0.01) and standard surgical technique (P= 0.02). CONCLUSIONS NO-AVB is a frequent complication following SU-AVR, and its incidence strongly depends on the surgical technique. Baseline first-degree AVB and LaQD independently predict NO-AVB and should be considered when deciding the duration of postoperative electrocardiographic monitoring.

The present study evaluates the safety and efficacy of the Adipose Graft Transposition Procedure (AGTP) as a biological regenerative innovation for patients with a chronic myocardial scar. This prospective, randomized single-center controlled study included 10 patients with established chronic transmural myocardial scars. Candidates for myocardial revascularization were randomly allocated into two treatment groups. In the control arm (n = 5), the revascularizable area was treated with CABG and the non-revascularizable area was left untouched. Patients in the AGTP-treated arm (n = 5) were treated with CABG and the non-revascularizable area was covered by a biological adipose graft. The primary endpoint was the appearance of adverse effects derived from the procedure including hospital admissions and death, and 24-hour Holter monitoring arrhythmias at baseline, 1 week, and 3 and 12 months. Secondary endpoints of efficacy were assessed by cardiac MRI. No differences in safety were observed between groups in terms of clinical or arrhythmic events. On follow-up MRI testing, participants in the AGTP-treated arm showed a borderline smaller left ventricular end systolic volume (LVESV; p = 0.09) and necrosis ratio (p = 0.06) at 3 months but not at 12 months. The AGTP-treated patient with the largest necrotic area and most dilated chambers experienced a noted improvement in necrotic mass size (− 10.8%), and ventricular volumes (LVEDV: − 55.2 mL and LVESV: − 37.8 mL at one year follow-up) after inferior AGTP. Our results indicate that AGTP is safe and may be efficacious in selected patients. Further studies are needed to assess its clinical value. (ClinicalTrials.org , AdiFlap Trial). The Adipose Graft Transposition Procedure (AGTP) is a new surgical technique for reducing the scar after a heart attack. It has been evaluated in 10 patients for the first time and has been proved to be safe. This technique consists on the use of the existing fat surrounding the heart that has beneficial properties. The procedure is easy for the surgeons to perform. The next step will be to test the efficacy in a larger population.

Introducción y objetivosLa reparación mitral es el tratamiento de elección de la insuficiencia mitral grave degenerativa por prolapso. El objetivo del estudio es analizar los resultados a medio plazo de la cirugía reparadora mitral.MétodosEstudio prospectivo de pacientes con insuficiencia mitral grave degenerativa, por prolapso de uno o dos segmentos valvulares en los que se realizó cirugía reparadora mitral en nuestro centro (2002–2008). Se practicó valoración clínica y ecocardiográfica precirugía, en la intervención y en el seguimiento.ResultadosSe intervinieron 100 pacientes (edad media 65±12 años, hombres 66%). El estudio ecocardiográfico prequirúrgico nos permitió una correcta identificación de los segmentos valvulares afectos en el 96,3% de los casos. La mortalidad quirúrgica fue del 0% y la postoperatoria del 4%. Durante el seguimiento (mediana 31 meses [1–93) hubo una tasa de pacientes libres de reintervención del 98% al año y del 96% a los 5 años. La supervivencia actuarial fue del 94% al año y del 92% a los 5 años. Ningún paciente operado en CF I-II requirió reintervención, siendo la mortalidad hospitalaria y durante el seguimiento de cero.ConclusionesLa reparación valvular mitral se ha mostrado como una técnica segura y eficaz. Un equipo multidisciplinario permite la correcta identificación de pacientes candidatos y la aplicación de las técnicas quirúrgicas adecuadas. A la espera de un mayor seguimiento, los resultados son satisfactorios.Introduction and objectivesValve repair is the procedure of choice for severe mitral regurgitation due to leaflet prolapse. The aim of this study is to analyze the mid-term results of mitral valve repair.MethodsWe performed a prospective study including patients with severe degenerative mitral regurgitation due to leaflet prolapse (one or two segments) who underwent mitral valve repair during the study period (2002–2008) in our hospital. Clinical and echocardiographic evaluation was performed before surgery, intraoperatively and during the follow-up.ResultsMitral valve repair was performed in 100 patients (mean age 65±12 years-old, 66% males). The accuracy of preoperative echocardio-graphic identification of the prolapsed segments/ scallops was 96.3%. Intraoperative mortality was 0% and hospital mortality 4%. Median follow-up period was 31 months (1–93). Freedom from reoperation at 1 year and 5 years was 98 and 96%. The actuarial survival rate at 1 year and 5 years was 94 and 92%. No patient operated on in NYHA class I-II required a reoperation, being both inhospital and follow-up mortality zero in that group of patients.ConclusionsMitral valve repair proved to be a safe and effective technique. A multidisciplinary team allows a correct patient’s selection and the application of the right surgical technique. Awaiting for longer follow-up results are satisfactory.

Background The aim of the study was to analyse the presence of several metabolites related to atherosclerosis in the plasma of patients with unstable carotid plaque and in the plasma of healthy subjects. Materials and methods We included 20 patients who had undergone carotid endarterectomy and 20 healthy subjects as a control group. All the subjects recruited were male. We used a metabolomic approach with liquid chromatography coupled to mass spectrometry to evaluate plasma metabolite levels in the metabolic pathway involved in the progression of atherosclerotic plaque. Results We observed that circulating levels of 20-HETE were significantly higher in patients with atheroma plaque than in healthy subjects (p = 0.018). No differences were found with regard to the other metabolites analysed. We also conducted a random forest analysis and found that 20-HETE was the main differentiator in the list of selected metabolites. In addition, plasma levels of 20-HETE correlated positively with body mass index (r = 0.427, p = 0.007) and diastolic blood pressure (r = 0.365, p = 0.028). Conclusion This study confirms that of all the molecules studied only 20-HETE is related to carotid plaque. Further studies are needed to compare patients with stable carotid plaque vs. patients with unstable carotid plaque in order to confirm that 20-HETE could be a potential factor related to carotid plaque.

Introduccion y objetivos El incremento del intervencionismo percutaneo ha conllevado una disminucion significativa de la cirugia coronaria. El perfil del paciente coronario que se remite a cirugia es mas anoso, con mayor comorbilidad, peor funcion ventricular y con procedimientos percutaneos previos. En este sentido la cirugia ha intentado mejorar sus resultados desde varios frentes de actuacion. El objetivo es analizar y describir la experiencia inicial de la cirugia coronaria con mini-circulacion extracorporea (MCEC) en un grupo de cirugia cardiaca en el que se ha convertido en tecnica de eleccion. Metodos Entre enero de 2004 y abril de 2007, se analizo de forma retrospectiva a 408 pacientes sometidos a cirugia coronaria aislada con MCEC, 329 (80,6%) varones, con media (intervalo) de edad de 63,5 (28-83) anos. Un 63% tenia hipertension; el 49,3%, diabetes; el 69%, dislipemia, y el 52% eran fumadores. Resultados El EuroSCORE logistico (mortalidad esperada) era del 3,7% (1%-38%). El 34% de los pacientes tenian afeccion del tronco comun y el 87%, enfermedad de 3 vasos. En el 74% de los casos se realizo revascularizacion completa, con un numero medio de injertos de 2,97 (1-7). Se utilizo injerto de mamaria en el 100% de los casos. La mortalidad hospitalaria fue del 0,74%. Las complicaciones postoperatorias fueron pocas: el 0,98% preciso reintervencion por sangrado, en el 3,4% se elevo la troponina I de forma significativa, en el 6,4% se desarrollo insuficiencia renal y el 0,5% tuvo accidente vascular cerebral. Conclusiones La cirugia coronaria con MCEC permite realizar una revascularizacion completa en la mayoria de los pacientes, con buenos resultados de morbimortalidad.

OBJECTIVES - After a panel process, recommendations on the use of sutureless and rapid deployment valves in aortic valve replacement were given with special respect as an alternative to stented valves. METHODS - Thirty-one international experts in both sutureless, rapid deployment valves and stented bioprostheses constituted the panel. After a thorough literature review, evidence-based recommendations were rated in a three-step modified Delphi approach by the experts. RESULTS - Literature research could identify 67 clinical trials, 4 guidelines and 10 systematic reviews for detailed text analysis to obtain a total of 28 recommendations. After rating by the experts, 12 recommendations were identified and degree of consensus for each was determined. Proctoring and education are necessary for the introduction of sutureless valves on an institutional basis as well as for the individual training of surgeons. Sutureless and rapid deployment should be considered as the valve prosthesis of first choice for isolated procedures in patients with comorbidities, old age, delicate aortic wall conditions such as calcified root, porcelain aorta or prior implantation of aortic homograft and stentless valves as well as for concomitant procedures and small aortic roots to reduce cross-clamp time. Intraoperative transoesophageal echocardiography is highly recommended, and in case of right anterior thoracotomy, preoperative computer tomography is strongly recommended. Suitable annular sizes are 19–27 mm. There is a contraindication for bicuspid valves only for Type 0 and for annular abscess or destruction due to infective endocarditis. Careful but complete decalcification of the aortic root is recommended to avoid paravalvular leakage; extensive decalcification should be avoided not to create annular defects. Proximal anastomoses of concomitant coronary artery bypass grafting should be placed during a single aortic cross-clamp period or alternatively with careful side clamping. Available evidence suggests that the use of sutureless and rapid deployment valve is associated with (can translate into) reduced early complications such as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions and renal replacement therapy, respectively, and may result in reduced intensive care unit and hospital stay in comparison with traditional valves. CONCLUSION - The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves.

Ectopic thyroid tissue is a rare congenital anomaly that results from multiple events during development. The ectopic thyroid may lie in several human organs including the tongue and mediastinum. It is rarely seen as an intracardiac mass. We report the case of a patient with an intracardiac mass diagnosed by echocardiography. The pathology of the mass was compatible with ectopic thyroid tissue with no signs of malignancy.

Las complicaciones tromboembolicas y hemorragicas a largo plazo tras sustitucion valvular mitral con protesis mecanicas han sido comunicadas en la literatura. Sin embargo, existen escasos estudios con la valvula mecanica On-X Conform (MCRI). La protesis mitral On-X Conform tiene un unico tamano (25–33), con un orificio efectivo de 3,73 cm2, y se implanta en posicion supraanular (cara auricular). Material y metodos Entre 2000-2009 se implanto la protesis On-X Conform en posicion mitral en 353 pacientes. Todos los pacientes fueron estudiados retrospectivamente a partir de los registros de la base de datos del servicio de cirugia cardiaca y se realizo un seguimiento via telefonica, visita medica y busquedas en historia clinica. De ese grupo, se analizan 138 pacientes con patologia mitral (±tricuspide) aislada, y con un minimo de 1 ano de seguimiento. El seguimiento fue del 100%, con un seguimiento maximo de 7,66 anos y medio de 4,53 (591,87 patient-years-follow-up). Todos los pacientes iniciaron tratamiento anticoagulante con Sintrom® con indice internacional normalizado (INR) diana entre 2,5–3,5 y fueron controlados en su hospital o CAP de referencia (n.o medio controles/ano 10,8). Conclusiones 1) La protesis On-X Conform mitral puede implantarse de forma segura en cualquier paciente que requiera sustitucion valvular mitral; 2) En el seguimiento, las complicaciones relacionadas con la valvula han sido muy bajas, con tasas de tromboembolia del 1% ppy y hemorragia del 0,3% ppy. Resultados Trombosis 0,5% ppy Tromboembolia 1,01% ppy Hemorragia mayor 0,3% ppy Leak perivalvular 0,16% ppy Endocarditis 0,5% ppy Hemolisis 0 Disfuncion estructural 0 Disfuncion no estructural 0,16% ppy Reoperaciones relacionada valvula 0,84% ppy Explantes 0,67% ppy Muerte subita 0 Mortalidad relacionada valvula 0,33% ppy Morbilidad y mortalidad total 2,18% ppy

Background The return of extracorporeal circuit blood at the termination of cardiopulmonary bypass (CPB) is an important feature of blood conservation during cardiac surgery procedures globally. We report our initial clinical evaluation of the Hemobag system a blood-salvaging device designed for whole blood recovery of residual post-CPB volume. Methods Residual whole blood is hemoconcetrated through the multipass “recovery loop” circuit separate from the CPB and collected in the Hemobag System. This allows the surgeons to continue with surgery, decannulate, and administer protamine simultaneously while the Hemobag is in use and the CPB circuit remains safely primed. We have compared 25 patients receiving the Hemobag to a control group of 25 patients treated with the cell washer that represented our previous standard of care method of circuit blood-salvaging technique. Results The Hemobag system provided significantly higher hemoglobin, hematocrit, fibrinogen, albumin, and total protein levels in the final product reducing the amount of wasted autologous blood cells. There were no device-related complications. There were no significant differences in terms of blood utilization, chest tube drainage and clinical outcomes over the entire postoperative period among groups. Conclusions These results suggest that the Hemobag system is a safe and efficient method to multipass hemoconcentrate the residual diluted blood of the CPB circuit. The Hemobag has demonstrated its ability to maximize the composition of the residual CPB volume to achieve the best possible post-CPB hemoglobin, plasma protein and coagulation factors profile for the patient respect to CW.

Introduccion En octogenarios con enfermedad valvular aortica, la cirugia ha sido hasta ahora el unico tratamiento. Actualmente existe la posibilidad de implantar valvulas de manera percutanea. Por ello, revisamos nuestra experiencia con enfasis en la mortalidad y supervivencia a medio plazo en este grupo de pacientes. Material y metodos Desde noviembre de 2000 a enero de 2009, se han intervenido 103 pacientes, 72 con sustitucion valvular aortica aislada, 30 con pontaje coronario y 1 con aorta. La edad media fue de 81,7 (80-87), 57 mujeres y 46 hombres. La enfermedad fue en el 92% la estenosis aortica y en 23 existian lesiones coronarias. El EuroSCORE logistico medio fue 13,3% (6-50%). Resultados El seguimiento medio ha sido de 4,1 anos (0-8) y del 100%. Los dias de estancia en unidad de cuidados intensivos (UCI) fueron 6, y postoperatoria 17. La mortalidad fue de cinco pacientes (4,8%) y en el seguimiento de 17. Las causas fueron cardiacas en nueve y otras en el resto. De los 81 supervivientes, el 88% esta en GFI-II. La supervivencia actuarial a los 7 anos es del 72%, llegando al 90% incluyendo solo muerte cardiaca, y estan libres de tromboembolia el 94% a los 8 anos. Se valoran las curvas de supervivencia segun sexo, EuroSCORE y enfermedad coronaria anadida. Conclusiones La cirugia valvular en octogenarios presenta unos resultados a corto y medio plazo excelentes. Estos resultados deben tenerse en cuenta antes de proponer de manera generalizada tecnicas percutaneas.

Mitral valve repair is the procedure of choice to treat mitral valve regurgitation. However, the feasibility and durability of repair are influenced strongly by the valve pathology. The classic features of degenerative mitral valve disease include leaflet prolapse and annular dilatation. Risk of repair failure is increased by isolated anterior leaflet prolapse or bileaflet prolapse. A variety of techniques have been used to treat this pathology. The most popular include partial leaflet resection, chordal shortening, chordal transfer and chordal replacement. Use of artificial chordae with expanded polytetrafluoroethylene (e-PTFE) sutures is a well-known technique for mitral valve repair and long-term data validate this approach. The primary challenges with this technique are judging the proper length of the neochordae and tying the PTFE. Several different techniques have been proposed to solve these items but none of the established are very satisfactory. I describe a preliminary experience with a new device to determine the correct length of the neo-chordae and tying the knots without sliding in ten patients with severe mitral insufficiency referred for mitral valve repair.

The purpose of this study was to evaluate the safety and the clinical outcomes of aortic valve replacement (AVR) performed with minimally invasive extracorporeal circulation (miniECC) technique vs. standard cardiopulmonary bypass (CPB). From February 2006 to December 2007 a total of 181 isolated AVR were performed, of these 53 patients were operated using minimal extracorporeal circulation system and 128 patients were operated using the standard CPB. Demographic characteristics and operative data were similar in both groups except for EuroSCORE (P0.0001). Operative mortality (30 days) was 3.8% for miniECC group and 4.7% for CPB group (P=ns). Patients in both groups showed similar postoperative chest tube drainage (432+/-325 ml vs. 460+/-331 ml, P=ns). The percentage of transfused patients was similar in both groups (37.7% vs. 43.8%, P=0.45). The number of transfused blood bank products was higher in patients with a body surface area1.7 m(2) and who underwent traditional CPB in respect to miniECC system. Postoperatively renal injury, atrial fibrillation episodes, neurologic event rate, ICU and hospital stay length were similar in both groups. The miniECC is suitable for AVR providing good clinical results but the present results should not identify the miniECC system to be superior to the conventional CPB.

We have read with great interest the study by Zhao et al. ([1][1]), which concluded that intraoperative coronary angiography should perhaps eventually become the standard of care for coronary artery bypass grafting (CABG) surgery. We ask, is it really necessary to perform it routinely? They showed

Background and Aim: Monitorization of complications in patients underlying cardiac surgery may be difficult because cardiopulmonary bypass (CPB) can lead to a systemic inflammatory response syndrome because of exposure of blood to nonphysiological surfaces. The purpose of the study was to establish the baseline levels of procalcitonin (PCT) after cardiac surgery in our population in order to analyze a possible induction of the inflammatory response that might interfere with the diagnosis of infection by PCT. Methods: Serum samples from patients undergoing coronary artery bypass grafting or valve replacement were collected at the time of admission to intensive care unit, after surgery as well as in the first and second postoperative days. Patients were followed for the development of postoperative complications. PCT levels were measured by immunoluminometric assay. Results: The mean PCT values were significantly higher in the first postoperative day in all the groups except the control group. No increased PCT levels were found related neither to duration of CPB, nor to time of aortic clamping. Only patients who presented complications had significantly increased PCT values immediately after surgery (p = 0.004), in the first postoperative day (p < 0.0001), and in the second postoperative day (p < 0.0001) with respect to those who recovered uneventfully. Conclusions: A slight and transient increase in PCT levels was observed in the first postoperative day after cardiac surgery. Significant elevation of PCT was only observed when complications were present.

Introduction and objectives. The increasing use of percutaneous interventions has resulted in a significant reduction in coronary artery bypass grafting. Today, patients referred for surgery are older, have more comorbidities, and have undergone previous percutaneous intervention, and their ventricular function is poorer. As a result, surgery has attempted to improve its results by adopting a number of different strategies. The aim of this study was to investigate and describe one cardiac surgery unit’s initial experience with coronary artery bypass grafting using mini-extracorporeal circulation (MECC), which had become its technique of choice. Methods. A retrospective analysis of 408 patients who underwent isolated coronary artery bypass grafting using MECC between January 2004 and April 2007 was carried out. Of the 408, 329 (80.6%) were men, their mean age was 63.5 years (28-83 years), 63% had hypertension, 49.3% had diabetes, 69% had hyperlipidemia, and 52% were smokers. Results. The surgical mortality rate predicted by the logistic EuroSCORE was 3.7% (range, 1-38). Overall, 34% of patients had left main coronary artery disease and 87% had 3-vessel disease. In 74%, complete revascularization was carried out using a mean of 2.97 (range, 1-7) grafts per patient. A mammary artery graft was used in all cases. The in-hospital mortality rate was 0.74%. There were few postoperative complications: 0.98% of patients required further surgery because of bleeding, 3.4% had a significantly elevated troponin-I level, 6.4% developed kidney failure, and 0.5% suffered a stroke. Conclusions. Coronary artery bypass grafting using MECC enabled complete revascularization to be performed in most patients, and morbidity and mortality rates were low.

A 2-year-old patient with severe mitral regurgitation associated with a mass originating from the anterior leaflet of the mitral valve is reported. Excision of the tumor and mitral valve repair was performed. Four years later the child remains asymptomatic with no recurrence of the tumor or regurgitation.

La valvula Mitroflow (Sorin Group) ha sido utilizada frecuentemente como sustituto protesico en la valvulopatia aortica. Sin embargo algunos estudios han favorecido la duda acerca del deterioro estructural acelerado de dicha protesis incluso en pacientes de edad avanzada. Material y metodos Analizamos de forma retrospectiva nuestra experiencia en los ultimos 10 anos. El seguimiento medio fue de 4,2 anos y completo en el 97%. En el periodo de enero de 2001 a 2010 se implantaron 181 protesis Mitroflow. Edad media al implante 76,0 ± 5,6 anos (83,4% mayores de 69 anos); 61,4% mujeres; 95% estenosis aortica (EAo) predominante; 53 pacientes (29,2%) con procedimientos asociados. La poblacion a estudio presentaba 90% hipertension arterial (HTA); 51% diabetes mellitus; 48% dislipemia, y 12,1% insuficiencia renal cronica (IRC). El 85% de las protesis fueron de tamano 19–21. Se analiza el deterioro estructural progresivo y necesidad de reintervencion mediante controles ecocardiograficos (anuales). Resultados Durante el periodo estudiado la supervivencia del grupo a los 3, 5 y 10 anos fue del 98, 92 y 82%, respectivamente. La presencia de mismatch teorico en el postoperatorio inmediato fue del 4,9% (EAo/SC Conclusiones – Los gradientes transprotesicos en pacientes con EOA/SC superior a 1 cm2/m2 fueron bajos y se mantuvieron estables en el seguimiento a largo plazo. – Durante el seguimiento tres pacientes se reintervinieron por deterioro estructural, a los 6, 5 y 3 anos. Tabla 1 Endocarditis 1,04% ppy Disfuncion no estructural 0 Leak periprotesico 1,44% ppy Tromboembolia 0 Hemorragias mayores 2 AV C hemorragicos (1 paciente ACXFA – sintrom) 1 HDA 0,9% ppy Disfuncion estructural 1,015% ppy Reintervencion deterioro Estructural 1,01% ppy Aparicion insuficiencias 1,92% ppy

A 45-year-old man was admitted due to an acute neurological deficit. An intracranial mass was diagnosed and removed. The histo-pathological study suggested a metastatic lesion from a sarcoma. Then a positron emission tomography, a computed tomography, and a magnetic …

ObjetivoTras más de 10 años desde las primeras aplicaciones de la operación de Ross en España describimos el grado de implantación y sus resultados.MétodosAnualmente los centros nacionales que realizan esta intervención envían sus datos al coordinador. Analizamos morbimortalidad, disfunción de auto y homoinjerto, y necesidad de reintervención.ResultadosDesde febrero de 1991 hasta mayo de 2004 se han incluido 281 pacientes. La etiología más frecuente fue la congénita (166, 59,4%). La insuficiencia aórtica fue el tipo de lesión predominante (126, 44,83%). Nueve (3,2%) pacientes requirieron balón de contrapulsación intraaórtico. La mortalidad a 30 días fue del 3,2% (n=7). El seguimiento está completo en el 98,2%, con una media de 46,08 ± 33,09 meses (rango 1–159), estando el 28,89% (n=84) de los pacientes seguidos más de 4 años. Respecto al estatus del autoinjerto, el 82,91% (233) se encuentra sin insuficiencia, presentando 12 (4,27%) insuficiencia moderada y cuatro (1,42%) insuficiencia grave (96,73±1,2% libres de reintervención). El homoinjerto se encuentra normofuncionante o con disfunción leve en 255 pacientes (90,74%), presentando siete (2,49%) estenosis grave. Cuatro (1,42%) pacientes han requerido alguna reintervención sobre el tracto de salida del ventrículo derecho. La supervivencia a 48 meses es de 96,3 ± 1,05%.Conclusiones1. El número de pacientes incluidos de forma anual tiende a mantenerse y crecer. 2. El número de centros implicados continúa en aumento pero la mayor actividad se concentra en un grupo reducido de centros. 3. La morbimortalidad inicial es baja. 4. El índice de disfunción del homo y/o autoinjerto es aceptable.ObjectiveTen years after the introduction of the Ross operation in Spain, we intend to describe and analyze the national experience with this approach for aortic valve replacement.MethodsCardiac Surgery Centers in Spain currently performing this intervention submit data from new patients or follow-ups to the coordinator on a yearly basis. Morbidity, mortality, autograft and homograft dysfunction and need for reintervention are reported.ResultsSince February 1991 to May 2004, 281 patients were included. The most frequent aortic lesion was aortic regurgitation (126, 44.83%), being congenital the most prevalent ethiology (166, 59.4%). Nine (3.2%) patients required intraoperative aortic counterpulsation. Perioperative mortality was 3.2% (n=7). Follow-up is 98.7% complete, with an average of 46.08 ± 33.09 months (range 1-159), being 28.89% (n=84%) followed for more than 4 years. The autograft remains competent in 233 patients (82.91%), presenting 4 (1.18%) with severe regurgitation (96.73±1.2 free from reoperation). The homograft is normal or shows mild stenosis in 255 patients (90.74%), presenting 7 (2.49%) with severe stenosis. Four (1.42%) required reintervention (surgical or interventional) on the right ventricular outflow tract. Actuarial survival is 96.3 ± 1.05% at 48 months.Conclusions1. The indications for this procedure tends to increase in Spain, with more patients included every year. 2. The number of centers involved remains stable although there is a small group of reference centers. 3. The initial morbid- ity and mortality of the procedure remains low. 4. The long-term complications related to homo or autograft failure remain as low as those previously reported with shorter follow-up.

Presentamos dos pacientes que sufrieron un accidente de tráfico con resultado de traumatismo de la válvula mitral. En el primer caso, al cuarto día del accidente, se diagnosticó insuficiencia mitral masiva por ruptura de la cabeza del músculo papilar anterolateral, con versión completa de los segmentos A1 y P1, procediéndose a reparación quirúrgica al mes del accidente, siendo la válvula mitral estructuralmente normal. En el segundo caso, el diagnóstico se hizo a los 10 días del accidente. Se trataba de una insuficiencia mitral grave por ruptura de cuerdas del velo posterior. La reparación quirúrgica se llevó a cabo a los 2 meses y medio del accidente. En este caso la válvula mitral era, además, degenerativa. En ambos casos la cirugía consistió en reparación valvular mitral. Se revisa la ruptura traumática de la válvula mitral.