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Introducción y objetivos: la oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria y/o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos: en marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes COVID-19 tratados mediante ECMO veno-arterial (V- A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias pre-implante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento post-alta. Resultados: se analizaron un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media 52.7 y 49.4 años respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33.3% y 34.9% de los pacientes con ECMO V-A y V-V respectivamente fueron dados de alta del hospital (p=NS) y la mortalidad fue similar, del 56.2% y 50.9% de los casos respectivamente, la inmensa mayoría durante la ECMO y predominantemente por fracaso multiorgánico. El 14.0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196+/-101.7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0.967, IC 95% 0.95-0.99, p=0.004) y la procedencia del propio hospital (OR 0.48, IC 95% 0.27-0.88, p=0.018), mientras que la edad (OR 1.063, IC 95% 1.005-1.12, p=0.032), la hipertensión arterial (3.593, IC 95% 1.06-12.19, p=0.04) y las complicaciones en ECMO globales (2.44, IC 95% 0.27-0.88, p=0.019), digestivas (OR 4,23, IC 95% 1.27-14.07, p=0.019) y neurológicas (OR 4.66, IC 95% 1.39-15.62, p=0.013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones: la terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la HTA y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional sólo se ve influenciada por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave, mejoraría los resultados y la futura investigación clínica

Background and aim of the study We explored the current evidence available on total arterial revascularization (TAR) carrying out a meta-analysis of propensity score-matched studies comparing TAR versus non-TAR strategy. Methods PubMed, EMBASE, and Google Scholar were searched for propensity score-matched studies comparing TAR vs non-TAR. The generic inverse variance method was used to compute the combined hazard ratio (HR) of long-term mortality. The Der-Simonian and Laird method were used to compute the combined risk ratio (RR) of 30-day mortality, deep sternal wound infection, and reoperation for bleeding. Results Eighteen TAR vs non-TAR matched populations were included. Meta-analysis showed a significant benefit in terms of long-term survival of the TAR group over the non-TAR group (HR: 0.73; 95% confidence interval [CI]: 0.68-0.78). Better long-term survival over non-TAR strategy was confirmed by both subgroups: TAR with the bilateral internal mammary artery (BIMA) and TAR without BIMA. Meta-regression suggests that TAR may offer a higher protective survival effect in diabetic patients (coefficient: -0.0063; 95% CI: -0.01 to 0.0006), when carried out with BIMA (coefficient: -0.15; 95% CI: -0.27 to -0.03) or using three arterial conduits (coefficient: -0.12; 95% CI: -0.25 to 0.007). A TAR strategy carried out using BIMA, differently from TAR without BIMA, increases the risk of deep sternal infection (RR: 1.44; 95% CI: 1.17-1.77). Conclusions TAR provides a long-term survival benefit compared with the non-TAR strategy. Also, compared with TAR without BIMA, TAR with BIMA may offer a higher protective long-term survival effect at the expense of a higher risk of sternal deep wound infection.

El propósito de la presente investigación es identificar y analizar la red de valor e innovación considerando la red social, de conocimiento y tecnológico dentro del plan de gestión de la innovación de zarzamora en el municipio de Los Reyes, Michoacán, distinguiendo dentro de esta el papel que desempeña la empresa Productores Agropecuarios por la Calidad (PROCAL) como una Sociedad de Producción Rural de Responsabilidad Limitada. Con esta finalidad, se aplicó la metodología de redes de innovación, que se basa en el proceso para la gestión de la innovación, así como en las etapas del ciclo del proyecto. En base a los resultados obtenidos, se pudo concluir que existe gran diversidad de productores con distintas capacidades tecnológicas asociadas a diversos patrones de producción y distribución del conocimiento tácito; algunos con altas habilidades para socializar el conocimiento de difusión, otros con altas capacidades para producir, pero sin socializar el conocimiento tácito. Dentro de la red de valor, el papel de PROCAL se centra en funcionar como complementador, no obstante, su actuación debe ser reforzada con bases sólidas para contribuir al favorecimiento de los diversos eslabones que componen la red; lo que se verá reflejado en un mayor beneficio para la empresa. Para ello, debe continuar reforzando sus vínculos con las diferentes instituciones gubernamentales y privadas, así como con los centros de investigación y de fomento.

End-to-end trained convolutional neural networks have led to a breakthrough in optical flow estimation. The most recent advances focus on improving the optical flow estimation by improving the architecture and setting a new benchmark on the publicly available MPI-Sintel dataset. Instead, in this article, we investigate how deep neural networks estimate optical flow. A better understanding of how these networks function is important for (i) assessing their generalization capabilities to unseen inputs, and (ii) suggesting changes to improve their performance. For our investigation, we focus on FlowNetS, as it is the prototype of an encoder-decoder neural network for optical flow estimation. Furthermore, we use a filter identification method that has played a major role in uncovering the motion filters present in animal brains in neuropsychological research. The method shows that the filters in the deepest layer of FlowNetS are sensitive to a variety of motion patterns. Not only do we find translation filters, as demonstrated in animal brains, but thanks to the easier measurements in artificial neural networks, we even unveil dilation, rotation, and occlusion filters. Furthermore, we find similarities in the refinement part of the network and the perceptual filling-in process which occurs in the mammal primary visual cortex., 16 pages, 15 figures

Summary The aim of the present study was to analyse the incidence of major adverse cardiovascular events in patients undergoing either coronary artery bypass grafting (CABG) or percutaneous coronary intervention with drug-eluting stents for left main stem disease. Five manuscripts publishing 5-year results of 4 trials (SYNTAX, PRECOMBAT, NOBLE and EXCEL) were included. Overall meta-analysis with inclusion of the 5-year results from the EXCEL trial using the protocol definition for myocardial infarction showed that CABG is associated with a significant reduction in the risk of major adverse cardiovascular events (MACE) (risk ratio = 0.74; 95% confidence interval = 0.68–0.80). When the universal definition was used to define myocardial infarction in the EXCEL trial, the analysis demonstrated a larger benefit of coronary surgery in terms of reduction in the risk of MACE (risk ratio = 0.70; 95% confidence interval = 0.63–0.76). Non-significant differences were detected in terms of risk of overall mortality, cardiac mortality or stroke. In conclusion, this meta-analysis shows that CABG significantly reduces the risk of MACE in patients with left main stem disease. The inclusion of the 5-year results of the EXCEL trial using third universal definition amplifies the benefit of CABG over percutaneous coronary intervention.

Flying insects are capable of vision-based navigation in cluttered environments, reliably avoiding obstacles through fast and agile maneuvers, while being very efficient in the processing of visual stimuli. Meanwhile, autonomous micro air vehicles still lag far behind their biological counterparts, displaying inferior performance at a much higher energy consumption. In light of this, we want to mimic flying insects in terms of their processing capabilities, and consequently show the efficiency of this approach in the real world. This letter does so through evolving spiking neural networks for controlling landings of micro air vehicles using optical flow divergence from a downward-looking camera. We demonstrate that the resulting neuromorphic controllers transfer robustly from a highly abstracted simulation to the real world, performing fast and safe landings while keeping network spike rate minimal. Furthermore, we provide insight into the resources required for successfully solving the problem of divergence-based landing, showing that high-resolution control can be learned with only a single spiking neuron. To the best of our knowledge, this work is the first to integrate spiking neural networks in the control loop of a real-world flying robot. Videos of the experiments can be found at https://bit.ly/neuro-controller ., 8 pages, 6 figures, camera-ready version to appear in IEEE Robotics and Automation Letters

In the AlphaPilot Challenge, teams compete to fly autonomous drones through an obstacle course as fast as possible. The 2019 winning team MAVLab reflects on the challenge of beating human pilots.

Adding to a thus far limited number of archaeological identifications of cacao residues in pottery in ancient Mesoamerica, this study presents the first such evidence from the southern Guatemalan piedmont in the Southern Maya Region. To save on cost, an original sample of 150 vessels from the site of Chocola was reduced to 43 using semi-quantitative testing to determine the presence of fatty acids and carbohydrates, indicating plant remains. Including these 43, because of Hershey's generosity, all 150 samples were analyzed by high-performance liquid chromatography by the method of Hurst. Cacao residues were found in ten vessels, or 6.7% of the 150 HPLC tested samples: (23.5% of the SQT-reduced sample) five bowls, three jars, and two plates, ranging in date from ca. 600 BCE–200 CE. Of the three sectors of the site, elite, administrative, and commoner/agricultural, distribution of all but one of the vessels was in the first and third sectors, suggesting consumption patterns in the ancient city and possibly, also, early intensive prehispanic arboriculture of cacao.

Resumen La dextrocardia es una rara anomalia cardiaca congenita. Aunque la incidencia de enfermedad coronaria es similar a la poblacion en general, son pocos los casos documentados en la literatura. La disposicion anatomica en esta anomalia constituye un desafio a la hora de planificar la tecnica quirurgica y los injertos a utilizar, como lo describen los casos presentados. Presentamos el caso de un paciente varon de 73 anos de edad, con enfermedad coronaria de 2 vasos que fue sometido a una cirugia de revascularizacion arterial completa, sin circulacion extracorporea y sin modificaciones significativas de la tecnica convencional.

The combination of spiking neural networks and event-based vision sensors holds the potential of highly efficient and high-bandwidth optical flow estimation. This paper presents the first hierarchical spiking architecture in which motion (direction and speed) selectivity emerges in an unsupervised fashion from the raw stimuli generated with an event-based camera. A novel adaptive neuron model and stable spike-timing-dependent plasticity formulation are at the core of this neural network governing its spike-based processing and learning, respectively. After convergence, the neural architecture exhibits the main properties of biological visual motion systems, namely feature extraction and local and global motion perception. Convolutional layers with input synapses characterized by single and multiple transmission delays are employed for feature and local motion perception, respectively; while global motion selectivity emerges in a final fully-connected layer. The proposed solution is validated using synthetic and real event sequences. Along with this paper, we provide the cuSNN library, a framework that enables GPU-accelerated simulations of large-scale spiking neural networks. Source code and samples are available at https://github.com/tudelft/cuSNN., Comment: 14 pages, 14 figures

[EN] Objective: To identify preoperative parameters of anatomo-electrical atrial remodelling in order to identify the subgroup of patients more favourable to long-term sinus rhythm (SR) re-establishment after concomitant ablation of persistent-permanent atrial fibrillation (AF). Methods: The study included 50 consecutive patients undergoing concomitant surgical ablation of persistent-permanent AF with cryoablation and bipolar radiofrequency Maze IV pattern. The variables collected before the operation were: demographic variables, morbidity, AF evolution time, transthoracic echocardiographic study, and digital electrocardiogram register for f-wave signal organisation analysis (sample entropy [SampEn]). An assessment was also made of the individual and combined association of atrial remodelling parameters with SR restoration by area under ROC curve (AUC). Results: Follow-up 22.32 +/- 3.19 months. Mean AF onset time 4.00 +/- 4.28 years. Mean left atrium diameter 49.90 +/- 8.18 mm (range = 32 - 81 mm), and SR restoration of 62% at the end of follow-up. Parameters best linked to postoperative SR restoration were left atrium diameter (AUC = 0.848)and SampEn (AUC = 0.845). Cut-off points were 50 mm and 0.0857, respectively, obtaining a model with a predictive accuracy when both parameters combined with an AUC = 0.893. Conclusions: Preoperative anatomo-electrical remodelling analysis through indirect non-nvasive variables could be useful to select patients more favourable to SR restoration after concomitant ablation of AF., [ES] Objetivo: Identificación de parámetros de remodelado auricular anatomoeléctrico preoperatorios que permitan seleccionar un subgrupo de pacientes favorable al restablecimiento del ritmo sinusal (RS) a largo plazo tras ablación quirúrgica concomitante de fibrilación auricular (FA) persistente-permanente. Métodos: Cincuenta pacientes consecutivos sometidos a ablación quirúrgica concomitante de FA persistente-permanente por patrón Maze IV mediante crioblación y radiofrecuencia bipolar. Preoperatorio: se consideraron variables demográficas, morbilidad, tiempo de evolución de FA, estudio de ecocardiografía transtorácica y registro de electrocadiograma digital para análisis de organización de señal de ondas f (entropía muestral [SampEn]). Valoración de la asociación individual y conjunta de los parámetros de remodelado auricular con la restauración de RS mediante área bajo la curva ROC (ABC). Resultados: Seguimiento medio 22,32 ± 3,19 meses. Tiempo medio de evolución de FA 4,00 ± 4,28 años. Diámetro auricular izquierdo medio 49,90 ± 8,18 mm (rango = 32–81 mm). Restauración RS 62% al cierre del seguimiento. Los parámetros que mejor se asociaron con la restauración de RS postoperatorio fueron el diámetro auricular izquierdo (ABC = 0,848) y SampEn (ABC = 0,845). Hallados puntos de corte para ambos en 50 mm y 0,0857, respectivamente; se obtuvo un modelo con capacidad predictiva ABC = 0,893. Conclusiones: El análisis del grado de remodelado auricular anatomoeléctrico preoperatorio mediante variables indirectas incruentas podría ser útil para seleccionar los pacientes más favorables para el restablecimiento de RS tras ablación concomitante de FA.

Chapter 2 defines the physical environment and cultural geography of Chocolá and the econiches it occupies. The major flora and fauna are described, as are the soils, the extraordinary volcanoes and other plate tectonics of Chocolá’s geological setting, and the similarly extraordinary water resources of Chocolá’s piedmont rainforest—the highest rainfall in Central America, two rivers, several streams, and at least nine natural springs.

This chapter explains why the archaeological project was created and in so doing details the research context of Chocolá, both the modern small village and the large ancient city lying beneath and around it. The history of Maya archaeology is reviewed, emphasizing the long-believed-seminal but ironically little studied Southern Maya Region in which Chocolá sits so centrally, including the efforts, in the 1920s, by Robert Burkitt, the first to excavate at the site. The other major southern area sites are described, as is a “German factor” in the South—the particularly strong presence of Germans in Guatemala in both the postcolonial epoch of coffee production and in the early archaeology of Great Southern Maya sites. Throughout, reference is made to a debate about the relative importance of the Southern Maya Region as compared with the northern Petén for the emergence of Classic Maya civilization in the Lowlands.

Chapter 5 provides, in summary form, the first detailed account of Chocolá’s ceramic pottery. For the first time, the wares and figurines of the ancient city are described for the benefit of other Maya and Mesoamerican researchers. This includes a type-variety system and the first tentative ceramic sequence for the ancient city.

Chapter 4 abstracts and summarizes the very copious field data from the three lengthy field seasons at Chocolá, including the specific evidence obtained about the very extensive water control system that was discovered. Intensive grid excavations were undertaken in five operations: Mound 15, the northernmost part of the elite north sector, Mounds 6 and 7, in the southern part of the north sector, Mound 2, in the central administrative sector, and Mound 5, in the south sector. Accordingly, our three field seasons provide the specific evidence and artifacts we have been able to use to understand the clearly hierarchical structure of the ancient society and city. Of particular importance for a better understanding of the material underpinnings of Chocolá is our research at Mound 5, in the south, where we believe cacao arboriculture was developed for long-distance trade in the Preclassic period.

Before the authors’ research, Chocolá was no more than an intriguing legend. Chocolá’s apparent political links to the greatest Preclassic southern Maya area polity, Kaminaljuyu, would make any discovery about Chocolá conceivably vital to a better understanding of Maya origins and New World archaeology, as both ancient cities are located in the Southern Maya Region. Two facts led researchers to search more specifically for the material bases for Chocolá’s rise to power: 1) Mesoamerica’s greatest rainfall, 2) cacao groves around the modern village lying atop the ancient city. Cacao was so important to the Maya that, mythologically, the cacao god was the maize god’s brother and uncle of the “Hero Twins,” conceived as the aboriginal creators of the Maya people. If water control systems have been documented archaeologically at virtually all great ancient cities around the world, cacao is uniquely a Maya “invention,” the Maya being the first people in the world to domesticate the plant and cultivate it through intensive agriculture. These two discoveries—impressive water management and cacao at Preclassic Chocolá—likely are not coincidental. A complex, hierarchical society would have been in place for arboriculture of water-thirsty cacao for long-distance ancient trade. Thus, two material substances, one necessary for human survival, the other highly valued throughout Mesoamerica as consumable and essential in Maya mythology, may explain, in part, how this and other Southern Maya “kingdoms of chocolate” may represent a “sweet beginning” for one of the greatest civilizations of the ancient world.

Chapter 6 provides the first catalog of a corpus of sculpture hitherto limited to one (a fragment of the magnificent stela, Chocolá Monument One) and expands it to more than thirty. Also discussed is the diaspora of probably many other carved monuments from Chocolá. As with Chocolá’s near neighbor city and polity, Takalik Abaj, both Olmec or Olmecoid and clearly Maya sculptures and motifs, such as Kaminaljuyu Stela 10, are represented in Chocolá’s corpus. As a result of what the research project has recovered and from information about other monuments, additions now to the corpus include another well-carved stela, Monument 22, a potbelly monument, and a “capture” monument, as well as many examples of pedestal monuments and “cupule” altars, whose function may be related to water worship. Also, the likelihood that the extraordinary circular monument known as the “Shook Altar” was carved at Chocolá is explained.

This chapter details the two principal materialist research foci of the project, water and cacao. Water control systems in Mesoamerica and at ancient Maya cities are reviewed in order to set the discoveries at Chocolá in context in an attempt to understand both functional and ideological meanings of water control at the ancient city. Chocolá’s hydraulic engineering, including stone conduits and canals, closely resembles the systems at Takalik Abaj and Kaminaljuyu, suggesting a deliberate sharing of technology and underscoring the likelihood of links between these three ancient cities and polities. Similarly, the context of cacao in ancient Mesoamerica and specifically in the ancient Maya world is explained, leading to the hypothesis of intensive surplus arboriculture—large cacao groves—that, it is proposed, underlay Chocolá’s rise to wealth and power as a complex society. In addition, a “mystery tale” is recounted, in which one of the most stunning carved monuments of the Southern Maya Region, the so-called Shook Altar, plays a central role in the authors’ theory of surplus cacao production at Chocolá and long-distance trade of the commodity.

For the first time, the ethnohistory of Chocolá and the Guatemalan piedmont—from the Conquest to the colonial period to the postcolonial present day—is provided in some detail, shedding light on the modern factors that impacted the site and led to the gigantic modern-epoch coffee farm at Chocolá and the village of the Maya (primarily K’iche’- and Kaqchikel-speaking) workers attracted, or coerced, to labor on the farm.

In addition to summarizing our research at Chocolá, in this final chapter the problematic issues challenging archaeologists working in the piedmont and the Southern Maya Region as a whole are reviewed—a far more difficult situation for archaeological research than in the Lowland jungles to the north. A stress is put on the likely great archaeological riches remaining to be discovered in the Guatemalan piedmont and coast, but, at the same time, the urgency of the threat to these riches from the enormous pressures of modern development as Guatemala continues its largely unplanned urban, suburban, and industrial expansions through the otherwise plantation-rich south. Because archaeology in the Lowlands has more or less always been well funded, and with no shortage of archaeologists focused on the Lowland Maya, present and future researchers are urged to “look south” for future research in hopes of salvaging for study and for world heritage what remains of a region still little studied but, from all evidence, one that was seminal to later developments in Maya civilization and wider Mesoamerica.

et al., [Objective]: Peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) is a transcriptional coactivator that has been proposed to play a protective role in mouse models of cardiac ischemia and heart failure, suggesting that PGC-1α could be relevant as a prognostic marker. Our previous studies showed that the estimation of peripheral mRNA PGC-1α expression was feasible and that its induction correlated with the extent of myocardial necrosis and left ventricular remodeling in patients with myocardial infarction. In this study, we sought to determine if the myocardial and peripheral expressions of PGC-1α are well correlated and to analyze the variability of PGC-1α expression depending on the prevalence of some metabolic disorders. [Methods]: This was a cohort of 35 consecutive stable heart failure patients with severe aortic stenosis who underwent an elective aortic valve replacement surgery. mRNA PGC-1α expression was simultaneously determined from myocardial biopsy specimens and blood samples obtained during surgery by quantitative PCR, and a correlation between samples was made using the Kappa index. Patients were divided into two groups according to the detection of baseline expression levels of PGC-1α in blood samples, and comparisons between both groups were made by chi-square test or unpaired Student’s t-test as appropriate. [Results]: Based on myocardial biopsies, we found that mRNA PGC-1α expression in blood samples showed a statistically significant correlation with myocardial expression (Kappa index 0.66, p, Grant from Sociedad Valenciana de Cardiología, 2013 to Óscar Fabregat-Andrés.

ResumenIntroducción y objetivosComparar requerimientos transfusionales intra y postoperatorios inmediatos entre pacientes sometidos a recambio valvular aórtico por miniesternotomía en «J» y por esternotomía media longitudinal.MétodosEstudiados 655 pacientes sometidos a recambio valvular aórtico entre 2005 y 2013, 498 por abordaje convencional (grupoC) y 120 por abordaje mínimamente invasivo (grupoM). Confeccionados 120 emparejamientos mediante propensity score matching, basado en 18 variables preoperatorias. Analizado número de transfusiones de hemoderivados intraoperatoriamente y hasta 72 h del postoperatorio.ResultadosNo se encontraron diferencias significativas en variables preoperatorias, incluidos valores de hemoglobina, hematocrito y recuento de plaquetas. El porcentaje de pacientes transfundidos del grupo M fue menor: 52,5% vs. 63,3% (p = 0,089) para concentrado de hematíes 11,6% vs. 24,1% (p = 0,012) para unidades de plaquetas y 14,5% vs. 27,5% (p = 0,011) para plasma fresco congelado. La cantidad de hemoderivados transfundidos también fue menor en el grupo M: 1,74±2,17 vs. 2,23±2,57 (p = 0,112) para concentrado de hematíes; 0,13±0,38 vs. 0,32±0,38 (p = 0,007) para unidades de plaquetas y 0,30±0,77 vs. 0,59±1,12 (p = 0,002) para plasma fresco congelado. El abordaje mínimamente invasivo se presenta como factor protector ante la necesidad transfusional de unidades de plaquetas y plasma fresco congelado: OR 0,414 (0,206-0,832) p = 0,013 y OR 0,435 (0,227-0,834) p = 0,012. En el análisis de morbimortalidad, la transfusión de plasma fresco congelado se presenta como factor de riesgo positivo: OR 4,182 (1,287-13,588), p = 0,017.ConclusiónEl abordaje mínimamente invasivo disminuye las necesidades transfusionales de hemoderivados y de esta manera las complicaciones asociadas a las mismas.AbstractIntroduction and objectivesTo compare intraoperative and postoperative transfusion requirements in patients undergoing aortic valve replacement by mini-sternotomy in “J” vs conventional sternotomy.MethodsThe study included 655 patients who underwent aortic valve replacement between 2005 and 2013, with 498 patients by the conventional approach (groupC) and 120 by a minimally invasive approach (groupM). A propensity score matching was performed to find 120 matched pairs based on 18 preoperative variables. An analysis was made of the number of blood units transfused intraoperatively and up to 72hours postoperatively.ResultsNo significant differences were found in preoperative variables, including hemoglobin, hematocrit, and platelet count. The percentage of transfused patients in group M was lower: 52.5% vs 63.3% (P=.089) for packed red blood cells (RBC); 11.6% vs 24.1% (P=.012) for platelet pool, and 14.5% vs 27.5% (P=.011) for fresh frozen plasma (FFP). The number of units of blood transfused was also lower in the M group: 1.74±2.17 vs 2.23±2.57 (P=.112) for RBC; 0.13±0.38 vs 0.32±0.38 (P=.007) for platelet units and 0.30±0.77 vs 0.59±1.12 (P=.002) for FFP. The minimally invasive approach shows to be a protective factor for platelets and FFP transfusion: OR 0.414 (0.206 to 0.832), P=.013 and OR 0.435 (0.227 to 0.834), P=.012, respectively. In the analysis of mortality, FFP transfusion was a risk factor for mortality: OR 4.182 (1.287 to 13.588) P=.017.ConclusionThe minimally invasive approach reduces blood transfusion requirements and thus the complications related to it.

This paper proposes a novel method for corresponding visual measurements to map points in a visual-inertial navigation system. The algorithm is based on the minimization of the photometric error on sparse locations of the image region, and realizes a gain in robustness that comes from the elimination of the need of feature-extraction for correspondence. The system is compared to a standard approach based on feature extraction, within a visual-inertial EKF formulation. High-fidelity simulation results show the proposed method improves the horizontal RMS error by means of increasing the number of features corresponded by the algorithm.

Objectives Neochordal repair is particularly limited in case of large prolapse with absence of a reference point on a nearby segment. Our aim was to overcome these limitations by means of a simple technique: the 'Folding Leaflet'. Methods Ninety-six patients underwent this technique between January 2009 and August 2012 from a global mitral valve (MV) repair group of 384 patients. A subgroup of 68 patients with complex lesions, bileaflet, commissural or multisegment prolapse, was selected. These more challenging patients were considered as the study group in order to assess the efficacy of our technique. The neochordae were fixed to the papillary muscle with a simple stitch and then were passed through the free margin of the prolapsing leaflet. Free-edge remodelling was achieved weaving this suture and surpassing the coaptation line. Then, the leaflet was folded and its free margin was temporarily approximated edge-to-edge to the adjacent annulus. This was used as the reference point while the neochordae were tied without the need for adjacent healthy chordae or use of callipers. Complete echocardiographic follow-up was obtained at 6-month intervals. Results All patients had ≥ 2 prolapsed segments: posterior leaflet (40 patients), anterior leaflet (13 patients) or both leaflets (15 patients). Annuloplasty was routinely used and the mean number of neochordae per patient was 4.1 ± 2.2 (2-13). Mean follow-up was 28 ± 14 months (5-49 months). There was only one in-hospital death. Another patient died by pneumoniae (15th postoperative month). At the first-month follow-up, 51 patients had no mitral regurgitation (MR) and 16 patients had Grade 1 MR. Only 1 patient had more than mild regurgitation at the 6-month follow-up. There was no evidence of Grade 3 or 4 MR in any patient. At the 2-year follow-up, 34 patients remained with no MR or trace MR and 7 patients had Grade 1 MR. Conclusions MV repair for complex degenerative MR using this technique of neochordal repair results in excellent early and mid-term outcomes. This technique facilitates the extensive use of neochordae in case of large areas of prolapse.

ResumenObjetivosDescribir nuestra experiencia con una técnica de abordaje vascular periférico en procedimientos de cirugía cardiaca mínimamente invasiva (CCMI): Heart-Port® e implante valvular aórtico transfemoral (TAVI).MétodosAnálisis en laboratorio experimental y práctica quirúrgica. Procedimiento: incisión en pliegue inguinal (3-4cm). Exposición de vaso/s femoral/es sin disección ni loop vascular. En mitad superior del vaso, 2 puntos longitudinales, intramurales, en «U», apoyados a ambos lados del eje vascular. Canulación por técnica de Seldinger en punto medio del vaso, equidistante de ambos pares de parches. Decanulación por anudado alternativo.ResultadosOchenta y un pacientes sometidos a procedimientos de CCMI: 52 Heart-Port® y 29 TAVI-transfemoral. Mortalidad global precoz: 2 pacientes (TAVI), sin relación con complicaciones vasculares. Ausencia de morbilidad asociada al abordaje en el grupo de Heart-Port®. En TAVI: una disección focal iliaca, un hematoma retroperitoneal y un caso de linforrea, resueltos con tratamiento conservador. Ausencia de isquemia aguda/hematoma/seudoaneurisma/reparación quirúrgica o intravascular o limitación funcional basal. El análisis en laboratorio demostró efecto de bolsa de tabaco sólo en el sentido longitudinal, sin causar estenosis transversal.ConclusionesEste método de acceso arterial periférico puede ser aplicado a diferentes procedimientos de CCMI resultando simple (2 suturas y técnica Seldinger), reproducible, rápido (no requiere reconstrucción tras decanulación) y seguro (no requiere pinzado vascular, técnica Seldinger «a cielo abierto», baja tasa de complicaciones).AbstractObjectivesTo describe our experience with a technique for peripheral vascular approach in minimally invasive cardiac surgery (MICS): Heart-Port® and transfemoral aortic valve implantation (TAVI).MethodsExperimental laboratory analysis and surgical practice. Procedure: groin incision (3-4cm) for femoral vessels exposure, without dissection or vascular loops use. Placement of two longitudinal, intramural, “U” shaped, pledgeted stitches in the upper half of the vessel. Seldinger cannulation in the half point of the top of the vessel, between both pairs of pledgets. Decanulation by alternative knotting of the stitches.Results81 patients undergoing MICS procedures: 52 Heart-Port® and 29 transfemoral-TAVI. Early mortality: 2 patients (TAVI) not related to vascular complications. Absence of morbidity related to vascular approach in Heart-Port® group. In TAVI group: one focal iliac dissection, one retroperitonal haematoma and one case of lymphorrea; managed by conservative treatment. Absence of acute ischaemia/haematoma/pseudoaneurysm/need of surgical or endovascular repair or functional limitation different from basal preoperative. Laboratory analysis showed only longitudinal purse-string effect, limiting transverse diameter stenosis.ConclusionsThis method for peripheral vascular approach can be applied in different MICS procedures resulting simple (2 stitches and Seldinger cannulation), reproducible, fast (does not require artery reconstruction after decannulation) and safe (does not require vascular clamp, “open-field” Seldinger technique, low rate of complications).

Resumen Introduccion y objetivos El objetivo es comparar resultados clinicos intrahospitalarios entre pacientes sometidos a recambio valvular aortico aislado por abordaje minimamente invasivo frente a esternotomia estandar. Metodos Se incluyo a 615 pacientes sometidos a recambio valvular aortico entre 2005 y 2012, 532 mediante abordaje estandar (grupo E) y 83 mediante miniesternotomia en «J» (grupo M). Resultados No se encontraron diferencias significativas en cuanto a edad (69,27 ± 9,31 frente a 69,40 ± 10,24 anos) y EuroSCORE logistico (6,27 ± 2,91 frente a 5,64 ± 2,17) entre los grupos E y M. Tampoco en la incidencia de diabetes mellitus, hipercolesterolemia, hipertension arterial y enfermedad pulmonar obstructiva cronica o el tamano de valvulas implantadas (grupo E frente a grupo M, 21,94 ± 2,04 y 21,79 ± 2,01 mm). Si las hubo en los tiempos de circulacion extracorporea y de pinzamiento aortico, mayores en el grupo E: 102,90 ± 41,68 frente a 81,37 ± 25,41 min (p Conclusiones El abordaje minimamente invasivo presenta resultados al menos equiparables al estandar en cuanto a morbimortalidad y tiempos quirurgicos, y en nuestra serie ha permitido disminuir significativamente la estancia hospitalaria. Dado que el estudio es retrospectivo, creemos que se debe confirmar estos hallazgos en estudios prospectivos aleatorizados.

Introduction and objectives The aim of this study was to compare the in-hospital clinical outcomes of minimally invasive, isolated aortic valve replacement vs median sternotomy. Methods Between 2005 and 2012, 615 patients underwent aortic valve replacement at a single institution, 532 by a median sternotomy (E group) and 83 by a J-shaped ministernotomy (M group). Results No significant differences were found between the E and M groups in terms of age (69.27 [9.31] years vs 69.40 [10.24] years, respectively), logistic EuroSCORE (6.27 [2.91] vs 5.64 [2.17], respectively), size of implanted valve prosthesis (21.94 [2.04] mm vs 21.79 [2.01] mm, respectively), or the incidence of diabetes, hypercholesterolemia, high blood pressure, or chronic obstructive pulmonary disease. Mean cardiopulmonary bypass time was 102.90 (41.68) min for the E group vs 81.37 (25.41) min for the M group (P

ResumenIntroducciónEl empleo de neocuerdas de politetrafluoroetileno (PTFE) ha aumentado, bien como técnica complementaria a la resección cuadrangular o como procedimiento único de reparación. Analizamos su impacto valorando si facilita la reparabilidad y mejora los resultados.Material y métodosUn total de 203pacientes fueron intervenidos de insuficiencia mitral degenerativa entre 1997 y 2011, con una edad media de 62±12años (36% sexo femenino). Se consideró plastia compleja al prolapso comisural, de ambos velos o multisegmentario. Se compararon 2subgrupos técnicos: resección sin neocuerdas (grupoA: 140pacientes) y neocuerdas sin resección (grupoB: 46pacientes). Se excluyeron 17pacientes con resección complementada con neocuerdas. Se valoró la complejidad de las lesiones junto con la mortalidad y la durabilidad de la reparación.ResultadosMortalidad hospitalaria global: 3,4% (7pacientes); en grupoA: 4,3% (6pacientes) y en grupoB: 2,2% (un paciente). Supervivencia actuarial a 5 y 10años: 89±2 y 77±4%. En seguimiento (58±42meses), 22pacientes fallecieron en grupoA (15,7%) y 2 en grupoB (4,3%). Recidiva de insuficiencia grado 3-4/4 en grupoB vs grupoA: 1 (2,2%) vs 20 (14,3%, pacientes vivos al alta), p

ResumenIntroducciónLa etiología y otros factores pueden variar los resultados de la reparación mitral. Analizamos la supervivencia y la durabilidad en pacientes de diversa etiología.Material y métodosFueron intervenidos 406 pacientes de reparación mitral (1997–2011) con edades entre 19–84 años. De ellos, 156 mujeres (38,4%), 57,1% en grado New York Heart Association III-IV. Se consideraron 5 grupos de pacientes: degenerativa (grupo-D), 203; isquémica (grupo-I), 90; funcional no isquémica (grupo-F), 19; reumática (grupo-R), 61 y endocarditis (grupo-E), 33. Se empleó la anuloplastia sobrecorrectora en isquémicas y funcionales. La resección cuadrangular y el implante de neocuerdas fueron predominantes en las degenerativas, mientras que varias técnicas de reseccion-reconstruccion se utilizaron en las reumáticas y endocarditis.ResultadosHubo 18 éxitus en los 30 primeros días poscirugía (4,4%), mortalidad por grupos: 3,4, 4,4, 0, 6,6 y 10%. Supervivencia actuarial: 86±1% y 70±4% a 5 y 10 años. La mortalidad tardía fue mayor en funcionales e isquémicas (31,6 y 20%) siendo en D, R y E: 12,3, 11,5 y 13,3%. Mayor durabilidad en degenerativas (vs. no degenerativas) estando libres de insuficiencia grado 3–4/4: 86±2 vs. 84±2% (p=0,46) los 5 primeros años y 82±3 vs. 54±1% (p=0,02), posteriormente. El grupo-R se asoció a recidiva grado-3 (odds ratio: 1,98, intervalo de confianza 95%: 1,01–3,89; p=0,05) y grado-4 (odds ratio: 3,31, intervalo de confianza 95%: 1,17–9,32; p=0,02). Catorce pacientes precisaron sustitución protésica: 3, 1, 1, 6 y 3, respectivamente.ConclusionesLos resultados de la cirugía reparadora fueron satisfactorios. Supervivencia, tasa de recidiva y reoperación fueron excelentes en valvulopatía degenerativa. La reumática presentó menor durabilidad y la isquémica y funcional mostraron menor supervivencia.AbstractBackgroundEtiology and other factors may influence the outcomes of mitral valve repair. We have analyzed survival and durability in a variety of etiologies.Material and Methods406 patients underwent mitral valve repair (1997–2011) with ages between 19–84 years. 156 were females (38.4%). 57.1% patients were in NYHA class III-IV. 5 groups were considered: degenerative (group-D), 203; ischemic (group-I), 90; functional (non-ischemic) (group-F), 19; rheumatic (group-R), 61 and endocarditis (group-E), 33 patients. Undersized annuloplasty was used in ischemic and functional groups. Quadrangular resection and neochordal repair were predominant in case of degenerative etiology whereas a variety of resective and reconstructive techniques were used in rheumatic and endocarditis groups.Results30-day mortality was 4.4%: 3.4%, 4.4%, 0%, 6.6% and 10% in respective groups. 5 and 10-year survival: 86±1% and 70±4%. Long-term mortality was higher in groups F and I (31.6% and 20%) compared with 12.3%, 11.5% and 13.3% in groups D, R and E. Group-D had higher durability and freedom from grade 3–4/4 mitral regurgitation than non-degenerative groups: 86±2 vs 84±2% (p=0.46) at 5 years and 82±3 vs 54±1% (p=0.02) at later follow-up. Group-R was associated with recurrent grade-3 and grade-4 mitral regurgitation (OR: 1.98, 95%-CI: 1.01–3.89; p=0.05 and OR: 3.31, 95%-CI: 1.17–9.32; p=0.02). 14 patients underwent mitral valve replacement: 3, 1, 1, 6 and 3.ConclusionsThe outcomes of mitral valve repair were successful. Survival, recurrence rate and reoperation were excellent in group-D. Rheumatic regurgitation had shorter durability and functional mitral regurgitation had lower survival.

OBJECTIVES: Increasing degrees of renal impairment are associated with higher rates of morbimortality after coronary artery bypass grafting (CABG). This incremental risk has not been well studied in off-pump procedures (OPCAB). We assessed its impact on OPCAB and on-pump CABG (ONCAB). METHODS: A total of 1769 patients undergoing primary CABG (January 1995 through June 2011) had complete data on glomerular filtration rate (eGFR). 930 patients had Stage 2 renal insufficiency, 330 Stage 3, 27 Stage 4 and 465 normal renal function (Stage 1). Seventeen patients with end-stage disease (Stage 5) were excluded. The OPCAB technique was selectively used in 350 high-risk patients. Preoperative variables and postoperative outcomes were compared among eGFR subgroups and between matched and unmatched OPCAB vs ONCAB groups. RESULTS: Stages 3–4 patients were older (P< 0.0001), with higher prevalence of diabetes (36.8, 35.0, 39.7 and 74.1%, P< 0.01, 1–4 eGFR groups) peripheral arteriopathy (6.0, 9.0, 15.8 and 29.6%, P< 0.0001) and lower left ventricular ejection fraction (LVEF) (GFR-LVEF correlation: Pearson: 0.12, P< 0.0001). On-pump GFR groups had increasingly higher in-hospital mortality (1.0, 1.2, 3.5 and 15.4%, P< 0.0001), but no differences were observed in OPCAB (5.5, 4.8, 5.4 and 7.1%, P= 0.97). Similar trends on in-hospital morbidity were observed in ONCAB vs OPCAB groups: low cardiac output (P< 0.01), pneumonia (P< 0.01) and stroke (P< 0.05). GFR only predicted mortality in ONCAB patients (odds ratio (OR): 0.96, 95% CI: 0.94–0.98; P< 0.01). Patients with higher eGFR stages had statistically more reduced long-term survival, and this pattern was similar in the three treatment groups, also including the OPCAB group, who had the lowest survival in patients with eGFR stage 4. CONCLUSIONS: Patients with low GFR (Stages 3–4) undergoing ONCAB were at increased risk of early morbimortality. In contrast, there were no significant differences in operative morbimortality among eGFR groups in OPCAB patients. This ‘off-pump advantage’ on early outcomes was not observed at the long-term follow-up.

OBJECTIVES: We aim to describe our experience in coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass by comparing intraoperative and postoperative outcomes. METHODS: From January 1993 to June 2013, 3097 patients underwent consecutive emergency and scheduled CABG surgery. A total of 1770 patients underwent on-pump CABG (ONCABG) and 1327 off-pump CABG (OPCABG). A propensity score matching was performed to identify appropriate matched-pair patients; univariable and multivariable logistic regression analyses were performed to assess significant predictors of hospital and 30-day morbidity and mortality composite end-points. Morbidity composite end-point was defined as any renal, pulmonary, cardiovascular and neurological complication that occurred during hospital stay. We collected all-cause mortality data during the study period. RESULTS: We identified 1004 patients in each group. There were no significant differences in thirty day mortality, 2.8 vs 3.8%, in OPCABG and ONCABG, respectively (P = 0.21). Cardiovascular, neurological, respiratory and renal complications were more frequent in the ONCABG group: 13.9 vs 8.7% (P < 0.001), 3.9 vs 2.2% (P = 0.03), 13.5 vs 7.5% (P < 0.001), 7.1 vs 5.3% (P = 0.095), respectively. The long-term all-cause mortality rate was 12.3 vs 12.9% in the OPCABG versus ONCABG group (P = 0.42), respectively. In both uni- and multivariable analysis preoperative renal failure, chronic obstructive pulmonary disease and ONCABG were independent predictors of mortality and morbidity composite end-points. CONCLUSIONS: OPCABG is associated with less postoperative morbimortality and shorter hospital and intensive care unit length of stay. ONCABG resulted as an independent predictor of morbidity and mortality composite end-point. No statistically significant differences were observed in long-term all-cause mortality between groups.

Objective Neurologic events after coronary artery bypass grafting are an infrequent but devastating complication. This study analyzed the preoperative predictive abilities of the CHADS 2 and CHA 2 DS 2 VASc stroke scores in patients undergoing isolated coronary artery bypass grafting. Methods Included in the study were 2910 patients who underwent isolated coronary artery bypass grafting during a 19-year period. CHADS 2 and CHA 2 DS 2 VASc scores were computed for all patients, and outcomes were evaluated in terms of perioperative stroke and compared with 2 specific models for predicting surgical coronary artery bypass grafting stroke (Northern New England Cardiovascular Disease Study Group and Multicenter Study of Perioperative Ischemia Research Group). Perioperative stroke discrimination was quantified by computing the area under the receiver operating characteristic curve. Results Overall, 62 (2.1%) had perioperative strokes. Areas under the curve were 0.71 (95% confidence interval, 0.64-0.78) for CHADS 2 , 0.72 (95% confidence interval, 0.65-0.79) for CHA 2 DS 2 VASc, 0.69 (95% confidence interval, 0.61-0.76) for Northern New England Cardiovascular Disease Study Group, and 0.73 (95% confidence interval, 0.67-0.80) for Multicenter Study of Perioperative Ischemia Research Group scores. Northern New England Cardiovascular Disease Study Group and CHA 2 DS 2 VASc scores were better at discriminating patients with particularly low or high risk of stroke. Conclusions CHADS 2 and CHA 2 DS 2 VASc scores predicted perioperative coronary artery bypass grafting strokes with discriminatory abilities similar to those of specific predictive surgical coronary artery bypass grafting stroke models. All schemes tested showed similar limitations in discriminating patients with high postoperative stroke risk, with a high proportion being classified as having intermediate stroke risk.

ResumenLa insuficiencia mitral funcional comúnmente va asociada a la miocardiopatía dilatada, y su corrección se basa habitualmente en realizar una anuloplastia mediante el implante de un anillo rígido. Presentamos un caso de insuficiencia mitral severa en el contexto de una miocardiopatía dilatada que fue corregida mediante el implante de un anillo Geoform® con buen resultado postoperatorio inmediato pero con fracaso tardío de la técnica por dehiscencia de la prótesis anular y fallo de la anuloplastia que obligó a una reintervención e implante de una prótesis valvular mecánica para la solución definitiva del problema.AbstractFunctional mitral regurgitation often is associated with dilated cardiomyopathy, or left ventricular remodeling. Surgical repair result commonly in an annuloplasty ring. We present a case of severe mitral regurgitation due to dilated cardiomyopathy treated with implant of Geoform® annuloplasty ring, with a good immediate outcome, and a successive failure of the annuloplasty due to dehiscence of the ring and requirement of a mitral valve replacement.

Objetivo: Describir nuestra experiencia y evaluar los resultados a corto y mediano plazo de la miecto-mía videoasistida en el tratamiento de la obstrucción del tracto de salida del ventrículo izquierdo (OTSVI) en pacientes con miocardiopatía hipertrófica. Materiales y métodos: 52 pacientes con edad media de 56,2 (rango 12 - 83) y Euroscore de riesgo de 4,1 ± 1,92 con diagnóstico de OTSVI fueron intervenidos de manera consecutiva en un mismo centro mediante miectomía videoasistida. Se realizó seguimiento clínico y ecocardiográfico con controles al mes y al año del postoperatorio. Resultados: Entre las patologías asociadas encontramos 11 pacientes con valvulopatía aórtica, 2 con valvulopatía mitral, 3 con cardiopatía isquémica, 1 con aneurisma de aorta ascendente y 1 con foramen oval permeable resueltos en el mismo acto quirúrgico. La mortalidad hospitalaria global fue de 5,8% (3 pacientes). En el momento de la intervención, 8 (15,4%) se encontraban en clase funcional II de la NYHA, 42 (80,8%) en clase III y 2 (3,8%) en clase IV. El gradiente máximo subaórtico disminuyó de 80,7 mmHg ± 29,43 en el preoperatorio a 19,0 mmHg ± 15,57 (p

Validar las escalas de riesgo CHADS2 y CHA2DS2VASC como modelos predictivos de desarrollo de accidente cerebrovascular (ACV) en cirugía coronaria aislada (CCA). Métodos: Pacientes consecutivos con CCA entre enero de 2003 – octubre de 2011. Puntuaciones CHADS2 y CHA2DS2VASC computadas para todos los pacientes, considerándose variable de resultado la aparición de ACV perioperatorio precoz (primer mes postoperatorio y/o alta hospitalaria). Considerado ACV el evento neurológico con focalidad clínica (ictus/ataque isquémico transitorio [AIT]). Dos modelos específicos ya validados para la predicción de ACV tras CPC, Northern New England Cardiovascular Disease Study Group (NNECDSG) y Multicenter Study of Perioperative Ischemia (McSPI) Research Group, fueron asimismo computados para todos los pacientes y comparados con los previos. La capacidad discriminativa fue cuantificada por el cálculo del área bajo la curva ROC (AUC). Además, dicha capacidad predictiva de los esquemas fue estudiada por distribución de sus puntuaciones en tres estratos atendiendo a la incidencia de ACV postoperatorio: baja (

El accidente cerebrovascular (ACV) perioperatorio es una seria complicación en cirugía coronaria por su letalidad y secuelas. El antecedente de ACV puede ser un factor predisponente. Estudiamos su relación con el desarrollo de ACV quirúrgico y la influencia de ambos en la supervivencia precoz y a largo plazo. Material y métodos: Se han considerado 3.556 pacientes intervenidos consecutivamente de cirugía coronaria aislada entre 1995–2011; 208 (5,8%) habían sufrido al menos un ACV previo. Se estudió su perfil de riesgo y la incidencia de ACV perioperatorio junto con la mortalidad hospitalaria y tardía. Resultados: Los pacientes con ACV previo mostraron mayor frecuencia de factores de riesgo cardiovascular como hipertensión (68,8 vs 56,6%; p < 0,01) o diabetes (51,0 vs 39,2%; p < 0,01). También mayor arteriopatía periférica (28,4 vs 11,0%; p < 0,0001) y coronaria (número vasos: 2,7 ± 0,5 vs 2,6 ± 0,6; p < 0,05). Mayor incidencia de ACV perioperatorio (3,8 vs 1,0%; p < 0,01) y fallo renal agudo (11,1 vs 5,4%; p < 0,01), pero sin aumento significativo de mortalidad hospitalaria (5,3 vs 3,0%; p = 0,09). Sí aumentó en caso de ACV perioperatorio: 11,9 vs 3,1%; p < 0,01 (odds ratio [OR]: 4,8; intervalo de confianza [IC] 95%: 1,69–13,6; p < 0,01). La arteriopatía periférica se asoció a ACV quirúrgico (p < 0,05) y mortalidad precoz (p < 0,01). Junto a ACV previo y quirúrgico fueron predictores independientes de mortalidad tardía (supervivencia a 10 años en pacientes con y sin ACV previo: 61 ± 4% vs 77 ± 0,9%; p < 0,0001). Conclusiones: El ACV perioperatorio supone una complicación de elevada mortalidad hospitalaria, pero también durante el seguimiento. ACV previo y arteriopatía periférica son factores asociados a dicha complicación y también reducen la supervivencia tardía.

Describir nuestra experiencia de formación MIR en procedimientos de ablación quirúrgica concomitante de FA. Material y métodos: Trescientos ochenta y ocho pacientes sometidos a crioablación concomitante (1999–2011): 9 médicos internos residentes (MIR) supervisados (94 cirugías) y 6 cirujanos staff (294 cirugías). Variables preoperatorias, intraoperatorias (válvulas intervenidas, cirugía coronaria asociada, valvopatía reumática, patrón ablación, tiempos pinzado aórtico y circulación extracorpórea [CEC]) y postoperatorias (mortalidad precoz, implante de marcapasos [MP]), accidente cerebrovascular (ACV), ritmo sinusal (RS) al alta y seguimiento). Ajuste por propensity-score case-match: 166 pacientes (83/grupo) según variables preoperatorias. Resultados: Seguimiento medio 5,46 ± 2,76 años. Grupos comparables. No existieron diferencias significativas en los procedimientos quirúrgicos concomitantes, aunque en el grupo MIR predominó sustitución protésica mitral sobre reparación (p 0,05). En el análisis de los resultados por año de formación MIR, mejoró la restauración de RS (alta: R3: 68,00%, R4: 74,07%, R5: 77,42%; p

Objetivos la cirugia del prolapso de velo anterior mitral supone una mayor dificultad que otras reparaciones. La reseccion triangular, el acortamiento o la transposicion de cuerdas no suelen ser utiles, especialmente si existe una amplia rotura de cuerdas. El implante de cuerdas artificiales podria ser valido siempre que logre una longitud de neocuerda y una superficie de coaptacion adecuadas. Estudiamos su eficacia en un paciente con afectacion amplia del velo anterior. Material y metodos varon de 58 anos, prolapso de velo anterior (A2-A3) con rotura de multiples cuerdas primarias. Insuficiencia mitral grave (ORE: 0,52 cm2) con chorro de regurgitacion posterior. Implante de 5 pares de neocuerdas (politetrafluoroetileno [PTFE] CV-4) sin reseccion de tejido. Anclaje en ambos musculos papilares sin parche ni anudado. Identificacion de la linea de coaptacion en el borde libre del velo e implante de las neocuerdas a lo largo de su superficie de coaptacion hasta rebasar dicha linea. Repliegue del velo sobre el anillo y anudado de las neocuerdas tomando como referencia el plano anular. Anuloplastia con anillo CE Physio-II 32 mm. Resultados excelente resultado funcional tras la reparacion con ausencia de regurgitacion residual o SAM. Altura de coaptacion: 12 mm. Paciente asintomatico y sin complicaciones en el postoperatorio temprano. Conclusiones la reparacion con neocuerdas se ha mostrado eficaz en un paciente con prolapso amplio del velo anterior asociado a rotura multiple de cuerdas. La tecnica empleada permite remodelar el borde libre del velo logrando una buena superficie de coaptacion y un ajuste preciso de la longitud de las neocuerdas.

La EPOC figura entre la comorbilidad habitual en la estenosis aórtica de alto riesgo quirúrgico. La espirometría permite cuantificar su gravedad. Valoramos su repercusión en los resultados clínicos posquirúrgicos. Material y métodos: Mil setecientos cuarenta y cinco pacientes fueron intervenidos de sustitución valvular aórtica por estenosis grave (1995–2011). En todos se realizó espirometría, diagnosticando EPOC (volumen espiratorio forzado en el primer segundo [FEV1] < 75%) en 439 (25,2%): ligera (FEV1 > 60%) en 225 (12,9%), moderada (FEV1: 40–59%) en 143 (8,2%) y grave (FEV1 < 40%) en 69 (4%). Se estudió su impacto en morbimortalidad. Resultados: El paciente EPOC mostró peor perfil de riesgo, especialmente si grado moderado-grave: mayor edad (67 ± 11, 69 ± 7, 68 ± 10 y 70 ± 7 años [p < 0,01] para ausencia EPOC ligera, moderada o grave), frecuencia creciente de arteriopatía periférica e insuficiencia renal crónica (IRC) (p < 0,01) y menor fracción de eyección (FE) (60 ± 15%, 57 ± 16%, 56 ± 17 y 56 ± 12%; p < 0,05). Se observó mayor tasa de complicaciones en EPOC moderada-grave (vs resto), bajo gasto cardíaco (GC) (4,2 vs 1,7%; p < 0,05), in-suficiencia respiratoria (14,6 vs 5,3%; p < 0,0001), fallo renal agudo (11,8 vs 5,7%; p < 0,01) y hemodiálisis (4,2 vs 1,1%; p < 0,05). Creciente mortalidad hospitalaria: 5,9, 1,8, 8,4 y 20,3% (p < 0,001) y tardía (supervivencia actuarial a 5–10 años en EPOC moderada-grave vs resto: 69 ± 3% vs 88 ± 9% y 45 ± 4% vs 73 ± 1%; p < 0,0001). EPOC moderada-grave fue predictor de ambas mortalidades (odds ratio [OR]: 2,28; intervalo de confianza [IC] 95%: 1,20-4,3; p < 0,05 y hazard ratio [HR]: 2,6; p < 0,0001). Conclusiones: La EPOC en grado moderado-grave en pacientes con estenosis aórtica candidatos a cirugía es un factor de riesgo de primer orden. Supone un aumento no sólo de morbimortalidad hospitalaria sino también tardía y, por tanto, debe considerarse en la selección del tratamiento más adecuado.