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La reparación valvular es considerada actualmente como el tratamiento quirúrgico electivo de la insuficiencia mitral cuando la anatomía valvular es favorable. La anuloplastia mitral provee los mejores resultados en la enfermedad degenerativa, con una mortalidad hospitalaria < 1% y supervivencia actuarial del 90 y 80% a los 5 y 10 años, respectivamente; la mayoría de pacientes permanecen libres de reoperación e insuficiencia mitral residual (90% a los 10 años). Esta técnica no resulta tan satisfactoria en la enfermedad reumática, y aunque hemos obtenido resultados satisfactorios, otros autores presentan incidencia elevada de reoperación por disfunción mitral. La disfunción valvular mitral postoperatoria a largo plazo (20 años) es significativamente mayor en pacientes menores de 20 años (26,8 vs 4,5%). La enfermedad congénita de la válvula mitral constituye un grupo heterogéneo, debiendo considerarse la anuloplastia como una parte de la reconstrucción valvular, siendo preciso tratar quirúrgicamente el resto de anomalías congénitas asociadas. En estos casos, la mortalidad hospitalaria oscila entre 1-10%, con una incidencia de reoperación por disfunción valvular a largo plazo de 20-50%, dependiendo del tipo de cardiopatía congénita. La cirugía reparadora en la insuficiencia mitral isquémica sigue constituyendo motivo de controversia por la complejidad de los mecanismos que la ocasionan. En estos pacientes, la anuloplastia soluciona parcialmente la regurgitación, al aumentar la zona de coaptación de los velos, pero no logra corregir las alteraciones en la movilidad valvular ni los cambios geométricos del aparato subvalvular. En el 25% de los pacientes operados reaparece una insuficiencia mitral, por lo que se recomienda utilizar un anillo restrictivo con objeto de incrementar la coaptación valvular. Recientemente, en estos casos se emplea la anuloplastia asimétrica, que corrige el defecto de la región posterolateral del anillo y válvula. La anuloplastia en pacientes con miocardiopatía dilatada e insuficiencia cardíaca terminal, propuesta por Bolling, ha dado resultados satisfactorios, con mejoría de la clase funcional NY HA, disminución de la hospitalización y supervivencia al año del 84%, a pesar de que a los 5 años sobreviven menos de la mitad de los pacientes.En resumen, la anuloplastia mitral debe considerarse como parte de la cirugía reparadora, siendo necesario individualizar su utilización de forma que, para cada paciente, la reconstrucción valvular «completa» requerirá un determinado modelo de prótesis anular y de técnicas reparadoras asociadas. Debemos evitar, de este modo, generalizar el tratamiento quirúrgico como hemos venido haciendo incorrectamente durante años.Valve repair is currently considered as the elective surgical approach for mitral insufficiency when valve anatomy is appropriated. Mitral annuloplasty for degenerative disease provides the best results: hospital mortality

RésumenHace 40 años, Norberto G. de Vega publicó la anuloplastia de sutura que lleva su nombre y que, desde entonces, se utiliza en todo el mundo con resultados satisfactorios a largo plazo. se han introducido diversas modificaciones técnicas tratando de mejorarla, aunque se dispone de escasa información sobre estos pacientes. Pocos meses después de la publicación de la técnica de De Vega, comenzó un debate, que persiste en la actualidad, sobre la mejor alternativa quirúrgica para el tratamiento de la insuficiencia tricúspide significativa, anillo protésico o anuloplastia de sutura, a pesar de haberse demostrado científicamente una afectación considerable en la movilidad y dinámica de los diferentes componentes del aparato valvular cuando se utiliza un anillo protésico, en comparación con la anuloplastia de De Vega, que respeta la función fisiológica de la válvula. Durante estas décadas, se han ampliado las indicaciones de la técnica de De Vega para el tratamiento de determinadas cardiopatías congénitas, lesiones orgánicas de diverso origen, afectación traumática valvular, e incluso su utilización profiláctica en el trasplante cardíaco y asistencia ventricular. Las guías internacionales siguen siendo cautas en recomendar indicaciones o las técnicas más idóneas de reparación y sustitución protésica valvular, por lo que falta un consenso general sobre la cirugía tricúspide. Sin duda, en el futuro se encontrarán las respuestas a algunas preguntas aún sin resolver sobre esta apasionante y tantas veces olvidada válvula tricúspide.AbstractDe Vega annuloplasty. A historical perspectiveForty years ago Norberto G. Vega developed the suture annuloplasty that bears his name and which, since then, has been extensively used throughout the world with satisfactory long-term results. Various modified techniques have been introduced, trying to improve it, but little information has been published on those surgical patients. Within a few months of publication of the De Vega annuloplasty, a debate began that persists today about the best surgical alternative for the treatment of significant tricuspid insufficiency, the prosthetic ring versus suture annuloplasty, despite being scientifically proven that there is a significant distortion in the mobility and dynamics of the different components of the valve when using a prosthetic ring, as compared with the De Vega annuloplasty, which respects the normal valve physiology. During these decades, the indications for de Vega annuloplasty have expanded to treat congenital heart diseases, organic and traumatic tricuspid lesions, and even as a prophylactic alternative to prevent postoperative tricuspid regurgitation after heart transplantation and ventricular assist devices implantation. international guidelines are still cautious in recommending new indications and the best surgical approach for repair or replacement so there is no general consensus on tricuspid valve surgery. Certainly in the future, answers will be found to some still unresolved questions about this exciting and often forgotten tricuspid valve.

ObjectiveThe objective was to analyze the short- and long-term results of patients with previous tricuspid valve repair who had valve dysfunction and required cardiac reoperations.MethodsBetween 1976 and 2002, 74 patients with a mean age of 53.8 ± 12.2 years underwent valve reoperations for dysfunction of previous tricuspid valve repair. Mitral and tricuspid lesions were diagnosed in 40 patients (54%), triple valve disease (mitral, aortic, tricuspid) was diagnosed in 26 patients (35.1%), isolated tricuspid disease was diagnosed in 6 patients (8.1%), and aortic and tricuspid lesions were diagnosed in 2 patients (2.7%). Reoperations included tricuspid valve replacement in 43 patients (58.1%) and a new tricuspid valve repair procedure in the remaining 31 patients (41.9%).ResultsHospital mortality (30-day or within first admission) was 35.1% (n = 26). In the multivariate analysis, risk factors for hospital mortality included body mass index less than 20 kg/m2 and greater than 24 kg/m2, triple valve disease, use of intra-aortic balloon counterpulsation, and presence of postoperative complications. The follow-up was complete in 100% of patients, with a mean follow-up of 14.2 years (range 4 months to 26 years). The late mortality was 40.5% (n = 30). Predictors of late mortality were body mass index less than 20 kg/m2, cardiac surgery before 1991, and development of dysfunction early after tricuspid valve repair. At the follow-up closing date, 19 patients are alive (25.7%). The actuarial survival was 11.8% ± 4.9% at 26 years.ConclusionsPatients with failure of a tricuspid valve repair procedure requiring reoperation have a poor prognosis with a high mortality rate both in-hospital and in the long-term.

A total of 970 adult patients undergoing cardiovascular operations during a 1-year period were eligible for a case-control study on the risk factors for nosocomial infection. Cases were defined as patients in whom a postoperative infection developed. Every case was paired with one uninfected subject. Nosocomial infection occurred in 89 (9.2%) patients. A total of 120 episodes of infection were diagnosed (1.3 episodes per patient). The infection ratio was 12.4%. Surgical site infection was the most common (5.6%), followed by pneumonia (3.2%), urinary tract infection requiring the use of intravenous antibiotics (1.8%), deep surgical site (0.9%), and bacteremia (0.7%). Advanced age, urgent intervention, duration of surgical procedure, blood transfusion, and use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage) were significantly associated with infection in the bivariate analysis. Nosocomial infection resulted in a significant increase in the length of hospital stay. Cases showed an almost fivefold greater risk of death than controls (odds ratio, 4.73; 95% confidence interval, 1.11 to 6.83; p = 0.009). Age older than 65 years, female sex, and mode of surgical intervention were selected in the multivariate analysis for patients undergoing cardiac operations, whereas general anesthesia or assisted ventilation, central venous catheter, and blood transfusion were the variables selected for patients undergoing operation for vascular disorders. In summary, the recognition of risk factors for postoperative infection in patients undergoing cardiovascular surgical procedures may contribute to improve their prognosis and to more organized surveillance and control activities in the hospital environment. (J T HORAC C ARDIOVASC S URG 1996;112:908-13)

This report provides retrospective follow-up data on 88 patients who received an Ionescu-Shiley bovine pericardial valve in the aortic position between August, 1977, and June. 1980. Seven instances of primary tissue degeneration occurred in seven of the 65 patients followed up until June, 1984. Cumulative duration of follow-up was 335.5 patient-years. The linearized incidence of primary tissue failure was 2.08% per patient-year. The actuarial rate of freedom from valve failure for patients with an Ionescu-Shiley valve in aortic position was 79% +/- 8% at 7 years of follow-up. This series shows a higher incidence of primary tissue failure with this prosthesis than with the glutaraldehyde-preserved porcine xenograft in the aortic position at 7 years' follow-up.

Summary A 55 year old man with a left ventricular aneurysm, secondary to a previous myocardial infarction, was hospitalized due to a Salmonella virchow bacteraemia. During a 3-week hospital course he was persistently bacteraemic and febrile despite antibiotic treatment. Gallium isotope scanning and 2-D-echocardiography were helpful in demonstrating the presence of an infected false aneurysm at the site of a true aneurysm. Surgical resection in addition to prolonged antibiotic therapy was necessary for cure.

Right ventricular outflow tract (RVOT) reconstruction with a new composite pericardial monocusp patch incorporating a sinus of Valsalva was performed in 7 patients. There was one hospital death. Follow-up ranged from 20 to 52 months (mean 25.4 months, cumulatively 206 patient months). Four patients have been recatheterized at an average of 6.5 months (1 to 12 months) after surgery. The average RVOT gradient was 9 +/- 2 mmHg, and mean right ventricular end-diastolic pressure was 10 +/- 5.5 mmHg. All except one have a competent pulmonary valve with normally functioning monocusp, and no thrombosis, calcification or aneurysmal dilatation.

A composite bovine pericardial monocusp patch was implanted in the right ventricular outflow tract of 30 dogs. The monocusp patch incorporates a molded sinus of Valsalva designed according to a computer-analyzed study of the normal anatomy. Twenty-two dogs survived the operation and were killed between 1 and 34 months postoperatively (mean, 19.5 ± 3.5 months). Two implants showed signs of infective endocarditis 2 and 2.5 months, respectively, after operation; 1 was thrombosed at 7 months, and 1 was calcified 8 months postoperatively. In the remaining 18 animals, there was no stenosis, thrombosis, or degeneration of tissue in the monocusp. Macroscopic and microscopic studies of these grafts showed normal structure and pliability of the monocusp valve up to 34 months after operation.

Mujer de 75 años con bocio multinodular tóxico intratorácico, insuficiencia mitral degenerativa y síndrome febril, diagnosticada de endocarditis infecciosa (EI) activa por S. lugdunensis. Con la sospecha de EI mitral e imposibilidad de estudio ecocardiográfico transesofágico por el bocio, fue intervenida quirúrgicamente realizándose en el mismo acto quirúrgico hemitiroidectomía y ecocardiografía transesofágica, la cual confirmó insuficiencia mitral grave y vegetación de 6cm originada en la proximidad de la orejuela izquierda (Fig. 1). Se realizó exéresis de la verruga mural (Fig. 2) y reparación mitral mediante técnica de Alfieri y anuloplastia flexible con buen resultado y curación del proceso infeccioso.A 75-year-old female with intrathoracic toxic goiter, degenerative mitral insufficiency and fever was diagosed as having S. lugdunensis infective endocarditis (IE). With the suspicion of mitral IE and unabilitiy to perform transesophageal echocardiogram due to goiter, she underwent operation. Trans esophageal echocardiogram and thyroidectomy were performed. Echo confirmed a 6cm vegetation originated in the vicinity of the left atrial appendage (Fig. 1) and severe mitral regurgitation. Excision of the mural vegetation (Fig. 2), Alfieri type of repair and flexible mitral annuloplasty were performed with good result and cure of the infection.