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Objectives Cardiac surgery is a life-saving procedure in patients diagnosed with infective endocarditis (IE). There are several validated risk scores developed to predict early-mortality; nevertheless, long-term survival has been less investigated. The aim of the present study is to analyze the impact of IE-specific risk factors for early and long-term mortality. Methods An observational retrospective study was conducted that included all patients who underwent surgery for IE from 2002 to 2016. Median follow-up time after surgery was 53.2 months (IQI 26.2–106.8 months). In-hospital mortality was analyzed using multiple logistic regression. Long-term survival was analyzed after one, two and five years. Cox proportional hazards regression was employed to identify risk factors related to long-term mortality. Results Of the 180 patients underwent cardiac surgery, 133 were discharged alive (in-hospital mortality was 26.11%). 6 variables were identified as independent factors associated with in-hospital mortality, most of them closely related to the severity of IE: age, multivalvular involvement, critical preoperative status, preoperative mechanical ventilation, abscess and thrombocytopenia. Long-term survival in patients discharged alive was 89.1%, 87.4% and 77.6% after one, two and five years. Long-term mortality was independent of specific IE factors and 86.51% of deaths were not related to cardiovascular or infectious diseases. Conclusion Despite the high perioperative mortality rate after surgical treatment for active IE, long-term survival after hospital discharge was acceptable, regardless of the severity of the endocarditis episode. Although in-hospital survival depended mainly on several IE factors, long-term survival was not related to the severity of endocarditis baseline affection.

Resumen: Introducción: La trombocitopenia preoperatoria se ha relacionado con un peor pronóstico en la endocarditis infecciosa. Objetivo: Valorar la influencia de la trombocitopenia en la cirugía de la endocarditis infecciosa en nuestra serie. Métodos: Análisis retrospectivo unicéntrico de los pacientes intervenidos por endocarditis infecciosa entre 2002 y 2016. Análisis de supervivencia a corto y a largo plazo, estratificado en función de la presencia de trombocitopenia (recuento plaquetario

Resumen: Introducción: La vancomicina tópica ha demostrado su eficacia para disminuir la incidencia de infección de la herida quirúrgica, sin embargo, su utilidad en cirugía cardiaca permanece en duda. Objetivos: Estudiar el efecto de la vancomicina tópica sobre la incidencia de infección de la herida de esternotomía tras cirugía cardiaca. Material y método: Estudio observacional, retrospectivo, comparando la incidencia de infección de esternotomía entre una cohorte en la que se empleó la profilaxis antibiótica habitual, frente a otra en la que además se asoció vancomicina tópica. Resultados: Se incluyeron un total de 525 pacientes, 47,43% en el grupo tratado con vancomicina. La incidencia global de infección fue significativamente superior en el grupo sin vancomicina (3,6% frente a 10,1%) implicando un riesgo relativo de 2,8 (IC 95% 1,35-5,83; p = 0,004). Las diferencias fueron significativas en la incidencia de infecciones superficial y profunda (p = 0,05), sin alcanzar la significación estadística en la infección órgano-espacio (p = 0,22). El efecto beneficioso de la vancomicina se mantuvo en un modelo de regresión ajustado por los posibles factores de confusión identificados (tabaquismo, reintervención, nefropatía y grado NYHA): odss ratio 3,48 (IC 95% 1,44-8,41; p = 0,006). Los gramnegativos fueron el principal agente causal en el grupo con vancomicina (57,1%) y los grampositivos en el grupo sin vancomicina (66,7%), aunque estas diferencias no alcanzaron la significación estadística. Conclusión: El empleo de vancomicina tópica disminuye la incidencia de infección de la herida de esternotomía, tanto superficial como profunda. Su uso podría producir un cambio en el espectro etiológico de la infección esternal. Abstract: Introduction: Topical vancomycin has demonstrated effectiveness in decreasing the incidence of surgical wound infection; however, its usefulness in cardiac surgery remains in doubt. Objectives: To analyse the effectiveness of topical vancomycin in the reduction of sternal wound infection in cardiac surgery. Material and method: A retrospective observational study was conducted to compare the incidence of sternotomy infection in a cohort in which the usual antibiotic prophylaxis was used, with another cohort in which topical vancomycin was also used. Results: A total of 525 patients were included in the study, with 47.43% in the group treated with vancomycin. The incidence of infection was significantly higher in the group without vancomycin (3.6% versus 10.1%), implying a relative risk of infection of 2.8 (95% CI; 1.35-5.83, p = .0035). The differences were statistically significant as regards the incidence of superficial and deep infections (p = .05), but did not reach statistical significance in organ-space infection (p = .22). The beneficial effect of vancomycin was maintained in a logistic regression model adjusted for possible confounding factors (smoking, re-operation, nephropathy, and NYHA functional grade class): odss ratio 3.48 (95% CI; 1.44-8.41, p = .006). Gramnegative microorganisms were the main causative agent in the vancomycin group (57.1%), whereas it was grampositive in the group without vancomycin (66.70%), although these differences did not reach statistical significance. Conclusion: The use of topical vancomycin decreases the incidence of superficial and deep sternotomy wound infections. Its use could lead to a change in the aetiological spectrum of sternal wound infection. Palabras clave: Infección herida quirúrgica, Vancomicina, Esternotomía media, Profilaxis antibiótica, Antibioterapia tópica, Keywords: Surgical site infection, Vancomycin, Median sternotomy, Antibiotic prophylaxis, Topical antibiotic therapy

Resumen: Recientemente, se ha publicado en la Revista Española de Cardiología un Documento de Consenso sobre el manejo del tratamiento antitrombótico en el paciente quirúrgico, fruto de la colaboración de varias de las sociedades de especialidades implicadas en el manejo de este tipo de pacientes, entre ellas la SECTCV. En esta revisión, se intenta tanto comentar este documento como ampliarlo con puntualizaciones, centrándolo en nuestra especialidad.Para ello, además de seguir las recomendaciones aportadas en la citada publicación, se añaden las presentes en las guías clínicas de medicación perioperatoria elaboradas por la European Association for Cardio-Thoracic Surgery en 2017.El paciente con tratamiento antitrombótico (tanto anticoagulante como antiagregante) es una entidad común en el contexto de la cirugía cardíaca, por lo que estas pautas son de aplicación frecuente en la práctica diaria. No obstante, cada caso debe someterse a una evaluación individualizada, teniendo en cuenta tanto el riesgo hemorrágico como trombótico, según las características del paciente o de la intervención a realizar, a la hora de tomar las decisiones. Abstract: A Consensus Document has recently been published in the Spanish Journal of Cardiology (Revista Española de Cardiología) on the management of antithrombotic treatment in the surgical patient. This has been prepared with the collaboration of several societies of the specialties involved in the management of this type of patient, among them the Spanish Society of Thoracic-Cardiovascular Surgery (SECTCV). In this review, it is intended to comment on this Document, as well as to amplify it with some points, focusing them on our speciality.For this, besides following the recommendations provided in the aforementioned publication, the present ones are added in the clinical guides for peri-operative medication prepared by the European Association for Cardio-Thoracic Surgery in 2017.The patient on antithrombotic treatment (both anticoagulant as well as anti-platelet) is a common entity in the cardiac surgery context, so these recommendations are frequently applied in daily practice. However, each case must be subjected to an individualised assessment, taking into account the haemorrhagic, as well as the thrombotic risk, depending on the patient characteristics or the intervention to be performed, when making decisions. Palabras clave: Tratamiento antitrombótico, Antiagregante, Anticoagulante, Manejo perioperatorio, Keywords: Antithrombotic treatment, Anti-platelet, Anticoagulant, Perioperative management

Resumen: Introducción: La cirugía de sustitución valvular tricúspide (SVT) aislada es una intervención poco frecuente, con una indicación controvertida, en gran parte debido a su mal pronóstico. Material y métodos: Se analizaron todos los pacientes intervenidos de SVT aislada entre los años 2003 y 2014. Se analizó: a) Mortalidad perioperatoria y a largo plazo; y b) Aparición de complicaciones relacionadas con las prótesis tricúspides a largo plazo (trombosis y degeneración protésica). Resultados: Durante el periodo de estudio se realizaron 40 intervenciones de SVT aislada. El 82,5% de los pacientes se encontraban en clase funcional iii/iv de la NYHA, y el 70% tenían hipertensión pulmonar al menos moderada (presión sistólica arterial pulmonar > 40 mmHg). La mortalidad perioperatoria fue del 25%, infraestimada por EuroSCORE I (mortalidad estimada del 13,89%). La anemia preoperatoria (OR: 0,52; IC 95%: 0,30-0,89; p = 0,017) se asoció con una mayor mortalidad perioperatoria. La reintervención se asoció con una tendencia a una mayor mortalidad perioperatoria (p = 0,081). La supervivencia tardía, tras 44 meses de seguimiento mediano, fue del 57,50%. Los factores significativamente asociados con una peor supervivencia en el seguimiento fueron: 1) Hipertensión pulmonar severa (OR: 5,77; IC 95%: 1,06-31,26; p = 0,042) y 2) Clase funcional iv (OR: 8,31; IC 95%: 1,48-49,06; p = 0,004). Los pacientes intervenidos en clase funcional iv de la NYHA presentaron una escasa supervivencia a largo plazo (12,5% de supervivencia al año; log rank p = 0,004). Conclusiones: La SVT aislada se asocia con una alta mortalidad, debido a la indicación de la intervención en avanzados estados de cardiopatía.La indicación de cirugía ha de hacerse de manera precoz, antes del deterioro de la función ventricular derecha o de la aparición de hipertensión pulmonar severa. La cirugía en clase funcional NYHA iv supone un escaso beneficio en términos de supervivencia tardía. Abstract: Background: Isolated tricuspid valve replacement (TVR) is a rarely performed procedure, with controversial indications for performing surgery, mostly due to the poor outcomes reported. Material and methods: All patients undergoing isolated TVR between 2003 and 2014 were included. We analyzed: a) Perioperative mortality and long-term mortality; b) Prosthetic valves related complications during follow-up (thrombosis and biological valve deterioration). Results: A total of 40 patients underwent isolated TVR during the study period. 82.5% of these patients where in III-IV/IV NYHA functional class, and 70% of them had at least moderate pulmonary hypertension (mean PAP > 40 mmHg). Perioperative mortality was 25%. The EuroSCORE I underestimated the mortality associated to this procedure (estimated mortality of 13.89%). Preoperative anemia (OR: 0.52; CI 95%: 0.30-0.89; P = .017) was associated to a higher perioperative mortality. There was a trend towards a higher mortality in patients with previous cardiac surgery (P = .081). Late survival, after 44 months of median follow-up, was 57.50%. Long-term survival was influenced by: 1) Severe pulmonary hypertension (OR: 5,77; CI: 95%: 1.06-31.26; P = .042); 2) NYHA class IV (OR: 8.31; CI: 95%: 1.48-49.06; P = .004). Patients who were operated in NYHA IV had a poor long-term survival (12.5% of one-year survival, log Rank P = .004). Conclusions: Isolated TVR is associated to a high mortality, mostly due to surgery timing, when the patient is already in an advanced heart failure situation.Indication for surgery must be done promptly, before the right ventricle function deterioration or the development of severe pulmonary hypertension. Performing surgery when the patient is in IV NYHA functional class, provides scarce benefit regarding long-term survival. Palabras clave: Valvulopatía, Insuficiencia tricúspide, Sustitución valvular tricúspide, Cirugía tricúspide aislada, Keywords: Valvular heart disease, Tricuspid tegurgitation, Tricuspid valve replacement, Isolated tricuspid surgery

bstract We report an unusual complication of acute infective endocarditis, found in a 70 year-old man with a previous history of two cardiac surgery procedures. The first one was a full root replacement (BentallDe Bono procedure), associated with three bypasses (one mammary and two vein grafts). The second procedure was a mitral valve replacement through a right thoracotomy ought to native mitral valve endocarditis. In the current admission, echocardiography showed a periaortic abscess (Figure 1) and severe prosthetic mitral valve insufficiency. CT scan showed a big collection in the anterior mediastinal space adjacent to the composite graft (Figure 2), which was suspected to be purulent material. A third surgical intervention was programmed despite the extreme surgical risk. During the median sternotomy, a massive bleeding occurred. It was originated in the mediastinal collection, which truly was a collection of contained bleeding, originated in the 10 yearsold anastomosis of the saphenous vein to the composite graft, which was completely detached due to endocarditic involvement of the aortic graft. The institution of cardiopulmonary bypass before sternal opening enabled the surgical team to maintain a stable hemodynamic situation and to continue the procedure satisfactorily. You can submit your Manuscripts at: https://symbiosisonlinepublishing.com/submitManuscript.php

The case is reported of a 55 year-old woman, with a previously known congenital septal defect, who was admitted to the emergency department with a diagnosis of meningoencephalitis, septic shock, and rapid clinical deterioration. Echocardiography revealed a vegetation occupying the right-side heart. Endocarditis affectation of the septal defect, aortic and tricuspid valves was noted and blood cultures were positive for Staphylococcus aureus. Urgent surgical treatment was performed whereby the ventricular septal defect was closed, a meticulous debridement of the affected area was conducted, and the aortic and tricuspid valves were replaced.

La esternotomia media continua siendo el gold-standart de abordaje quirurgico en cirugia cardiaca. Aun realizada correctamente, laapertura media del esternon presenta complicaciones en el 1-5% de los casos que varian en su gravedad desde la infeccion de la heridaquirurgica a la lesion de estructuras intratoracicas. En el presente estudio se describe un caso de rotura de electrodos de marcapasostras esternotomia media por retraccion y fibrosis del tronco venoso braquiocefalico. Debido a la ausencia de articulos semejantes enla literatura y al extendido empleo de la esternotomia en pacientes portadores de marcapasos permanente, se pretende disminuirlas lesiones asociadas mediante la publicacion de un infrecuente caso de lesion iatrogenica durante la apertura esternal, con escasosprecedentes en la literatura publicada hasta la fecha. MED.UIS. 2016;29(3):95-9.Palabras clave: Procedimientos quirurgicos cardiacos. Marcapasos artificial. Esternotomia. Enfermedad iatrogenica.

We report a case of a 23-year-old man who was diagnosed with Kawasaki disease that progressed to a coronary aneurysm in the left main coronary artery (LMA). He had suffered from acute coronary syndrome and then underwent an emergent percutaneous coronary angioplasty, in which a polyurethane-covered stent was placed inside the aneurysm. The stent was thrombosed one year later, despite the patient had been treated with anticoagulant and antiplatelet therapy. Emergency percutaneous intervention was then performed. LMA was reopened and stent malposition was observed. Therefore, urgent coronary bypass grafting was performed in which a high degree of competitive flow was observed through the reopened stent. LMA was ligated at the inflow of the aneurysm, resulting in an improvement of graft flow. Left main ligature has not been previously reported.

Right heart floating thrombus or “embolus in transit” can be a very dangerous condition, usually associated to pulmonary thromboembolism. Even though many treatment options have been considered, nowadays, the recommended approach remains unclear. Surgical embolectomy has been used as an option, usually less preferred than thrombolysis or percutaneous approach, but it can be a safe and effective procedure in patients with high risk of embolization.

HighlightsCoronary artery dissection is an unfrequent complication, which in an important number of cases has a iatrogenic cause. Most of them occur after a percutaneous procedure, and usually the right coronary artery is the one affected.We report the case of a iatrogenic right coronary dissection after valve replacement surgery. The cause was assumed to be the antegrade cannulation of the ostium for cardioplegic perfussion.What we consider particularly interesting about this case is that it had a delayed clinical manifestation, 9 days after surgery, having a normal immediate post-operative course. The diagnosis was achieved by coronary angiography, and no interventional treatment was performed.