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Background Although presurgical nasal decontamination with mupirocin (NDM) has been advocated as a measure for preventing postsurgical mediastinitis (PSM) due to Staphylococcus aureus, this strategy is not universally recommended due to lack of robust supporting evidence. We aimed to evaluate the role of preoperative NDM in the annual incidence of S. aureus PSM at our institution. Methods An interrupted time-series analysis, with an autoregressive error model, was applied to our single-center cohort by comparing preintervention (1990–2003) and postintervention (2005–2018) periods. Logistic regression was performed to analyze risk factors for S. aureus PSM. Results 12 236 sternotomy procedures were analyzed (6370 [52.1%] and 5866 [47.9%] in the pre- and postintervention periods, respectively). The mean annual percentage adherence to NDM estimated over the postintervention period was 90.2%. Only 4 of 127 total cases of S. aureus PSM occurred during the 14-year postintervention period (0.68/1000 sternotomies vs 19.31/1000 in the preintervention period; P Conclusions Our experience suggests the implementation of preoperative NDM significantly reduces the incidence of S. aureus PSM.

Resumen: Introducción y objetivos: La hipertensión pulmonar tromboembólica crónica es una rara consecuencia de la embolia pulmonar aguda. La cirugía de tromboendarterectomía pulmonar es el tratamiento de elección. Cuando la afectación es distal (nivel iii anatomoquirúrgico o segmentario) supone un mayor desafío quirúrgico y presenta mayor riesgo de morbimortalidad perioperatoria. Analizamos los resultados de la tromboendarterectomía pulmonar en pacientes con hipertensión pulmonar tromboembólica crónica nivel i-ii y nivel iii en nuestro centro. Métodos: Desde febrero de 1996, hemos realizado 290 tromboendarterectomías pulmonares consecutivas, 260 con seguimiento mínimo de un año (media de 67 meses [rango 17-279]). Dividimos esta población en grupo 1 (210 pacientes con hipertensión pulmonar tromboembólica crónica nivel i y ii) y grupo 2 (50 pacientes con hipertensión pulmonar tromboembólica crónica nivel iii [19%]) Resultados: La supervivencia al año fue del 94% en el grupo 1 y del 96% en el grupo 2, a los 3 años, del 93 y el 96%, y a los 5 años, del 90 y el 96%, respectivamente (p = 0,352). La mortalidad hospitalaria (6% vs. 4%, p = 0,473), la oxigenación con membrana extracorpórea perioperatoria (6% vs. 0%, p = 0,058), la tasa de ventilación mecánica de más de 48 horas (34% vs. 42%, p = 0,306) y la hipertensión pulmonar residual (resistencias vasculares pulmonares superiores a 400 dinas.s.cm−5) a los 6 meses de seguimiento (22% vs. 19%, p = 0,680) no presentaron diferencias estadísticamente significativas. Conclusiones: La tromboendarterectomía pulmonar en hipertensión pulmonar tromboembólica crónica con afectación distal o segmentaria, cuando es realizada en un centro experto, puede obtener resultados a corto-medio plazo excelentes y similares a los pacientes intervenidos con afectación más proximal. Abstract: Introduction and objectives: Chronic thromboembolic pulmonary hypertension is a rare consequence of an acute pulmonary embolism. Pulmonary thromboendarterectomy is the treatment of choice. It represents a greater surgical challenge in distal chronic thromboembolic disease (level iii, segmental). It also presents a higher risk of perioperative morbidity and mortality. We analyzed the results of pulmonary thromboendarterectomy in patients with level i-ii and level iii chronic thromboembolic pulmonary hypertension in our center. Methods: Since February 1996, we have performed 290 consecutive pulmonary thromboendarterectomy, 260 of them with a minimum follow-up of one year (mean of 67 months [rank 17-279]). We divided this population into group 1 (210 patients with chronic thromboembolic pulmonary hypertension levels i and ii) and group 2 (50 patients with chronic thromboembolic pulmonary hypertension level iii [19%]). Results: Survival rate was 94% in group 1 and 96% in group 2 after one year, 93% and 96% after 3 years, and 90% and 96% after 5 years, respectively (P=.352). No statistically significant differences were found regarding hospital mortality (6% vs. 4%, P=.473), perioperative extracorporeal membrane oxigenation (6% vs. 0%, P=.058), the rate of mechanical ventilation for more 48 hours (34 vs. 42%, P=.306) and residual pulmonary hypertension (pulmonary vascular resistance greater than 400 dynes/sec/cm−5) at 6 months of follow-up (22% vs. 19%, P=.680). Conclusions: Pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension with distal involvement, when performed in an expert center, can obtain short-to-medium-term results excellent and similar to those of patients operated on with more proximal involvement.

Resumen: Se presenta el caso de un varón de 70 años de edad, quien debutó con fibrilación auricular no valvular, en quien, dos meses después y mediante ecocardiografía, se objetivaron dos masas contiguas en la aurícula derecha. Las masas eran dependientes de la válvula de Eustaquio, alcanzaban el septo interauricular y se asemejaban a un mixoma. Ambas fueron resecadas mediante cirugía, sin complicaciones intraoperatorias ni postoperatorias. El estudio anatomo-patológico concluyó que eran compatibles con trombos sin componente tumoral. Durante el seguimiento permaneció asintomático y en ritmo de fibrilación auricular. Abstract: The case is presented on a 70 year-old male who debuted with non-valvular atrial fibrillation. Two months later, and using cardiac ultrasound, two contiguous masses were observed in the right atrium. The masses were hanging from the Eustachian (inferior vena cave) valve, reached the interatrial septum and resembled a myxoma. Both were surgically resected, with no intra- or post-operative complications. The patient remained asymptomatic and in atrial fibrillation rhythm during follow-up.

Las complicaciones mecanicas del infarto agudo de miocardio (IAM) tienen una incidencia menor al 1%, debido al aumento en el uso de la reperfusion y particularmente la revascularizacion percutanea precoz1,2.

Resumen: El nuevo coronavirus SARS-CoV-2 es el responsable de la pandemia actual (COVID-19) y la consecuente emergencia sanitaria internacional. El espectro clínico de esta entidad es amplio, con recientes reportes de casos con afectación cardíaca, principalmente miocarditis, en pacientes COVID-19. Hasta la fecha hay escasos reportes de casos COVID-19 con necesidad de cirugía cardíaca. La posición de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) ha sido la de asegurar la correcta atención de pacientes emergentes y urgentes, de acuerdo con las guías clínicas actuales, sin embargo, en algunos casos la distinción entre la afectación de etiología cardíaca o pulmonar puede dificultar la toma de decisiones. Presentamos el caso de un varón con endocarditis infecciosa e infección intercurrente por COVID-19, en el que fue fundamental el consenso multidisciplinar para sentar la indicación quirúrgica, debido a que su sintomatología generaba controversia con las guías clínicas actuales de la Sociedad Europea de Cardiología (ESC) sobre endocarditis infecciosa. Consideramos que la adaptación de las guías durante la emergencia sanitaria actual y la toma multidisciplinar de decisiones pueden facilitar la actuación terapéutica en casos complejos de patologías cardíacas con indicación quirúrgica y coinfección por COVID-19. Abstract: The new SARS-CoV-2 coronavirus is responsible for the current pandemic (COVID-19) and the consequent international health emergency. The clinical spectrum is broad, with recent reports of cases with cardiac involvement, mainly myocarditis, in COVID-19 patients. To date there are few reports of COVID-19 cases in need of heart surgery. The position of the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE) has been to ensure the correct care of emerging and urgent patients, according to current clinical guidelines, however, in some cases the distinction between involvement of cardiac or pulmonary etiology can make the decision-making difficult. We present the case of a man with infective endocarditis and intercurrent infection with COVID-19, in which multidisciplinary consensus was essential to set the surgical indication, because his symptomatology generated controversy with current clinical guidelines of the European Society of Cardiology (ESC) on infective endocarditis. We consider that the adaptation of the guidelines during the current health emergency and the multidisciplinary decision-making can facilitate therapeutic action in complex cases of cardiac pathologies with surgical indication and COVID-19 coinfection.

Model for End-Stage Liver Disease scoring system excluding international normalized ratio (MELD-XI) has been related with worse outcomes after heart transplantation (HT). However, according to standards in prognostic models research, before implementing a risk score for daily clinical decision-making, its performance and impact on clinical practice/outcomes should be evaluated. The aim of this study was to evaluate the ability of the MELD-XI score to predict outcomes in daily clinical practice.We retrospectively reviewed 190 consecutive adults undergoing HT between 2005-2015. Patients were stratified into low (MELD-XI 12) and high (MELD-XI ≥12) risk cohorts. Mortality rates at 30 days and 1 year were compared between MELD-XI groups. MELD-XI ability to predict 1-year mortality was assessed by the area under the receiver operating curve (AUC) and compared to that of bilirubin, creatinine, and pulmonary vascular resistance (PVR).Mortality rates at 30 days and 1 year were similar between groups (8% vs 13%; P = .28 and 21% vs 29%; P = .21, respectively). MELD-XI ability to predict 1-year mortality was poor and similar to that of bilirubin, creatinine, and PVR (0.51 vs 0.47 vs 0.50 vs 0.50, respectively).MELD-XI score utility in HT clinical decision-making is scarce since its discrimination ability is poor and similar to other simple prognostic variables.

Resumen: Los pseudoaneurismas son una rara y grave complicación de endocarditis infecciosa, cirugía cardiaca previa, traumatismo torácico etc. Pueden conllevar serias complicaciones, como su rotura, compresión de estructuras cardiacas o fistulización. Describimos el caso de un varón de 42 años intervenido en 2015 de sustitución de raíz aórtica con preservación valvular (técnica de David), anuloplastia mitral y cierre de foramen oval permeable. En agosto del 2017 ingresó por síndrome febril de origen urinario, que no respondió al tratamiento convencional. Con la sospecha de endocarditis infecciosa, se obtuvieron hemocultivos que fueron positivos para Staphylococcus aureus meticilino-sensible. Se realizó un ecocardiograma observándose una imagen en raíz aórtica compatible con absceso. Se optó por tratamiento conservador y revaluación. Dos semanas después, el ecocardiograma mostró un pseudoaneurisma en el tracto de salida del ventrículo izquierdo. Una angiotomografía computarizada cardiaca confirmó este hallazgo y además, su fistulización a la aurícula derecha. Es trasladado a nuestro hospital donde es intervenido. En la cirugía observamos un absceso originado en la base del seno no coronariano con rotura del velo aórtico que se continuaba hasta fistulizar en aurícula derecha. Se realizó reconstrucción del anillo aórtico con parche de pericardio heterólogo y sustitución valvular aórtica mediante prótesis mecánica desde la raíz aórtica, y cierre de fístula desde aurícula derecha. Los cultivos de las muestras quirúrgicas resultaron estériles y el ecocardiograma postoperatorio no mostró complicaciones. La cirugía es fundamental para evitar las posibles complicaciones de un pseudoaneurisma y, si se asocia a una endocarditis infecciosa, erradicar la extensión de la infección. Abstract: Pseudoaneurysms are rare and severe complications of infective endocarditis, previous heart surgery, thoracic trauma, etc. They can lead to serious complications, such as their rupture, compression of cardiac structures, or fístula formation. A case is presented of a 42 year-old male who underwent aortic root replacement with valve preservation (David procedure), mitral valve annuloplasty, and patent foramen ovale closure in 2015. In August 2017 he was admitted to hospital with a fever of urinary origin that did not respond to standard treatment. Suspecting an infective endocarditis, blood cultures were collected, which were positive for Methicillin-sensitive Staphylococcus aureus. An echocardiogram was performed, in which was observed an image compatible with an abscess in the aortic root. The chosen course of action was conservative management and subsequent re-evaluation. Two weeks later the echocardiogram showed a left ventricular outflow tract pseudoaneurysm. A CT angiography confirmed this finding, as well as a right auricular fistula. The patient was transferred to our hospital where he underwent surgery. During the surgery, an abscess was observed that originated from the base of the non-coronary aortic sinus with rupture of the aortic valve that continued into a right auricular fistula. The aortic annulus was re-constructed with a heterologous pericardial patch and the aortic valve was replaced from its root with a mechanical prosthesis. Closure of the fistula from the right atrium was also performed. Cultures from the surgical specimens were sterile, and the post-surgery echocardiogram did not show any complications. Surgery is essential to avoid any possible pseudoaneurysm complications and should the pseudoaneurysm be associated with an infective endocarditis, surgery is necessary to eradicate the spreading of the infection. Palabras clave: Falso aneurisma, Endocarditis, Cirugía cardiaca, Reoperación, Tracto de salida de ventrículo izquierdo, Keywords: False aneurysm, Endocarditis, Cardiac surgery, Re-operation, Left ventricular outflow tract

Resumen Objetivo La membrana de oxigenacion extracorporea (ECMO) es un tipo de asistencia circulatoria que asocia elevada mortalidad. Sin embargo, superar la fase inicial de soporte mecanico no implica supervivencia ni a corto ni a largo plazo. Objetivo: describir las caracteristicas y evolucion de los pacientes con shock cardiogenico refractario (SCR) asistidos con ECMO veno-arterial (ECMO-VA) en un hospital con programa de trasplante cardiaco. Diseno Estudio de cohortes y retrospectivo de centro unico. Ambito UCI cardiologica de un hospital terciario. Pacientes Un total de 46 pacientes asistidos consecutivamente con una ECMO-VA durante 6 anos. Intervenciones Analisis de la mortalidad hospitalaria tras la retirada del soporte mecanico, de la supervivencia global (SG) y de los factores asociados. Resultados Quince pacientes (33%) fallecieron con la ECMO-VA y 31 (67%) sobrevivieron a su retirada tras un soporte de 8 dias (RIC: 5-15); 14 pacientes fueron trasplantados. La mortalidad hospitalaria en estos pacientes fue del 32% (10/31) y se relaciono con: edad (p = 0,001), SAPS-II (p = 0,009), sangrado de canulas (p = 0,01), indicacion de SCR post-IAM (p = 0,001). Con una mediana de seguimiento de 27 meses (RIC: 11-49), seguian vivos el 91% de los pacientes que fueron dados de alta del hospital. La SG tras la retirada de la ECMO-VA se relaciono con el tipo de indicacion (p = 0,002), teniendo peor pronostico los pacientes con SCR postinfarto. Conclusiones En nuestra experiencia, la ECMO-VA es un tipo de asistencia mecanica que puede utilizarse en el manejo del SCR. Asocia una mortalidad precoz elevada, pero tras superar la fase hospitalaria la supervivencia de los pacientes es buena.

Objective Extracorporeal membrane oxygenation (ECMO) affords mechanical circulatory assistance associated to high mortality. However, weaning from such mechanical support may not imply improved short- or long-term survival. This study describes the characteristics and evolution of patients with refractory cardiogenic shock (RCS) subjected to venoarterial ECMO (VA-ECMO) in a hospital with a heart transplant program. Design A single-center, retrospective cohort study was carried out. Setting The cardiovascular ICU of a tertiary hospital. Patients Forty-six patients consecutively subjected to VA-ECMO over 6 years. Interventions Hospital mortality after weaning from ECMO and overall survival (OS) were analyzed. Results Fifteen patients (33%) died with VA-ECMO and 31 (67%) were weaned after 8 days of support (IQR: 5–15). Fourteen patients under went transplantation. Hospital mortality in these patients was 32% (10/31), and was associated to age ( p = 0.001), SAPS II score ( p = 0.009), cannulation bleeding ( p = 0.01) and post-acute myocardial infarction RCS ( p = 0.001). After a median follow-up of 27 months (IQR: 11–49), 91% of the patients discharged from hospital were still alive. Overall survival after weaning from assistance was associated to the type of cardiac disease ( p = 0.002). Patients with RCS after acute myocardial infarction had a poorer prognosis. Conclusions In our experience, VA-ECMO can be used as mechanical assistance in the management of RCS. The technique is associated to high early mortality, though the long-term survival rate after hospital discharge is good.

Resumen Describimos el caso de un varon joven natural de China que ingresa en la UVI por posible shock septico de origen respiratorio. Presentaba abscesos a distintos niveles, principalmente en el pulmon, y en el ecocardiograma se observo una masa multilobulada de gran tamano en la auricula derecha, con aparente origen en la valvula de Eustaquio. El manejo inicial del paciente fue conservador, optandose por tratamiento antibiotico y anticoagulante, pero ante la falta de respuesta y la presencia de nuevos episodios embolicos necrotizantes se decidio intervenir quirurgicamente. Las masas intracardiacas a dicho nivel son infrecuentes y la actitud terapeutica inicial es controvertida. La presentacion clinica, junto con el estudio de imagen, nos guia sobre la etiologia mas probable, pero sera el estudio anatomopatologico de la pieza el que nos de el diagnostico de certeza, siendo los trombos la masa intracardiaca mas frecuente. La anticoagulacion suele ser la medida terapeutica inicial y, en caso de no obtenerse respuesta, la cirugia es una opcion diagnostico-terapeutica adecuada y segura.

ResuménLa cirugía cardiovascular (CCV) es una especialidad de la medicina que se ocupa de los trastornos y enfermedades del sistema cardiocirculatorio que requieren una terapéutica quirúrgica. El presente documento está dedicado a los aspectos definitorios de la especialidad y a los organizativos de la actividad profesional incluyendo la acreditación y homologación. se define asimismo la sociedad profesional, la sociedad Española de Cirugía Torácica-Cardiovascular (SECTCV) en sus aspectos relacionados con la profesión, con la formación continuada así como la comunicación en el seno y fuera de la misma al igual que la necesidad y existencia de la fundación Cirugía y Corazón (FCC). También se focaliza en la actividad en CCV y los requerimientos estructurales mínimos para llevar a cabo el componente de intervención de la CCV. Por último, se confirman las recomendaciones para su práctica y se presentan los requerimientos de calidad y del programa docente de la especialidad. Este documento de la junta directiva de la SECTCV y asesores externos de la misma confirma la realidad de la especialidad y sus contenidos como señas de identidad inalienables.AbstractCardiovascular surgery (CVS) is a branch of medicine related to the diseases of the cardio-circulatory system requiring surgical treatment. this current document is dedicated to all aspects defining the specialty and the organization of the professional activity including accreditation and credentialing. The professional society, the spanish society of thoracic-Cardiovascular surgery (SECTCV) is also defined and insights on its professional, continuing education and communication given as well as the background for the Cirugía y Corazón foundation. Attention is also given to the activity in CVS and the core requirements for practice. The recommendations for practice and quality requirements and the postgraduate teaching programme are also presented. This document of the Council of the SECTCV and its external advisors confirms the reality of the specialty and its contents as sound signs of identity.

En los últimos 15 años se han desarrollado nuevas tecnologías en cirugía cardíaca para evitar la incisión más frecuente, la esternotomía media, o la circulación extracorpórea, intentando así realizar una cirugía menos invasora. Entre estas técnicas se sitúa la cirugía mediante puertos o Heart Port™. Los principales beneficios de esta técnica radican, entre otros, en la disminución del traumatismo quirúrgico, lo que se asocia a una disminución del dolor postoperatorio y de la estancia hospitalaria así como a una mayor satisfacción de los pacientes desde un punto de vista estético. La cirugía valvular mitral y/o tricúspide de mínimo acceso es, en la actualidad, una técnica reproducible y segura, que puede desarrollarse con una morbimortalidad semejante a la técnica convencional, considerándose a día de hoy una opción válida de tratamiento para cualquier paciente sometido a una cirugía de sustitución o reparación mitral o tricúspide. En este artículo se describen las peculiaridades de la técnica quirúrgica y se analizan los resultados en cuanto a morbimortalidad postoperatoria de las diferentes series publicadas.In the past 15 years new technologies have been developed in cardiac surgery to avoid both the most common incision and extracorporeal circulation trying to perform less invasive surgery. Heart Port™ access is among these new techniques. The main benefits of this approach are among others decreased surgical trauma, which is associated to a reduction in postoperative pain and hospital stay as well as a greater satisfaction of patients from an aesthetic point of view. Nowadays minimally invasive cardiac surgery is effectively associated with low morbidity and mortality and it is considered a valid treatment option for any mitral or tricuspid valvular surgery. This article describes surgical aspects of minimally invasive surgery and analyses morbidity and mortality outcomes of the different published studies.

Ultrafiltration (UF) is used to ameliorate the deleterious effects of cardiopulmonary bypass (CPB) in cardiac surgery patients. There are two different methods; conventional ultrafiltration (CUF), performed during CPB, and modified ultrafiltration (MUF), performed after CPB is finished. It has not been established which is better, and controversy remains regarding the optimal UF strategy. The objective of this study was to evaluate if MUF alone, or combined with CUF, could achieve greater fluid removal and contribute to better postoperative clinical outcomes. Also, the potential technique complications were studied. This was a prospective study which enrolled 125 consecutive adult patients receiving elective cardiac surgery with CPB. We analysed three treatment groups: MUF, CUF and both. Ultrafiltration was performed using a non-pulsatile CPB with a non-occlusive roller pump, Sarns 9000, and a polysulfone ultrafilter, Minntech. We studied pre- and intraoperative data and immediate postoperative clinical outcomes: total amount of drainage, transfusion needs, respiratory outcome, cardiac, renal and neurologic complications. Statistical analysis was performed using SPSS 11.0. All three groups were homogeneous and did not have differences in terms of demographic factors, previous history, risk scores, intervention and operative data. Volume of filtrate removal in the group which applied both techniques was larger than in the CUF or MUF groups alone (2569+/-823 vs 1679+/-651 vs 1398+/-353 ml, respectively, p=0.0001); however, despite this difference, there was no difference in the immediate postoperative fluid balances between the groups (596+/-1244 vs 880+/-1054 vs 986+/-1190 ml, p=0.30). Respiratory parameters and postoperative morbidity data analysed (total amount of drainage, transfusion needs, haemoglobin, acute lung injury, time with inotropes, ventricular failure, cardiogenic shock, neurologic complications and renal failure) were similar in all three groups, without statistical differences. Extubation time (10+/-7 vs 8.9+/-3 vs 9.4+/-7.9 hours, p=0.72) and ICU stay (56.6+/-72 vs 66.5+/-109 vs 44.2+/-25 hours, p=0.43) also were similar between the groups. We did not find any technique complication associated with any patient. In the present study, with adult patients receiving elective cardiac surgery, the combined ultrafiltration group had a larger fluid removal. However, neither type of ultrafiltration nor amount of filtered volume was accompanied by different postoperative ICU clinical outcomes. Ultrafiltration was considered a safe and reliable technique, with no related complications.