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Resumen: La ventana aorto-pulmonar es una rara anomalía cardiaca congénita; sin embargo, no es infrecuente que se asocie a diferentes cardiopatías congénitas. La comunicación interauricular es la anomalía más frecuentemente asociada. La combinación de ventana aorto-pulmonar e interrupción del arco aórtico constituye el prototipo donde la ventana aorto-pulmonar se asocia a una cardiopatía congénita compleja. Estas asociaciones de ventana aorto-pulmonar con otras cardiopatías congénitas complejas pueden ser muy variadas e inusuales, aumentando los riesgos de morbimortalidad en la evolución de los pacientes que las padecen. Presentamos 3 casos clínicos donde la ventana aorto-pulmonar se asocia a otras cardiopatías complejas tales como interrupción del arco aórtico, obstrucción del tracto de salida ventricular izquierdo y comunicación interventricular múltiple. Estas asociaciones complejas pueden ser corregidas quirúrgicamente en periodo neonatal con unos resultados aceptables, a pesar de su rareza y escasa experiencia quirúrgica acumulada. Abstract: The aorto-pulmonary window is a rare congenital heart anomaly, however, this anomaly is not uncommon associated with different congenital heart diseases. Atrial septal defect is the most frequently associated anomaly. The combination of aorto-pulmonary window and interrupted aortic arch constitutes the prototype which the aorto-pulmonary window is associated with complex congenital heart disease. These aorto-pulmonary window associations with other complex congenital heart diseases can be very varied and unusual, increasing the risk of morbidity and mortality in the evolution of patients who suffer from them. We present three case reports where the aorto-pulmonary window is associated with other complex heart diseases such as interrupted aortic arch, left ventricular outflow tract obstruction, and multiple ventricular septal defects. These complex associations can be surgically corrected in neonatal period with acceptable results, despite their rarity and little accumulated surgical experience.

Resumen: Introducción y objetivos: Nuestro estudio pretende comparar los resultados a corto y medio plazo de la cirugía asistida con circulación extracorpórea sin pinzamiento aórtico frente a la cirugía coronaria convencional con parada cardíaca en pacientes con disfunción ventricular severa. Métodos: Desde enero de 2012 hasta enero de 2019 se analiza un grupo de 64 pacientes con fracción de eyección disminuida (

Pulmonary embolism typically occurs from deep venous thrombosis (DVT). However, not always a DVT can be identified, and 'in situ' generation of pulmonary embolism has been considered, referred to in the literature as 'De novo pulmonary embolism' (DNPE). The objective of the study is to assess risk factors, comorbidities, clinic characteristics and long-term evolution of patients with pulmonary embolism in the absence of an identified source. Retrospective study of 280 patients with pulmonary embolism, 190 pulmonary embolisms with DVT group and 90 (32%) pulmonary embolism without DVT (DNPE group), admitted to an Internal Medicine Department of a tertiary hospital from January 2012 to December 2015. In the DNPE group, segmental and subsegmental arteries were more frequently affected (P = 0.01). As compared with pulmonary embolisms with DVT group: older age, female sex, sedentary lifestyle, diabetes mellitus, arterial hypertension, heart failure, respiratory infections and chronic obstructive pulmonary disease (COPD) were significantly more frequent in DNPE. In multivariate analysis, respiratory infection [odds ratio (OR) 12.2, P < 0.0001], COPD (OR 8.7, P < 0.0001) and female sex (OR 3.0, P = 0.003) were independently associated risk factors. Long-term mortality (median follow-up 15 months) was also higher in DNPE group (34 vs. 16%, P = 0.01). De novo pulmonary embolism occurred in 32% of cases of pulmonary embolisms and was more frequent in female and COPD patients or those with respiratory infections as compared with pulmonary embolisms in which DVT was identified as a source of embolism.

Resumen Introducción El tumor retroperitoneal con extensión a la vena cava inferior (VCI) más frecuente es el carcinoma de células renales. Tiene una supervivencia a 5 años de hasta un 32% cuando se realiza nefrectomía radical y trombectomía. El tratamiento quirúrgico es complejo y puede necesitar el soporte de circulación extracorpórea y parada circulatoria e hipotermia. Métodos Estudio descriptivo, retrospectivo, mediante análisis de datos de pacientes intervenidos de tumores con invasión de la VCI entre 1992 y 2015. Se recogieron datos demográficos, tumorales, de técnica quirúrgica, intraoperatorios, posquirúrgicos y de mortalidad. Las variables cuantitativas se presentan como media±desviación estándar y las cualitativas como número de casos. La supervivencia se registró por curvas de Kaplan-Meier. Resultados Se presentan 18 pacientes con tumores retroperitoneales (carcinoma de células renales 66%) con extensión a VCI. Se utilizó circulación extracorpórea en 13casos y paro circulatorio en 5. Doce pacientes tuvieron un aumento de creatinina >0,3mg/dl sin precisar terapias de sustitución renal. La estancia en la Unidad de Cuidados Críticos fue de 2,8±2 días. La supervivencia media fue de 791±633 días, con una mortalidad a los 30 días del 11% y a los 5 años del 72%. Conclusiones El tumor con extensión a VCI presenta un desafío quirúrgico. La supervivencia a corto plazo es elevada; a largo plazo es limitada por el proceso neoplásico. Introduction The most frequent tumor located at the inferior vena cava (IVC) is renal cell carcinoma. When radical nephrectomy and thrombectomy is performed, survival is 32%. It is a complex surgery that may require extracorporeal circulation support and hypothermic circulatory arrest. Methods Retrospective descriptive study via data analysis of patients operated on tumors with IVC invasion within 1992 and 2015. The data collected included demographic, tumor, surgical technique, intraoperative, post-surgical and mortality date. The quantitative variables are presented as mean±standard desviation, and the qualitative variables as number of cases. Survival has been registred by means of the Kaplan-Meier curves. Results We present 18 patients with IVC tumor extension (renal cell carcinoma 66%). The extracorporeal circulation was used in 13 of the cases and circulatory arrest in 5. Twelve patients showed an increase in creatinine>0.3mg/dl without requiring renal replacement therapy. The stay in Intensive Care Unit was 2.8±2 days. The mean survival rate was 791±633 days, with a 30-day mortality rate of 11% and a 5-year mortality rate of 72%. Conclusions Tumors with IVC extension are a rare pathology that poses a surgical challenge and requires a multidisciplinary team for its management. Short-term survival is high, being limited by the neoplastic process in the long term.

OBJECTIVES Ranolazine improves vascular function in animal models. We evaluate the effects of ranolazine on vascular function and adrenergic response in human saphenous vein. METHODS Rings from 53 patients undergoing coronary artery bypass grafting were mounted in organ baths. Concentration–response curves to ranolazine were constructed in rings precontracted with phenylephrine, endothelin-1, vasopressin, KCl and the thromboxane A2 analogue U-46619. In rings precontracted with phenylephrine, relaxation to ranolazine was tested in the absence and presence of endothelial factors inhibitors, K+ channel blockers and verapamil. The effects of ranolazine on frequency–response and concentration–response curves to phenylephrine were performed in the absence and presence of endothelial factors inhibitors and K+ channel blockers. Endothelial nitric oxide synthase, α1 adrenergic receptor and large conductance Ca2+-activated K+ channel protein expressions were measured by Western blotting. RESULTS Ranolazine (10−9–10−4 M) produced a concentration-dependent relaxation only in rings precontracted with phenylephrine that was reduced by endothelial denudation, NG-nitro-l-arginine methyl ester (10−4 M), charybdotoxin (10−7 M) and verapamil (10−6 M). Ranolazine diminished adrenergic contractions induced by electrical field stimulation (2–4 Hz) and phenylephrine (10−9–10−5 M) that were prevented by tetraethylammonium (10−3 M) and charybdotoxin (10−7 M). Ranolazine significantly decreased α1 adrenergic receptor and increased large conductance Ca2+-activated K+ channel protein expression in the saphenous vein. CONCLUSIONS Ranolazine diminishes the adrenergic vasoconstriction, acting as α1 antagonist, and by increasing large conductance Ca2+-activated K+ channel involvement. The relaxant effects of ranolazine are partially mediated by endothelial nitric oxide, large conductance Ca2+-activated K+ channels and the blockade of voltage-dependent Ca2+ channels.

[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.

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.

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.

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.

ObjetivosPresentar la experiencia inicial del abordaje toracoscópico unilateral como técnica para la ablación de la fibrilación auricular (FA) aislada.Material y métodos.Entre abril y octubre de 2007, en cinco pacientes con FA aislada sintomática se realizó un procedimiento quirúrgico de ablación mediante toracoscopia derecha, consistente en un patrón de aislamiento eléctrico epicárdico circunferencial alrededor de las cuatro venas pulmonares (VP) con un dispositivo de ablación por microondas flexible.ResultadosLa mortalidad en el perioperatorio fue nula y la estancia hospitalaria media de 4 días. Un paciente requirió conversión in situ a miniesternotomía. El aislamiento eléctrico de las VP, comprobado intraoperatoriamente, fue efectivo en tres casos. Al final del seguimiento, en mayo de 2008, en tres pacientes había recidivado la FA clínica.ConclusionesLa técnica de la ablación de la FA por toracoscopia unilateral es reproducible y tiene una baja morbilidad. La tecnología empleada, única para este tipo de abordajes unilaterales, no ha ofrecido la efectividad esperada. Hemos abandonado el procedimiento en espera de nuevos medios tecnológicos.PurposeTo present the initial experience with thoracoscopic approach as a treatment option for lone atrial fibrillation (AF).MethodsBetween April and October 2007, five patients with symptomatic lone AF underwent a surgical ablation procedure through right thoracoscopic approach, consisting in a circunferential epicardial electric isolation pattern of the four pulmonary veins with a flexible microwave ablation device.ResultsThere were no hospital deaths and the average hospital stay was 4 days. In one patient an in situ conversion to mini-sternotomy was needed. At the end of the follow-up, three patients were again in AF.ConclusionsThe thoracoscopic ablation surgery is reproducible and has a low morbidity rate. The technology used, unique for this kind of unilateral approaches, did not show the expected effectiveness. We have abandoned this procedure waiting for new technical means.

IntroducciónAunque la reparación quirúrgica es el tratamiento de elección de la insuficiencia mitral, la durabilidad y tasa de reoperación son aspectos relevantes. Distintos factores pueden mermar su eficacia. Valoramos nuestra experiencia analizando ambos aspectos.Material y métodosSe estudiaron 218 pacientes intervenidos desde febrero de 1998 a agosto de 2007, con edad media de 62±12 años. Setenta y seis pacientes eran mujeres (34,9%) y 68,8% estaban en grado funcional NYHA III-IV. Se agruparon en cinco grupos según la etiología: degenerativa (grupo A) 119 pacientes, isquémica (grupo B) 44, funcional no isquémica (grupo C) 14, reumática (grupo D) 26 y endocarditis (grupo E) 15 pacientes. Las técnicas en el grupo A fueron: resección cuadrangular (83 pacientes), sliding (8), neocuerdas (16), transposición cuerdas (8) y Alfieri (11); en el grupo D: anuloplastia (16), comisurotomía (11), resección-decalcificación (5), Alfieri (2); en el grupo E: cierre perforación (9), resección (7), comisuroplastia (2). La anuloplastia aislada se realizó en los grupos B y C.ResultadosLa mortalidad temprana fue mayor en los grupos B, C y E. Hubo 13 fallecidos en los 30 primeros días (5,9%) y tres tardíamente. La supervivencia actuarial a 5 años fue 97±1% (seguimiento medio: 44±29 meses), la libertad de reoperación 91±2% y de recidiva grado III-IV a 5 y 10 años 85±2 y 82±3%. La edad (HR: 1,07; IC 95%: 1,01-1,13; p

Background We studied the participation of K + channels on the adrenergic responses in human saphenous veins as well as the intervention of dihydropyridine-sensitive Ca 2+ channels on modulation of adrenergic responses by K + channels blockade. Methods Saphenous vein rings were obtained from 40 patients undergoing coronary artery bypass surgery. The vein rings were suspended in organ bath chambers for isometric recording of tension. Results Iberiotoxin (10 −7 mol/L), an inhibitor of large conductance Ca 2+ -activated K + channels, and charybdotoxin (10 −7 mol/L), an inhibitor of both large and intermediate conductance Ca 2+ -activated K + channels, enhanced the contractions elicited by electrical field stimulation and produced a leftward shift of the concentration–response curve to norepinephrine. In contrast, the inhibitor of small conductance Ca 2+ -activated K + channels apamin (10 −6 mol/L) did not modify the contractile response to electrical field stimulation or norepinephrine. In the presence of the dihydropyridine Ca 2+ -channel blocker nifedipine (10 −6 mol/L), iberiotoxin and charybdotoxin failed to enhance the contractile responses to electrical field stimulation and norepinephrine. Conclusions The results suggest that large conductance Ca 2+ -activated K + channels are activated by stimulation with norepinephrine to counteract the adrenergic-induced contractions of human saphenous vein. Thus, inhibition of these channels increases significantly the contraction, an effect that appears to be mediated by an increase in Ca 2+ entry through L-type voltage-dependent Ca 2+ channels.

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.

The functional properties of the endothelium of human thyroid arteries remain unexplored. We investigated the intervention of nitric oxide (NO), prostacyclin (PGI(2)) and endothelium-derived hyperpolarizing factor (EDHF) in the responses to acetylcholine and noradrenaline in isolated thyroid arteries obtained from multi-organ donors. Artery rings were suspended in organ baths for isometric recording of tension. The contribution of NO, PGI(2) and EDHF to endothelium-dependent relaxation was determined by the inhibitory effects of N(G)-monomethyl-L-arginine (L-NMMA), indomethacin, and K(+) channel inhibitors respectively. Acetylcholine induced concentration-dependent relaxation; this effect was not modified by indomethacin and was only partly reduced by L-NMMA, but was abolished in endothelium-denuded rings. The relaxation resistant to indomethacin and L-NMMA was abolished by using either apamin combined with charybdotoxin, ouabain plus barium, or a high-K(+) solution. Noradrenaline induced concentration-dependent contractions which were of greater magnitude in arteries denuded of endothelium or in the presence of L-NMMA.In conclusion, the results indicate that in human thyroid arteries the endothelium significantly modulates responses to acetylcholine and noradrenaline through the release of NO and EDHF. EDHF plays a dominant role in acetylcholine-induced relaxation through activation of Ca(2+)-activated K(+) channels, inwardly rectifying K(+) channels and Na(+)-K(+)-ATPase.

In arteries, agonists such as acetylcholine release an endothelium-derived hyperpolarizing factor (EDHF) that is neither nitric oxide nor prostacyclin.To examine the responses to acetylcholine in segments of forearm veins from patients with chronic renal failure who either had never received dialysis or had undergone long-term dialysis, and to determine the contribution of nitric oxide and EDHF to endothelium-dependent relaxation in veins from patients with chronic renal failure.Isometric tension was recorded in rings of forearm vein from 34 non-dialysed patients, 27 dialysed patients and 14 multiorgan donors (controls).Relaxation in response to acetylcholine was reduced in veins of non-dialysed and dialysed patients. The inhibitors of nitric oxide synthase NG-monomethyl-l-arginine (l-NMMA) and NG,NG-dimethyl-l-arginine (ADMA) reduced by 50% the maximum relaxation in response to acetylcholine in veins from controls and non-dialysed patients; the remaining relaxation was inhibited by 20 mmol/l KCl or by the K+ channel blockers tetraethylammonium chloride, iberiotoxin, charybdotoxin and the combination of barium plus ouabain, but not by apamin or glibenclamide. Relaxation in veins from dialysed patients was inhibited by K+ channel blockade but not by l-NMMA or ADMA.The results demonstrate that the endothelium-dependent relaxation in forearm veins from controls and non-dialysed patients is mediated by release of nitric oxide and EDHF. In contrast, the relaxation in veins from dialysed patients is mediated mainly by EDHF. EDHF-induced relaxation involves activation of large-conductance Ca2+-activated K+ channels.

We studied the relaxant effects of milrinone, an inhibitor of phosphodiesterase 3, and rolipram, an inhibitor of phosphodiesterase 4, on contracted human penile dorsal artery and deep dorsal vein. Vascular rings from 12 multi-organ donors were suspended in organ baths for isometric recording of tension. Both milrinone and rolipram inhibited (100%) the contraction induced by noradrenaline and shifted the relaxation–response curves to the cAMP forming agents prostaglandin E1 and forskolin to the left. The findings indicate that the cAMP pathway appears to be a main determinant of relaxation in human penile vessels.

Urocortin, an endogenous peptide structurally related to corticotropin-releasing factor (CRF), has potent cardiovascular effects, suggesting that it may be of significance in cardiovascular regulation. The objective of this study was to analyse the effects of urocortin and its action mechanisms on human blood vessels. To this, 3 mm long segments from human saphenous veins were prepared for isometric tension recording in an organ bath. In the segments at basal resting tone, urocortin did not produce any effect, but in the segments precontracted with endothelin-1 (1 – 10 nM), urocortin (1 pM – 10 nM) produced concentration-dependent relaxation. This relaxation was not modified by the inhibitor of nitric oxide synthase NG-nitro-L-arginine methyl ester (L-NAME, 100 μM), but it was potentiated by the cyclo-oxygenase inhibitor meclofenamate (10 μM) and it was reduced by the inhibitors of high-conductance Ca2+-dependent potassium channels tetraethylammonium (TEA, 10 mM) and charybdotoxin (100 nM). These results indicate that human saphenous veins are very sensitive to urocortin, which produces vascular relaxation by a mechanism independent of nitric oxide and dependent of high-conductance Ca2+-dependent potassium channels, and that it may be opposed by the release of vasoconstrictor prostanoids. Therefore, urocortin may be of significance for regulation of the venous circulation in humans. Keywords: Ion channels, peptides, prostaglandins, vasodilation, veins Introduction Urocortin is a recently isolated 40 amino acid peptide, which has a high degree of structural homology with corticotropin-releasing factor (CRF), and belongs to a group of structurally related peptides which includes, in addition to urocortin and CRF, fish urotensin I and amphibian sauvagine (Parkes & May, 2000). CRF and urocortin may act as neurotransmitters in the central nervous system and may also act on peripheral tissues, particularly in the cardiovascular system. These peptides produce potent effects on the cardiovascular system when administered both intravenously or directly into the central nervous system (Parkes & May, 2000; Parkes et al., 2001). It has been observed that the effects of intravenous urocortin are more potent than those of CRF, probably because the affinity of urocortin is higher than that of CRF for the subtype of CRF – R2β receptors (Vaughan et al., 1995), which are expressed in peripheral tissues (Perrin et al., 1995). Moreover, urocortin mRNA is expressed in smooth muscle cells of blood vessels and in cardiac myocites (Parkes & May, 2000). Because of that, it has been suggested that urocortin may be the endogenous CRF-like peptide that binds to cardiovascular receptors and mediates their cardiocirculatory effects (Parkes et al., 2001). In rats, intravenous urocortin produce potent and long lasting hypotension which might be due to systemic vasodilation, and tachycardia, probably in part baroreflex mediated (Vaughan et al., 1995). Indeed, it has been shown that this peptide produces relaxation of rat basilar arteries (Schilling et al., 1998) and of rat coronary circulation (Terui et al., 2001). In mice, urocotin also produces hypotension, which is abolished in knockout mice with the CRF – R2 receptor subtype inactivated (Bale et al., 2000; Coste et al., 2000). Interestingly, these knockout mice have elevated resting blood pressure, suggesting that activation of CRF – R2 receptors may play a role in regulation of basal vascular tone (Coste et al., 2000). However, there may exist species differences in the vascular effects of urocortin, as in sheep this peptide increases systemic blood pressure, in addition to increasing cardiac contractility (Parkes et al., 1997). All these observations have aroused the interest for the possible role of urocortin in cardiovascular regulation. In addition, urocortin is produced in human hearts, and it increases in failing hearts (Nishikimi et al., 2000), suggesting that this peptide could be involved in human cardiovascular regulation under normal and pathologic conditions. Considering that there is marked species variability in the cardiovascular effects of urocortin, these effects should be also studied in human tissues before the results obtained in animals can be extrapolated to humans. To our knowledge, there is only one study analysing the response to urocortin in human blood vessels, this study shows that this peptide produces dilatation of human perfused placenta (Leitch et al., 1998). Therefore, the objective of our study was to analyse the effects of urocortin on human blood vessels, using segments from human saphenous veins. The role of nitric oxide, prostanoids and potassium channels in the vascular effects of urocortin were also examined.

Background . Sildenafil is currently used in the treatment of erectile dysfunction. However, assessment of direct effects of sildenafil on coronary arteries and on arteries used as coronary grafts is unknown. This study was designed to investigate the effects of sildenafil on contracted human coronary, internal mammary, and radial arteries obtained from multiorgan donors. The observations were extended to forearm veins. Zaprinast was included in this study for comparison. Methods . Segments of left coronary, internal mammary, and radial arteries, and forearm veins were obtained from 16 multiorgan donors. Vascular rings were suspended in organ bath chambers and isometric tension was recorded. Then the effects of sildenafil, zaprinast, and sodium nitroprusside on precontracted vessels were studied. Results . Sildenafil (10 −8 − 3 × 10 −5 mol/L) caused concentration-dependent relaxation in the internal mammary arteries, radial arteries, and forearm veins. In the coronary arteries, sildenafil had a modest relaxant effect. In addition, sildenafil amplified the relaxation induced by sodium nitroprusside in all four vessels. Relaxation was unaffected by the inhibitor of nitric oxide synthase N G -monomethyl-L-arginine (10 −4 mol/L). Compared with zaprinast, sildenafil was eight to ten times more potent in terms of EC 50 values. Conclusions . The direct relaxant effects of sildenafil together with its synergistic interaction with nitric oxide donors should be considered in patients undergoing coronary bypass surgery, patients with low blood pressure, and patients receiving antihypertensive regimes.

Objectives: Plasma levels of endogenous guanidino-substituted analogues of L -arginine are increased in various pathologic conditions. In the present study we determined the effects of some of these compounds on basal and stimulated release of nitric oxide in human internal thoracic and radial arteries. Methods: Rings of human internal thoracic and radial arteries were obtained from 16 multiorgan donors. The rings were suspended in organ baths for isometric recording of tension. Results: N G -monomethyl L -arginine (10 –6 to 10 –3 mol/L) and N G ,N G -dimethyl L -arginine (10 –6 to 10 –3 mol/L) caused concentration- and endothelium-dependent contractions. Maximal force of contractions for N G -monomethyl L -arginine and N G ,N G -dimethyl L -arginine in the internal thoracic artery were 18.0% ± 4.3% and 17.8% ± 3.8%, respectively, of the contraction to 100 mmol/L KCl, and those found in the radial artery were 9.6% ± 2.5% and 9.1% ± 2.4%, respectively. Aminoguanidine (10 –5 to 3 × 10 –3 mol/L) and methylguanidine (10 –5 to 3 × 10 –3 mol/L) produced endothelium-independent contractions. L -Arginine (10 –3 mol/L) prevented the contractions by N G -monomethyl L -arginine and N G ,N G -dimethyl L -arginine but did not change contractions induced by aminoguanidine and methylguanidine. N G -monomethyl L -arginine and N G ,N G -dimethyl L -arginine inhibited, in a concentration-dependent manner, the endothelium-dependent relaxation to acetylcholine in the internal thoracic artery and had little attenuating effect in the radial artery; aminoguanidine and methylguanidine were without effect. Conclusions: The results suggest that the contractions induced by N G -monomethyl L -arginine and N G ,N G -dimethyl L -arginine are due to inhibition of both basal and stimulated nitric oxide production, whereas aminoguanidine and methylguanidine do not affect the synthesis of nitric oxide. An increase in the plasma concentration of N G -monomethyl L -arginine and N G ,N G -dimethyl L -arginine is likely to represent a risk factor for abnormal vasomotor tone in conduit arteries used as coronary grafts. (J Thorac Cardiovasc Surg 2000;120:729-36)

Las noticias médicas aparecen con cierta frecuencia en los medios de difusión escrita general. En la mayoría de las ocasiones estas noticias no son contrastadas, con lo que la información que se da a la población es errónea. Dicha difusión no está exenta de una cierta contaminación sensacionalista e incluso comercial. En este caso las implicaciones éticas y deontológicas son evidentes. La responsabilidad de estas acciones recae en tres estamentos diferentes: los profesionales de la salud que las «lanzan» a los medios, los propios medios de comunicación y las instituciones sanitarias.Medical news appears with certain frequency in press media. In most cases this news is not confirmed, therefore the information given to the population is inappropriate. This diffusion is not unaffected by a certain sensationalist and even commercial contamination. In these cases the ethical and deontological implications are clearly evident. The responsibility of these actions falls on three different groups: the health professionals that launch them into the media, the media themselves and the health institutions.

The aim of the present study was to characterize neurogenic and pharmacological responses of human penile deep dorsal vein and to determine whether the responses are mediated by nitric oxide from neural or endothelial origin. Ring segments of human penile deep dorsal vein were obtained from 22 multiorgan donors during procurement of organs for transplantation. The rings were suspended in organ bath chambers for isometric recording of tension. We then studied the contractile and relaxant responses to electrical field stimulation and to vasoactive agents. Electrical field stimulation (0.5–2 Hz) and noradrenaline (3×10−10–3×10−5M) caused frequency- and concentration-dependent contractions that were of greater magnitude in veins denuded of endothelium. The inhibitor of nitric oxide synthesis NG-nitro-L-arginine methyl ester hydrochloride (L-NAME, 10−4M) increased the adrenergic responses only in rings with endothelium. In preparations contracted with noradrenaline in the presence of guanethidine (10−6M) and atropine (10−6M), electrical stimulation induced frequency-dependent relaxations. This neurogenic relaxation was prevented by L-NAME, methylene blue (3×10−5M) and tetrodotoxin (10−6M), but was unaffected by removal of endothelium. Acetylcholine (10−8–3×10−5M) and substance P (3×10−11–3×10−7M) induced endothelium-dependent relaxations. In contrast, sodium nitroprusside (10−9–3×10−5M) and papaverine (10−8–3×10−5M) caused endothelium-independent relaxations. The results provide functional evidence that the human penile deep dorsal vein is an active component of the penile vascular resistance through the release of nitric oxide from both neural and endothelial origin. Dysfunction in any of these sources of nitric oxide should be considered in some forms of impotence.

Background —Arginine vasopressin (AVP) not only acts directly on blood vessels through V 1 receptor stimulation but also may modulate adrenergic-mediated responses in animal experiments in vivo and in vitro. The aim of the present study was to investigate whether AVP can contribute to an abnormal adrenergic constrictor response of human saphenous veins. Methods and Results —Saphenous vein rings were obtained from 32 patients undergoing coronary artery bypass surgery. The vein rings were suspended in organ bath chambers for isometric recording of tension. AVP (3×10 −9 mol/L) enhanced the contractions elicited by electrical field stimulation at 1, 2, and 4 Hz (by 80%, 70%, and 60%, respectively) and produced a leftward shift of the concentration-response curve to norepinephrine (half-maximal effective concentration decreased from 6.87×10 −7 to 1.04×10 −7 mol/L; P 1 vasopressin receptor antagonist d(CH 2 ) 5 Tyr(Me)AVP (10 −6 mol/L) prevented the potentiation evoked by AVP. The selective V 1 receptor agonist [Phe, 2 Orn 8 ]-vasotocin (3×10 −9 mol/L) induced potentiation of electrical stimulation–evoked responses, which was also inhibited in the presence of the V 1 receptor antagonist (10 −6 mol/L). In contrast, the V 2 receptor agonist desmopressin (10 −9 to 10 −7 mol/L) did not modify neurogenic responses, and the V 2 receptor antagonist [d(CH 2 ) 5 , D-Ile, 2 Ile, 4 Arg 8 ]-vasopressin (10 −8 to 10 −6 mol/L) did not prevent the potentiation induced by AVP. The dihydropyridine calcium antagonist nifedipine (10 −6 mol/L) did not affect the potentiating effect of AVP. Conclusions —The results suggest that low concentrations of AVP facilitate sympathetic neurotransmission and potentiate constrictor effects of norepinephrine in human saphenous veins. These effects appear to be mediated by V 1 receptor stimulation and are independent of calcium entry through dihydropyridine calcium channels. Thus, AVP may contribute to vascular mechanisms involved in acute ischemic syndromes associated with venous grafts, particularly if the sympathetic nervous system is activated.

Purpose: The goal of this study was to determine the effects of vasopressin and the selective V 2 -receptor agonist desmopressin on human saphenous veins, with special emphasis on endothelium-mediated responses. Methods: Human saphenous vein segments were obtained from 35 patients undergoing coronary bypass surgery. Paired segments, one normal and the other deendothelized by gentle rubbing, were mounted for isometric recording of tension in organ baths. Concentration-response curves to vasopressin and desmopressin were determined in the presence and in the absence of either the V,-receptor antagonist d(CH 2 ) 5 Tyr(Me)AVP (10 −6 mol/L), the V 1 -V 2 receptor antagonist desGly-d(CH 2 ) 5 D-Tyr(Et)ValAVP (10 −6 mol/L), indomethacin (10 −6 mol/L), or N G -nitro-L-arginine methyl ester hydrochloride (L-NAME, 10 −4 mol/L). Results: In vein rings under resting tension, vasopressin produced concentration-dependent, endothelium-independent contractions with a concentration of vasopressin producing-half-maximal contractions (EC 50 ) of 3.44 × 10 −8 mol/L. The vasopressin V 1 -receptor antagonist (10 −6 mol/L) displaced the control curve to vasopressin 9.86-fold to the right in a parallel manner. In precontracted vein rings previously treated with the V 1 -antagonist (10 −6 mol/L), vasopressin caused endothelium-dependent relaxations. This relaxation was reduced significantly by indomethacin (10 −6 mol/L) and unaffected by the V 1 -V 2 -receptor antagonist (10 −6 mol/L) or by L-NAME (10 −4 mol/L). Desmopressin caused endothelium-dependent relaxations in precontracted vein rings that were inhibited by the mixed V 1 -V 2 -receptor antagonist and by indomethacin, but not by the V 1 -antagonist or by pretreatment with L-NAME. Conclusions: These observations indicate that vasopressin exerts contractile effects on human saphenous vein by V 1 -receptor stimulation. Vasopressin causes dilatation of human saphenous vein only if V 1 -receptor blockade is present. This relaxation appears to be mediated by the release of relaxant Prostaglandins, probably derived from endothelial cells, and is independent of V 2 -receptor stimulation or release of nitric oxide. Desmopressin elicits relaxation that is largely dependent on V 2 -receptor stimulation, which may bring about the release of dilating Prostaglandins from the endothelial cells.

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 (

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

Comparar resultados obtenidos en pacientes sometidos a recambio valvular aórtico aislado por abordaje mínimamente invasivo frente a esternotomía estándar. Métodos: Entre enero de 2006 – diciembre de 2011, 524 pacientes fueron sometidos de forma programada a recambio valvular aórtico aislado, de los cuales 454 fueron realizados mediante abordaje estándar (grupo E) y 70 mediante miniesternotomía en «J» (grupo M). Consideradas variables preoperatorias, tiempos de circulación extracorpórea (CEC) y clampaje aórtico, resultados postoperatorios (morbimortalidad, estancias en unidad de cuidados intensivos [UCI] y postoperatoria total) y coste económico global (estancias en UCI, sala, intervención quirúrgica, consumo de fungible, implante y otros recursos). Resultados: Las características preoperatorias de la población fueron similares, sin diferencias significativas en cuanto a edad (68 ± 9 vs 69 ± 8 años) y EuroSCORE I aditivo (6,04 ± 3,00 vs 5,38 ± 2,23) entre grupo E y M, respectivamente. Sin embargo sí hubo diferencias significativas en cuanto a mortalidad (4,2 vs 0%; p < 0,005), tiempo de CEC (95 ± 38 vs 84 ± 21 min; p < 0,001), tiempo de clampaje aórtico (72 ± 28 vs 65 ± 15 min; p < 0,001), días de estancia en UCI (4,31 ± 5,27 vs 3,14 ± 1,2; p < 0,05) y días totales de estancia hospitalaria (9,68 ± 7,6 vs 7,87 ± 4,0; p < 0,05) entre grupo E y M, respectivamente. El grupo M presentó un consumo de 1.771,21 €/paciente inferior al grupo E. Conclusión: La cirugía mínimamente invasiva para el recambio valvular aórtico puede ser beneficiosa tanto en términos de morbimortalidad como en términos económicos. Dado que el estudio presentado es retrospectivo, creemos que futuros análisis prospectivos aleatorizados serían convenientes para profundizar los hallazgos obtenidos.

Objetivos «Respetar, no resecar» es un nuevo paradigma en la reparacion valvular mitral basado en el empleo de neocuerdas. Presentamos una nueva tecnica que facilita su empleo multiple. Valoramos su seguridad y eficacia en un paciente con prolapso de todos los segmentos valvulares. Material y metodos varon de 58 anos, disnea grado New York Heart Association (NYHA) II y sindrome de Barlow con prolapso marcado de ambos velos. Insuficiencia mitral grave (ORE: 0,48 cm 2 ). Fraccion de eyeccion (FE): 60%. Durante la cirugia se confirma prolapso de todos los segmentos valvulares. Implante de 13 pares de neocuerdas (politetrafluoroetileno [PTFE] CV-4): 7 en velo posterior y 6 en el anterior. Cierre desgarro hendidura P2-P3 y anuloplastia (anillo CE Physio-II 34 mm). Insercion de la neocuerda en el papilar correspondiente con punto simple, sin parche ni anudado. Remodelado del velo en «palo de hockey» tras insertar la neocuerda a lo largo de una amplia superficie del borde libre (el exceso de tejido se transfiere de la superficie auricular a la de coaptacion). Repliegue de velos sobre el anillo y anudado de las neocuerdas sin acortamiento (longitud calculada sobre el nivel del anillo). Resultados ausencia de regurgitacion residual en la ecocardiografia intraoperatoria y posquirurgica (3 meses). Gradiente transvalvular medio: 2,5 mmHg con area estimada de 2,6 cm 2 . Ausencia de complicaciones quirurgicas. Asintomatico en el ultimo seguimiento. Conclusiones la tecnica empleada facilita el uso extensivo de neocuerdas incluso en la reconstruccion completa de la valvula mitral. Al evitar el acortamiento de neocuerdas, permite la preservacion del tejido y movilidad de ambos velos, logrando una reparacion «mas fisiologica».

Describir nuevos factores de riesgo de implante de marcapasos (MP) postoperatorio tras ablación quirúrgica concomitante de fibrilación auricular (FA) y nuestra experiencia en el seguimiento a medio plazo. Métodos: Trescientos setenta y cuatro pacientes consecutivos sometidos a ablación concomitante de FA entre 1997–2010. Seguimiento del ritmo: electrocardiograma (ECG) cada 1–4 meses y registros de actividad del MP durante 30 meses. Resultados: Treinta y tres implantes de MP (8%): 6% disfunción sinusal, 94% bloqueo auriculoventricular (BAV)-III. Ablación de FA: patrones Maze III/no completos (47,8/52,1%) con crioablación (43,5%), radiofrecuencia-monopolar (10,1%), radiofrecuenciabipolar (8,8%), microondas (29,6%) y ultrasonidos (3,7%). Retraso medio hasta implante 8,4 ± 2,7 días. En el grupo con implante MP, recuperación ritmo sinusal 16 pacientes (48%) aplicándose estimulación VDD/DDD; 17 (51%) mantuvieron FA con implante 4 VDD y 13 VVI. La cirugía valvular tricúspide (odds ratio [OR]: 3,2), edad superior a 70 (OR: 2,7), aurícula izquierda superior a 60 mm (OR: 2,3), patrón Maze III (OR: 2,4) y radiofrecuencia-microondas monopolares (OR: 2,8) se mostraron en modelos uni/multivariante relacionados con un riesgo incrementado de implante de MP postoperatorio (p < 0,005). El ritmo cardíaco se recuperó en el 91% de los casos, en los primeros 3 meses del postoperatorio, manteniéndose en los siguientes 30 meses de seguimiento. Sólo 5,7% del tiempo medio, en el grupo de MP a demanda, presentaron estimulación eléctrica. Conclusión: El implante del MP tras ablación concomitante de FA es un fenómeno multifactorial. La cirugía concomitante, grados de remodelado auricular avanzados y el propio procedimiento de ablación han sido hallados factores de riesgo independientes en el postoperatorio inmediato. Esta complicación fue reversible en más del 90% de casos de nuestra serie de forma temprana y sostenida a medio plazo.

Objective: Development of late significant tricuspid regurgitation (TR) after successful mitral valve replacement (MVR) is not infrequent. The impact of different aetiologies or diverse surgical procedures has not been adequately investigated. We studied the influence of subvalvular preservation techniques during MVR on the incidence of late TR. Methods: A total of 801 patients with grade 2+/4+ preoperative TR underwent MVR without associated tricuspid procedures from January 1994 to August 2008. In 595 patients, only posterior mitral leaflet preservation was performed (group A). In the remaining 206 patients, both anterior and posterior leaflets were retained (group B). Postoperative development of significant TR was defined as a TR increase by more than one grade from preoperative or final TR grade 3+/4+ at follow-up. Results: The global incidence of postoperative significant TR was 8.6%, with higher incidence in females (9.4% vs 6.7%, p = 0.12), rheumatic disease (9.7% vs 6.5%, p = 0.07), patients with previous AF (11.8% vs 3.8%, p < 0.001) and, especially, in group A (10.8% vs 2.4%, p < 0.001). The Maze procedure was protective in patients with AF (the incidence with and without associated Maze was 6.7% vs 13.2%, p = 0.04). Preoperative left-atrial diameters were higher in patients with postoperative development of TR (56 9m m vs 51 12 mm, p = 0.01). Group A (p = 0.04) and preoperative atrial fibrillation (p = 0.001) were significant predictors of late postoperative TR. Late functional TR decreased free survival from chronic heart failure. Conclusions: Several clinical and operative factors are associated with the development of significant TR after MVR. Although early surgical intervention for TR may be recommended in selected patients, complete subvalvular preservation of the mitral valve and routine surgical ablation of atrial fibrillation can significantly reduce its incidence. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

La mejora de la calidad de vida de la sociedad actual genera una poblacion cada vez mas envejecida, y con ello el aumento de las enfermedades degenerativas, asi como de las morbilidades asociadas. Ello exige el desarrollo de tecnicas que produzcan una menor agresion quirurgica a estos pacientes. El recambio valvular aortico transcateter actualmente permite tratar a aquellos pacientes con valvulopatia aortica que presentan un elevado riesgo quirurgico. Es una tecnica en auge, aumentando paulatinamente los pacientes que son sometidos a esta tecnica. Sin embargo, no todos los pacientes son candidatos a este procedimiento, bien por dificultades tecnicas asociadas a la anatomia del paciente, bien por la necesidad de una mayor oferta tecnologica de la industria. La mayoria de las publicaciones actuales se centran en los resultados y complicaciones asociadas a la tecnica, no existiendo en la literatura actual una revision de casos que analice los resultados quirurgicos de aquellos pacientes que han sido descartados para la misma. Realizamos una revision de 19 casos incluidos en programa de recambio valvular aortico transcateter, en los que la tecnica fue desestimada, incluyendose en lista de espera para cirugia convencional. Analizamos las causas por las que fueron rechazados, riesgo quirurgico, morbilidades asociadas, el manejo posterior de estos pacientes, asi como de los resultados quirurgicos.