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BACKGROUND: The present study is a sub-analysis of the multicenter, randomized PERSIST-AVR trial (PERceval Sutureless Implant versus Standard Aortic Valve Replacement) comparing the in-hospital and 1-year results of sutureless versus conventional stented bioprostheses in isolated surgical aortic valve replacement (SAVR) within two different surgical approaches: mini-sternotomy (MS) and full-sternotomy (FS).METHODS: A total of 819 patients (per-protocol population) underwent preoperative randomization to sutureless or stented biological valve at 47 centers worldwide. Sub-analysis on isolated SAVR was performed. Results were compared between sutureless and stented within the two different surgical approaches.RESULTS: 285 patients were implanted with Perceval (67% in MS) and 293 with stented valves (65% in MS). Sutureless group showed significantly reduced surgical times both in FS and MS. In-hospital results show no differences between Perceval and stented valves in FS, while a lower incidence of new-onset of atrial fibrillation (3.7% vs 10.8%) with Perceval in MS. After 1-year, use of sutureless valve showed a significant reduction of MACCE (5.2% vs 10.8%), stroke rate (1.0% vs 5.4%), new-onset of atrial fibrillation (4.2% vs 11.4%) and re-hospitalizations (21.8 days vs 47.6 days), compared to stented valves but presented higher rate of pacemaker implantation (11% vs 1.6%).CONCLUSIONS: Sutureless bioprosthesis showed significantly reduced procedural times during isolated SAVR in both surgical approaches. Patients with sutureless valves and MS access showed also better 1-year outcome regarding MACCEs, stroke, re-hospitalization and new-onset atrial fibrillation, but presented a higher rate of permanent pacemaker implantation compared to patients with stented bioprosthesis.

Resumen: Introducción: Las prótesis aorticas de rápido despliegue aparecieron hace 10 años para tratar la estenosis aórtica. El sistema de válvula Edwards Intuity es una prótesis biológica basada en la válvula Edwards Magna con un marco infraanular. Presentamos los resultados clínicos y hemodinámicos a corto y largo plazo obtenidos con esta prótesis biológica. Métodos: Ciento diecisiete pacientes (65% varones, 75 ± 4,5 años) con estenosis aórtica (gradiente medio preoperatorio de 49,6 ± 12 mm Hg) recibieron una prótesis Edwards Intuity entre septiembre de 2012 y diciembre de 2019. Se incluyeron en una base de datos prospectiva que recogía diferentes variables. La media de seguimiento fue de 36 ± 21 meses. Resultados: Mortalidad hospitalaria del 3,4%, supervivencia al año, a los 3 y 6 años del 95%, 90% y 81%, respectivamente. Se utilizó hemiesternotomía media superior en 78 pacientes (67%). La mediana de tiempos de isquemia miocárdica y de circulación extracorpórea de toda la serie fueron 40 (33-50) minutos y 59 (48-73) minutos. Gradientes medios al alta, al año y a los 2 años fueron 10 ± 4 mm, 9 ± 3,5 mm y 8,4 ± 3,4 mm Hg. Ocho pacientes (7%) necesitaron marcapasos en el postoperatorio. Dos pacientes (0,6%) se reintervinieron en seguimiento por endocarditis y otro (0,3%) se reintervino por fuga periprotésica. Conclusión: El sistema de válvula Edwards Intuity presenta buenos resultados clínicos y hemodinámicos a corto y largo plazo. Estas prótesis aórticas se pueden considerar una alternativa a las prótesis convencionales, sobre todo en cirugía de mínimo acceso y en intervenciones complejas. Abstract: Introduction: Rapid deployment aortic valves appeared ten years ago to treat aortic stenosis. The Edwards Intuity Valve System is a biological prosthesis based on the Edwards Magna valve with an infra-annular framework. We present the short and long-term clinical and hemodynamic results obtained with this biological prosthesis. Methods: One hundred seventeen patients (65% male, 75 ± 4.5 years) with aortic stenosis (mean preoperative gradient of 49.6 ± 12 mm Hg) received an Edwards Intutiy prosthesis between September 2012 and December 2019. They were included in a prospective data base that collected different variables. The mean follow-up was 36 ± 21 months. Results: Hospital mortality of 3.4%. Survival at one, three and six years of 95%, 90% and 81%, respectively. Upper hemisternotomy was used in 78 patients (67%). The median times of myocardial ischemia and extracorporeal circulation for the entire series were 40 (33-50) minutes and 59 (48-73) minutes. Average gradients at discharge, one year and two years were 10 ± 4 mm, 9 ± 3.5 mm and 8.4 ± 3.4 mm Hg. Eight patients (7%) required pacemakers in the postoperative period. Two patients (0.6%) underwent surgery for endocarditis and another (0.3%) underwent surgery for periprosthetic leak. Conclusion: The Edwards Intutiy valve system presents good short and long term clinical and hemodynamic results. These aortic prostheses can be considered an alternative to conventional prostheses, especially in minimal access surgery and in complex interventions.

Resumen: La cirugía cardiovascular es la especialidad médica que se ocupa de la prevención, diagnóstico y tratamiento quirúrgico de los trastornos y enfermedades del sistema cardiocirculatorio. Los continuos y rápidos avances en el diagnóstico y tratamiento de las enfermedades cardiovasculares justifican la necesidad de llevar a cabo una actualización de los principales aspectos definitorios y organizativos de la especialidad, relacionados con la profesión (de la práctica, calidad asistencial), con el programa docente de la especialidad, la formación continuada de los cirujanos, los procesos de acreditación desde la Sociedad Española de Cirugía Torácica-Cardiovascular, entre otros.Este documento, elaborado por expertos de la cirugía cardiovascular, representa la opinión de la Sociedad Española de Cirugía Torácica-Cardiovascular y actualiza los principales aspectos de la especialidad en nuestro país. Abstract: Cardiovascular surgery is the medical specialty that deals with the prevention, diagnosis, and surgical treatment of disorders and diseases of the circulatory system. The continuous and rapid advances in the diagnosis and treatment of cardiovascular diseases justify the need to update the main, defining, and organisational aspects of the specialty, related to the profession (its practice, quality care), aspects on the teaching program of the specialty, the continuing education program of the surgeons, the processes of accreditation from the Spanish Society of Thoracic-Cardiovascular Surgery, etc.This document, prepared by experts in cardiovascular surgery, represents the opinion of the Spanish Society of Thoracic-Cardiovascular surgery and updates the main aspects of the specialty in our country. Palabras clave: Cirugía cardiovascular, Cirugía cardíaca, Cirugía torácica, Cirugía vascular, Recomendaciones, Keywords: Cardiovascular surgery, Cardiac surgery, Thoracic surgery, Vascular surgery, Recommendations

International audience; Objective: Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.Methods: The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.Results: At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.Conclusions: Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.

Background Aortic stenosis is currently the most frequently occurring valve pathology. Developments, such as transcatheter prostheses and rapid deployment prostheses, allow for the offer of a valve replacement to higher risk patients, but these techniques are linked with a higher need for a permanent pacemaker during the immediate postoperative period. Methods We studied the incidence and the factors associated with permanent pacemaker implantation after aortic valve replacement with Edwards Intuity rapid deployment prosthesis. Results Between October 2012 and December 2016, the Edwards Intuity prosthesis was implanted in 71 patients (68% male, 75.3 ± 5 years old). Six patients (8%) required a permanent pacemaker during immediate postoperative period. Univariate analysis showed that a history of acute myocardial infarction (AMI) (P = .046, B = 7.5, 95% CI [1.039-54.1]) and preoperative amiodarone (P = .009, B = 31.5; 95% CI [2.32-426]) were associated with a higher need for a pacemaker during the postoperative period. Conclusions The incidence of permanent pacemaker implantation during the immediate postoperative period of aortic valve replacement with Edwards Intuity prosthesis was 8%, a value which is within the limits reported for conventional aortic prostheses. Preoperative amiodarone treatment and previous AMI may increase the need for a pacemaker during the postoperative period of these aortic prostheses.

ResumenObjetivoDisponemos de una nueva clase de prótesis aórticas de despliegue rápido para tratamiento quirúrgico de la estenosis aórtica. Permitirían disminuir los tiempos quirúrgicos y facilitarían la cirugía mínimamente invasiva. Presentamos nuestra experiencia inicial con la válvula Edwards Intuity en el contexto del estudio multicéntrico Foundation.Pacientes y métodosEntre septiembre de 2012 y febrero de 2014 se implantaron 25 prótesis aórticas Edwards Intuity en 26 pacientes (77±4,3años; 52% varones). Veinticuatro (96%) fueron reemplazo valvular aislado, y 9 pacientes (36%) tuvieron abordaje mínimamente invasivo. Los pacientes fueron estudiados al alta, a los 3meses y al año de la intervención.ResultadosHubo éxito en el implante en el 96,2% de los pacientes (25/26). No hubo mortalidad hospitalaria. Seguimiento medio de 11±5,4meses, supervivencia acumulada del 96%. Un paciente falleció a los 11meses por un ictus isquémico. El tiempo medio de pinzamiento aórtico fue de 38,2±10,1min y el tiempo medio de circulación extracorpórea, de 62,4±11,1min. A los 3meses, el área valvular efectiva media fue de 1,70±0,42cm2. El 91% de los pacientes (23/25) estaban en grado funcionali en el seguimiento.ConclusionesEl implante de la válvula Edwards Intuity para el tratamiento de la estenosis aórtica ha sido factible, seguro y eficaz. Los tiempos de isquemia miocárdica y de circulación extracorpórea parecen reducirse en comparación con la cirugía valvular aórtica habitual. El comportamiento hemodinámico inicial de la prótesis Edwards Intuity es excelente.AbstractObjectiveA new class of rapid deployment prostheses is now available for surgical treatment of aortic stenosis. These prostheses offer the possibility of reducing the duration of cardiopulmonary bypass and aortic clamping times, and facilitate the use of minimally invasive surgery. We present our initial experience with the Edwards Intuity valve in the context of a multicentre Foundation study.Patients and methodsBetween September 2012 and February 2014, 25 Edwards Intuity valves were implanted in 26 patients (77±4.3years; 52% male). Twenty-four (96%) were isolated aortic valve replacement; a minimally invasive approach was used on 9 patients (36%). Patients were studied at discharge, three months, and one year after surgery.ResultsImplantation success rate was 96.2% (25/26). There was no hospital mortality. Mean follow-up of 11±5.54months, cumulative survival of 96%. One patient died eleven months after surgery due to ischaemic stroke. The mean aortic clamping time was 38.2±10.1minutes, and the mean cardiopulmonary bypass (CPB) time was 62.4±11.1minutes. In the echocardiography at 3months, the mean effective valve area was 1.70±0.42cm2, and 91% of patients (23/25) were in functional classi NYHA at follow-up.ConclusionsThe implantation of the Edwards Intuity valve for surgical treatment of aortic stenosis has shown to be feasible, safe and effective. Times of myocardial ischaemia and extracorporeal circulation appear to be reduced compared with normal aortic valve surgery. The initial haemodynamic performance of the Edwards Intuity prosthesis is excellent.

Objective: Patients with congenital heart disease (CHD) and valve dysfunction requiring surgery present a challenge for surgical treatment. Most of these patients have complex anatomy and have unde...

Objective: Aortic prostheses with rapid deployment have recently emerged with shorter surgical times and less invasive approaches for the treatment of aortic stenosis. The appearance of the treatme...

La ablación quirúrgica de las arritmias ha experimentado en los últimos años un notable desarrollo. La ablación intraoperatoria es una técnica simple, aunque requiere de formación específica y experiencia por parte del cirujano. Estas técnicas demandan recursos propios de los que, en ocasiones, es difícil disponer. El Grupo de Trabajo en Cirugía de las Arritmias y Estimulación Cardíaca de la Sociedad Española de Cirugía Torácica y Cardiovascular ha considerado recomendable definir el actual papel del cirujano cardiovascular en la ablación quirúrgica de las arritmias. Estas recomendaciones surgen de la necesidad de proporcionar a cada paciente el grado de cuidado que requiere, establecer los recursos estructurales, técnicos y humanos, y suscribir cuál debe ser el nivel de formación asistencial del personal sanitario implicado.In recent years the surgical ablation of cardiac arrhythmias has experienced a notable development. Surgical ablation is a simple technique, however requires specific surgical training, experience and skills. These techniques demand specific resources but they are sometimes difficult to achieve. The Grupo de Trabajo en Cirugía de las Arritmias y Estimulación Cardíaca of the Sociedad Española de Cirugía Torácica y Cardiovascular has considered necessary to define the current role of the cardiovascular surgeon in the surgical ablation of arrhythmias. These recommendations arise from the need to provide each patient with the required degree of care, to optimize the structural and human resources and to determine which level of training the healthcare personnel should achieve.

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty.

IntroducciónLa combinación de cirugía convencional y tratamiento endovascular podría ser una alternativa válida en el manejo de la enfermedad de aorta torácica con implicación de troncos supraaórticos (TSA).Material y métodosPresentamos dos casos con estrategia quirúrgica similar, basada en revascularización de TSA y colocación de endoprótesis torácica ocluyendo dos de los troncos, y embolización posterior de éstos.ResultadosEl paciente 1, diagnosticado de aneurismas en aorta abdominal (AAA), torácica descendente (AATD) y en arteria subclavia derecha aberrante, fue intervenido previamente del AAA realizándose endoaneurismorrafia. A éste se le practicó una derivación aortobiaxilar previa a la colocación de la endoprótesis y posterior embolización de arteria subclavia derecha. En el postoperatorio desarrolló paraparesia transitoria. El paciente 2, con historia de seudoaneurisma postraumático distal al istmo tratado con cirugía convencional 20 años antes, presentaba dilatación de aorta torácica a nivel del istmo y afectación de arteria subclavia izquierda. En éste se realizó derivación aortocarotideosubclavia izquierda tras la que se implantó la endoprótesis torácica, con embolización posterior de arteria subclavia y vertebral izquierda. El paciente no presentó ninguna complicación. En seguimiento a 1 año no hubo complicaciones.ConclusionesEl abordaje del arco aórtico usando técnicas endovasculares presenta el problema de la oclusión de TSA. El uso de derivaciones quirúrgicas hace posible esto. El abordaje combinado es aún una técnica nueva pero que podría ser una alternativa válida a la cirugía abierta de arco y aorta torácica descendente. Nuestra experiencia es satisfactoria, aunque no concluyente por tratarse sólo de dos casos.IntroductionThe aim of the study is to report our initial experience with combined open surgical treatment and endovascular therapy in the treatment of complex thoracic aortic disease.Material and methodsTwo patients treated with similar surgical strategy including surgical revascularization of the neck vessels and deployment of thoracic aortic stent-graft.ResultsPatient 1, with concomitant aneurysms of abdominal aorta (AAA), descending thoracic aorta (DTAA) and aberrant right subclavian artery that underwent surgical resection of the AAA. Patient 2 was diagnosed of left subclavian artery pseudoaneurysm twenty years after open surgical repair of distal arch post-traumatic pseudoaneurysm. Both patients first underwent open surgical revascularization of the neck vessels (aorto-biaxillary bypass in patient 1 and aorto-left carotid-left subclavian bypass in patient 2) and the 2nd step of the procedure was the deployment of thoracic endograft with occlusion of the origin of the neck vessels. The right subclavian artery in patient 1 and left subclavian and vertebral artery in patient 2 were embolized. Patient 1 experienced transient paraparesia. Patient 2 had no complications. After 1-year of follow-up no complications have been detected.ConclusionsCombined surgical and endovascular approach to the aorta arch may represente an alternative to open surgery of the arch and descending thoracic aorta. Our satisfactory experience is too short as there are only two cases reported.

IntroducciónEl uso de estatinas se asocia a una reducción de accidentes coronarios en prevención primaria y secundaria y después de angioplastia primaria.ObjetivoInvestigar si el empleo de estatinas en pacientes sometidos a cirugía de revascularización coronaria (CRC) se asocia a beneficio clínico.MétodosSe incluyeron 102 pacientes consecutivos con enfermedad coronaria para CRC electiva y aislada. En el momento de la inclusión se registró el tratamiento preoperatorio y las variables clínicas basales. En el seguimiento se registró la aparición de muerte de origen cardíaco e infarto agudo de miocardio (IAM) en los primeros 30 días.ResultadosRecibían estatinas 61 pacientes (60%) frente a 41 (40%) que no las recibían. No se encontraron diferencias significativas entre ambas poblaciones respecto a las características basales. A los 30 días se produjo una muerte cardíaca (1,6%) en el grupo que recibió estatinas, frente a cinco (12,2%) en el grupo que no las recibían (p=0,02), el IAM ocurrió en cuatro (6,6%) frente a 8 (19,5%) (p=0,04) y el resultado compuesto de muerte cardíaca o IAM ocurrió en cinco (8,2%) frente a 10 (24,4%) (p=0,02). En un modelo multivariado, el tratamiento preoperatorio con estatinas se mantuvo como un factor independiente de predicción (p=0,01; odds ratio [OR]: 3,6) de la aparición de muerte de causa cardíaca o IAM durante los primeros 30 días después de la intervención.ConclusiónEl tratamiento previo con estatinas se asocia de forma significativa e independiente a un menor riesgo de IAM o muerte de origen cardíaco en pacientes sometidos a CRC.IntroductionStatin treatment diminishes adverse cardiac events both in primary and secondary prevention and also after percutaneous coronary intervention.ObjectiveTo study if preoperative statin treatment is associated with any clinical advantage after coronary artery surgery.MethodsWe enrolled 102 consecutive patients with coronary artery disease, scheduled for elective coronary artery surgery. Combined procedures were excluded. Preoperative treatment and the clinical baseline characteristics were recorded in all patients at inclusion. Cardiac death and acute myocardial infarction (AMI) were recorded during the first 30 days.ResultsSixty one patients (60%) were on preoperative statin treatment vs. 41 (40%) who were not. There were no differences at baseline level between both groups. There was one cardiac death at 30 days (1.6%) in the statin-treatment group vs. five deaths (12.2%) in the nostatin group (p=0.02). Acute myocardial infarction presented in four (6.6%) vs. eight (19.5%) (p=0.04). The primary combined cardiac endpoint made of cardiac death or AMI occurred in five (8.2%) vs. 10 (24.4%) (p=0.02). In a multivariate model, preoperative statin treatment remained an independent predictor (p=0.01; odds ratio [OR] 3.6) of cardiac death or AMI during the first 30 days after surgery.ConclusionPreoperative statin-treatment was significative and independently associated with less risk of AMI or cardiath death in patients who underwent coronary artery bypass grafting.

Presentamos la experiencia inicial con la canulación de la arteria axilar en su tercera porción extratorácica en la raíz del brazo derecho o hueco axilar. De diciembre de 2003 a mayo de 2004, hemos intervenido cuatro pacientes con enfermedad de aorta ascendente en los cuales hemos colocado la cánula de retorno arterial de la circulación extracorpórea a través de la arteria axilar derecha.Desde el punto de vista técnico el paciente se coloca en decúbito supino y brazo derecho en extensión de 90°, incisión a nivel del hueco axilar. Tras exponer la arteria se introduce cánula 20F iniciando así la circulación extracorpórea sin problemas de resistencia, pudiendo alcanzar flujos máximos adecuados a la superficie corporal de cada paciente. Permite protección cerebral directa si es necesaria la parada circulatoria. No ha habido complicaciones neurológica, isquémica o infecciosa en la extremidad superior derecha.Se describe vía de acceso arterial alternativa válida para la circulación extracorpórea. Una serie más amplia de pacientes aportará datos comparativos.The aim of this study is to report our initial experience with the cannulation of the axillary artery in the right arm. This is an alternative approach to the ascending aorta and it is to be compared with the femoral and infraclavicle axillary. From December 2003 to May 2004, four patients with as ascending aortic disease were operated on cardiopulmonary bypass with this axillary approach.In the operating room the patient was positioned with the right arm extended 90°. An incision in the right axillary cavity was performed, the subcutaneous tissue was dissected and the prevascular fascia opened. The axillary artery lies in a superior and posterior position when referred to the vein. Special care was taken to avoid injury to the brachial plexus. A 20F arterial cannula is inserted through transverse arteriotomy and cardiopulmonary bypass started. We did not record high perfusion pressure rates. No neurological, infectious or ischemic complications in the right arm have been recorded.This suggested axillary approach is an excellent alternative when compared to the femoral and infraclavicle approaches, because it is feasible and swift. It also provides good antegrade pump flow rates, cerebral protection during hypothermic and circulatory arrest and makes the chest free from cannulations.

Q fever is characterized by its clinical polymorphism. Cardiac involvement in acute Q fever is rare. We report a case of pleuro-pericarditis that rapidly evolved to pericardial constriction during an acute episode of Coxiella burnetii infection. Constrictive pericarditis was confirmed by hemodynamic measurements, echocardiography, and magnetic resonance. Indirect immunofluorescence assay revealed positive serology for acute Q fever. The patient underwent a successful pericardiectomy and was given antibiotics. The histopathologic study of the excised pericardium showed C. burnetii in a large cluster of organisms. After a 6-month follow-up period, the individual was asymptomatic.

Introduccion En los tiempos actuales la tendencia en la cirugia cardiaca es a realizar procedimientos menos agresivos, en ocasiones demandados por los pacientes. Por este motivo decidimos iniciar el programa de cirugia aortica por miniesternotomia. Material y metodos Desde enero de 2010 - enero de 2012 hemos operado a 20 pacientes de sustitucion valvular aortica, por estenosis grave, a traves de una miniesternotomia en «J» por el cuarto-quinto espacio intercostal, con una incision cutanea de 10 cm (rango 8-12). Se trataba de 14 varones y 6 mujeres, con una media de edad de 58 anos (rango 28–77). Se implantaron 15 protesis mecanicas y 5 biologicas. Resumen de la tecnica Miniesternotomia en «J» (4–5.° espacio intercostal). Apertura de pericardio y puntos de traccion. Canulacion aortica y unicava superior. Drenaje en vena pulmonar superior derecha (VPSD). Aortotomia transversa. Extirpacion e implante de valvula aortica. Cierre de aortotomia. Purgado de cavidades. Hot-shoot. Resultados No ha fallecido ningun paciente, no hemos tenido ninguna dehiscencia esternal ni hemorragia postopera-toria. El tiempo de clampaje medio fue 55 min (rango 40–60). El sangrado medio ha sido de 450 cc (rango 200–1.000), el tiempo de intubacion de 180 min (rango 90–500), alta hospitalaria a los 6 dias (rango 4–12), y no hemos presentado ninguna infeccion. Conclusiones La cirugia aortica por miniesternotomia en «J» es un abordaje seguro para la cirugia de sustitucion valvular aortica. Nuestros resultados son satisfactorios hasta el momento. Es una tecnica reproducible. Pensamos que el antiguo aforismo de «a grandes cirujanos, grandes incisiones» ya no esta vigente.

Introduccion y objetivos Desde 2006 se dispone de la via de implante percutanea para las protesis valvulares aorticas. Por el momento esta via percutanea se ha reservado para pacientes de alto riesgo con la cirugia con circulacion extracorporea (CEC). Presentamos la experiencia inicial en nuestro hospital con protesis aortica percutanea via transfemoral. Pacientes y metodos Se intervinieron 33 pacientes (60% mujeres; 81,6 ± 4,4 anos de edad media) entre junio de 2008 y febrero de 2010. EuroSCORE logistico medio de 21% ± 12,5; EuroSCORE aditivo 9 ± 2,3; seguimiento medio de 7 meses (1-20). Se implantaron 20 protesis n.° 23 (60%) y 12 n.° 26 (40%). Resultados Durante la hospitalizacion fallecieron tres pacientes (9%). En un paciente no se logro colocar la protesis (3%). Las complicaciones mas frecuentes fueron las vasculares en 10 pacientes (30%), seguidas de la insuficiencia cardiaca en cuatro pacientes (12%) y de la necesidad de implantar un marcapasos en otros dos (6%). Fueron transfundidos 16 pacientes (47%). Estancia en cuidados intensivos 1,8 ± 2,3 dias, y en hospital 10,8 ± 9,7 dias. En el seguimiento fallecieron tres pacientes (10%), y seis pacientes (21%) reingresaron en el hospital por causa cardiaca. El ecocardiograma postoperatorio mostro insuficiencia aortica grado II en cuatro pacientes (14%). Conclusiones La via transfemoral permite tratar a pacientes de alto riesgo quirurgico para el uso de CEC, sin embargo no esta exenta de riesgos importantes. Mayor experiencia y seguimiento permitiran conocer los pacientes que mas se beneficien de este abordaje.

The aortic valve sparing operation is of great interest in the treatment of severe aortic insufficiency caused by annulus enlargement in aortic annuloectasia. If valve leaflets are normal, and we want to prevent complications derived from valve prosthesis and chronic anticoagulation, techni

Low-output syndrome is one of the leading causes of death following open-heart surgery or high-risk angioplasty. Ventricular assist devices have been used to treat patients who suffer from postoperative cardiogenic shock despite use of an intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist device that has been shown to reduce infarct size and to accelerate recovery of stunned myocardium. We report our initial experience using the Impella device for the treatment of cardiogenic shock following cardiopulmonary bypass and for maintaining hemodynamic stability in high-surgical-risk patients undergoing unprotected left coronary artery angioplasty.

70 Paravalvular aortic regurgitation after autoexpandibles aortic protheses. Comparison between Edwards-Sapien protheses and Perceval sutureless aortic valve. {#article-title-2} Purpose: The transcatheter aortic valve implantation (TAVI) has proved to be an alternative treatment for severe aortic stenosis in high risk patients. New surgical techniques with autoexpandibles suturless aortic valve protheses have shown good results with a less invasive surgical approach and a reduction in surgical time. The purpose of the study was to compare initial echocardiographic results after aortic valve implantation by both techniques. Methods: We studied 142 consecutive patients submitted to TAVI and 33 patients submitted to aortic valve replacement (AVR) with autoexpandibles sutureless Perceval valves. Clinical and demographic variables were registered and a transthoracic echocardiography study was performed before the implantation and after the procedure or surgery. Maximum and mean aortic gradients were registered as well as the paravalvular aortic regurgitation (AR). The latter was classified in two grades: I= null o mild; II= moderate or severe. Results: The 142 patients submitted to TAVI were diagnosed of symptomatic severe aortic stenosis with a high surgical risk (Logistic EuroSCORE 10,4 ± 7,8), and higher age than the ones submitted to surgery (81,8 vs. 79,8; p=0,005). From the 33 patients submitted to AVR with Perceval protheses, 5 of them (15%) were also performed a coronary artery bypass graft. The incidence of paravalvular AR was grade I (null o mild) in 25 patients (86%), and grade II (moderate or severe) in 4 (14%). In patients with TAVI, 94 of them (69,1%) presented null or minimum paravalvular AR, while in the 42 remaining patients (30,9%) it was grade II, with statistically significant differences between the 2 types of protheses ( p=0,046). Both protheses presented similar aortic gradients in the study after the implantation, without statistically significant differences between TAVI and Perceval protheses in maximum Doppler gradient (20,98 vs. 23,87 mmHg; p= 0.152) and mean gradient (11,16 vs. 13,31 mmHg; p=0.063). The relation between time-velocity integral of the LV outflow tract and aortic valve after the implantation was also similar between both groups (median 0,55 vs. 0,53; p= 0,228). Conclusions: The early echocardiographic study after the implantation of autoexpandible aortic protheses shows comparable results between both types of protheses in terms of gradients, with a higher incidence of paravalvular aortic regurgitation in the group of TAVI. # 71 Exercise echocardiographic determinants of BNP changes during follow-up in asymptomatic patients with aortic stenosis and preserved left ventricular function {#article-title-3} Purpose: B-type natriuretic peptide (BNP) level may be a useful prognostic marker in asymptomatic patients with severe aortic stenosis (AS). Recently updated European Society of Cardiology guidelines recommend its measurement and the use of exercise stress echocardiography to optimize risk stratification in these patients. The goal of this study was to correlate exercise echocardiographic data and BNP changes during follow-up in asymptomatic patients with AS and preserved left ventricular (LV) function. Methods: We studied 61 asymptomatic patients (age: 70±13 years; 64% of males) with ≥ moderate AS (aortic valve area: 0.98±0.25cm2) and preserved LV ejection fraction (69±6%) who underwent resting and exercise Doppler echocardiography with concomitant BNP level measurement at baseline. None of the patients developed symptoms during test. BNP measurement was repeated after at least 6-months follow-up (22±12.5 months; median: 20; range: 7-47 months) and then each 6- or 12-month, according to the individual management. Results: From baseline to the last BNP measurement during follow-up, the distribution of BNP changes was: 65.5±129.5pg/mL; median: 29; range: -104-+675pg/mL. Patients were divided into 2 groups according to the median of serial BNP changes. There were no significant differences regarding clinical characteristics (all p

PURPOSE To report endovascular repair of dual aneurysms in a patient with Behcet's disease. CASE REPORT A 37-year-old man diagnosed 6 months prior with Behcet's disease presented with a pulsating abdominal mass. Computed tomography revealed a 70-mm-diameter pseudoaneurysm in the abdominal aorta and another (20 mm) in the celiac trunk 5 mm from the aorta. Staged endovascular repair began with the aortic aneurysm, which was excluded with a bifurcated 23 x 140-mm Excluder stent-graft. Three days later, 2 Jostent stent-grafts were placed in the celiac trunk, successfully excluding the lesion. Fifteen days later, the patient was discharged on a regimen of clopidogrel, cyclosporine, and warfarin. At 6 months, the CT scan showed good perfusion of the stent-grafts. CONCLUSIONS Aneurysmal involvement of the celiac trunk in a patient with Behcet's disease is a rare pathology that appears amenable to stent-graft repair.

We present a successful use of biventricular pneumatic assistance during seven days allowing the recovery from a severe primary graft failure that occurred in the operating room. Suboptimal donors are associated with higher rates of immediate graft failure; however proper use of mechanical assistance can help to recover graft function.

Currently, there are not solid evidence-based recommendations on the treatment of in-transit right heart thromboemboli. We present a case of acute pulmonary embolism with right ventricular entrapped thrombus detected by echocardiography. Surgical thrombectomy was successfully carried out. Treatment options are discussed and the need of a randomized trial is stressed.

Las válvulas aórticas biológicas sin soporte Sorin Freedom Solo (FS) han demostrado una mejoría en el aumento del orificio de área efectivo, así como un mejor perfil en los gradientes transvalvulares, fracción de eyección del ventrículo izquierdo (FEVI) y regresión de la hipertrofia ventricular izquierda. También, se ha comprobado una reducción en los tiempos de isquemia miocárdica y de circulación extracorpórea. Sin embargo no hay mucha información sobre su comportamiento en el contexto de endocarditis valvular. Material y métodos: Desde noviembre de 2006 – septiembre 2011, se implantaron 17 prótesis FS en 16 pacientes (50% hombres, 60,2 ± 15 años) por endocarditis bacteriana. Se determinó la cantidad de plaquetas en el día 5 postimplante, así como la fracción de eyección (FE) y los gradientes transvalvulares posquirúrgicos. Seguimiento medio de 22,5 ± 26 meses. Resultados: La prevalencia de trombocitopenia (< 150.000 plaquetas) y trombocitopenia grave (< 50.000 plaquetas) ha sido de 68,8 y 31,3%, respectivamente. Hubo un total de 4 muertes hospitalarias (25%), 2 intraoperatorias. Gradiente transvalvular medio de 22 ± 18 mmHg, FEVI postoperatoria media de 52,4 ± 10,3%. Tres pacientes fueron reintervenidos, 2 por deterioro precoz (16%), 1 por nueva endocarditis (8%). Conclusión: La prótesis aórtica biológica sin soporte FS muestra un buen perfil hemodinámico, mejorando significati-vamente los gradientes transvalvulares. Nuestra prevalencia de trombocitopenia al quinto día y durabilidad de la válvula se encuentran en valores similares a lo publicado en la literatura. El uso de dicha prótesis en endocarditis aórtica debe considerarse una alternativa eficaz al demostrarse baja tasa de reincidencia de endocarditis.

Objetivos La circulacion extracorporea y el tiempo de isquemia prolongados pueden aumentar la morbimortalidad en la cirugia de recambio valvular aortico, especialmente en pacientes anosos y de alto riesgo quirurgico. El uso de protesis autoexpandibles acorta significativamente estos tiempos y ofrece ventajas quirurgicas. Material y metodos De abril-diciembre de 2011 hemos implantado una valvula aortica biologica, sin suturas, autoexpandible, Perceval S (Sorin Biomedica, Sallugia, Italy) a 15 pacientes (edad media 77,4 ± 3; EuroSCORE logistico medio de 14 ± 4%) con estenosis aortica y con/sin cirugia coronaria concomitante. Recogemos la tecnica de implantacion tan reproducible a cualquier cirujano y los parametros hemodinamicos y clinicos de estos pacientes. Resultados Los tiempos de isquemia fueron de 26 ± 10 min y de circulacion extracorporea de 45 ± 14 min. Los gradientes hemodinamicos al alta fueron de 22 ± 10 de gradiente pico aortico y de 12 ± 7 de gradiente medio. Dos pacientes recibieron cirugia combinada con puente de arteria mamaria interna a descendente anterior. Perdimos un paciente por sepsis, lo que supone una mortalidad del 6,6%. Conclusiones El desarrollo de nuevas tecnologias, como es la valvula Perceval S en la cirugia de recambio valvular aortico con/sin cirugia coronaria combinada, ofrece al cirujano nuevas posibilidades para acortar tiempos quirurgicos buscando una reduccion de la morbimortalidad, sin disminuir la seguridad, con unos buenos resultados clinicos y hemodinamicos en pacientes de alto riesgo quirurgico. Suponen una mejora tecnica cuando existe una calcificacion valvular aortica extrema y/o anillos aorticos pequenos.

Introduccion y objetivos La transfusion de concentrados de hematies (CH) en cirugia de revascularizacion miocardica (CRM) primaria se asocia a complicaciones y varia mucho entre centros. Ciertas caracteristicas de los pacientes podrian predecir la transfusion de CH en CRM. Disenamos un estudio para conocer las variables clinicas asociadas a transfusion de CH en CRM primaria, analizando su impacto sobre la mortalidad a corto y a largo plazo. Pacientes y metodos Estudio prospectivo observacional de 102 pacientes (72% varones, 64,8 ± 9,4 anos) intervenidos entre 2002-2003. Se utilizo un analisis regresion logistica para identificar predictores de transfusion de CH. Resultados Se transfundieron 81 pacientes (79%), con una mediana de 3 (2-6) CH. El 30% (25 pacientes) recibieron mas de 4 u CH. Seis pacientes fallecieron en el periodo hospitalario (5,8%). En el analisis de regresion logistica resultaron predictores independientes de transfusion de CH: el uso de aminas inotropicas (p = 0,041; odds ratio [OR]: 9,6; IC 95%: 1,10-83,3), la hemoglobina preoperatoria (p = 0,009; OR: 1,9; IC 95%: 1,17-3,16) y el numero de vasos coronarios enfermos (p = 0,035; OR: 3,35; IC 95%: 1,09-10,302). La transfusion de CH no se asocio con mayor mortalidad ni a corto (p = 0,807; 83 vs 79%) ni a largo plazo (p = 0,265; 91 vs 79%). El mejor punto de corte para la hemoglobina preoperatoria fue 13,3 g/dl. Conclusiones Nuestra tasa de transfusion de CH en CRM primaria es alta. Pacientes con hemoglobina preoperatoria menor de 13,3 g/dl, con enfermedad coronaria mas extensa y con apoyo inotropico, tienen mayor riesgo de transfusion perioperatoria en nuestro ambiente.