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Resumen Objetivos El acido tranexamico se utiliza para prevenir la hiperfibrinolisis y disminuir el sangrado postoperatorio y el empleo de hemoderivados en cirugia cardiaca con circulacion extracorporea. Este trabajo evalua la eficacia de dosis bajas o altas de acido tranexamico mediante un estudio de cohortes, prospectivo, realizado en 2 hospitales de Valencia. Material y metodos Se seleccionaron 427 pacientes, 207 en el Hospital General Universitario (dosis bajas [DB]) y 220 en el Hospital Universitario y Politecnico La Fe (dosis intermedias [DI] y dosis altas [DA]), entre enero de 2019 y enero de 2020. Se estudio la presencia de hiperfibrinolisis por tromboelastometria rotacional, la administracion de hemoderivados en el intra y postoperatorio, el debito por drenajes en las 12 primeras horas postoperatorias y la aparicion de convulsiones. Se realizo un analisis comparativo univariante y multivariante. El analisis univariante de todas las categorias se llevo a cabo tras realizar un emparejamiento por indice de propension entre DB y DA, y entre DB y DI. Resultados No hubo diferencias estadisticamente significativas en la hiperfibrinolisis, la administracion de concentrados de hematies, el debito por drenajes en las 12 primeras horas ni la aparicion de convulsiones. El grupo DB recibio menos fibrinogeno que el grupo DA (p = 0,014) y DI (p = 0,040). En cambio, la cantidad de plasma fresco congelado administrado al grupo DB fue significativamente superior a la del grupo DI (p = 0,0002). Conclusiones La administracion de dosis bajas de acido tranexamico es tan efectiva como la de dosis mas elevadas en la profilaxis de la hiperfibrinolisis y la prevencion del sangrado postoperatorio en cirugia cardiaca.

Resumen: La ecocardiografía transesfofágica es una técnica semiinvasiva que permite una evaluación de la morfología y función cardiaca a tiempo real y que constituye, a día de hoy, un estándar de calidad en las intervenciones de cirugía cardiovascular. Se ha convertido en una herramienta fundamental tanto de monitorización como de diagnóstico en el perioperatorio que permite la correcta planificación quirúrgica y manejo farmacológico dirigido.El objetivo de este documento es dar respuesta de forma consensuada y avalada por la evidencia científica de cuándo y cómo debe hacerse la ecocardiografía transesfofágica intraoperatoria en cirugía cardiovascular, qué aplicaciones tiene en el intraoperatorio, quién debe realizarla y cómo debe transmitirse la información obtenida durante el estudio. Los autores han hecho una revisión sistemática de las guías internacionales, artículos de revisión y ensayos clínicos para dar respuesta a estas preguntas. Abstract: Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management.The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

Introduction Cardiac surgery (CS) is associated with a significant use of blood products. The aim of this study was to evaluate the effect of red blood cells concentrates (RBC) transfusion on regional cerebral oxygen saturation (SrO2) in patients undergoing CS with additive EuroSCORE I > 6. Material and methods This is a prospective descriptive study. Patients with additive EuroSCORE I > 6 undergoing CS with extracorporeal circulation were included in the study. The demographic values, perioperative complications, hospital/ICU length of stay (LOS), as well as the preinduction baseline SrO2 values, the lowest SrO2 value during surgery, number of blood products transfused, hemoglobin (HB) and pre and postransfusional SrO2 values were recorded, and events of significant decrease in SrO2 below 20% of basal value or decrease below 50%. We considered responders those who had an increase post-transfusion SrO2 at least 20% of pre-transfusion value, an increase of standard deviation (7.9) or an increase up to basal SrO2. Results Data from 57 patients were collected. The average additive EuroSCORE I was 7.4 (SD 2.6) and the EuroSCORE II was 6.1 (SD 7.4). 52% were male. 35.1% of patients received intraoperative transfusion of at least one unit of RBC. The overall mortality was 8.7% (N = 5). During surgery 29.8% of the overall sample presented a decrease of more than 20% of baseline SrO2 or a value lower than 50%. Patients with a significant decrease in SrO2 presented a higher rate of perioperative complications (p = 0.04) and longer ICU-LOS 4.3 (SD 3.6) vs. 6.8 (SD 8.2) days (p = 0.01) and hospital LOS 10.1 (SD 3.1) vs. 14.2 (SD 9.4) days (p = 0.01). Pretransfusional HB was 7.4 (SD 0.8) mg/dl and postransfusional value was 8.4 (SD 0.8) (p = 0.00). Pretransfusional SrO2 was 59 (SD 8.6) and increased non- significantly after RBC transfusion to 61.1 (SD 7.9) (p = 0.1). Only 6 patients out of 21 could be considered responders. There were no significant differences in morbidity, mortality or LOS between responders and non-responders. Discussion In our population a non statistically significant increase in SrO2 was observed after RBC transfusion. When considering responders few patients were identified by SrO2. In conclusion SrO2 might not be reliable triger to decide transfusion.

Resumen Introduccion La cirugia cardiaca se asocia a un uso significativo de hemoderivados. El objetivo de este estudio fue evaluar el efecto de la transfusion sobre la saturacion regional de oxigeno cerebral (SrO2) en pacientes tratados mediante cirugia cardiaca con EuroSCORE I aditivo > 6. Material y metodos Estudio prospectivo observacional. Se incluyo en el estudio a los pacientes con EuroSCORE I aditivo > 6 tratados mediante cirugia cardiaca con circulacion extracorporea. Se recogieron los valores demograficos, complicaciones perioperatorias, estancias hospitalarias, asi como el valor de SrO2 basal preinduccion, el valor mas bajo de hemoglobina (Hb) registrado durante la cirugia, el valor de la Hb y la SrO2 pre y postransfusional, asi como la existencia de una caida significativa de mas del 20% del valor basal de la SrO2 o por debajo del 50%. Consideramos como respondedores a la transfusion aquellos que presentaron un aumento de la SrO2 postransfusion de al menos el 20% del valor previo, un aumento de la desviacion estandar (DE) (7,9) o un aumento hasta el nivel basal. Resultados Se recogieron los datos de 57 pacientes. El EuroSCORE I aditivo medio ± DE fue de 7,4 ± DE 2,6 y el EuroSCORE II fue de 6,1 ± DE 7,4. El 52% fueron varones. Se trasfundio al menos un concentrado de hematies al 35,1% de la muestra (20 pacientes). La SrO2 pretransfusional fue 59 ± DE 8,6 y aumento de forma no significativa tras la transfusion del primer CH (61,19 ± 7,9; p = 0,1). Un 29,8% de los pacientes presentaron durante la cirugia una disminucion de la SrO2 del 20% con respecto a su basal o un valor inferior al 50%. Los pacientes con una disminucion significativa de la SrO2 presentaron un mayor tasa de complicaciones perioperatorias (p = 0,04). La estancia en la Unidad de Cuidados Intensivos (UCI) fue mayor en los pacientes con una disminucion significativa de la SrO2 respecto a los que la no presentaron (6,8 ± 8,2 dias vs. 4,3 ± 3,6; p = 0,01) al igual que la estancia hospitalaria (14,2 ± 9,4 dias vs. 10,1 ± 3,1; p = 0,01). En nuestra muestra, 6 de los 21 pacientes fueron respondedores. No hubo diferencias significativas en la morbilidad o la mortalidad entre los respondedores y los no respondedores. Discusion En nuestra poblacion, se observo un aumento no significativo en la SrO2 tras la transfusion. Cuando se analizaron los respondedores a la transfusion por incrementos de SrO2, pocos pacientes fueron identificados como respondedores. En conclusion, la SrO2 podria no ser una herramienta que guie la transfusion en pacientes tratados mediante cirugia cardiaca con EuroSCORE I aditivo > 6.

[ES] La ecocardiografía transesfofágica es una técnica semiinvasiva que permite una evaluación de la morfología y función cardiaca a tiempo real y que constituye, a día de hoy, un estándar de calidad en las intervenciones de cirugía cardiovascular. Se ha convertido en una herramienta fundamental tanto de monitorización como de diagnóstico en el perioperatorio que permite la correcta planificación quirúrgica y manejo farmacológico dirigido. El objetivo de este documento es dar respuesta de forma consensuada y avalada por la evidencia científica de cuándo y cómo debe hacerse la ecocardiografía transesfofágica intraoperatoria en cirugía cardiovascular, qué aplicaciones tiene en el intraoperatorio, quién debe realizarla y cómo debe transmitirse la información obtenida durante el estudio. Los autores han hecho una revisión sistemática de las guías internacionales, artículos de revisión y ensayos clínicos para dar respuesta a estas preguntas., [EN] Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.

Resumen Debido a la grave situacion de pandemia que vivimos causada por el COVID-19, la Seccion de Anestesia Cardiaca, Vascular y Toracica de la SEDAR pretende dar informacion de los aspectos mas relevantes a considerar en pacientes con sospecha o infeccion confirmada por coronavirus que van a ser sometidos a cirugia toracica. Creemos que es esencial mantener una optima transmision de informacion para llevar a cabo maniobras seguras, tanto para los pacientes como para el personal sanitario. La estrategia de manejo debe basarse en una organizacion exquisita del trabajo, definiendo quien, como y cuando va a realizar cada tarea y procedimiento. Las recomendaciones que se proponen, tras valorar el riesgo-beneficio en el escenario especifico de la cirugia de torax y la experiencia de expertos en toracica obtenida en el estudio COV2-VIAEREA, tratan de asesorar sobre los aspectos anestesicos claves a tener en cuenta ante una eventual necesidad de cirugia toracica en el contexto de la pandemia por COVID-19.

OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politecnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.

Resumen Introduccion El objetivo de este estudio es describir nuestra experiencia en la cirugia de revascularizacion coronaria aislada en pacientes mayores de 80 anos e identificar los riesgos especificos y predictores de mortalidad precoz. Material y metodos Entre enero de 1999 y junio de 2013, 3.097 pacientes fueron sometidos a cirugia de revascularizacion coronaria aislada. Se analizaron los pacientes mayores de 80 anos de edad. Se realizo una regresion mutivariante de Cox para predictores de mortalidad. Resultados Se identificaron 99 pacientes mayores de 80 anos (grupo-80; edad media 82 ± 3,5 anos) y 2.957 menores de 80 anos (grupo control; edad media 64,2 ± 9,7 anos). El EuroSCORE aditivo fue 8,4 ± 4,8 y 4,6 ± 4,6 (p 80 anos vs. Conclusion La cirugia de revascularizacion coronaria aislada se realiza preferentemente en pacientes mayores de 80 anos sin CEC. Presentan una mayor incidencia de complicaciones cardiovasculares, reintervenciones por sangrado en el postoperatorio inmediato y una mortalidad mas elevada.

Cardiac surgery (CS) is associated with a significant use of blood products. The aim of this study was to evaluate the effect of red blood cells concentrates (RBC) transfusion on regional cerebral oxygen saturation (SrOThis is a prospective descriptive study. Patients with additive EuroSCORE I6 undergoing CS with extracorporeal circulation were included in the study. The demographic values, perioperative complications, hospital/ICU length of stay (LOS), as well as the preinduction baseline SrOData from 57 patients were collected. The average additive EuroSCORE I was 7.4 (SD 2.6) and the EuroSCORE II was 6.1 (SD 7.4). 52% were male. 35.1% of patients received intraoperative transfusion of at least one unit of RBC. The overall mortality was 8.7% (N = 5). During surgery 29.8% of the overall sample presented a decrease of more than 20% of baseline SrO2 or a value lower than 50%. Patients with a significant decrease in SrO2 presented a higher rate of perioperative complications (P=0.04) and longer ICU-LOS 4.3 (SD 3.6) vs. 6.8 (SD 8.2) days (P=0.01) and hospital LOS 10.1 (SD 3.1) vs. 14.2 (SD 9.4) days (P=0.01). Pretransfusional HB was 7.4 (SD 0.8) mg/dl and postransfusional value was 8.4 (SD 0.8) (P =0.00). Pretransfusional SrO2 was 59 (SD 8.6) and increased non- significantly after RBC transfusion to 61.1 (SD 7.9) (P=0.1). Only 6 patients out of 21 could be considered responders. There were no significant differences in morbidity, mortality or LOS between responders and non-responders.In our population a non statistically significant increase in SrO2 was observed after RBC transfusion. When considering responders few patients were identified by SrO

Introduction: Hepatopulmonary syndrome (HPS) is a serious, progressive disease. Its pathophysiology resides in a hypoxic intrapulmonary shunt and severe clinical deterioration. Liver transplantation (LT) is the only effective treatment in appropriately selected patients. Objective: To acknowledge the importance of early diagnosis of HPS. Patients and methods: Observational, descriptive, retrospective trial including 8 patients with HPS that received LT between April 2006 and August 2014. The clinical data prior to transplantation and follow-up after the procedure were reviewed. A multivariate analysis (stepwise forward logistic regression analysis) was used to identify the variable that could potentially increase the risk of death. Results: Of the 8 patients, death could only be significantly predicted based on the pre-LT arterial blood partial oxygen pressure (PaO2) (p = 0.002). The average pre-LT PaO2 of the patients that died was 51.5 ±2.49 SD, with a statistically significant difference (p = 0.002). None of the variables was statistically significant for HPS reversibility. The survival rate of patients diagnosed with HPS following the LT was 62.5%. Conclusions: The level of pre-LT hypoxemia is an important predictor for immediate postoperative mortality. Early detection of the condition is critical to reduce the post LT morbidity and mortality so that the indication for transplant is made at the right time, regardless of the stage of liver disease. The most efficient clinical strategy could be the use of appropriate early detection protocols for HPS through screening of hypoxemia in patients with portal hypertension. Introducción: El síndrome hepatopulmonar (SHP) es una enfermedad grave y progresiva cuya fisiopatología reside en un shunt intrapulmonar con hipoxia y deterioro clínico severo. Como único tratamiento efectivo se ha postulado el trasplante hepático (TH), en pacientes adecuadamente seleccionados. Objetivo: Reconocer la importancia del diagnostico temprano del SHP. Pacientes y métodos: Mediante un estudio observacional, descriptivo, con carácter retrospectivo de 8 pacientes con SHP, a los que se les realizó TH en el período entre Abril 2006-Agosto 2014. Se han revisado los datos clínicos previos al trasplante y el seguimiento tras este. Se empleó un estudio multivariante (stepwise forward logistic regression analisis), para determinar cual variable podría incrementar el riesgo de muerte. Resultados: De los 8 pacientes, el resultado de muerte sólo pudo ser predicho significativamente por el factor presión parcial de oxígeno en sangre arterial (PaO2) pre-TH (p=0,002). La PaO2 pre-TH promedio de los pacientes que fallecieron era de 51,5 +/- 2,49 DS, siendo la diferencia estadísticamente significativa (p=0,002). Ninguna variable resultó estadísticamente significativa para reversibilidad del SHP. La supervivencia de los pacientes con criterio de SHP posterior al TH fue de 62,5%. Conclusiones: El grado de hipoxemia pre-TH es un factor predictor importante de mortalidad en el postoperatorio inmediato. La precocidad en la detección de la entidad es fundamental tanto para disminuir la morbimortalidad post TH como para indicar éste en el momento óptimo independientemente del estadío de la enfermedad hepática. Protocolos adecuados de detección precoz del SHP mediante screening de hipoxemias en pacientes con hipertensión portal, puede ser la estrategia clínica más eficiente.

Introduction We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup. Material and method From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed. Results We identified 99 patients older than 80 years (80-group; mean age 82 ± 3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2 ± 9.7 years). Additive EuroSCORE was 8.4 ± 4.8 and 4.6 ± 4.6 (p 0 .001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (p 0 .001) in the 80-group vs. the control group, respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (p 0 .001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; p = 0 .001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; p = 0 .001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6–19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1–12.2). The mean follow-up was 6.3 ± 4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period. Conclusion Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant. We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant. We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.

ResumenIntroducciónEl síndrome hepatopulmonar (SHP) es una enfermedad grave y progresiva cuya fisiopatología reside en un shunt intrapulmonar con hipoxia y deterioro clínico severo. Como único tratamiento efectivo se ha postulado el trasplante hepático (TH), en pacientes adecuadamente seleccionados.ObjetivoReconocer la importancia del diagnóstico temprano del SHP.Pacientes y métodosMediante un estudio observacional, descriptivo, con carácter retrospectivo de 8 pacientes con SHP, a los que se les realizó TH en el período entre abril del 2006 y agosto del 2014. Se han revisado los datos clínicos previos al trasplante y el seguimiento tras este.Se empleó un estudio multivariante (stepwise forward logistic regression analysis), para determinar cuál variable podría incrementar el riesgo de muerte.ResultadosDe los 8 pacientes, el resultado de muerte solo pudo ser predicho significativamente por el factor presión parcial de oxígeno en sangre arterial (PaO2) pre-TH (p = 0,002).La PaO2 pre-TH promedio ± desviación estándar de los pacientes que fallecieron era de 51,5 ± 2,49, siendo la diferencia estadísticamente significativa (p = 0,002).Ninguna variable resultó estadísticamente significativa para reversibilidad del SHP.La supervivencia de los pacientes con criterio de SHP posterior al TH fue de 62,5%.ConclusionesEl grado de hipoxemia pre-TH es un factor predictor importante de mortalidad en el postoperatorio inmediato. La precocidad en la detección de la entidad es fundamental tanto para disminuir la morbimortalidad post-TH como para indicar este en el momento óptimo, independientemente del estadio de la enfermedad hepática. Protocolos adecuados de detección precoz del SHP mediante cribado de hipoxemias en pacientes con hipertensión portal pueden ser la estrategia clínica más eficiente.AbstractIntroductionHepatopulmonary syndrome (HPS) is a serious, progressive disease. Its pathophysiology resides in a hypoxic intrapulmonary shunt and severe clinical deterioration. Liver transplantation (LT) is the only effective treatment in appropriately selected patients.ObjectiveTo acknowledge the importante of early diagnosis of HPS.Patients and methodsObservational, descriptive, retrospective trial including 8 patients with HPS that received LT between April 2006 and August 2014. The clinical data prior to transplantation and follow-up after the procedure were reviewed.A multivariate analysis (stepwise forward logistic regression analysis) was used to identify the variable that could potentially increase the risk of death.ResultsOf the 8 patients, death could only be significantly predicted based on the pre-LT arterial blood partial oxygen pressure (PaO2) (P=.002).The average pre-LT PaO2 of the patients that died was 51.5 ± 2.49 SD, with a statistically significant difference (P=.002).None of the variables was statistically significant for HPS reversibility.The survival rate of patients diagnosed with HPS following the LT was 62.5%.ConclusionsThe level of pre-LT hypoxemia is an important predictor for immediate postoperative mortality. Early detection of the condition is critical to reduce the post LT morbidity and mortality so that the indication for transplant is made at the right time, regardless of the stage of liver disease. The most efficient clinical strategy could be the use of appropriate early detection protocols for HPS through screening of hypoxemia in patients with portal hypertension.