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Resumen Antecedentes y objetivo En los ultimos anos la cirugia cardiaca minimamente invasiva (CCMI) se ha desarrollado y aplicado a mayor numero de dolencias, especialmente en cirugias sobre la valvula mitral, por presentar resultados comparables a las tecnicas convencionales con menor agresividad y tiempo de recuperacion. La CCMI que necesita ventilacion unipulmonar se ha asociado a la aparicion de edema pulmonar unilateral (EPU), que constituye una complicacion potencialmente grave. El objetivo es determinar la incidencia de EPU tras CCMI mitral y los factores asociados a su desarrollo. Material y metodos Estudio observacional descriptivo y unicentrico. Se analizaron los pacientes tratados con CCMI sobre valvula mitral (minitoracotomia derecha), recogidos de manera consecutiva entre los anos 2015 y 2017. Resultados Se incluyo a un total de 93 pacientes, de los cuales 23 presentaron EPU. Las complicaciones mas habituales tras la CCMI mitral fueron: fibrilacion auricular (38,7%), EPU (28%) y bloqueo auriculoventricular de segundo o tercer grado transitorio o definitivo (19,4%). El grupo EPU presento mayor tiempo de estancia en UCI (3,3 ± 8,0 vs. 1,84 ± 2,23 dias) y mayor tiempo total de hospitalizacion (15,5 ± 34,7 vs. 10,6 ± 7,5 dias). La mortalidad en el grupo EPU fue del 3,9%. Se encontro asociacion significativa entre las siguientes variables recogidas y el desarrollo de EPU postoperatorio: pulsioximetria basal preoperatoria, uso preoperatorio de IECA, fibrilacion auricular postoperatoria y volumen de drenajes en las primeras 24 h. Conclusiones La incidencia de EPU es elevada y su aparicion se asocia a mayor estancia en UCI y mayor tiempo total de hospitalizacion. Se requieren mas estudios para comprender su fisiopatologia y aplicar medidas que ayuden a disminuir su aparicion.

Purpose The feasibility and effects of multimodal prehabilitation in patients with advanced ovarian cancer (AOC) undergoing a cytoreductive surgery are unknown. We aimed to evaluate the feasibility of a multimodal prehabilitation program in patients with AOC and its impact on postoperative outcomes.Methods We prospectively compared 15 patients with AOC stage scheduled to undergo a citorreductive surgery between December 2019 and January 2021 after a multimodal prehabilitation program consisting of supervised exercise training, nutritional optimization and psychological preparation versus a control cohort of 19 patients matched according to clinical and surgical characteristics who underwent surgery without prehabilitation between January 2018 and November 2019. In both groups, the enhanced recovery after surgery guidelines were followed. We analyzed adherence to the program, comprehensive complication index (CCI), hospital length of stay, and time to starting chemotherapy. Results Overall adherence to the multimodal prehabilitation program was 80%, with 86.7% adherence to exercise training, 100% adherence to nutritional optimization, and 80% adherence to psychological preparation. Median hospital stay was shorter in the prehabilitation cohort [5 days (IQR, 4-6) vs. 7 days (IQR,5-9) in the control cohort, p=0.04]. CCI score in the prehabilitation cohort was 9.3 (SD 12.12) vs. 16.61 (SD 16.89) in the control cohort, p=0.2. Median time to starting chemotherapy was shorter in the prehabilitation cohort compared to control cohort [25 days (IQR, 23-25) vs. 35 days (IQR 28-45), p=0.03]. Conclusion Multimodal prehabilitation is feasible and safe in patients with AOC. This study found significantly shorter hospital stays and time to starting chemotherapy in the multimodal prehabilitation cohort.

Trasplante combinado de corazón e hígado; Cardiomiopatía Trasplantament combinat de fetge i cor; Cardiomiopatia Combined heart-liver transplant; Cardiomyopathy Background Uhl's anomaly is an extremely rare congenital heart defect characterized by absence of the right ventricle myocardium and preserved left ventricular myocardium. Although the disease has a poor prognosis and is generally fatal in the perinatal period, some patients may reach adulthood. Methods We describe a case of Uhl's anomaly complicated with heart failure and decompensated cardiac cirrhosis in a 42-year-old man treated by combined heart-liver transplant. Results The patient underwent heart transplant using the bicaval technique followed by subsequent liver transplant with the piggyback technique without venovenous bypass. Total ischemia time was 108 minutes for the heart and 360 and 25 minutes of cold and warm ischemia, respectively, for the liver. No intraoperative complications occurred. The patient was discharged without severe complications on postoperative day 22. Pathologic examination of the organs reported advanced cirrhosis of the liver and severe dilated myocardiopathy of right ventricle with absence of myocardium and a normal left ventricle. Twenty-seven months after the transplant the patient has been free from hospital admissions, with normal function of both transplanted organs. Conclusions We report the first successful combined heart-liver transplant for Uhl's anomaly indication in an adult patient. Despite of the insufficient knowledge of natural history of this exceptional disease, we successfully apply the management principles of other end-stage right heart disorders complicated with liver failure.

Background Continuous invasive analgesia remains the gold-standard method for managing acute post-operative pain after major surgery. However, this procedure is not exempt from complications that may have detrimental effects on the patient and affect the post-operative recovery process. Data of the complications of continuous catheter analgesic techniques (CCATs) and their impact on pain relief are scarce in the literature. Material and methods We conducted a prospective longitudinal study and patients who underwent a surgical procedure and received continuous invasive analgesia after surgery were included. Post-operative analgesic strategy, pain scores (NRS), CCAT's characteristics and technical complications were recorded. Patient satisfaction was determined. Descriptive statistics and Student's t-tests were applied for the comparative analyses. Results We collected data from 106 patients. Mean duration of the CCAT was 47.52 ± 21.23 h and 52 patients (49.1%) were controlled in conventional hospitalisation units whereas 54 patients (50.9%) were controlled on intensive or high-dependency care units. The overall incidence of technical complications was 9.43%. The most common complications were catheter displacement (2.38%), inflammation at the IV catheter insertion point (2.38%) and excessive dosing of analgesic drugs (2.38%). Mean NRS scores were ≤3 during the permanence of CCATs. Maximum pain intensity was significantly higher in patients who suffered technical complications (mean ± standard deviation [ x ¯ ± SD ] : 4.4 ± 2.8 vs. 2.9 ± 1.9; p Satisfaction levels with the technique and overall satisfaction with the pain management strategy were negatively impacted by the occurrence of complications. Conclusions The incidence of technical complications of CCATs was 9.43% and had a negative impact in pain control and patient's satisfaction.

Resumen Antecedentes La analgesia continua invasiva es el metodo de referencia para el manejo del dolor postoperatorio en cirugia mayor pero no esta exenta de posibles complicaciones. Existe poca informacion sobre las complicaciones de las tecnicas analgesicas continuas con cateter (TACC) y su impacto en el control del dolor. Material y metodos Disenamos un estudio prospectivo longitudinal incluyendo a pacientes tratados mediante cirugia que recibieron una TACC postoperatoria. Se registraron el tipo de analgesia, la intensidad del dolor mediante escala NRS, las caracteristicas de las TACC, sus complicaciones tecnicas y la satisfaccion de los pacientes. Se aplico estadistica descriptiva y analisis comparativo mediante t de Student. Resultados Se registraron datos de 106 pacientes. La duracion de las TACC fue 47,52 ± 21,23 h; 52 pacientes (49,1%) fueron controlados en hospitalizacion convencional y 54 (50,9%) en unidades de criticos o alta dependencia. La tasa global de complicaciones tecnicas fue del 9,43%. Las complicaciones mas frecuentes fueron desplazamiento del cateter (2,38%), inflamacion en el punto de insercion del cateter IV (2,38%) y dosificacion excesiva de analgesicos (2,38%). El valor medio de NRS fue ≤ 3 durante la permanencia de la TACC. La intensidad maxima de dolor fue mayor en los pacientes con complicaciones tecnicas (media ± desviacion estandar [x ± DE]: 4,4 ± 2,8 vs. 2,9 ± 1,9; p La satisfaccion con la comodidad de la tecnica y la satisfaccion global con el tratamiento del dolor se redujeron significativamente en presencia de complicaciones. Conclusiones La incidencia de complicaciones tecnicas de las TACC fue del 9,43% y tuvieron un impacto negativo en el control del dolor postoperatorio y en la satisfaccion de los pacientes.

IntroductionPrehabilitation programmes that combine exercise training, nutritional support and emotional reinforcement (multimodal prehabilitation) have demonstrated efficacy reducing postoperative complications in the context of abdominal surgery. However, such programmes have seldom been studied in cardiac surgery, one of the surgeries associated with higher postoperative morbidity and mortality. This trial will assess the feasibility and efficacy in terms of reduction of postoperative complications and cost-effectiveness of a multimodal prehabilitation programme comparing to the standard of care in cardiac surgical patients.Methods and analysisThis is a single-centre, randomised, open-label, controlled trial with a 1:1 ratio. Consecutive 160 elective valve replacement and/or coronary revascularisation surgical patients will be randomised to either standard of care or 4–6 weeks of multimodal prehabilitation that will consist in (1) two times/week supervised endurance and strength exercise training sessions, (2) promotion of physical activity and healthy lifestyle, (3) respiratory physiotherapy, (4) nutrition counselling and supplementation if needed, and (5) weekly mindfulness sessions. Baseline, preoperative and 3-month postoperative data will be collected by an independent blinded evaluator. The primary outcome of this study will be the incidence of postoperative complications.Ethics and disseminationThis study has been approved by the Ethics Committee of Clinical investigation of Hospital Clinic de Barcelona (HCB/2017/0708). The results will be disseminated in a peer-reviewed journal.Trial registration numberNCT03466606.

Background Multimodal prehabilitation is a preoperative intervention with the objective to enhance cancer patients’ functional status which has been showed to reduce both postoperative morbidity and hospital length of stay in digestive oncologic surgery. However, in lung cancer surgery patients further studies with higher methodological quality are needed to clarify the benefits of prehabilitation. The main aim of the current protocol is to evaluate the cost-effectiveness of a multimodal prehabilitation program supported by information and communication technologies in moderate-to-high risk lung cancer patients undergoing thoracic surgery. Methods A Quadruple Aim approach will be adopted, assessing the prehabilitation program at the following levels: i) Patients’ and professionals’ experience outcomes (by means of standardized questionnaires, focus groups and structured interviews); ii) Population health-based outcomes (e.g. hospital length of stay, number and severity of postoperative complications, peak oxygen uptake and levels of systemic inflammation); and, iii) Healthcare costs. Discussion This study protocol should contribute not only to increase the scientific basis on prehabilitation but also to detect the main factors modulating service adoption. Trial registration NCT04052100 (August 9, 2019).

[No abstract available]

Purpose Frailty and poor functional performance are associated with worse outcomes after heart transplantation (HT). Prehabilitation performed to improve patients preoperatively has been shown to improve surgery outcomes in other high-risk patients, but there is no experience in patients prior to HT. We postulate that a combined prehabilitation program in patients on the waiting list for HT may improve short-term outcomes after HT, reduce hospitalization days and be cost-effective. Methods All patients entering the waiting list from July 2017 to July 2020 were offered to join an 8 weeks prehabilitation program consisting in 2 hours/week personalized moderate-high-intensity exercise training, nutritional optimization and mindfulness sessions. Patients completing a minimum of 12 sessions (6 weeks) were included as Prehab-Group (Prehab-G). Patients who decline to participate or underwent HT before starting the program were included as controls (Contr-G). Urgent HT and multiorgan transplants were excluded. Primary endpoints were total length of stay (LOS) and cost of HT hospitalization. Secondary endpoints were hours of mechanical ventilation, intensive care LOS and 30 days re-hospitalization. Results We enrolled 49 patients, from them 28 pat. entered the program. 18 patients in the Prehab-G and 17 patients in the Contr-G reached transplantation. There were no adverse events during the exercise sessions. Baseline characteristics show no differences between groups except for higher ratio of males (89% vs 47%, p=0.01) and longer median time on waiting list for the Prehab-G (242±228 vs 92±56 days, p Conclusion A prehabilitation program for patients awaiting HT is feasible and safe. Patients completing at least 6 weeks of training had shorter LOS and lower total and direct cost for the HT admission compared to patients without prehabilitation.

Background Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016–2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011–2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants). Methods The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability. Discussion The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection. Trials registration NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018). Electronic supplementary material The online version of this article (10.1186/s12913-019-4174-2) contains supplementary material, which is available to authorized users.

Introduction Background: Data for the utility of continuous trans-esophageal echocardiography (TEE) monitoring during trans venous lead extraction remain scarce. Removal of the implanted transvenous lead system can be a significantly complex procedure, facing main complications. Our objective: the retrospective assessment of the TEE in the monitoring during trans venous lead extraction of implantable cardiac devices (pacemaker and implantable cardiac defibrillator). Methods From November 2013 to November 2018 the transvenous lead extraction of 93 leads in 50 patients was reviewed. Lead extraction techniques combined traction and mechanical approach by the same surgeon. Extraction procedures were performed under general anesthesia either total intravenous or inhalation anesthesia. Invasive arterial line blood pressure and continuous TEE monitoring were performed. TEE images of different projections were acquired and stored before and immediately after the extraction of each lead. Results From the 50 patients (mean age 58.9 years, 64% male, 1.86% lead per patient) which had the following indication: lead dysfunction (24%), upgrade (8%), infection (54%), or other (14%). The lead extraction was complete for 69 out of 93 leads (74.19%), partial extraction was for 24 leads out of 93 leads (25.80%). General anesthesia by total intravenous (30%) and inhalation anesthesia (70%). New TEE findings following TEE were observed in 7 of 50 cases (14%). Two cases which had new mild tricuspid regurgitation without the need of re-intervention, new appearance or worsening of tricuspid regurgitation in three cases which needed non-emergency re-intervention and pericardial effusion in two cases. No cases needed rescue surgery. In all other cases, TEE findings did not entail immediate diagnostic or therapeutic measures. Discussion New findings necessitating immediate therapeutic measures occurred zero cases, no mortality, yet all patients with new TEE findings had strict observational control. We suggest TEE monitoring during trans venous lead extraction, as it provides useful real-time information and should be standard of care monitoring during lead extraction, to guide trans operative and postoperative management. TEE presents some non-negligible risks associated with its use and is a costly procedure, such investment, however, may have a high return in terms of increased patient safety.

Introduction Adult congenital heart disease (ACHD) represents a growing population in many cardiac centers and it's a challenge for all physicians involved. Multidisciplinary teams integrated by cardiologists, echocardiographers, cardiac surgeons, cardiac anesthesiologists, radiologists and others, have been created in many hospitals to manage such patients (1). The objective was to describe the adult congenital cardiac population scheduled for cardiac surgery in our reference center. Methods We included all patients scheduled for cardiac surgery with a diagnosis of ACHD from January 2017 to May 2018. A retrospective review of medical records was performed for demographics, type of heart defect, intraoperative management, postoperative evolution, ICU length of stay and outcome at 30 days. Results A total of 1060 patients underwent elective cardiac surgery between the study period. Sixty-six patients (6.22%) had the diagnosis of ACHD. Mean age was 53.5±17 years [range 19 to 85 years], 63.6% were male and mean EuroSCORE II was 1.51 [range 0.5 to 5.41]. Type and number of diagnoses were: bicuspid aortic valve 45 patients, atrial septal defect 12 patients, congenital pulmonary stenosis 2 patients, congenital aortic stenosis 1 patient, sub-aortic membrane 1 patient, right coronary artery anomaly 1 patient, single ventricle 1 patient, tetralogy of Fallot 1 patient, Ebstein's anomaly 1 patient and partial atrioventricular canal defect 1 patient. Eight of the 45 patient with aortic bicuspid valve had associated aortic root aneurysm. All patients were monitored with transesophageal echocardiography (TEE). Twenty-five patients (37.8%) were extubated in the operating room. Nine patients (13.6%) required blood products. Percentage of postoperative complications were: arrhythmias (28.7%), renal dysfunction (15.1%), hemorrhage >500ml at 24h (10.6%), respiratory alterations (7.5 %), neurologic events (4.5%), intubation >24h (4.5%), re-operation (3.03 %) and gastrointestinal problems (1.51%). Mean ICU length of stay was 3.27 days [range 1 to 9 days]. There was no mortality at 30 days. Discussion The incidence of ACHD in this review was low and bicuspid aortic valve was the most common anomaly. Operative cardiac risk and age showed a wide range. In this small sample post-operative complications were lower than reported in the literature (2). As reference center for ACHD now the number of complex cases is increasing mainly by those diagnosed and treated in the childhood and coming for a second or third operation.

Introduction Transoesophageal echocardiography (TOE) use has experienced an exponential growth in cardiac surgery (CS). The latest guidelines recommend TOE for all adult patients undergoing CS, but the management of unexpected-TOE findings (ATOEF) after cardiopulmonary bypass (CPB) might be controversial. We reviewed the outcomes of those patients with ATOEF after CBP managed without immediate surgical revision. Methods A systematic TOE use policy is applied in our institution for patients undergoing CS. Intraoperative TOE is performed by a senior anaesthesiologist. Data from intraoperative TOE cases were collected prospectively between January 2014 and December 2017. The presence of post-CPB ATOEF and its impact on the immediate surgical treatment decision-making was analysed. Results A total of 2421 TOE examinations were registered, with 197 post-CPB ATOEF. Among those with post-CPB ATOF, 108 (55%) led to immediate surgical treatment. The remaining 89 (45%) cases with post-CPB ATOEF did not received surgical treatment. These non-treated ATOEF were characterised into: 25 (28%) periprosthetic leak, 1 (1%) intraprosthetic regurgitation, 20 (22%) regurgitations after mitral valve (MV) repair, 11 (12%) regurgitations after aortic valve (AoV) repair, 7 (8%) and 2 (2%) regurgitations related to native MV and AoV respectively, 12 (13%) systolic anterior motion of the MV and 11 (12%) classified as other findings. The immediate postoperative follow-up showed the persistence of 36% of periprosthetic regurgitations, 100% of intraprosthetic regurgitations, 70% and 91% related to MV and AoV repair respectively, 86% and 100% related to native MV and AoV respectively. Two patients died in the immediate postoperative period and none required immediate re-do surgery due to the findings. The 6-12 month follow-up showed the persistence of 34% of periprosthetic leaks, 100% of intraprosthetic regurgitations, 70% and 91% of those related to MV and AoV repair, 71% and 100% of those related to native MV and AoV. Among all post-CPB ATOEF, 2 (2%) patients have required surgical treatment related to the finding in the long-term follow-up. Discussion Almost half of the post-CBP ATOEF did not lead to an immediate surgical treatment. Follow up echocardiography in the immediate postoperative period and at 6-12months, showed reduction of periprosthetic leaks. However, we observed stability of left-sided valve repair regurgitations. The incidence of reinterventions due to post-CBP ATOEF was low, reinforcing our current decision making.

Resumen Objetivo Determinar la importancia de la ecocardiografia transesofagica (ECOTE) intraoperatoria en la decision quirurgica en pacientes intervenidos de cirugia cardiaca. Pacientes y metodo Estudio prospectivo observacional en pacientes de cirugia cardiaca intervenidos desde enero de 2009 hasta mayo de 2012, a los que se monitorizo con ECOTE por el anestesiologo responsable. Los datos recogidos fueron: 1) tipo de cirugia; 2) diagnostico ecocardiografico preoperatorio (ECO basal); 3) diagnostico ecocardiografico antes de entrar en circulacion extracorporea (CEC) (ECOTE pre-CEC); 4) si habia diferencias entre la ECO basal y la ECOTE pre-CEC (hallazgo nuevo pre-CEC) y si estas diferencias modificaban la cirugia planeada, y 5) diagnostico ecocardiografico despues de la desconexion de CEC (hallazgo no esperado pos-CEC) y si estos hallazgos ecocardiograficos pos-CEC hacian reinstaurarla. Para el analisis de datos se utilizo el programa de software SPSS®. Resultados El total de pacientes estudiados fue de 1.273; la monitorizacion con ECOTE mostro «hallazgos nuevos pre-CEC» en 98 pacientes (7,7%) y en 43,8% de estos modifico la cirugia programada; de estos hallazgos, los mas frecuentes fueron alteraciones de la valvula mitral que no habian sido diagnosticadas, lo que determino la sustitucion o reparacion de la misma que no estaba programada. La incidencia de «hallazgos no esperados pos-CEC» fue del 6,2% (79 pacientes), y de estos, en el 46,8% se requirio reinstaurar la CEC y modificar la cirugia realizada. Las reparaciones valvulares fallidas y las protesis valvulares disfuncionantes fueron las causas principales que motivaron la reentrada en CEC. En los 42 pacientes restantes, con «hallazgos no esperados pos-CEC», no hubo cambios en la conducta quirurgica, ya que se considero que el hallazgo ecocardiografico no era lo suficientemente significativo como para reinstaurar la CEC y revisar o cambiar el procedimiento quirurgico. Conclusion En cirugia cardiaca, la monitorizacion intraoperatoria con ECOTE por el anestesiologo aporta informacion importante antes y despues de la CEC que modifico el manejo quirurgico.

Despite septal myectomy remaining the gold standard septal reduction therapy for hypertrophic obstructive cardiomyopathy (HOCM), there has been a disproportionate use of alcohol septal ablation (ASA) worldwide. Absolute resolution of left ventricular outflow tract (LVOT) obstruction with ASA is not achieved in a substantial proportion of patients. The mechanisms of failure from ASA are partially understood and described. Residual obstruction in hypertrophic cardiomyopathy is associated with worse clinical outcomes and mortality. There is a growing number of patients who present with significant residual gradients after ASA and require a rescue septal myectomy operation, which then carries an increased risk of perioperative complications and life-long sequelae. This contrasts with the excellent outcomes achieved by septal myectomy without previous percutaneous intervention. Despite complete resolution of obstruction in rescue myectomy, the outcomes remain compromised by the prior ASA.

Introduction Heparin induced thrombocytopenia (HIT) is frequent in patients under extracorporeal membrane oxygenation (ECMO) or ventricular assist device support (VAD). Therapeutic plasma exchange (TPE) and use of direct thrombin inhibitors (DTI) as argatroban have proven to be useful. However, monitoring its effect can be difficult as activated clotting time (ACT) or standard coagulation tests (prothrombin time (PT) and activated partial thromboplastin time (aPTT)) lack enough reliability. Coagulation assessment during surgery may be challenging, especially during heart transplantation (HT) where there is narrow margin to metabolize DTI. Methods A 51-year-old male presented a myocardial infarction with cardiac arrest and arrhythmic storm requiring support with ECMO and VAD. The patient needed HT and was anticoagulated with intravenous argatroban for 3 weeks before surgery because of HIT (31000 thrombocytes/μL). Four TPE were performed and four intravenous doses of specific gammaglobulin (1g/kg) were given achieving negative values of anti-PF-4 antibodies. Argatroban infusion was stopped 6 hours before surgery. Results The coagulation test pre-surgery showed 98000 thrombocytes/μL, PT 39%, aPTT 55,1s fibrinogen 3,5g/L, haemoglobin 93g/L. Intraoperative anticoagulation was established with full dose unfractionated heparin and tranexamic acid was given (20mg/kg bolus+6mg/kg/h infusion). After coming off by-pass, anticoagulation was reverted with protamine and 2 units of PRBC, 1000mL fresh frozen plasma (FFP), two platelet pools and 1200IU 4-factor-prothrombin-complex-concentrate (PCC; Prothromplex®: 1200IU factor II, 1000IU factor VII, 1200IU factor IX and 1200IU factor X) were administered empirically. Despite being ACT back to baseline, significant diffuse bleeding was clinically noticed. ROTEM was performed showing prolonged EXTEM, INTEM and HEPTEM clotting time (CT). A second dose of PCC was administered and one unit of PRBC was transfused. Because no improvement was noticed, a second ROTEM was performed showing increased CT in all tests, with no heparin contribution (table 1). A litre of FFP was then administered with significant reduction of bleeding, allowing for chest closure. No further significant blood loss was observed in intensive care. The patient was weaned from mechanical ventilation on day 4 and discharged from the ward after 21 days. No thrombotic/bleeding events were noticed during the hospital stay. Discussion ROTEM was useful detecting coagulation factors deficiency in an appropriate time. Unexpected prolongation of CT after PCC administration may suggest residual thrombin inhibition by argatroban, that was neutralized with FFP administration.

Introduction Left atrial dissection (LATD) is an infrequent (incidence 0.16%) however serious condition (mortality 13.8%). Methods The authors present three-LATD between 2016 and 2018 (from 2475 cardiac-surgery cases). Results Case 1 - A 57-year-old female with severe mitral regurgitation (P2 prolapse) was admitted for elective mitral valve repair (MVr). After two unsuccessful MVr attempts due to systolic anterior motion, a mitral valve replacement (MVR) was performed. LATD was diagnosed on the transoesophageal echocardiography (TOE). Conservative approach was decided based on the patient stability. However, LATD increased on the TOE and surgical treatment was required. She was successfully weaned form cardiopulmonary bypass (CPB) and transferred to the intensive care unit (ICU) stable on inotropes. Unfortunately, the patient died thirteen days after surgery due to airway and respiratory complications. A post-mortem study confirmed the patency of cardiac sutures. Case 2 - A 74-year-old male with severe mitral regurgitation (P2-P3 prolapse) was admitted for elective mitral valve repair and pulmonary vein ablation. A LATD associated to intra and peri- annular leaks was diagnosed on the post- repair TOE. Surgical treatment on CPB was required. The LATD was repaired and MVR was performed. The patient was weaned form CPB and transferred to the ICU on Right-Ventricular Assistance Device (RVAD) and inotropes due to RV failure. He was successfully weaned from RVAD and then discharged from hospital two months after the initial surgery. Case 3 - A 85-year-old female with severe aortic and moderate mitral regurgitation was admitted for elective aortic valve replacement and MVr. A LATD was diagnosed on the post-CPB TOE without affecting pulmonary-vein drainage or left atrial filling. Conservative approach was decided based on patient's stability. Consecutive TOE controls showed no changes. Therefore, he was transferred to the ICU and discharged from hospital one month after surgery. Discussion As in the authors’ three-case series, this infrequent cardiac-surgery complication has been mainly related to mitral valve surgery (56.3%). Treatment depends on patients’ clinical status, left-atrial filing impairment and LATD progression on TOE. Both surgical and conservative treatments have been reported successfully. Therefore, TOE is paramount in order to diagnosed and deal with this condition.

Introduction Prehabilitation programs designed to improve functional status showed efficacy to increase functional capacity and to prevent postoperative complications in selected high-risk surgical populations. Patients awaiting heart transplantation (HT) usually exhibit poor quality of life and this situation usually progresses while waiting for HT. Objective to evaluate the effect of a multimodal prehabilitation program on quality of life and functional capacity in patients waiting HT. Methods Adult patients listed for HT were included. Exclusion criteria were hospitalized patients, clinical instability, refusal to participate and living far away or not availability for transportation to the hospital twice weekly. The prehabilitation program was initiated after baseline assessment and all participants were reassessed after having completed 8 weeks of program. The intervention consisted in exercise training and promotion of physical activity, nutritional counselling and whey protein supplementation when necessary and coping of the psychological stress using mindfulness therapy. The exercise training consisted in 2 sessions of 1 hour per week of personalized monitored supervised moderate to high-intensity interval training and endurance strength training at the hospital's outpatient gym during 8 weeks. All patients were instructed on breathing exercises with an incentive inspirometer. After 8 weeks, and until HT, patients followed a maintenance program consisted in 1 session per week of supervised training and were empowered to maintain their level of physical activity Results 24 patients were included in the study from July 2017 to April 2019 (21 males, Age 56+10). Two patients were transplanted before starting the program and 8 patients before the 8-weeks assessment. None of the patients withdrew from the study. Over the duration of the study, 9 enrolled patients were successfully transplanted. One patient asked to opt out from the HT waiting list after having completed the program. No complications occurred during the program. Discussion This study suggests that a multimodal prehabilitation program in patients awaiting HT is feasible, safe and may increase functional capacity and quality of life.

Background and Objectives Damage to peripheral nerves provokes chronic neuropathic pain that lasts beyond the duration of the nerve injury. The presence of pain signs have been reported in areas other than those attributed to the injured nerve, i.e., in contralateral regions. We evaluated the presence, magnitude, and chronology of mechanical and cold allodynia in the contralateral paw of rats undergoing unilateral ligation of the L5 and L6 spinal nerves. Methods Twenty-three male Sprague-Dawley rats underwent spinal nerve ligation of the left L5 and L6 spinal nerves (SNL group) and 7 rats received a sham surgery without nerve ligation (sham group). Signs of mechanical allodynia as assessed with von Frey filaments, and cold allodynia as assessed with the acetone drop test, were studied before surgery and throughout 21 postoperative days. Responses of ipsilateral and contralateral paws of the SNL group were compared between themselves and with those in the sham group. Results Rats in the SNL group developed mechanical and cold allodynia responses in the ipsilateral paw, and also in the contralateral paw. Allodynia in the contralateral paw appeared later, becoming statistically significant on day 10 after surgery for mechanical allodynia and on day 21 for cold allodynia as compared with the sham group. Contralateral pain was of a lower intensity than on the ipsilateral side. Conclusions After L5 and L6 spinal nerve ligation, rats developed mechanical and cold allodynia in the contralateral paw, suggesting extraterritorial development of neuropathic signs. This finding has implications for future study design and therapeutic approaches.

Von Frey monofilaments (VFM) and Electronic von Frey are used as quantitative sensory testing to explore mechanical hyperalgesia. The aim of the study was to determine VFM and Electronic von Frey reproducibility and the time required for testing undamaged areas in volunteers and surgical in-hospital patients.Prospective study in 2 groups of individuals without neurological disorders and not receiving treatments that alter sensorial response. Group 1 was formed by 30 healthy volunteers and group 2 by 28 patients after knee arthroplasty who received unilateral femoral block as postoperative analgesia. Testing was performed by 2 trained investigators in the forearm and abdominal wall and repeated 24 hours later. Pain threshold was determined as the VMF or the pressure rate applied with the Electronic von Frey referred to as unpleasant. The time used in each test was measured. Intraobserver and interobserver reproducibility were analyzed by means of Kappa and Lin coefficients.Intraobserver and interobserver reproducibility for VFM was only fair or moderate in both groups (Kappa0.6). Intraobserver reproducibility for Electronic von Frey was good in Group 1 (Lin 0.61 to 0.8) and almost perfect in Group 2 (Lin0.8). No differences were found between the 2 tested areas. Time used was 6.03 and 3.16 minutes for VFM and Electronic von Frey, respectively.Exploration of mechanical allodynia in postoperative patients requires rapid and reliable quantitative sensory testing. Electronic von Frey was more reliable and rapid than VFM in exploring mechanical pain thresholds in undamaged areas in volunteers and patients. Further studies are required to confirm whether these results can be extrapolated to areas affected by surgery.