Nueva técnica para prevenir las macrorreentradas auriculares tras cirugía cardiaca en pacientes con cardiopatías congénitas

1. Objetivo: Presentar y evaluar un metodo simple que podria prevenir una de las complicaciones a largo plazo más frecuentes tras la cirugia de las cardiopatias congenitas: la taquicardia auricular macrorreentrante. Esta arritmia puede ocurrir tras varios años (incluso decadas) del procedimiento quirurgico. Suele aparecer como consecuencia tardia de una atriotomia derecha, componente inherente de muchas intervenciones para la correccion de estas cardiopatias. La atriotomia derecha da lugar a una larga cicatriz en el miocardio auricular derecho. Esta cicatriz, como cualquier otra, constituye una barrera a la conduccion electrica, lo que permite que circuitos macrorreentrantes puedan formarse a su alrededor y originar una taquicardia por reentrada. Este mecanismo es el objetivo de nuestro metodo propuesto: prevenir la formacion de circuitos macrorreentrantes alrededor de cicatrices de atriotomia derecha. 2. Métodos: El metodo propuesto se implementa tras finalizar la circulacion extracorporea y anudar las bolsas de tabaco de las canulaciones venosas. Consiste en construir una linea de sutura transmural sobre la pared auricular derecha desde la vena cava inferior (VCI), barrera de conduccion natural, a la incision de atriotomia. Esta linea de sutura cruzaria los sitios de canulaciones venosas en caso de que estas se hubiesen realizado sobre miocardio auricular (en lugar de sobre las propias venas cavas). Con ello, la VCI, atriotomia y sitios de canulacion quedarian conectados en serie mediante una sutura transmural en la pared auricular. Si la linea de sutura constituyese una barrera a la conduccion electrica, prevendria los circuitos reentrantes alrededor de las cicatrices auriculares derechas. Esto fue analizado en 13 adultos mediante mapeo electro-anatomico. En todos ellos se habia realizado una atriotomia derecha para el cierre de una comunicacion interauciular: 8 de ellos anadiendo la linea de sutura propuesta (grupo experimental) y 5 sin ella (grupo control). 3. Resultados: En todos los casos, la cicatriz de atriotomia fue identificada como una barrera a la conduccion electrica mediante evidencia electrofisiologica de fibrosis. En los 8 pacientes en los que se llevo a cabo la linea de sutura propuesta esta tambien dio lugar a una cicatriz, siendo una barrera completa a la conduccion. En los 5 pacientes que formaron parte del grupo control existia una conduccion electrica libre entre la VCI y la cicatriz de atriotomia. 4. Conclusiones: La linea de sutura propuesta da lugar a una cicatriz y, de este modo, se convierte en una barrera a la conduccion electrica. Por tanto, podria prevenir los circuitos de reentrada alrededor de las incisiones auriculares y sus consecuentes arritmias.1. Objective: To present and test a simple method that may prevent one of the commonest long-term complications of surgery for congenital heart disease: atrial reentrant tachycardia. This arrhythmia may occur many years (even decades) after the operation. It is most commonly explained as a late consequence of right atriotomy, which is an inherent component of many operations for congenital heart disease. Right atriotomy results in a long scar on the right atrial myocardium. This scar, as any scar, is a barrier to electrical conduction, and macro-reentrant circuits may form around it causing reentrant tachycardia. This mechanism is the target of our proposed preventive antiarrhythmic method, i.e. to prevent the formation of reentrant circuits around right atriotomy scars. 2. Methods: The proposed method is implemented after termination of cardiopulmonary bypass and tying the venous purse-strings. It consists of constructing a full-thickness suture line on the intact right atrial wall from the IVC (a natural conduction barrier) to the atriotomy incision. This suture line is made to cross the venous cannulation sites if these are on the atrial myocardium (rather than being directly on the venae cavae). Thus, the IVC, atriotomy and cannulation sites are connected to each other in series by a full-thickness suture line on the atrial wall. If this suture line becomes a conduction barrier, it would prevent reentrant circuits around right atrial scars. This was tested in 13 adults by electroanatomical mapping. All 13 had previously undergone right atriotomy for ASD closure: 8 of them with the addition of the proposed preventive suture line (treatment group) and 5 without (control group). 3. Results: In all 13 cases, the atriotomy scar was identified as a barrier to electrical conduction with electrophysiological evidence of fibrosis (scarring). In all 8 patients with the proposed suture line, this had also become a scar and a complete conduction barrier. In the 5 patients without this suture line, there was free electrical conduction between the IVC and atriotomy scar. 4. Conclusions: The proposed suture line becomes a scar and conduction barrier. Therefore, it would prevent reentrant circuits around atrial scars and their consequent arrhythmias

Arteria coronaria derecha anómala que nace del tronco coronario izquierdo con curso entre los grandes vasos: manejo quirúrgico de un caso y revisión

ResumenLas anomalías de las arterias coronarias son alteraciones congénitas raras que en algunos casos, debido a su trayecto anómalo, pueden producir síntomas como la angina, síncopes o incluso la muerte súbita. Además, su manejo terapéutico no está bien establecido. Presentamos el caso de un varón de 64 años con clínica de dolor torácico y síncopes de repetición en el que se descubre una arteria coronaria única con una arteria coronaria derecha que nace del tronco coronario izquierdo y que discurre entre las grandes arterias. La compresión que ejercen estas estructuras justifica la clínica del paciente, por lo que se decide una actitud quirúrgica como terapia más adecuada consistente en la translocación de la arteria coronaria derecha a su seno de Valsalva correspondiente, evitando así la compresión producida por las grandes arterias y sobre todo la necesidad de realizar un bypass coronario. A los 7 meses de la intervención el paciente permanece asintomático.El manejo quirúrgico de las anomalías coronarias sintomáticas puede ser una alternativa segura sobre todo en los casos donde la anatomía coronaria permita evitar el bypass.AbstractAnomalies of the coronary arteries are rare congenital disorders that because of their anomalous course can produce symptoms in some cases, such as angina, syncope or even sudden death. Furthermore, their therapeutic management is not well established. The case is presented of a 64 year-old male with symptoms of chest pain and repeated syncope, in which a single coronary artery is discovered with a right coronary artery that originates from the left main coronary artery and runs between the great arteries. The compression exercised by these structures is responsible for the patient's clinical condition, thus a more appropriate therapy is decided, such as a surgical approach involving the translocation of the right coronary artery to the corresponding sinus of Valsalva. This prevents the compression produced by the great arteries, as well as the need for coronary bypass surgery. The patient is asymptomatic at seven months after surgery.The surgical management of symptomatic coronary anomalies can be a safe alternative, especially in cases in which the coronary anatomy helps to avoid a bypass

Perfil genético asociado a pacientes con síndrome aórtico agudo complicado: el estudio GEN-AOR

[EN] Introduction and objectives: Genetic testing is becoming increasingly important for diagnosis and personalized treatments in aortopathies. Here, we aimed to genetically diagnose a group of acute aortic syndrome (AAS) patients consecutively admitted to an intensive care unit and to explore the clinical usefulness of AAS-associated variants during treatment decision-making and family traceability. Methods: We applied targeted next-generation sequencing, covering 42 aortic diseases genes in AAS patients with no signs consistent with syndromic conditions. Detected variants were segregated by Sanger sequencing in available family members. Demographic features, risk factors and clinical symptoms were statistically analyzed by Fisher or Fisher-Freeman-Halton Exact tests, to assess their relationship with genetic results. Results: Analysis of next-generation sequencing data in 73 AAS patients led to the detection of 34 heterozygous candidate variants in 14 different genes in 32 patients. Family screening was performed in 31 relatives belonging to 9 families. We found 13 relatives harboring the family variant, of which 10 showed a genotype compatible with the occurrence of AAS. Statistical tests revealed that the factors associated with a positive genetic diagnosis were the absence of hypertension, lower age, family history of AAS and absence of pain. Conclusions: Our findings broaden the spectrum of the genetic background for AAS. In addition, both index patients and studied relatives benefited from the results obtained, establishing the most appropriate level of surveillance for each group. Finally, this strategy could be reinforced by the use of stastistically significant clinical features as a predictive tool for the hereditary character of AAS. ClinicalTrials.gov (Identifier: NCT04751058)[ES] Introducción y objetivos: El papel de la genética en el diagnóstico y la personalización de los tratamientos de las aortopatías, es cada vez mayor. En este estudio se analizó la prevalencia de variantes genéticas en pacientes con síndrome aórtico agudo (SAA) admitidos consecutivamente en una unidad de cuidados intensivos y se evaluó su utilidad clínica. Métodos: Mediante secuenciación masiva, se analizó 42 genes asociados a aortopatías en pacientes con SAA no sindrómico. Las variantes identificadas se segregaron mediante secuenciación Sanger en los familiares disponibles. Además, se estudió la relación entre los resultados genéticos y algunas características clínicas mediante la aplicación de los test exactos de Fisher y de Fisher-Freeman-Halton. Resultados: El análisis de los datos genómicos de 73 pacientes de SAA dio como resultado la identificación de 34 variantes candidatas en 32 individuos, localizadas en 14 genes diferentes. La segregación familiar se realizó en 31 individuos pertenecientes a 9 familias, donde se encontraron 13 portadores de los que 10 mostraron un genotipo compatible con SAA. El estudio estadístico indicó que la ausencia de hipertensión, una menor edad, una historia familiar de SAA y la ausencia de dolor están asociadas con un estudio genético positivo. Conclusiones: Se amplió el espectro mutacional asociado a SAA. Además, tanto los pacientes índice como los familiares estudiados se han visto beneficiados por estos resultados, por lo que se puede establecer el protocolo de seguimiento adecuado para cada uno de ellos. Por último, es importante destacar la posibilidad de utilizar variables clínicas estadísticamente significativas como factores predictores del carácter hereditario del SAA. ClinicalTrials.gov (Identifier: NCT04751058)Este trabajo contó con el apoyo del Instituto de Salud Carlos III (ISCIII), Ministerio de Economía y Competitividad de España y fue cofinanciado por la Unión Europea (FEDER, «Una manera de hacer Europa ») [PI18-00612; PI19/01550; PI21-00244; IMP/00009], Consejería Regional de Salud y Familias del Gobierno Autónomo de Andalucía [PEER-0501-2019; PEER-0470-2019], Consejería Regional de Transformación Económica, Industria, Conocimiento y Universidades de Andalucía [P20_00887] y la Fundación Isabel.Peer reviewe

Spatiotemporal Characteristics of the Largest HIV-1 CRF02_AG Outbreak in Spain: Evidence for Onward Transmissions

Background and Aim: The circulating recombinant form 02_AG (CRF02_AG) is the predominant clade among the human immunodeficiency virus type-1 (HIV-1) non-Bs with a prevalence of 5.97% (95% Confidence Interval-CI: 5.41–6.57%) across Spain. Our aim was to estimate the levels of regional clustering for CRF02_AG and the spatiotemporal characteristics of the largest CRF02_AG subepidemic in Spain.Methods: We studied 396 CRF02_AG sequences obtained from HIV-1 diagnosed patients during 2000–2014 from 10 autonomous communities of Spain. Phylogenetic analysis was performed on the 391 CRF02_AG sequences along with all globally sampled CRF02_AG sequences (N = 3,302) as references. Phylodynamic and phylogeographic analysis was performed to the largest CRF02_AG monophyletic cluster by a Bayesian method in BEAST v1.8.0 and by reconstructing ancestral states using the criterion of parsimony in Mesquite v3.4, respectively.Results: The HIV-1 CRF02_AG prevalence differed across Spanish autonomous communities we sampled from (p < 0.001). Phylogenetic analysis revealed that 52.7% of the CRF02_AG sequences formed 56 monophyletic clusters, with a range of 2–79 sequences. The CRF02_AG regional dispersal differed across Spain (p = 0.003), as suggested by monophyletic clustering. For the largest monophyletic cluster (subepidemic) (N = 79), 49.4% of the clustered sequences originated from Madrid, while most sequences (51.9%) had been obtained from men having sex with men (MSM). Molecular clock analysis suggested that the origin (tMRCA) of the CRF02_AG subepidemic was in 2002 (median estimate; 95% Highest Posterior Density-HPD interval: 1999–2004). Additionally, we found significant clustering within the CRF02_AG subepidemic according to the ethnic origin.Conclusion: CRF02_AG has been introduced as a result of multiple introductions in Spain, following regional dispersal in several cases. We showed that CRF02_AG transmissions were mostly due to regional dispersal in Spain. The hot-spot for the largest CRF02_AG regional subepidemic in Spain was in Madrid associated with MSM transmission risk group. The existence of subepidemics suggest that several spillovers occurred from Madrid to other areas. CRF02_AG sequences from Hispanics were clustered in a separate subclade suggesting no linkage between the local and Hispanic subepidemics

¿Qué queremos decir con el término «univentricular»?

El término «univentricular», aunque frecuentemente usado, es un término confuso debido a que su significado literal no tiene que ver en absoluto con el significado con el que realmente se emplea en la práctica clínica. Esta falta de precisión suele ser fuente de constantes malentendidos, sobre todo para aquellos profesionales que no están muy familiarizados con las cardiopatías congénitas. Además sucede que un mayor grado de confusión en el uso de dicho término viene dado porque el mismo se emplea para referirse a 3 conceptos diferentes: corazón univentricular, fisiología univentricular y camino o protocolo univentricular. Por esta razón, se hace conveniente aclarar, de manera sencilla y precisa, cual es su verdadero significado. Tal es el objetivo de este artículo

Clinical impact of rotational thromboelastometry in cardiac surgery

Patients undergoing cardiac surgery are at high risk of postoperative bleeding, which is related to worse prognosis and survival. The use of ROTEM®, together with the implementation of a specific treatment algorithm, to reduce the risk of postoperative bleeding. An observational, comparative, cross-case study with historical controls. A total of 1772 consecutive patients admitted to intensive care unit after having undergone cardiac surgery, was divided into 3 groups: Group 1: Coagulation was only monitored by the classical coagulation test (control group). Group 2: Monitorization was done by ROTEM®, according to a protocol designed in our center. Group 3: VerifyNow® was added to ROTEM®, implementing a specific treatment algorithm. We observed a decreased of red blood cell transfusion (Group 1 55.5%, Group 2 52.7%, Group 3 46.6%, P < 0.01). Postoperative results include a significant reduction in complications with a marked improvement in overall survival in the ROTEM® - guided groups. Conclusions: Monitoring of hemostasis by POCT'S (ROTEM® and VerifyNow®) in patients undergoing cardiac surgery and cardiac transplantation was associated with a decreased incidence of blood transfusion, postoperative clinical complications, and mortality.This research was funded by the INSTITUTE OF CARLOS III, grant number: PI18/01197 . This study was co-financed by FEDER Funds

Follow-up of a simple method for aortic valve reconstruction with fixed pericardium in children.

In 2013, we published a simple method for aortic valve reconstruction in children using fixed pericardium in this journal. This was not expected to be a durable solution but a temporizing measure in the absence of other solutions, in order to buy time for growth that would allow subsequent prosthetic valve insertion. As such, this was implemented in 3 patients with excellent immediate results, as reported in our original publication. We are now writing to provide longer term information. In 2 cases, a newborn and a 12-year-old boy, the valve calcified heavily at 4 years' follow-up. By then, the valvar annulus had grown sufficiently to accept a prosthetic valve in both cases. In these 2 cases, the material used for valve reconstruction was autologous pericardium fixed in 0.6% gluteraldehyde. In the third patient, a 3-year-old girl, the valve failed by dehiscence of the suture line 6 months following surgery. In this case, fixed bovine pericardium had been used, which is more rigid than autologous pericardium, thus possibly explaining the dehiscence. However, the pericardial patch was not calcified. Thus, the described method lived up to our expectation of buying time for growth for later insertion of a prosthetic valve in 2 of the 3 cases

Associations between Body Image and Self-Perceived Physical Fitness in Future Spanish Teachers

Body image is a complex construct related to how each person perceives their own body and how they value it. Physical fitness and physical activity are factors that can influence the perception of a better or worse body image. This study aimed to identify the potential associations between body image and physical fitness self-perception in future Spanish teachers, analysing possible sex-related differences. A total of 278 Spanish university students answered the Multidimensional Body Self Relations Questionnaire and the International Fitness Scale, having an average age of 22 years, of which 40% were men and 60% were women. Nonparametric techniques (Spearman’s Rho test) were used as the data did not fit normality. The findings showed associations between body image and perceived physical fitness, confirming differences between the sexes. Correlations were found between the first three dimensions of the Multidimensional Body Self Relations and the International Fitness Scale, with sex-related differences being more significant in women than in men, and between the physical abilities self-assessed by the International Fitness Scale (except flexibility) and the dimensions of the Multidimensional Body Self Relations (except Dimension 4). Since body image influences well-being and conditions the time spent exercising, public health organisations and universities should design supports to improve master students’ body image through physical activity programmes, education and sex-specific individualised attention

The morphologically right and left ventricles cannot be distinguished by their coronary arterial pattern.

The morphologically right and left ventricles are distinguished from each other based on their internal anatomical features, because their external (epicardial) surfaces do not appear to have any distinguishing mark for such ventricular identification. Nevertheless, ventricular identification based on epicardial characteristics, if these were possible, would be interesting to surgeons, because this would enable them to identify each ventricle rapidly upon opening the chest. This made us curious as to whether or not the two ventricles may be distinguished based on their epicardial coronary arterial patterns, because this is the most obvious epicardial ventricular feature. This idea led us to formulate the following 2 hypotheses: (i) The morphologically left ventricle is always the one that receives the higher number of the marginal arteries as compared to the morphologically right ventricle. (ii) Only the morphologically left ventricle receives the diagonal arteries from the anterior and posterior interventricular arteries. These hypotheses were tested in this anatomical observational study by examination of 98 normal and 398 congenitally malformed formaldehyde-preserved hearts encompassing most malformations, including rare ones and hearts in which 1 ventricle is hypoplastic. These examinations show that both hypotheses are false. The two ventricles cannot be distinguished from each other based on the number of marginal arteries that they receive or which one receives diagonal arteries; both ventricles may receive diagonal arteries from either or both interventricular arteries