Effect of Preoperative Infusion of Levosimendan on Biomarkers of Myocardial Injury and Haemodynamics After Paediatric Cardiac Surgery: A Randomised Controlled Trial

Trial registry number: EudraCT 2012-005310-19.Key Points A randomised controlled trial was conducted to test the hypothesis that preoperative infusion of levosimendan would decrease myocardial injury biomarkers (troponin I and B-type natriuretic peptide) after paediatric cardiac surgery more efficiently than placebo. Troponin I and B-type natriuretic peptide levels were higher with placebo at 12 and 24 h after cardiopulmonary bypass, but the differences were not statistically significant. Lactic acid level was significantly lower and oxygen delivery (DO2) was significantly higher at 12 and 24 h after surgery in Levosimendan group. The results highlight the importance of this new drug and its possible benefit with regard to myocardial injury; however, evaluation in larger, adequately powered trials is needed to determine the efficacy of levosimendan.Objective The aim was to test the hypothesis that preoperative infusion of levosimendan would decrease patients’ cardiac biomarker profiles during the immediate postoperative stage (troponin I and B-type natriuretic peptide levels) more efficiently than placebo after cardiopulmonary bypass. Methods In a randomised, placebo-controlled, double-blinded study, 30 paediatric patients were scheduled for congenital heart disease surgery. 15 patients (50%) received prophylactic levosimendan and 15 patients (50%) received placebo from 12 h before cardiopulmonary bypass to 24 h after surgery. Results Troponin I levels were higher in the placebo group at 0, 12, and 24 h after cardiopulmonary bypass, although the mean differences between the study groups and the 95% confidence intervals (CIs) for troponin I levels did not present statistically significant differences at any of the three time points considered (mean differences [95% CIs] − 3.32 pg/ml [− 19.34 to 12.70], − 2.42 pg/ml [− 19.78 to 13.95], and − 79.94 pg/ml [− 266.99 to 16.39] at 0, 12, and 24 h, respectively). A similar lack of statistically significant difference was observed for B-type natriuretic peptide (mean differences [95% CIs] 36.86 pg/dl [− 134.16 to 225.64], − 350.79 pg/dl [− 1459.67 to 557.45], and − 310.35 pg/dl [− 1505.76 to 509.82]). Lactic acid levels were significantly lower with levosimendan; the mean differences between the study groups and the 95% CIs for lactate levels present statistically significant differences at 0 h (− 1.52 mmol/l [− 3.19 to − 0.25]) and 12 h (− 1.20 mmol/l [− 2.53 to − 0.10]) after cardiopulmonary bypass. Oxygen delivery (DO2) was significantly higher at 12 h and 24 h after surgery (mean difference [95% CI] 627.70 ml/min/m2 [122.34–1162.67] and 832.35 ml/min/m2 [58.15 to 1651.38], respectively). Conclusions Levosimendan does not significantly improve patients’ postoperative troponin I and B-type natriuretic peptide profiles during the immediate postoperative stage in comparison with placebo, although both were numerically higher with placebo. Levosimendan, however, significantly reduced lactic acid levels and improved patients’ DO2 profiles. These results highlight the importance of this new drug and its possible benefit with regard to myocardial injury; however, evaluation in larger, adequately powered trials is needed to determine the efficacy of levosimendan

Endovascular Technique for Ascending Aorta Repair Based on TEVAR and TAVI Procedures

Purpose: Ascending aorta (AAo) acute pathology still has an open-surgery indication with a high mortality rate associated to cardiopulmonary bypass and circulatory arrest. In these cases, the endovascular aortic approach could be an excellent option. The aim of the present study is to detail an optimized technique for the endovascular treatment of AAo diseases, based on thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve implantation (TAVI) procedures. Technique: The procedure implies the usual preparation for TEVAR and TAVI implants. A transient pacemaker lead is necessary to deliver the prosthesis under "rapid pacing." As in the TAVI technique, a final high-support guidewire is placed at the left ventricle. The proximal landing zone is the sinotubular junction (zone 0B). Transesophageal echocardiography is essential to ensure aortic valve function and patency in coronary arteries during the delivery. To assess a potential occlusion of the brachiocephalic artery, a guidewire is positioned in the descending aorta from the axillary artery. Finally, a noncovered stent is implanted to stabilize the AAo prosthesis. Conclusion: The technique presented here can standardize a safe and reproducible procedure to endovascular repair of AAo diseases. However, new devices specifically designed for the AAo could facilitate the transcatheter approach. Clinical impact: Ascending aorta acute pathology still has an open-surgery indication with high mortality rate associated to cardiopulmonary bypass and circulatory arrest. Moreover, near 30% of patients are not considered suitable for surgery because of age, critical situation or the presence of severe comorbidities. The present study provides a detailed and optimized technique for the endovascular treatment of ascending aorta disease, based on TEVAR and TAVI procedures

Left superior vena cava draining into the left atrium: Clinical entities, diagnosis and surgical treatment.

Left superior vena cava draining into the left atrium in the absence of coronary sinus is an anomaly that can appear in heterotaxy syndrome and unroofed coronary sinus syndrome. Regardless of the origin of these syndromes, biventricular repair can be done through rerouting by intracardiac procedures or through disconnection-reconnection of the left superior vena cava to the right atrium or right superior vena cava by extracardiac procedures. Different techniques can be used for this purpose, each of which has its own advantages and limitations. Therefore, appropriate selection is necessary to obtain the best results for each patient, and many factors, such as patient anatomy, age, associated cardiomyopathies, etc., have to be considered. In this review, we focus on heterotaxy and unroofed coronary sinus syndromes, associated cardiomyopathies, the state-of-the-art in their surgical treatment and our results in a sample of 10 patients. Our experience highlights the importance of accurate diagnosis and specific selection of surgical technique for the management of biventricular repair in patients with left superior vena cava draining into the left atrium in the absence of coronary sinus

Left superior vena cava draining into the left atrium: Clinical entities, diagnosis and surgical treatment

There are two different clinical entities in which a persistent left superior vena cava (LSVC) can drain into the left atrium (LA) in the absence of coronary sinus: heterotaxy syndrome and unroofed coronary sinus syndrome (UCSS). In these cases, biventricular repair can be done by intracardiac rerouting or by disconnection-reconnection to the right atrium (RA) or to the right superior vena cava (RSVC) using extracardiac procedures. In the period from 1998 to 2016, 10 patients with LSVC draining into the LA underwent 11 surgeries for biventricular repair. The present study focuses on heterotaxy syndrome and unroofed coronary sinus syndrome (UCSS), associated cardiomyopathies, the state of the art in their surgical treatment and our results in our sample. Our experience highlights that accurate diagnosis and appropriate selection of surgical technique, considering different characteristics, such as patient anatomy, age, associated cardiomyopathies, etc., are important for patient outcome

Mathematical model optimized for prediction and health care planning for COVID-19

Objetivo La pandemia de la COVID-19 ha supuesto una amenaza de colapso de los servicios hospitalarios y de UCI, y una reducción de la dinámica asistencial de pacientes afectados por otras patologías. El objetivo fue desarrollar un modelo matemático diseñado para optimizar las predicciones relacionadas con las necesidades de hospitalización e ingresos en UCI por la COVID-19. Diseño Estudio prospectivo. Ámbito Provincia de Granada (España). Pacientes Pacientes consecutivos de COVID-19 hospitalizados, ingresados en UCI, recuperados y fallecidos desde el 15 de marzo hasta el 22 de septiembre de 2020. Intervenciones Desarrollo de un modelo matemático tipo SEIR capaz de predecir la evolución de la pandemia considerando las medidas de salud pública establecidas. Variables de interés Número de pacientes infectados por SARS-CoV-2, y hospitalizados e ingresados en UCI por la COVID-19. Resultados A partir de los datos registrados hemos podido desarrollar un modelo matemático que refleja el flujo de la población entre los diferentes grupos de interés en relación a la COVID-19. Esta herramienta nos ha permitido analizar diferentes escenarios basados en medidas de restricción socio-sanitarias, y pronosticar el número de infectados, hospitalizados e ingresados en UCI hasta el mes de mayo de 2021. Conclusiones El modelo matemático es capaz de proporcionar predicciones sobre la evolución de la COVID- 19 con suficiente antelación como para poder conjugar los picos de prevalencia y de necesidades de asistencia hospitalaria y de UCI, con la aparición de ventanas temporales que posibiliten la atención de enfermos no-COVID.Objective The COVID-19 pandemic has threatened to collapse hospital and ICU services, and it has affected the care programs for non-COVID patients. The objective was to develop a mathematical model designed to optimize predictions related to the need for hospitalization and ICU admission by COVID-19 patients. Design Prospective study. Setting Province of Granada (Spain) Population Consecutive COVID-19 patients hospitalized, admitted to ICU, recovered and died from March 15 to September 22, 2020. Study variables The number of patients infected with SARS-CoV-2 and hospitalized or admitted to ICU for COVID-19. Results The data reported by hospitals was used to develop a mathematical model that reflects the flow of the population among the different interest groups in relation to COVID-19. This tool has allowed us to analyse different scenarios based on socio-health restriction measures, and to forecast the number of people infected, hospitalized and admitted to the ICU until May 2021. Conclusions The mathematical model is capable of providing predictions on the evolution of the COVID- 19 sufficiently in advance as to anticipate the peaks of prevalence and hospital and ICU care demands, and also the appearance of periods in which the care for non-COVID patients could be intensified.Ministerio de Economı́a, Industria y Competitividad de España, la Agencia Estatal de Investigación y el Fondo Europeo de Desarrollo Regional (MTM2017-89664-P)Programa de Fondos de Desarrollo Regional / Fondo Social Europeo y la Comunidad Valenciana (GJIDI/2018/A/010 y GJIDI/2018/A/009)Fundación Ramón Areces, Madrid, Spain (CIVP18A3920

Complicaciones quirúrgicas de la extracción intravenosa de las infecciones de dispositivos de estimulación cardiaca

Resumen: Introducción: El implante de dispositivos de electroestimulación cardiaca (DECI) constituye una terapia útil para el tratamiento de diferentes cardiopatías. Sin embargo, su utilización no está exenta de complicaciones. La infección relacionada con los dispositivos de electroestimulación es una de las más frecuentes y serias que pueden producirse. La extracción intravenosa del sistema de electroestimulación es un procedimiento seguro y eficaz, dirigido al tratamiento de múltiples situaciones relacionadas con los dispositivos. Objetivo y métodos: En el presente artículo abarcamos las complicaciones relacionadas con los procedimientos de extracción, identificamos los factores de riesgo asociados a la morbimortalidad de los pacientes, y establecemos una guía de prevención y tratamiento de las complicaciones cardiovasculares mayores. Resultados: A pesar del crecimiento del número de procedimientos de extracción y del desarrollo de nuevos instrumentos, su práctica implica un riesgo potencial de complicaciones mayores y de morbimortalidad asociada. La realización de la técnica presentada, la correcta evaluación del riesgo quirúrgico del paciente y la estandarización del tratamiento completo como proceso asistencial son los 3 pilares básicos del tratamiento seguro y eficaz de las complicaciones relacionadas con los DECI. Conclusión: El procedimiento de extracción de los DECI que presentamos es eficaz y debe realizarse en un entorno seguro, implicando necesariamente un quirófano de cirugía cardiovascular, monitorización completa, ecocardiografía transesofágica y posibilidad de realizar esternotomía y cirugía de forma inmediata. Es necesario evaluar las posibles complicaciones y elaborar un proceso asistencial completo, teniendo en cuenta que las decisiones tomadas durante el implante inciden directamente en el potencial riesgo de la extracción. Abstract: Introduction: Implantation of cardiac electrostimulation devices (CIED) is a useful therapy for the treatment of various heart diseases. However, its use is not free of complications. Infection related to electrostimulation devices is one of the most common and serious complications. Intravenous removal of the electrostimulation system is a safe and effective procedure, aimed at the treatment of multiple pathological situations related to the devices. Objectives and methods: In the present article, we cover complications related to extraction procedures, identify risk factors associated with patient morbidity and mortality, and establish a guideline for the prevention and treatment of major cardiovascular complications. Results: Despite the growth in the number of extraction procedures and the development of new instruments, its practice involves a potential risk of major complications and morbi-mortality associated with the treatment. The performance of the technique presented here, the correct assessment of the patient's surgical risk, and the standardization of the entire process are the three basic pillars for a safe and effective treatment of complications related to CIED. Conclusion: The extraction procedure for CIED that we present is effective and should be performed in a safe environment, necessarily involving a cardiovascular surgery operating room, complete monitoring, transesophageal echocardiography, and the possibility of an immediate sternotomy and surgery. It is necessary to evaluate possible complications and develop a complete care process, considering that the decisions made during implantation have a direct impact on the potential risk of extraction

Valve repair in mitral endocarditis

Introducción: La endocarditis infecciosa (EI) es una patología que conlleva una elevada morbimortalidady representa un problema creciente de salud pública. El tratamiento quirúrgico es necesario en más dela mitad de los casos, y su principal finalidad es eliminar totalmente el tejido infectado y reconstruir laanatomía cardiaca normal, incluyendo la reparación o la sustitución de la/s válvula/s afectada/s.Objetivo y métodos: El presente estudio se centra en describir el procedimiento más apropiado para lacirugía de reparación mitral en casos de EI, atendiendo a la literatura y a la amplia experiencia adquiridapor parte del equipo quirúrgico. De igual modo, hemos recopilado a través de una búsqueda sistemáticade la literatura los resultados que se han ido reportando sobre la cirugía reparadora en comparación conel reemplazo valvular mitral.Resultados: La técnica quirúrgica descrita requiere de un estudio minucioso del grado de afectación ydesestructuración de los distintos segmentos valvulares. Consideramos que la resección con interposi-ción de parche de pericardio y/o implante de neocuerdas de Goretex®es la técnica estándar que permiteobtener resultados reproducibles. La revisión estructurada de las evidencias científicas disponibles veri-fica la seguridad de la reparación mitral para el tratamiento de la EI, aportando beneficios significativosen comparación con el reemplazo valvular.Conclusión: Los resultados quirúrgicos evaluados sugieren que la cirugía de reparación mitral deberíaser considerada el procedimiento de elección para el tratamiento quirúrgico de la EI, siempre que seatécnicamente posible.Introduction: Infective endocarditis (IE) is a pathology with a high morbidity and mortality rate andrepresents a growing public health problem. Surgical treatment is necessary in more than half of thecases, and its main purpose is to completely remove the infected tissue and reconstruct normal cardiacanatomy, including repair or replacement of the affected valve(s).Objectives and methods: The present study focuses on describing the most appropriate procedure formitral repair surgery in cases of IE, based on the literature and the extensive experience gained by thesurgical team. Likewise, we have compiled through a systematic search of the literature the results thathave been reported on reparative surgery compared to mitral valve replacement. Results: The surgical technique described requires a thorough study of the degree of involvement anddestructuring of the different valve segments. We consider resection with pericardial patch interpositionand/or Goretex®neochord implantation to be the standard technique that allows reproducible results. Thestructured review of the available scientific evidence verifies the safety of mitral repair for the treatmentof IE, providing significant benefits compared to valve replacement.Conclusion: The evaluated surgical results suggest that mitral repair surgery should be considered theprocedure of choice for the surgical treatment of IE, whenever technically feasible