Documento de consenso interdisciplinar de expertos en el manejo de la disección aórtica tipo B: comentarios y novedades a la luz del INSTEAD-XL

ResumenAnte la ausencia de evidencia científica sólida, un comité de expertos europeos ha publicado en la revista Journal of the American College of Cardiology un documento de consenso sobre el manejo de los diferentes subgrupos de pacientes con disección aórtica tipo B. Este documento está basado en un metaanálisis que recopila toda la experiencia publicada en los últimos años sobre disección aórtica tipo B, incluyendo a más de 6.700 pacientes.A pesar de su mejor pronóstico en fase aguda que la disección aórtica tipo A, la disección aórtica tipo B presenta un mal pronóstico a medio y largo plazo. El manejo limitado al tratamiento médico con control estricto de la presión arterial y el tratamiento de los casos complicados mediante cirugía abierta o técnicas endovasculares está sometido a controversia, especialmente por la disponibilidad y los buenos resultados de las técnicas endovasculares. Este documento pretende apoyar a los cirujanos o médicos que tratan la disección aórtica tipo B, estableciendo algunos algoritmos de manejo.Recogemos en este artículo las conclusiones y los datos fundamentales de este documento de consenso.La aparición posterior de los resultados a 5 años del estudio INSTEAD añaden una fuerte evidencia científica en contra de alguna de las principales conclusiones alcanzadas en este consenso y retan este consenso logrado solamente un año antes.AbstractDue to a lack of solid scientific evidence, an european experts committee have published in Journal of the American College of Cardiology an consensus document about the management of different subgroups of patients with type B aortic dissection. This document is based on a meta-analisys including the recent published experience that includes more than 6700 patients with type B aortic dissection.In spite of the better prognosis compared to type A dissection in the short term, type B dissection has a bad long term prognosis. The conservative management limited to tight blood pressure control and close surveillance to treat complicated cases with open surgery or endovascular therapy is under discussion, specially due to the feasibility and good results of endovascular technique. This consensus intends to support surgeons or doctors who deal with type B dissection and stablishs some management algorithm.We present in this article the conclusions and main data from this consensus document.The posterior publication of 5 years results of INSTEAD study adds an strong scientific evidence against some of this consensus principal conclusions and challenge the consensus just one year later

Role of Isolated Limb Perfusion in the Era of Targeted Therapies and Immunotherapy in Melanoma. A Systematic Review of The Literature

Background. Isolated limb perfusion (ILP) is a locoregional procedure indicated by the unresectable melanoma of the limbs. Its complexity and highly demanding multidisciplinary approach means that it is a technique only implemented in a few referral centers around the globe. This report aims to examine its potential role in the era of targeted therapies and immunotherapy by conducting a systematic review of the literature on ILP. Methods. PubMed, Embase and Cochrane Library were searched. The eligibility criteria included publications from 2000–2020 providing valid data o effectiveness, survival or toxicity. Studies in which the perfusion methodology was not clearly described, letters to the editor, non-systematic reviews and studies that applied outdated clinical guidelines were excluded. To rule out studies of a low methodological quality and assess the risk of bias, the following aspects were also required: a detailed description of the applied ILP regimen, the clinical context, follow-up periods, analyzed clinical endpoints, and the number of analyzed ILPs. The disagreements were resolved by consensus. The results are presented in tables and figures. Results. Twenty-seven studies including 2637 ILPs were selected. The median overall response rate was 85%, with a median complete response rate of 58.5%. The median overall survival was 38 months, with a 5-year overall survival of 35%. The toxicity was generally mild according to Wieberdink toxicity criteria. Discussion. ILP still offer a high efficacy in selected patients. The main limitation of our review is the heterogeneity and age of most of the articles, as well as the absence of clinical trials comparing ILP with other procedures, making it difficult to transfer its results to the current era. Conclusions. ILP is still an effective and safe procedure for selected patients with unresectable melanoma of the limbs. In the era of targeted therapies and immunotherapy, ILP remains an acceptable and reasonable palliative treatment alternative, especially to avoid limb amputations. The ongoing clinical trials combining systemic therapies and ILP will provide more valuable information in the future to clarify the potential synergism of both strategies

Mural Endocarditis: The GAMES Registry Series and Review of the Literature

Introduction Mural infective endocarditis (MIE) is a rare type of endovascular infection. We present a comprehensive series of patients with mural endocarditis. Method sPatients with infectious endocarditis (IE) from 35 Spanish hospitals were prospectively included in the GAMES registry between 2008 and 2017. MIEs were compared to non-MIEs. We also performed a literature search for cases of MIE published between 1979 and 2019 and compared them to the GAMEs series. Results Twenty-seven MIEs out of 3676 IEs were included. When compared to valvular IE (VIE) or device-associated IE (DIE), patients with MIE were younger (median age 59 years, p < 0.01). Transplantation (18.5% versus 1.6% VIE and 2% DIE, p < 0.01), hemodialysis (18.5% versus 4.3% VIE and 4.4% DIE, p = 0.006), catheter source (59.3% versus 9.7% VIE and 8.8% DIE, p < 0.01) and Candida etiology (22.2% versus 2% DIE and 1.2% VIE, p < 0.01) were more common in MIE, whereas the Charlson Index was lower (4 versus 5 in non-MIE, p = 0.006). Mortality was similar.MIE from the literature shared many characteristics with MIE from GAMES, although patients were younger (45 years vs. 56 years, p < 0.001), the Charlson Index was lower (1.3 vs. 4.3, p = 0.0001), catheter source was less common (13.9% vs. 59.3%) and there were more IVDUs (25% vs. 3.7%). S. aureus was the most frequent microorganism (50%, p = 0.035). Systemic complications were more common but mortality was similar. Conclusion MIE is a rare entity. It is often a complication of catheter use, particularly in immunocompromised and hemodialysis patients. Fungal etiology is common. Mortality is similar to other IEs

Clinical Features and Outcomes of Streptococcus anginosus Group Infective Endocarditis: A Multicenter Matched Cohort Study

Streptococcus anginosus; Endocarditis infecciosa; Estreptococs del grup viridansStreptococcus anginosus; Endocarditis infecciosa; Estreptococos del grupo viridansStreptococcus anginosus; Infective endocarditis; Viridans group streptococciBackground Although Streptococcus anginosus group (SAG) endocarditis is considered a severe disease associated with abscess formation and embolic events, there is limited evidence to support this assumption. Methods We performed a retrospective analysis of prospectively collected data from consecutive patients with definite SAG endocarditis in 28 centers in Spain and Italy. A comparison between cases due to SAG endocarditis and viridans group streptococci (VGS) or Streptococcus gallolyticus group (SGG) was performed in a 1:2 matched analysis. Results Of 5336 consecutive cases of definite endocarditis, 72 (1.4%) were due to SAG and matched with 144 cases due to VGS/SGG. SAG endocarditis was community acquired in 64 (88.9%) cases and affected aortic native valve in 29 (40.3%). When comparing SAG and VGS/SGG endocarditis, no significant differences were found in septic shock (8.3% vs 3.5%, P = .116); valve disorder, including perforation (22.2% vs 18.1%, P = .584), pseudoaneurysm (16.7% vs 8.3%, P = .108), or prosthesis dehiscence (1.4% vs 6.3%, P = .170); paravalvular complications, including abscess (25% vs 18.8%, P = .264) and intracardiac fistula (5.6% vs 3.5%, P = .485); heart failure (34.7% vs 38.9%, P = .655); or embolic events (41.7% vs 32.6%, P = .248). Indications for surgery (70.8% vs 70.8%; P = 1) and mortality (13.9% vs 16.7%; P = .741) were similar between groups. Conclusions SAG endocarditis is an infrequent but serious condition that presents a prognosis similar to that of VGS/SGG.This work was supported by Plan Nacional de I+D+i 2013‐2016 and Instituto de Salud Carlos III, Subdirección General de Redes y Centros de Investigación Cooperativa, Ministerio de Ciencia, Innovación y Universidades, Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0005), co‐financed by the European Development Regional Fund “A way to achieve Europe,” Operative Program Intelligent Growth 2014–2020. We thank CERCA Programme/Generalitat de Catalunya for institutional support. J. M. M. received a personal 80:20 research grant from Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, during 2017–2021

Aneurysm of the inferior mesenteric artery associated with obstruction of celiac and superior mesenteric arteries. Case report and revision of the literature

Presentamos un caso de gran aneurisma de la arteria mesentérica inferior que se extiende desde su origen hasta su bifurcación en arteria cólica izquierda y sigmoidea, con oclusión de la arteria mesentérica superior y tronco celíaco en un paciente de 64 años. El diagnóstico de certeza se realizó mediante arteriografía. El tratamiento consistió en la práctica de angioplastia y stent a la arteria mesentérica superior previa a la cirugía, que consistió en la resección del aneurisma y reimplantación por separado de la cólica izquierda y la sigmoidea. Se comenta el caso, la técnica empleada y revisión de los casos publicados en la literatura.We present a case of a large aneurysm of the inferior mesenteric artery that extends from its origin to its bifurcation in the left colic and sigmoid arteries, with occlusion of the superior mesenteric artery and celiac trunk in a 64-year-old patient. The definitive diagnosis was made by arteriography. Treatment consisted of angioplasty and stenting of the superior mesenteric artery prior to surgery, which consisted of resection of the aneurysm and separate reimplantation of the left colic and sigmoid arteries. The case, the technique used and a review of the cases published in the literature are discussed

Enlargement of mitral and aortic annulus in reoperations

Presentamos 3 casos clínicos de reintervenciones sobre válvulas aórtica y mitral donde tuvimos que realizar una ampliación de ambos anillos con parches de dacron, que se efectuó durante una variante técnica que combina el empleo de la vía transeptal ampliada y la técnica de Nicks. Los pacientes fueron dados de alta a los 10 días sin ninguna complicación postoperatoria.We present 3 clinical cases of reinterventions on aortic and mitral valves where we had to perform a widening of both rings with Dacron patches, which was carried out during a technical variant that combines the use of the widened transseptal approach and the Nicks technique. The patients were discharged after 10 days without any postoperative complications

Primary cardiac sarcoma. Only palliative therapy?

Presentamos el caso de una paciente de 72 años de edad, sin factores de riesgo cardiovascular, que refiere disnea progresiva de 4 meses de evolución, presíncope en relación con el esfuerzo, semiología de estenosis mitral e insuficiencia cardíaca debida a obstrucción valvular mitral por una masa intraauricular izquierda, por probable mixoma, trombosis u otro tumor cardíaco. En el acto operatorio, la resección completa del tumor fue imposible, debido a su carácter infiltrativo difuso, objetivándose en la anatomía patológica 2 procesos diferenciados, un tumor seudoinflamatorio y un atipla celular sugestiva de sarcoma mal diferenciado y de difícil catalogación histológica. A pesar de que no se administró terapia complementaria, la paciente fue dada de alta, mejorando inicialmente para fallecer a los 14 meses. Se comenta el caso, las diferentes opciones terapéuticas y una revisión de la literatura.We present the case of a 72-year-old patient, without cardiovascular risk factors, who reported progressive dyspnea of ​​4 months of evolution, presyncope in relation to effort, semiology of mitral stenosis and heart failure due to mitral valve obstruction by a mass. left intraatrial, due to probable myxoma, thrombosis or other cardiac tumor. In the operative act, the complete resection of the tumor was impossible, due to its diffuse infiltrative nature, objectifying in the pathological anatomy 2 differentiated processes, a pseudo-inflammatory tumor and a cellular atyple suggestive of a poorly differentiated sarcoma and of difficult histological cataloging. Although no complementary therapy was administered, the patient was discharged, initially improving to die at 14 months. The case, the different therapeutic options and a review of the literature are discussed

Intraoperatory transesophagic echocardiography in cardiac echinococcosis surgery

La hidatidosis cardíaca es una enfermedad infrecuente que debe considerarse ante toda imagen quística intramiocárdica. Su tratamiento es la extirpación quirúrgica. Presentamos un caso de hidatidosis miocárdica asintomática sin afectación intracardiaca. La ecografía transesofágica intraoperatoria se mostró útil para la detección de quistes residuales.Cardiac hydatid disease is a rare disease that should be considered in any intramyocardial cystic image. Its treatment is surgical removal. We present a case of asymptomatic myocardial hydatid disease without intracardiac involvement. Intraoperative transesophageal ultrasound was shown to be useful for the detection of residual cysts

Beating-heart left posterolateral thoracotomy for mitral valve replacement

Introduction and objectives: The case concerns a 34-year-old man with Marfan syndrome and Pectus Excavatum that has been previously operated on for an ascending aortic aneurysm and aortic regurgitation using the David I technique in 2007. The patient currently has severe mitral regurgitation due to rupture of the anterior chordae leaflet. The objective is to demonstrate that left posterolateral thoracotomy is a feasible alternative in certain selected cases for the treatment of mitral valve pathology.Methods: Given the anatomical characteristics of the patient, and previous cardiac surgery, posed the question of what would be the best approach for this case. After a review of the literature and expert consultations, it was decided to perform a mitral valve replacement via left posterolateral thoracotomy. To do this, after left posterolateral thoracotomy and cannulation at the level of the descending thoracic aorta and left common femoral vein (Seldinger), extracorporeal circulation was started. Given the impossibility of aortic clamping, it was decided to perform beating heart mitral valve replacement in a CO2 environment. To do this, a left atriotomy was performed and, using various recovery aspirators, an acceptable view of the mitral valve was achieved. I was decided to replace it, due to the technical difficulties that a valve repair would entail.Results: The mitral replacement was successfully performed by transoesophageal echocardiography.Conclusions: Left posterolateral thoracotomy may be an alternative for patients with concomitant pathologies that cause displacement of the heart towards the left hemithorax. Published by Elsevier Espana, S.L.U. on behalf of Sociedad Espanola de Cirugia Cardiovascular y Endovascular

Surgical managment of a patient with abdominal aortic aneurysm, horseshoe kidney

Presentamos un caso de un paciente con aneurisma de aorta abdominal infrarrenal, riñón en herradura y cardiopatía isquémica, que tras la angioplastia presentó un cuadro de shock hipovolémico debido a una rotura de la arteria ilíaca derecha. Se intervino de urgencias, practicando resección del aneurisma e implantación de prótesis bifurcada de dacron. Se comenta el caso, la técnica empleada y la estrategia a seguir en estos casos.We present a case of a patient with infrarenal abdominal aortic aneurysm, horseshoe kidney and ischemic heart disease, who after angioplasty presented hypovolemic shock due to rupture of the right iliac artery. He underwent emergency surgery, performing resection of the aneurysm and implantation of a bifurcated Dacron prosthesis. The case, the technique used and the strategy to follow in these cases are discussed