53 research outputs found
La orejuela izquierda como fuente de accidentes cerebrovasculares: cerrar (y cómo), o no cerrar (y por qué)
The left atrial appendage is considered the main source of emboli in strokes in
patients with atrial fibrillation. Oral anticoagulant therapy significantly
reduces the risk of cerebral embolic events compared to aspirin, but it is
associated with bleeding complications, and is not always used. Closure of the
left atrial appendage reduces the rate of thromboembolic events, and it is
currently recommended in patients with atrial fibrillation submitted to mitral
valve surgery. However, the formation of emboli in these patients may be due to
other causes, as the role of the atrial appendage could be less important than is
assumed. Moreover, not all patients are candidates for oral anticoagulation, and
not all are kept in a proper therapeutic range, which could justify the formation
of atrial thrombi. There are several methods for performing the closure of the
appendage: direct suture in concomitant mitral surgery, epicardial exclusion by
stapling or clips, or endovascular occlusion by percutaneous application.
However, the results seem inconclusive with regards to their effectiveness for
complete occlusion of the appendage, safety, and efficacy in preventing cerebral
embolic events. To add to the confusion, some authors reveal no clear benefit in
suture closure, and even describe an increased risk of thromboembolism. We
present a review of left atrial appendage closure for the prevention of strokes,
as well as the different procedures described above
Giant left atrial thrombus 17 years after orthotopic heart transplantation
We present the case of a 66-year-old woman who underwent orthotopic heart transplantation 17 years earlier for dilated cardiomyopathy.
After 7 years allograft coronary vasculopathy developed requiring coronary artery angioplasty. In year 15 postoperatively she experienced
congestive heart failure and she became symptomatic requiring diuretics and digoxin treatment. In year 16 postoperatively a routine
coronary computed tomography (CT) angiography study revealed a giant thrombus in the left atrium. The patient had had no thromboembolicrelated
symptoms. Anticoagulation therapy was introduced and the patient has not presented any thromboembolic-related complication.
As the symptoms of cardiac insufficiency worsened we decided to evaluate the patient for re-transplantation
Cirugía de la fibrilación auricular
Atrial fibrillation surgery is based on creating scars in the atrium, in order to
avoid re-entry phenomena that may initiate and perpetuate arrhythmia, and driving
the normal stimuli from the sinus node to the atrio-ventricular node. The
complexity and increased risk of the initial surgical technique, based on a
"cut-and-sew" procedure, have enhanced other current procedures, in which
different energies are used making it possible to perform scars in a safer and
less invasive way. At present, atrial fibrillation surgery is not performed
routinely in all cardiothoracic surgical centers, and there is no consensus in
which is the best type of technique. Even if the results are good, they depend on
multiples factors such as duration of arrhythmia, atrial size and type of
technique employed. In addition, there is some variability in the description
within the scientific community of the results and procedures used, which makes
its analysis confusing. In this paper we review the different techniques
described, the results and their application in minimally invasive surgery
Progresos en cirugía cardiaca
The development of cardiovascular surgery has been accompanied by a series of advances in complementary technology, which has made it possible to carry out safer and less aggressive surgery. In this article there is a review of the latest progress in coronary and valvular surgery, cardiac insufficiency, arrhythmia and the application of extracorporeal circulation in non-cardiac diseases. These advances can serve as the starting point in order to build a future adapted to the needs generated by both patient and diseas
Valoración global del corazón en el paciente con transplante cardiaco mediante tomografía computarizada de doble fuente
In routine clinical practice surveillance of heart
transplant recipients is usually performed using echocardiography
and conventional coronary angiography. The
latter permits diagnosis and follow-up of coronary allograft
vasculopathy. However, this procedure is invasive
and is not free of complications. Conventional multislice
computed tomography (MSCT) has been shown to be a
useful non-invasive tool for ruling out coronary artery
disease and evaluating cardiac function. However, due
to its limited temporal resolution betablocker administration
is required, and its usefulness in certain patient
populations with restricted response to this medication,
such as heart transplant recipients, may therefore be
limited. Dual-source CT (DSCT) allows evaluation of the
coronary arteries in all individuals independent of their
heart rate. In the case presented here, we demonstrate
that DSCT may be useful for evaluating cardiac function
and ruling out coronary allograft vasculopathy in heart
transplant recipients
Dual-source CT for visualization of the coronary arteries in heart transplant patients with high heart rates
OBJECTIVE. The purpose of this study was to evaluate the quality of dual-source CT images of the coronary arteries in heart transplant recipients with high heart rates.
SUBJECTS AND METHODS. Contrast-enhanced dual-source CT coronary angiography was performed on 23 heart transplant recipients (20 men, three women; mean age, 61.1 ± 12.8 years). Data sets were reconstructed in 5% steps from 30% to 80% of the R-R interval. Two blinded independent readers using a 5-point scale (0, not evaluative; 4, excellent quality) assessed the quality of images of coronary segments.
RESULTS. The mean heart rate during scanning was 89.2 ± 10.4 beats/min. Interobserver agreement on the quality of images of the whole coronary tree was a kappa value of 0.78 and for selection of the optimal reconstruction interval was a kappa value of 0.82. The optimal reconstruction interval was systole in 17 (74%) of the 23 of heart transplant recipients. At the best reconstruction interval, diagnostic image quality (score ≥ 2) was obtained in 92.1% (303 of 329) of the coronary artery segments. The mean image quality score for the whole coronary tree was 3.1 ± 1.01. No significant correlation between mean heart rate (ρ = 0.31) or heart rate variability (ρ = 0.23) and overall image quality score was observed (p = not significant).
CONCLUSION. Dual-source CT acquisition yields coronary angiograms of diagnostic quality in heart transplant recipients. Mean heart rate and heart rate variability during scanning do not have a negative effect on the overall quality of images of the coronary arteries
Trasplante de homoinjertos valvulares cardiacos y vasculares
The advances in the manipulation of human tissues,
the development of cryobiology, paediatric cardiac
surgery, the impossibility of obtaining an ideal
prosthetic cardiac valve and the surgical treatment of
cardiovascular infections have revived interest in the
use of homografts. The donors of these homografts
can be: a) Live donors: aortic and pulmonary valve of
the recipient of a heart transplant; b) Multiorgan
donors with a diagnosis of death according to neurological
criteria, whose heart is rejected for heart transplant;
c) Cadaver donors with asystolia of less than 8
hours.
Homograft cardiac valves are the substitute of
choice in aortic valve endocarditis, patients with
counter-indications for anticoagulation, reconstruction
of the outflow tract of the right ventricle, aortic
valve replacement in children and young adults
through the Ross operation, and an optional indication
is the aortic valve and/or rising aorta replacement
in patients over 60 years of age. Although there
are not sufficiently broad series of homogratfs with
arterial substitutes, with respect to the number of
patients and time of evolution, the results suggest
that this can benefit patients with vascular infection,
immunodepressed patients or complex patients
whose technique during the operation might require
a homograft
Association of cardiotrophin-1 with myocardial fibrosis in hypertensive patients with heart failure
Cardiotrophin-1 has been shown to be profibrogenic in experimental models. The aim of this study was to
analyze whether cardiotrophin-1 is associated with left ventricular end-diastolic stress and myocardial fibrosis
in hypertensive patients with heart failure. Endomyocardial biopsies from patients (n=31) and necropsies from 7
control subjects were studied. Myocardial cardiotrophin-1 protein and mRNA and the fraction of myocardial volume
occupied by collagen were increased in patients compared with controls (
P
<0.001). Cardiotrophin-1 overexpression in
patients was localized in cardiomyocytes. Cardiotrophin-1 protein was correlated with collagen type I and III mRNAs
(
r
=0.653,
P
<0.001;
r
=0.541,
P
<0.01) and proteins (
r
=0.588,
P
<0.001;
r
=0.556,
P
<0.005) in all subjects and with left
ventricular end-diastolic wall stress (
r
=0.450;
P
<0.05) in patients. Plasma cardiotrophin-1 and N-terminal pro-brain
natriuretic peptide and serum biomarkers of myocardial fibrosis (carboxy-terminal propeptide of procollagen type I
and amino-terminal propeptide of procollagen type III) were increased (
P
<0.001) in patients compared with controls.
Plasma cardiotrophin-1 was correlated with N-terminal pro-brain natriuretic peptide (
r
=0.386;
P
<0.005), carboxy-
terminal propeptide of procollagen type I (
r
=0.550;
P
<0.001), and amino-terminal propeptide of procollagen type III
(
r
=0.267;
P
<0.05) in all subjects. In vitro, cardiotrophin-1 stimulated the differentiation of human cardiac fibroblast to
myofibroblasts (
P
<0.05) and the expression of procollagen type I (
P
<0.05) and III (
P
<0.01) mRNAs. These findings
show that an excess of cardiotrophin-1 is associated with increased collagen in the myocardium of hypertensive patients
with heart failure. It is proposed that exaggerated cardiomyocyte production of cardiotrophin-1 in response to increased
left ventricular end-diastolic stress may contribute to fibrosis through stimulation of fibroblasts in heart failure of
hypertensive origi
Úlcera penetrante de aorta ascendente en un paciente asintomático
La úlcera penetrante de aorta (UPA) es la ulceración de una placa aterosclerótica que afecta a la lámina
elástica interna de la aorta, y que puede evolucionar hacia un hematoma de pared o una disección aórtica si se
produce el paso de sangre hacia la capa media. A pesar
de que se localiza más frecuentemente en la aorta descendente, puede presentar una alta mortalidad en caso
de situarse en la aorta ascendente, donde la cirugía está
indicada aunque el paciente se encuentre asintomático.
Presentamos el caso de un paciente sin sintomatología
con úlcera penetrante de aorta ascendente (UPAA) ascendente sometido a sustitución de aorta ascendente
por una prótesis vascular.Penetrating aortic ulcer (PAU) has been defined
as an atherosclerotic plaque ulceration that breaks
the internal elastic lamina of the aorta, which may
progress to a wall hematoma or aortic dissection in
case of blood seeping into the middle layer. Although
PAU is commonly located in the descending aorta,
the involvement of the ascending aorta can be fatal.
Therefore, surgery is indicated even in asymptomatic
patients presenting an ascending PAU. We report on an
asymptomatic patient with ascending PAU referred for
replacement of the ascending aorta with a composite
prosthetic graft
Left atrial appendage occlusion by invagination and double suture technique
Left atrial appendage (LAA) plays a crucial role as a source of atrial thrombus in patients with atrial fibrillation (AF). Thus, the need to close LAA becomes evident in patients with AF who undergo concomitant mitral valve surgery. Unfortunately, it has been reported a high rate of unsuccessful LAA occlusion, regardless of the technique employed.We propose a safe and simple method for LAA occlusion consisting in invagination of the appendage into the left atrium, followed by two sutures (purse string suture around the base of the LAA and a reinforce running suture)
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