Evolución de la cirugía coronaria en las dos últimas decadas

Consultable des del TDXTítol obtingut de la portada digitalitzadaEsta tesis realiza un estudio crítico y exhaustivo de la cirugía coronaria realizada en las últimas dos décadas por el servicio de cirugía cardíaca de la Vall d'Hebrón de Barcelona. Se distinguen claramente dos grupos, el primero con 2.501 pacientes intervenidos entre 1982 y 1999, que conforman una base de datos de 150.000 datos. El segundo grupo con 918 pacientes entre los años 2000 a 2003 forma una base de datos con 172.748 datos. Se analizan todas las variables, a fin de elucidar los factores del paciente, propios y patológicos, del proceso quirúrgico y del postoperatorio, a fin de identificar aquellas variables predictivas de morbi-mortalidad, determinantes por lo tanto de la evolución del paciente afecto de cardiopatía isquémica en nuestro entorno. Se analizan múltiples factores, entre ellos, el volumen de los pacientes intervenidos, al igual que la edad, el sexo, la existencia y tipo de comorbilidad, o patología no cardíaca, al igual que el tipo y grado de afectación cardíaca. También se analizan las características de la actuación quirúrgica, y el efecto de todos y cada uno de ellos en los resultados. Dentro de los resultados, se analiza tanto la comorbilidad total, como la específica, en términos de complicaciones globales y propias de diferentes órganos y sistemas vitales, responsables en última instancia de la evolución del paciente, tanto en forma de morbilidad, como de estancia hospitalaria. Igualmente se realiza un análisis de la técnica quirúrgica, en concreto la cirugía coronaria sin circulación extracorpórea, a fin de determinar su implicación en los resultados obtenidos por el equipo quirúrgico de la Vall d'Hebrón. Entre los resultados obtenidos, se muestran factores predictivos de morbilidad en el postoperatorio a la edad, el infarto de miocardio reciente, el angor inestable, la revascularización incompleta, el empleo de circulación extracorpórea (CEC), la insuficiencia renal y la cirugía urgente. Como factores predictivos de mortalidad destacan la edad, el empleo de CEC, la necesidad de balón de contrapulsación intraaórtico, la cirugía urgente y el infarto reciente. Finalmente se destacan los resultados de la cirugía coronaria sin CEC los cuales, sin duda, muestran a dicha técnica como una opción terapéutica razonable dentro del arsenal terapéutico para el paciente con miocardiopatía isquémica en nuestro medio

An Uncommon Cause of Dyspnea: Usefulness of Multimodality Cardiac Imaging

Tomografia computada; Falta d'alè; EcografiaComputed tomography; Shortness of breath; UltrasoundTomografía computarizada; Falta de aliento; EcografíaPericardial lipomas are very uncommon benign primary cardiac tumors. We describe the case of a patient with symptomatic large pericardial mass who presented with heart failure. Multimodality cardiac imaging helped us in the diagnosis of this unusual entity. (Level of Difficulty: Intermediate.

Extracorporeal membrane oxigenation in COVID-19 patients: Results of the ECMO-COVID Registry of the Spanish Society of Cardiovascular and Endovascular Surgery

Oxigenación con membrana extracorpórea; COVID-19; Insuficiencia cardiacaExtracorporeal membrane oxygenation; COVID-19; Heart failureOxigenació amb membrana extracorpòria; COVID-19; Insuficiència cardíacaIntroducción y objetivos La oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes con COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos En marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes con COVID-19 tratados mediante ECMO veno-arterial (V-A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias preimplante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento tras el alta. Resultados Se analizó a un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media de 52,7 y 49,4 años, respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33,3% y el 34,9% de los pacientes con ECMO V-A y V-V, respectivamente, fueron dados de alta del hospital (p = NS) y la mortalidad fue similar, del 56,2% y 50,9% de los casos respectivamente, la inmensa mayoría durante la ECMO y sobre todo por fracaso multiorgánico. El 14,0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196 ± 101,7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0,967; IC 95%: 0,95-0,99; p = 0,004) y la procedencia del propio hospital (OR 0,48; IC 95%: 0,27-0,88; p = 0,018), mientras que la edad (OR 1,063; IC 95%: 1,005-1,12; p = 0,032), la hipertensión arterial (3,593; IC 95%: 1,06-12,19; p = 0,04) y las complicaciones en ECMO globales (2,44; IC 95%: 0,27-0,88; p = 0,019), digestivas (OR 4,23, IC 95%: 1,27-14,07; p = 0,019) y neurológicas (OR 4,66; IC 95%: 1,39-15,62; p = 0,013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones La terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la hipertensión arterial y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional solo se ve influida por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave mejoraría los resultados y la futura investigación clínica.Background and aim: COVID-19 patients with severe heart or respiratory failure are potential candidates for extracorporeal membrane oxygenation (ECMO). Indications and management of these patients are unclear. Our aim is to describe the results of a prospective registry of COVID-19 patients treated with ECMO. Methods: An anonymous prospective registry of COVID-19 patients treated with veno-arterial (V-A) or veno-venous (V-V) ECMO was created on march 2020. Clinical, analytical and respiratory preimplantation variables, implantation data and post-implantation course data were recorded. The primary endpoint was all cause in-hospital mortality. Secondary events were functional recovery and the combined endpoint of mortality and functional recovery in patients followed at least 3 months after discharge. Results: Three hundred and sixty-six patients from 25 hospitals were analyzed, 347 V-V ECMO and 18 V-A ECMO patients (mean age 52.7 and 49.5 years respectively). Patients with V-V ECMO were more obese, had less frequently organ damage other than respiratory failure and needed less inotropic support; Thirty three percent of V-A ECMO and 34.9% of V-A ECMO were discharged (P = NS). Hospital mortality was non-significantly different, 56.2% versus 50.9% respectively, mainly during ECMO therapy and mostly due to multiorgan failure. Other 51 patients (14%) remained admitted. Mean follow-up was 196 ± 101.7 days (95%CI: 170.8-221.6). After logistic regression, body weight (OR 0.967, 95%CI: 0.95-0.99, P = 0.004) and ECMO implantation in the own centre (OR 0.48, 95%CI: 0.27-0.88, P = 0.018) were protective for hospital mortality. Age (OR 1.063, 95%CI: 1.005-1.12, P = 0.032), arterial hypertension (3.593, 95%CI: 1.06-12.19, P = 0.04) and global (2.44, 95%CI: 0.27-0.88, P = 0.019), digestive (OR 4,23, 95%CI: 1.27-14.07, P = 0.019) and neurological (OR 4.66, 95%CI: 1.39-15.62, P = 0.013) complications during ECMO therapy were independent predictors of primary endpoint occurrence. Only the post-discharge day at follow-up was independent predictor of both secondary endpoints occurrence. Conclusions: Hospital survival of severely ill COVID-19 patients treated with ECMO is near 50%. Age, arterial hypertension and ECMO complications are predictors of hospital mortality, and body weight and implantation in the own centre are protective. Functional recovery is only predicted by the follow-up time after discharge. A more homogeneous management of these patients is warranted for clinical results and future research optimization

Data analysis from the Spanish Registry of Cardiac Surgery (RECC) 2021-2022

Cardiovascular surgery; Acquired cardiac disease; Aortic surgeryCirurgia cardiovascular; Cardiopaties adquirides; Cirurgia aòrticaCirugía cardiovascular; Cardiopatías adquiridas; Cirugía aórticaIntroducción Desde el 8 de febrero de 2021, la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) puso en marcha el Registro Español de Cirugía Cardiaca (RECC) que está disponible para las diferentes unidades de cirujanos cardiovasculares de nuestro país. Es una herramienta que permite recopilar datos de pacientes sometidos a cirugía cardiaca, vascular o endovascular. Tras dos años de desarrollo, hemos llevado a cabo un análisis de la calidad de la información obtenida para adquirir una visión general de su contenido. Métodos La información ha sido analizada de forma anónima a nivel de paciente, hospital y provincia. Para la estimación de la mortalidad ajustada por riesgo se utilizó la escala de estimación de riesgo preoperatorio EuroSCORE II. Resultados Se han incluido en el RECC un total de 7.087 intervenciones, de las cuales 6.267 se trataban de cirugías cardiacas mayores. Del total de intervenciones mayores, 53,9% eran cirugías valvulares, 25,2% de revascularización miocárdica y 14,9% de aorta. La mortalidad global de la serie fue de 5,0% y el índice de mortalidad ajustada al riesgo (IMAR) de 0,88. La calibración del EuroSCORE II en la muestra global fue buena en los pacientes de riesgo más bajo, aunque sobreestimó la mortalidad en los de alto riesgo. Conclusiones El RECC se trata de una base de datos clínica nacional que permite el análisis de datos de pacientes con el fin de evaluar de forma precisa el volumen de la actividad, riesgo y resultados. A nivel local, podría utilizarse como una herramienta para mejorar la calidad de la atención y el desarrollo de programas correctivos.Introduction Since February 8, 2021, the Spanish Society of Cardiovascular and Endovascular Surgery got under way the Spanish Registry of Cardiac Surgery (RECC), which is available for the different units of cardiovascular surgeons in our country. It is a tool that allows collect patient-level data of patients undergoing cardiac, vascular or endovascular surgery. After two years of development, we have carried out an analysis of the quality of the information obtained in order to acquire an overview of its content. Methods The information has been analyzed anonymously at patient, hospital and province level. For risk-adjusted mortality estimation, the EuroSCORE II preoperative risk estimation scale was used. Results A total of 7087 interventions have been included. Six thousand two hundred and sixty-seven were major cardiac surgeries: 53.9% valvular, 25.2% coronary artery bypass grafting, and 14.9% aortic procedures. The overall mortality was 5.0% and the risk-adjusted mortality rate was 0.88. The EuroSCORE II calibration in the overall sample was good in the lowest-risk patients, although it overestimated mortality in high-risk patients. Conclusions RECC is a nationally defined clinical database in the field of cardiovascular surgery. RECC allows a patient-level data analysis in order to perform an accurate analysis of the volumen of activity, risk adjustment and results. Locally, it could be used as a tool to improve the quality of care and development of corrective programs

Oxigenación con membrana extracorpórea en el paciente COVID-19: resultados del Registro Español ECMO-COVID de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE)

Background and aim: COVID-19 patients with severe heart or respiratory failure are potential candidates for extracorporeal membrane oxygenation (ECMO). Indications and management of these patients are unclear. Our aim is to describe the results of a prospective registry of COVID-19 patients treated with ECMO. Methods: An anonymous prospective registry of COVID-19 patients treated with veno-arterial (V-A) or veno-venous (V-V) ECMO was created on march 2020. Clinical, analytical and respiratory preimplantation variables, implantation data and post-implantation course data were recorded. The primary endpoint was all cause in-hospital mortality. Secondary events were functional recovery and the combined endpoint of mortality and functional recovery in patients followed at least 3 months after discharge. Results: Three hundred and sixty-six patients from 25 hospitals were analyzed, 347 V-V ECMO and 18 V-A ECMO patients (mean age 52.7 and 49.5 years respectively). Patients with V-V ECMO were more obese, had less frequently organ damage other than respiratory failure and needed less inotropic support; Thirty three percent of V-A ECMO and 34.9% of V-A ECMO were discharged (P = NS). Hospital mortality was non-significantly different, 56.2% versus 50.9% respectively, mainly during ECMO therapy and mostly due to multiorgan failure. Other 51 patients (14%) remained admitted. Mean follow-up was 196 +/- 101.7 days (95%CI: 170.8-221.6). After logistic regression, body weight (OR 0.967, 95%CI: 0.95-0.99, P = 0.004) and ECMO implantation in the own centre (OR 0.48, 95%CI: 0.27-0.88, P = 0.018) were protective for hospital mortality. Age (OR 1.063, 95%CI: 1.005-1.12, P = 0.032), arterial hypertension (3.593, 95%CI: 1.06-12.19, P = 0.04) and global (2.44, 95%CI: 0.27-0.88, P = 0.019), digestive (OR 4,23, 95%CI: 1.27-14.07, P = 0.019) and neurological (OR 4.66, 95%CI: 1.39-15.62, P = 0.013) complications during ECMO therapy were independent predictors of primary endpoint occurrence. Only the post-discharge day at follow-up was independent predictor of both secondary endpoints occurrence. Conclusions: Hospital survival of severely ill COVID-19 patients treated with ECMO is near 50%. Age, arterial hypertension and ECMO complications are predictors of hospital mortality, and body weight and implantation in the own centre are protective. Functional recovery is only predicted by the follow-up time after discharge. A more homogeneous management of these patients is warranted for clinical results and future research optimization. (C) 2022 Sociedad Espanola de Cirugia Cardiovascular y Endovascular. Published by Elsevier Espana, S.L.U

Extracorporeal membrane oxigenation in COVID-19 patients: results of the ECMO-COVID Registry of the Spanish Society of Cardiovascular and Endovascular Surgery

© 2022 Sociedad Espanola de Cirugía Cardiovascular y Endovascular. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/. This document is the Published version of a Published Work that appeared in final form in Cirugía Cardiovascular. To access the final edited and published work see https://doi.org//10.1016/j.circv.2022.01.007Introducción y objetivos: La oxigenación con membrana extracorpórea (ECMO) ha resultado ser una opción terapéutica en los pacientes con insuficiencia respiratoria o cardiaca severa por COVID-19. Las indicaciones y manejo de estos pacientes están aún por determinar. Nuestro objetivo es evaluar los resultados de la terapia ECMO en pacientes con COVID-19 incluidos en un registro prospectivo e intentar optimizar los resultados. Métodos: En marzo de 2020 se inició un registro multicéntrico anónimo prospectivo de pacientes con COVID-19 tratados mediante ECMO veno-arterial (V-A) o veno-venosa (V-V). Se registraron las variables clínicas, analíticas y respiratorias preimplante, datos de implante y evolución de la terapia. El evento primario fue la mortalidad hospitalaria de cualquier causa y los eventos secundarios fueron la recuperación funcional y el evento combinado de recuperación funcional y mortalidad de cualquier causa a partir de los 3 meses de seguimiento tras el alta. Resultados: Se analizó a un total de 365 pacientes procedentes de 25 hospitales, 347 V-V y 18 V-A (edad media de 52,7 y 49,4 años, respectivamente). Los pacientes con ECMO V-V fueron más obesos, presentaban menos fracaso orgánico diferente al pulmonar y precisaron menos terapia inotrópica previa al implante. El 33,3% y el 34,9% de los pacientes con ECMO V-A y V-V, respectivamente, fueron dados de alta del hospital (p = NS) y la mortalidad fue similar, del 56,2% y 50,9% de los casos respectivamente, la inmensa mayoría durante la ECMO y sobre todo por fracaso multiorgánico. El 14,0% (51 pacientes) permanecían ingresados. El seguimiento medio fue de 196 ± 101,7 días. En el análisis multivariante, resultaron protectores de evento primario en pacientes con ECMO V-V el peso corporal (OR 0,967; IC 95%: 0,95-0,99; p = 0,004) y la procedencia del propio hospital (OR 0,48; IC 95%: 0,27-0,88; p = 0,018), mientras que la edad (OR 1,063; IC 95%: 1,005-1,12; p = 0,032), la hipertensión arterial (3,593; IC 95%: 1,06-12,19; p = 0,04) y las complicaciones en ECMO globales (2,44; IC 95%: 0,27-0,88; p = 0,019), digestivas (OR 4,23, IC 95%: 1,27-14,07; p = 0,019) y neurológicas (OR 4,66; IC 95%: 1,39-15,62; p = 0,013) fueron predictores independientes de mortalidad. El único predictor independiente de aparición de los eventos secundarios resultó el momento de seguimiento del paciente. Conclusiones: La terapia con ECMO permite supervivencias hospitalarias hasta del 50% en pacientes con COVID-19 grave. La edad, la hipertensión arterial y las complicaciones en ECMO son los predictores de mortalidad hospitalaria en pacientes con ECMO V-V. Un mayor peso corporal y la procedencia del propio hospital son factores protectores. La recuperación funcional solo se ve influida por el tiempo de seguimiento transcurrido tras el alta. La estandarización de los criterios de implante y manejo del paciente con COVID grave mejoraría los resultados y la futura investigación clínica.Background and aim: COVID-19 patients with severe heart or respiratory failure are potential candidates for extracorporeal membrane oxygenation (ECMO). Indications and management of these patients are unclear. Our aim is to describe the results of a prospective registry of COVID-19 patients treated with ECMO. Methods: An anonymous prospective registry of COVID-19 patients treated with veno-arterial (V-A) or veno-venous (V-V) ECMO was created on march 2020. Clinical, analytical and respiratory preimplantation variables, implantation data and post-implantation course data were recorded. The primary endpoint was all cause in-hospital mortality. Secondary events were functional recovery and the combined endpoint of mortality and functional recovery in patients followed at least 3 months after discharge. Results: Three hundred and sixty-six patients from 25 hospitals were analyzed, 347 V-V ECMO and 18 V-A ECMO patients (mean age 52.7 and 49.5 years respectively). Patients with V-V ECMO were more obese, had less frequently organ damage other than respiratory failure and needed less inotropic support; Thirty three percent of V-A ECMO and 34.9% of V-A ECMO were discharged (P = NS). Hospital mortality was non-significantly different, 56.2% versus 50.9% respectively, mainly during ECMO therapy and mostly due to multiorgan failure. Other 51 patients (14%) remained admitted. Mean follow-up was 196 ± 101.7 days (95%CI: 170.8-221.6). After logistic regression, body weight (OR 0.967, 95%CI: 0.95-0.99, P = 0.004) and ECMO implantation in the own centre (OR 0.48, 95%CI: 0.27-0.88, P = 0.018) were protective for hospital mortality. Age (OR 1.063, 95%CI: 1.005-1.12, P = 0.032), arterial hypertension (3.593, 95%CI: 1.06-12.19, P = 0.04) and global (2.44, 95%CI: 0.27-0.88, P = 0.019), digestive (OR 4,23, 95%CI: 1.27-14.07, P = 0.019) and neurological (OR 4.66, 95%CI: 1.39-15.62, P = 0.013) complications during ECMO therapy were independent predictors of primary endpoint occurrence. Only the post-discharge day at follow-up was independent predictor of both secondary endpoints occurrence. Conclusions: Hospital survival of severely ill COVID-19 patients treated with ECMO is near 50%. Age, arterial hypertension and ECMO complications are predictors of hospital mortality, and body weight and implantation in the own centre are protective. Functional recovery is only predicted by the follow-up time after discharge. A more homogeneous management of these patients is warranted for clinical results and future research optimization

Search for heavy resonances decaying to two Higgs bosons in final states containing four b quarks

A search is presented for narrow heavy resonances X decaying into pairs of Higgs bosons (H) in proton-proton collisions collected by the CMS experiment at the LHC at root s = 8 TeV. The data correspond to an integrated luminosity of 19.7 fb(-1). The search considers HH resonances with masses between 1 and 3 TeV, having final states of two b quark pairs. Each Higgs boson is produced with large momentum, and the hadronization products of the pair of b quarks can usually be reconstructed as single large jets. The background from multijet and t (t) over bar events is significantly reduced by applying requirements related to the flavor of the jet, its mass, and its substructure. The signal would be identified as a peak on top of the dijet invariant mass spectrum of the remaining background events. No evidence is observed for such a signal. Upper limits obtained at 95 confidence level for the product of the production cross section and branching fraction sigma(gg -> X) B(X -> HH -> b (b) over barb (b) over bar) range from 10 to 1.5 fb for the mass of X from 1.15 to 2.0 TeV, significantly extending previous searches. For a warped extra dimension theory with amass scale Lambda(R) = 1 TeV, the data exclude radion scalar masses between 1.15 and 1.55 TeV

Differential cross section measurements for the production of a W boson in association with jets in proton–proton collisions at √s = 7 TeV

Measurements are reported of differential cross sections for the production of a W boson, which decays into a muon and a neutrino, in association with jets, as a function of several variables, including the transverse momenta (pT) and pseudorapidities of the four leading jets, the scalar sum of jet transverse momenta (HT), and the difference in azimuthal angle between the directions of each jet and the muon. The data sample of pp collisions at a centre-of-mass energy of 7 TeV was collected with the CMS detector at the LHC and corresponds to an integrated luminosity of 5.0 fb[superscript −1]. The measured cross sections are compared to predictions from Monte Carlo generators, MadGraph + pythia and sherpa, and to next-to-leading-order calculations from BlackHat + sherpa. The differential cross sections are found to be in agreement with the predictions, apart from the pT distributions of the leading jets at high pT values, the distributions of the HT at high-HT and low jet multiplicity, and the distribution of the difference in azimuthal angle between the leading jet and the muon at low values.United States. Dept. of EnergyNational Science Foundation (U.S.)Alfred P. Sloan Foundatio

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI