Average and Interindividual Effects to a Comprehensive Cardiovascular Rehabilitation Program

Background: To describe the average effects and the interindividual variability after a comprehensive outpatient cardiovascular rehabilitation (CCR) program using concurrent exercise training prescribed according to cardiovascular risk stratification on cardiorespiratory fitness (CRF), anthropometric/body composition, quality of life and emotional health in patients of four cardiovascular disease profiles. Methods: CRF, anthropometric/body composition, quality of life, and emotional health were measured before and after a CCR and analyzed in heart valve surgery (HVS), heart failure with reduced ejection fraction (HFrEF), post-acute myocardial infarction (post-AMI), and in coronary artery disease (CAD) patients. Twenty, twenty-four, and thirty-two exercise sessions were prescribed according to mild, moderate, and severe baseline cardiovascular risk, respectively. In addition to concurrent exercise training, nutritional counseling, psychological support, and lifestyle education programs were performed. Results: The main outcomes by delta changes comparisons (Δ) revealed no significant differences at anthropometric/body composition as ΔBody fat decreases (HVS Δ−1.1, HFrEF Δ−1.0, post-AMI Δ−1.4, CAD Δ−1.2 kg) and ΔSkeletal muscle mass increases (HVS Δ+1.4, HFrEF Δ+0.8, post-AMI Δ+0.9, CAD Δ+0.9 kg), and CRF performance as ΔVO2peak increases (HVS Δ+4.3, HFrEF Δ+4.8, post-AMI Δ+4.1, CAD Δ+5.1 mL/kg/min) outcomes among HVS, HFrEF, post-AMI, and CAD (p > 0.05). Secondary outcomes showed significant pre-post delta changes in METs (HVS Δ+1.8, HFrEF Δ+0.7, post-AMI Δ+1.4, CAD Δ+1.4), and maximal O2pulse (HVS Δ+3.1, post-AMI Δ+2.1, CAD Δ+1.9). In addition, quality of life had a significant improvement in physical functioning (HVS Δ+17.0, HFrEF Δ+12.1, post-AMI Δ+9.8, CAD Δ+11.2), physical role (HVS Δ+28.4, HFrEF Δ+26.8, post-AMI Δ+25.6, CAD Δ+25.3), vitality (HVS Δ+18.4, HFrEF Δ+14.3, post-AMI Δ+14.2, CAD Δ+10.6) and social functioning (HVS Δ+20.4, HFrEF Δ+25.3, post-AMI Δ+20.4, CAD Δ+14.8) in all cardiovascular disease. For anxiety (HVS Δ−3.6, HFrEF Δ−2.3, post-AMI Δ−3.0, CAD Δ−3.1) and depression (HVS Δ−2.8, HFrEF Δ−3.4, post-AMI Δ−3.2, CAD Δ−2.3) significant changes were also observed. Conclusions: A CCR program that prescribes the number of exercise sessions using a cardiovascular risk stratification improves CRF, QoL, and emotional health, and the average results show a wide interindividual variability (~25% of non-responders) in this sample of four CVD profile of patients.

[Cardiac myxomas. Analysis of 78 cases]

BACKGROUND

The incidence rates of cardiac tumors are low.

AIM

To report the clinical presentation of cardiac myxomas and long-term evolution after resection.

MATERIAL AND METHODS

Review of a database of surgical patients undergoing surgical resection of a cardiac myxoma in a public hospital between 1990 and 2018.

RESULTS

Seventy-eight patients aged 53 ± 15 years (65% females) were included. The most frequent comorbidities were arterial hypertension (40.5%), hypothyroidism (15%) and diabetes mellitus (12%). The main presenting symptoms were dyspnea (33%), neurological deficit secondary to embolism (30%) and acute pulmonary edema (5%). The most common location was the left atrium, in 87%. During surgery, cardiopulmonary bypass and aortic cross-clamp times were 50.2 ± 19.6 and 33.4 ± 15.2 min, respectively. One patient died due to severe neurological involvement. Follow-up was completed in seventy-seven patients, with a mean echocardiographic follow-up time of 10.4 ± 7.7 years. Thirty-four patients were followed for more than 10 years. Six patients (7.7%) died during the follow-up and in six patients (7%) a recurrence was identified.

CONCLUSIONS

Cardiac myxoma usually has nonspecific symptoms. Surgical excision offers excellent short and long-term results. Complications and recurrence rates are low in non-hereditary myxomas but obligates to perform echocardiographic follow-up for early diagnosis of recurrence.

[Hospital mortality and long-term survival of 103 patients with infective endocarditis requiring surgery]

Background Infective endocarditis (IE) is a serious disease with high mortality, especially among the most severe cases undergoing surgery. Aim To analyze the clinical features, perioperative mortality and long-term survival of patients with infective endocarditis requiring surgery. Material and Methods Review of medical records of patients who underwent heart valve surgery for active infective endocarditis in a public hospital between 1995 and 2008. Demographic characteristics and comorbidities were described. Perioperative and 10 year survival were analyzed retrieving death certificates from the Chilean Identification Service. Results Data from 103 patients aged 46 ± 14 years (74% males) was analyzed. Thirty five percent of patients had an underlying predisposing heart condition such as congenital heart disease in 18.5% and prosthetic valves in 10%. The most common location was the aortic valve and the most common surgical procedure was heart valve replacement with a mechanical prosthetic valve in 87% of the cases. Pathogen identification in blood cultures was achieved in 48% of the cases. The most common causative microorganisms were S. aureus in 12%, coagulase-negative Staphylococcus in 11%, S. viridans in 10% and Enterococcus in 7%. Hospital mortality was 20.4% and ten-year survival was 65%. Conclusions Patients with severe IE requiring surgical treatment still have high perioperative and late mortality.

Left ventricular assist device (LVAD) program in Chile: first successful experience in South America

Background

The need to have a variety of tools to deal with end-stage heart failure (ES-HF), along with the limited heart transplantation availability encouraged us to create a pilot Left ventricular assist device (LVAD) program in a public health care system hospital in Chile.

Methods

A retrospective analysis of the first nine patients of an ongoing LVAD program initiated on August 2013 was performed, completing an average of 30 months of follow-up. The most important events regarding to morbidity and mortality are described.

Results

Nine patients with ES-HF underwent LVAD implantation surgery; one of them died 23 days after surgery and another died after 11 months. One patient successfully underwent heart transplantation after 16 months of HeartWare ventricular assist device (HVAD) support; the other six patients remain in the program and have an average follow-up of 846 days at the time of this study (range, 23-1,481 days). The survival rate at 6, 12 and 18 months follow-up was 89%, 78% and 78% respectively.

Conclusions

This new pioneering LVAD program in Chile has been successful and now constitutes a vital adjunct to all who work in heart transplantation and ES-HF programs. It offers an effective therapeutic alternative when there is a severe donor shortage, in cases of atypical blood types, emergencies, exceptional cases with contraindication for heart transplantation or when there is important donor-receiver size mismatch.

Risk scores do not predict high mortality after coronary artery bypass surgery in the presence of diastolic dysfunction

BACKGROUND

Although global postoperative mortality after on-pump coronary artery bypass grafting is approximately 3%, in some groups it can be considerably higher. Many conditions are known to increase mortality and have been included in well-known scoring systems; however, left ventricular diastolic dysfunction has not been sufficiently evaluated to identify its predictive value for mortality after coronary artery bypass grafting, nor is it integrated in currently used risk scores.

METHODS

Left ventricular filling pattern was prospectively evaluated in 191 patients scheduled for on-pump coronary artery bypass grafting. A follow-up of survival and complications was made for 30 days postoperatively. Observed mortality was compared with the mortality predicted by the scores of EuroSCORE and Parsonnet.

RESULTS

A correlation was found between diastolic function, the presence of comorbidities, and postoperative survival. There was no mortality in the group with normal filling pattern (0 of 33 patients). In the presence of an alteration of relaxation, mortality was 5 of 129 patients (3.8%); in the pseudonormal group it was 2 of 16 patients (12.5%); and in the restrictive group it was 6 of 13 patients (46.1%; p < 0.01). Parsonnet and EuroSCORE predicted a mortality of 1.5% to 1.6%, 1.5% to 2.0%, 1.5% to 2.2%, and 3.9% to 4.1% for each group, respectively. Mortality in the group with E deceleration time of 150 ms or greater was 2.8% and in the group with E deceleration time less than 150 ms was 17.3% (p < 0.01). Postoperative complications were also more frequent in the group with advanced dysfunction.

CONCLUSIONS

Severe diastolic dysfunction is a strong predictor of adverse outcome and mortality after on-pump coronary artery bypass grafting, and this high risk is not adequately predicted by EuroSCORE and Parsonnet score. Measures of diastolic function should be included in routine preoperative risk assessment.

[Severe aneurismal coronary artery disease probably caused by Kawasaki disease. report of one case]

We report a 16 year old male with a history of angina on exertion. A treadmill exercise test was positive for ischemia in concordance with a Thallium-201 scintigraphy showing a septal and infero-posterior reversible myocardial perfusión defect. Coronary angiography disclosed severe aneurysmal coronary artery disease. Bilateral internal mammary coronary artery bypass grafting was successfully performed. Kawasaki disease is the most likely etiology, although not confirmed.

Heart Transplantation in Chile: Preliminary Report From the Gustavo Fricke Hospital in Vina del Mar

OBJECTIVE

The aim of this study was to analyze our results as the national reference center of the public health network in Chile.

PATIENTS AND METHODS

Retrospective analysis of all transplantations performed between 1998 and 2005 was done and actuarial survival estimates were calculated according to Kaplan-Meier.

RESULTS

Heart transplantations were performed in 25 patients of mean age 43 +/- 11.2 years. Eight patients (32%) were transplanted from a national priority list; all patients were under intensive care support with inotropic therapy, 4 were mechanically ventilated, and 1 required an intra-aortic counter pulsation balloon. The average time on the waiting list was 145 days in nonurgent cases and 9.4 days in urgent ones. Perioperative mortality occurred in 1 patient (4%) due to primary graft failure; 2 patients died due to infectious complications during the first year of follow-up; and 1 died due to a non-cytomegalovirus (CMV) infection at 51 months after transplantation. Two patients developed acute rejection with full recovery. The most common morbidities in the current series were hypertension (71%); hyperlipidemia (71%); renal dysfunction (24%); diabetes (10%); and vasculopathy (10%). Actuarial survival rates were 87.2% and 74.7% at 12 and 86 months, respectively. At 7 years follow-up, 20 patients were in New York Heart Association (NYHA) Class I and one Class II.

CONCLUSION

Our heart transplantation program showed comparable results in the short and midterm follow-up when compared with other international reports, confirming that heart transplantation is an excellent therapeutic option for patients with end-stage heart failure.

[Partial left ventriculectomy for end stage dilated cardiomyopathy. Is it an alternative for heart transplantation?]

We present a case of a 60 year old male with end stage dilated cardiomyopathy in NYHA functional class IV in whom a partial left ventriculectomy was performed, a new surgical procedure developed in Brazil and done for the first time in Chile. Left ventricular size reduction produced an objective improvement on echocardiographic parameters of left ventricular function as well as in patient's NYHA functional class in the early post operative period.

[Cardiac transplantation: economizing cyclosporin A by including ketoconazole in the immunosuppressive schedule]

Use of cyclosporin A has improved survival in patients submitted to cardiac transplantation. However, high cost of cyclosporin poses a problem for many patients in Chile. Ketoconazole is able to reduce hepatic metabolism of cyclosporin and thus prolong therapeutic levels. A 74 to 82% reduction in cyclosporin requirements was obtained in a cardiac transplant patient by adding ketoconazole. No renal damage was detected. Therefore, this drug association may help extend cardiac transplantation programs in Chile.

Dissecting aneurysm of the ascending aorta with aorto-caval fistula. Fiberoptic oximetric findings and surgical management

A patient presented the rare complication of a dissecting aneurysm of the ascending aorta ruptured into the superior vena cava producing a left-right fistula. Continuous oximetric measurements by a fiberoptic pulmonary artery floated catheter was used to localize the site of the shunt. Emergency surgical repair was successfully performed.

Amrinone in the management of low cardiac output after open heart surgery

Hemodynamic effects of amrinone were studied in 2 groups of patients after open heart surgery. Group I consisted of 10 patients with moderate heart failure. In the absence of inotropic agents, their mean cardiac index (CI) was 2.02 +/- 0.41 liters/min/m2 and mean pulmonary capillary wedge pressure (PCWP) 19 +/- 3 mm Hg. Amrinone was administered 24 hours postoperatively by bolus injection (2 mg/kg) and by 12-hour infusions (20 micrograms/kg/min). Hemodynamic data and plasma concentrations were obtained 10 and 20 minutes after the bolus injection and at 1, 4, 8 and 12 hours during infusion. Significant beneficial changes were noted in CI, PCWP, right atrial pressure, systemic vascular resistance and pulmonary vascular resistance. Group II consisted of 5 patients in severe cardiogenic shock (mean CI 1.97 +/- 0.3 liters/min/m2, mean PCWP 28 +/- 8 mm Hg) despite adrenergic agonists in all patients and intraaortic counterpulsation in 2. After these measures, amrinone was given intravenously for 36 to 72 hours as additional inotropic support. Significant improvement was observed in CI, PCWP, right atrial pressure, systemic vascular resistance and pulmonary vascular resistance. Four patients in this group were discharged; 1 patient died after 5 days in acute renal failure and coma grade IV. No serious adverse effects of amrinone were observed in any group II patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical use and bacteriological studies of catheter contamination sleeves

A system combining a valved introducer sheath and a plastic protective sleeve enabling repositioning of pulmonary artery catheters was tested in 73 cardiac surgical patients. It was used for a mean time of 70.3 h and allowed for improved hemodynamic monitoring. A 12 percent incidence of valve contamination was found and makes the safety of the device questionable.