S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100001 El cliclo renovador Ansín Juan Carlos ,Consultorios Médicos Paitilla Ciudad de Panamá Panamá 04 2003 2003 5 3 3
S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100002 ALLHAT Y ANBP2... algunas respuestas y muchas preguntas... Pichel Daniel R. Rodríguez Antonio J. Motta Jorge A. ,Cardiólogos Asociados de Panamá Panamá 04 2003 2003 5 4 7
S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100003 Autotransfusión y terapia de componentes sanguíneos autológos en cirugía cardíaca: consideraciones generales y experiencia en el Hospital México Induni López Eduardo Alvarado Manuel Méndez Edgar Pucci Juan ,CCSS Hospital México Servicio de Cirugía de Tórax y Cardiovascular San José Costa Rica 04 2003 2003 5 9 18

Introducción: La autotransfusión sanguínea y terapia de componentes autólogos ha sido una modalidad que se ha utilizado desde hace más de 2 siglos experimentando gracias a los avances técnicos recientes, su implementación en maniobras que redundan en ahorro y eliminación de pérdidas sanguíneas en procedimientos quirúrgicos extensos, así como los riesgos inherentes a la transfusión homóloga. Objetivos: Disminuír el número de días de estancia hospitalaria en pacientes preparándose para cirugía extracorpórea, y emplear plaquetoferésis preoperatoria y gomas biológicas plaquetarias para disminuir el sangrado y los requerimientos transfusionales en cirugía cardíaca. Material y métodos: De los pacientes sometidos a cirugía cardíaca con circulación extracorpórea en el Hospital México en un período comprendido entre Febrero de 1997 y Febrero del 2003, fue utilizada la autotransfusión de glóbulos rojos por recuperación intraoperatoria en un total de 150 pacientes. A todos se les realizó autotransfusión de globulos rojos lavados para lo cual se utilizó la máquina tipo Cell Saver, Secuestra 1000, (Medtronic, Minneapolis, Mn.). Se incluyeron pacientes con reoperaciones cardíacas, cirugía coronaria múltiple o complicada, cirugías intracardíacas complejas, pacientes anémicos o de grupos sanguíneos raros sin posibilidad de obtener sangre y pacientes Testigos de Jehová como parte del protocolo de cirugía. A pacientes con cirugías complejas y sin previa heparinizacion, se les realizó secuesto plaquetario preoperatorio ademas de confeccionar gel sellante con concentrados plaquetarios. La circulación extracorpórea fué realizada con hipotermia moderada en todos los pacientes excepto en uno con una cirugía compleja en que se requirió arresto circulatorio con hipotermia profunda. Los datos referentes al hematocrito pre, trans y postoperatorios fueron recopilados, así como el número de unidades de componentes obtenidas, analizando otras variables relacionadas. Resultados: Se realizaron un total de 225 cirugías en 150 pacientes para un promedio de 1.5 procedimientos por paciente. De los 150 pacientes operados, 100 correspondieron a hombres (66%) y 50 a mujeres (33%). El promedio de edad fue de 47.8 (+ 22.8 -34.8). Veintiseis pacientes correspondieron a Testigos de Jehová por lo que su utilización fue indicada ante la condición de no ser transfundidos. Se procesaron un total de 317.76 litros de aspirado del campo operatorio. Un total de 156.45 litros de glóbulos rojos fueron recuperados del aspirado, correspondiendo a un promedio de 1.043 cc por paciente. A 26 pacientes se les realizó plaquetoféresis y plasmaféresis preoperatoria, obteniéndose 11.000 cc de plasma fresco, siendo un promedio de 423.07 cc, así como 5.600 cc de plaquetas (215.38 cc por paciente). Se confeccionó gel plaquetario en veinte pacientes, utilizado para sellar sitios sangrantes en reoperaciones, aneurismas de aorta y en suturas de cardiotomías, obteniéndose un promedio de 64.28 cc de gel plaquetario claro por paciente. La hemostasia fue exitosa en todos los pacientes después de realizada su aplicación. Un total de 30 unidades de banco fueron procesadas para separar los glóbulos rojos. Ningún paciente a los cuales se realizó plaquetoféresis requirió que fuese transfundido con plaquetas adicionales o plasma fresco. Las cuentas plaquetarias preoperatorias fueron en promedio 207.000 pks / mm3 y las postoperatorias de control fueron 203.000 / mm3. Se observó una disminución en el sangrado promedio post cirugía de 740 cc, a 230 cc en los que se realizó plaquetoféresis obteniéndose casi un 70 % menos de sangrado en los sellos de tórax. A los pacientes Testigos de Jehová, se les procesó un promedio de 650 cc, en relación al promedio general de 1.043 cc. El requerimiento transfusional homólogo en el postoperatorio inmediato por paciente, fue de 0.9 unidades, comparado con 4.1 unidades utilizadas por paciente normalmente existiendo una reducción de más del 70%. El hematocrito preoperatorio fue de 38.3%; al encontrarse en hemodilución transoperatoria por circulación extracorpórea se obtuvo un promedio de 20.5%, y en el postoperatorio inmediato del 31%. La estancia preoperatoria fue de 2 días en pacientes con autotransfusión comparado a 6.2 promedio cuando fue necesario conseguir donantes de sangre, y la estancia postoperatoria fue de 7 y 7.2 días respectivamente. Conclusiones: El presente trabajo nos muestra un método novedoso para el ahorro sanguíneo, siendo de gran importancia no solo en el ámbito económico al reducir los días de estancia pre y postoperatoria, sino que además se eliminan los riesgos de transfusión homóloga ampliamente conocidos. Se disminuyeron los requerimientos transfusionales de GRE en un 70% y se eliminaron los de plaquetas en su totalidad. Así mismo se redujo el sangrado postoperatorio en forma significativa del 68% en pacientes con plaquetoféresis, sumándose a ésto la efectividad del gel plaquetario que fue del 100%. Sin duda alguna la experiencia mostrada nos revela un procedimiento con un amplio horizonte de usos terapéuticos y resultados alentadores visto desde la perspectiva de las técnicas de ahorro sanguíneo.

Introduction: Blood auto transfusion and autologeous blood component therapy has been a modality that has been used for more than 2 centuries, and experiences, thanks to recent technical advances, its implementation in maneuvers which lead to saving and eliminating blood loss in extensive surgical procedures, as well as the inherent risks to the transfusion homologate. Objectives: To reduce the number of days of hospital stay in patients getting ready for extracorporeal surgery, and to use preoperatory plateletpheresis and biological platelet glues to reduce bleeding and transfusion requirements in heart surgery. Material and methods: Of the patients submitted to heart surgery with extracorporeal circulation in the México Hospital during the period of February 1997 to February 2003, the autotransfusion of red cells was used by recovery in a total of 150 patients. To each of them was performed an autotransfusion of washed red cells for which was used a Cell Saver type machine, Secuestra1000, (Medtronic, Minneapolis, Mn.). Included were patient with heart re-do, multiple or complicated coronary surgery, anemic patients or of strange sanguine groups without possibility of obtaining blood, and Jehova's Witness patients as part of the surgery protocol. Patients with complex surgeries and without previous heparinization underwent preoperative platelet sequestration besides the confection of sealing gel rich in platelet concentrate. Extracorporeal circulation was carried out with moderate hypothermia in all patients except for one with a complex surgery where circulatory arrest was required with profound hypothermia. Relating data to the pre, trans and post surgery hematocrit were gathered, as well as the number of component units obtained, analyzing other related variables. Results: A total of 225 surgeries in 150 patients were carried out for an average of 1.5 procedures per patient. Of the 150 operated patients, 100 were men (66%) and 50 were women (33%). The average age was 47.8 + 22.8 -34.8. Twenty six patients were Jehovah’s Witness and their participation was indicated under the condition that they were not to be transfused. A total of 317.76 liters of aspired sample was processed from the operation field. A total of 156.45 liters of red globules were recovered from the aspired sample, corresponding to an average of 1043 cc per patient. To 26 patients was carried out a pre surgery plateletpheresis and plasmapheresis, obtaining a total of 11,000 cc of fresh plasma, for an average of 423.07 cc, and 5,600 cc of platelets (215.38 cc per patient). Platelet rich gel was made in twenty patients, and used to seal bleeding sites in resurgeries, aortic aneurism and in cardiotomy sutures, obtaining an average of 64.28 cc of clear platelet gel per patient. The hemostasis was successful in all the patients after the application. A total of 30 bank units were processed to separate the red cells. None of the patients submitted to pre surgery plateletpheresis required transfusion of additional platelets or fresh plasma. The pre surgery platelet counts were an average of 207,000pks/mm3 and the post surgery control count was 203,000pks / mm3. One observes a decrease in the average post surgery bleeding from 740 cc, to 230 cc in those submitted to plateletpheresis obtaining almost 70% less bleeding in the thoracic drains. To the Jehova's Witness patients, an average of 650 cc was processed in relation to the general average of 1043 cc. The required homologous transfusion in the post surgery patient was of 0.9 units compared to 4.1 units used normally by a patient representing a reduction of more than 70%. The pre surgery hematocrit was of 38.3% and during hemodilution by extracorporeal circulation an average of 20.5% was obtained, and in the immediate post surgery a 31% was obtained. The pre surgery stay was of 2 days in auto transfusion patients compared to a 6.2 average when blood donors were required, and the postoperative stay was 7 and 7.2 days respectively. Conclusions: The present study shows a novel method for sanguine saving, which holds not only great importance in the economical environment due to the reduction in hospital days before and after surgery, but also for eliminating the broadly and well-known risks of homologous transfusion. The transfusion requirements of RBC were reduced up to 70% and those for platelets were eliminated entirety. Also post surgery bleeding decreased significantly in 68% in patients with plateletpheresys, adding to that the 100% effectiveness of the platelet gel. Without a doubt this experience reveals a procedure with a wide horizon of therapeutic uses and encouraging results seen from the perspective of the blood saving technicians.

 Cirugía Cardíaca Autotransfusión Técnicas de ahorro sanguíneo Transfusión autóloga Heard Surery Auto -transfussion Blood Save Technical Autologous transfussion Williamson KR Intraoperative blood salvage: a review Transfusion 1991 31 Blundell J Experiments on the transfusion of blood by the syringe Med Chir Trans 1818 9 Diamond LK Winthrobe MW A history of blood transfusion Blood pure and elocuent Blood pure and elocuent 1980 NY Mc Graw Hill Highmore W Practical remarks on an overloocked source of blood supply for transfusion in post partum hemorrage, suggested by a recent fatal case Lancet 1874 1 Duncan J An reinfusion of blood on primary and other amputations Br Med Jour 1886 1 Watson CM Autotransfusion: Review of the American literature with report of two additional cases Am Jour Surg 1936 33 Dyer R Intaoperative autotransfusion. A preliminary report and a new method Am J Surg 1966 112 Klebanoff G A disposable autotransfusion unit Am J Surg 1968 116 Klebanoff G Early clinical experience with a disposable unit for the intraoperative salvage and reinfusion of blood loss (Intraoperative transfusion) Am J Sur 1970 120 Duncan SE Patient experience with intraoperative autotransfusion Rev Surg 1974 31 Duncan SE Caution regarding autotransfusion Surgery 1974 76 Sharp WV Modern autotransfusion: Experience with a washed red cell processing technique Am J Surg 142 Wilson JD Autotransfusion: Historical review and preliminary report of a new method Mayo Clin Proc 1968 46 Wilson JD Autotransfusion during a transurethral resection of the prostate: Technique and preliminary clinical evaluation Mayo Clin Proc 1969 44 Autologous blood transfusion: Council on Scientific affairs JAMA 1986 256 Thurer RL Blood conservation in Maffei LM Autologous blood transfusion:current issues Arlington AABB 1988 Deviri E Total excision of giant angiolipoma of the chest wall with a-v malformation and with the use of an autotransfusion system J Cardiovasc Surg Torino 1987 28 Williamson KR Intraoperative transfusion:its role on orthotropic liver transplantation Mayo Clin Proc 1989 64 Culkin M Management of the severely anemic patient who refuses transfusion: lessons learned during the care of Jehova`s Witness Annals of Internal Medicine 1992 117 Vignali A A single unit of transfused allogenic blood increases postoperative infections Vox Sang 1996 71 Meryman H Transfusion induced alloinmunization and inmunosupression and the effects of leukocyte depletion Transfusion Medicine Reviews 1989 3 Cosgrove DM Blood conservation during myocardial revascularization Ann Thorac Surg 1979 28 Mc Carty PM Effect of blood conservation efforts in cardiac operations at the Mayo Clinic Mayo Clin Proc 1988 63 Keeling MM Introperative autotransfusion: Experience in 725 consecutive cases Ann Surg 1983 197 Yawn DH Autologous transfusion in the context of aneurysm surgery Autologous transfusion in the context of aneurysm surgery 1985 23 Symposium of intraoperative blood recovery and autologous transfusion Houston Texas Turner RH Hauer JM Cell washing in orthopedic surgery Autotransfusion Autotransfusion 1981 NY Elsevier Cotton RL Blood conservation using autotransfusion in total joint arthroplasty Iowa Orthopedic Jour 1991 11 Shulman G Autotransfusion worth in reconstructive spine surgery Transfusion 1996 36 DziK WH Use of intraoperative blood salvage during orthotropic liver transplant Arch Surg 1985 120 Santrach PJ Intraoperative blood salvage in neurosurgery Transfusion 1989 29 Boudreax JP Emergency autotransfusion: partial cleansing of bacteria laden blood by cell washing J Trauma 1983 23 Timberlake GA Autotransfusion of blood contaminadted by enteric contents: A potentially life saving measure in the massivelly hemorragic trauma patient J Trauma 1988 28 Homan B Tumor cells carried through autotransfusion: Are these cells still malignant? Acta Anaestesiol Belg 1984 35 Yawn PB Tumor cells carried through autotransfusion: Contraindication for intraoperative blood recovery? JAMA 1975 231 Salsbury N The significance of the circulating cancer cell Cancer Treat Rev 1975 2 Rovicsech F Inherent dangersof simultaneous application of microfibrillar colagen hemostat and blood saving devices J Thorac Cardiovasc Surg 1986 92 Cimochowskyi GE Implosion explosion of a Bentley cardiotomy reservoir with a cell saver during autotransfusion J Extracorporeal Technol 1985 17 Jurkovitch GJ Autotransfusion in trauma a pragmatic analysis Am J Surg 1984 148 Reeder GD Perioperative Autologous Sequestration 1: Physiology, phenomena and art Proc of the Academy of Cardiovasc Perf 1993 14 Hill AG Perioperative Autologous Secuestration 2: A Differential Centrifugation Technique for autologous Component therapy: Methods and results Proc of the Academy of Cardiovasc Perf 1993 14 Noon GP Use of preoperatively obtained platelets and plasma in patients undergoing cardiopulmonary by pass J Clin Apheresis 1990 5 Giordado GF Determinants of homologous blood usage utilizing autologous platelet rich plasma in cardiac operations Ann Thorac Surg 1989 47 Brecher ME Minimal exposure transfusion and the commited donor Transfusion 1990 30 Davies GG Platelet leukocyte plasmapheresis atenuates the deleterious effects of cardiopulmonary by pass Ann Thorac Surg 1992 53 Stover EP Platelet rich plasmapheresis with therapeutic platelet yield reduces allogenic red blood cell and platelet transfusions in high risk cardiac surgery Anestesiology 1996 85 Stover EP Intraoperative platelet sequestration reduces red blood cell and platelet transfusion in high risk cardiac surgery Transfusion 1996 36 Christenson JT Autologous Platelet sequestration in patients undergoing CABG Autologous Platelet sequestration in patients undergoing CABG 1996 Annual Meeting of the European Association for Cardiothoracic surgery Addonizio VP Preservation of platelet number and function with prostaglandin E1 during cardiopulmonary by pass in rhesus monkeys Surgery 1978 83 Christenson JT Plateletpheresis before redo CABG diminishes excessive blood transfusion Ann Thorac Surg 1996 62 Gu YJ Leukocyte depletion results in improved lung function and reduced inflamatory response after cardiac surgery J Thorac Cardivasc Surg 1996 112 Hart S Leucocyte depleting filters and cardiothoracic surgery Perfusion 1993 8 Hood AG Perioperative Autologous Sequestration 3: A New physiologic Glue with wound healing properties Proc of the American Acad of Cardiovasc Perf 1993 14 Cromak DT Current concepts in wound healing: Growth factor and macrophage interaction J Trauma 1990 30 Boldt G Acute preoperative plasmapheresis and established blood conservation technic Ann Thorac Surg 1990 50 Del Rossi AJ Platelet rich plasma reduces postoperative blood loss after cardiopulmonary by pass J Thorac Cardivasc Surg 1975 70 Giordano FG Autologous platelet rich plasma in cardiac surgery: Effect on intraoperative and postoperative transfusion requeriments Ann Thorac Surg 1988 46 Mc Kenna R The hemostatic mechanism after open heart surgery ; frecuency of abnormal platelet function during and after extracorporeal circulation J Thorac Cardiovasc Surg 1975 70 Stover EP Platelet rich plasmapheresis in cardiac Surgery Platelet rich plasmapheresis in cardiac Surgery Apri l 19 Cardiovascular anesthesia symposium Melbourne Autologous Blood component Theraphyt Program: Calculations for concentrated platelet secuestration Autologous Blood component Theraphyt Program: Calculations for concentrated platelet secuestration Standards for blood banks and transfusion Services Standards for blood banks and transfusion Services 1993 15 th Boldt J Acute rich plasmapheresis for cardiac surgery Journal of Cardiothoracic and Vascular Anesthesia 1995 9 Hirsh J Heparin The New Engl Journ Med 1991 324 Page PA CPD versus Heparin for anticoagulation during Autotransfusion procedures Perfusion Life 1991 3 Himpe D Priming solutions for cardiopulmonary by pass comparisson of three coloids Jour of Cardiothoracic and vascular Anesthesia 1991 5 Carranza JL Hemodilucion Intencional normovolemica con polimerizado de gelatina al 3.5% Revista anestesia en México 1990 11 Daves GG Plateletpheresis before cardiopulmonary by passI Anesthesiology 1994 80 Mohr R The hemostatic effecs of transfusing fresh whole blood versus platelet concentrates after cardiac operations J Thorac Surg 1988 96 Mc Kenna The hemostatic mechanism after open heart surgery J Thorac Cardiovasc Surg 1975 70 Giordano FG Autologous platelet rich plasma ; effects in intraoperative and postoperative transfusion requeriments AnnThorac Surg 1988 46 Office of medical applications on research, National Institute of Healt Perioperative red cell transfusion JAMA 1988 26 TrouWborst A Acute hipervolemic hemodilution to avoid blood transfusion during major surgery Lancet 1990 336 Hays JA Wound healing following mastectomy Aust N Z J Surg 1984 54 Meyers DL Spinal fluid leakage after skull base surgical procedures Otolaryngol Clin N Am 1984 17 Gibble JW Fibrin Glue The perfect operative sealant Transfusion 1990 30 Dresdale A Preparation of fibrine glue from single donor fresh frozen plasma Surgery 1985 97 Siedentop KH Extended experimental and preliminary surgical findings with fibrin tissue adhesive made from the patients own blood Laryngoscope 1986 96 Spotnitz WD Fibrin glue from stored plasma Amm Surg 1987 53 Saltz R Application of autologous fibrine glue in burn wounds J Burn Care Rehabil 1989 10 Hartman AR Autologous whole plasma fibrin gel; intraoperative procurement Arch Surg 1992 127 Stechison MT Rapid polimerizing fibrin glue from autologous or single donor glue J Neurosurg 1992 76 Nicholas JM Successful of autologous fibrin glue in traumatic broncopleural fistula J Trauma 1992 32 Oz Mc Autologous fibrin glue from intraoperatively collected platelet rich plasma Ann Thorac Surg 1992 53 Hood AG Perioperative Autologous Sequestration III A new physiologic Glue with wound healing properties in "Autologous Blood component Theraphyt Program" Perioperative Autologous Sequestration III A new physiologic Glue with wound healing properties in "Autologous Blood component Theraphyt Program" Davies GD Platelet leukocyte depletion plasmapheresis attenuates the deleterious effect of cardiopulmonary by pass Ann Thorac Surg 1992 53 Induni E Autotransfusion y terapia de componentes autólogos Acta Medica Costarricense 1998 40 ^s1 Induni E Tratamiento de fistula broncopleural con el uso de gomas biologicas en paciente de alto riesgo quirurgico Acta Medica Costarricense 1998 40 ^s1 Russel R The biology of human derived growth factor Cell 1986 46 Antoniades HN Radioinmuneassay of a human serum growth factor for Balb c.3t3 cells derivation from the platelets Natl Acad Sci 1977 74 Heldin CH Platelet derived growth factor purification and partial characterization Proc. Natl Acad Sci 1979 76 Holley RW Contact inhibition in cell division in t3t cell Natl Acad Sci 1968 60 Ross R A platelet dependent serum factor that stimulates the proliferation of smooth muscle cells in vitro Proc Natl Acad Sci 1974 71 Todaro G The iniciation of cell division in a contact inhibition mamalian cellline J Cell Comp Physiol 1965 66 Kaplan DR Platelet a- granules contains a growth factor for fibrobalsts Blood 1979 53 Antoniades HN Human platelet derived growth factor purification of pdgf-1 and pdgf -2 and the separation of the reduced subunits Natl Acad Sci 1981 78 Antoniades HN Isolation of a cationic polipeptide from human serum that stimulates the proliferation of 3T3 cells Proc Natl Acad Sci 1975 72 Heldin CH Platelet derived growth factor. Isolation of a large scale procedure and analysis of subunit composition Biochem J 1981 193 Deuel TF Human platelet derived growth factor . Purification and resolution in two active protein factors J Biol Chem 1981 256 Raines EW Platelet derived growth factor High yield purification and evidence for multiple forms J Biol Chem 1982 257 Pledger WJ Induction of DNA syntesis in Balb c3t3 cells by serum components reevaluation of the commitent process Proc Natl Acad Sci 1977 74 Vogel A Coordinate control of 3t3 cells proliferation by platelet derived growth factor and plasma components Proc Natl Academ Sci 1978 75 Stiles CD Dual control of cell growth factor Proc Natl Academ Sci 1979 76 Seppa H Platelet derived growth factor is chemotactic for fibroblasts J cell Biol 1982 92 Owen AJ Human platelet derived growth factor stimulates aminoacid factors and protein syntesis by human diplid fibroblasts in plasma free media Human platelet derived growth factor stimulates aminoacid factors and protein syntesis by human diplid fibroblasts in plasma free media 1982 79 Chait A Platelet derived growth factor stimulates activity of low density lipoproteins receptors Proc Natl Acad Sci 1980 77 Habenitch AJ Relation of cholesterolc and mevalonic acid in the cell cycle in smooth muscle and Swiss 3t3 cells stimulated to divided by platelet derived growth factor J Biol Chem 1980 255 Leslie CC Stimulation of phospholipid and cholesterol ester syntesis by platelet derived growth factor in normal and homozigous familial human skin fibroelasts Biochim Biophys Acta 1982 711 Antoniades HN Human platelet derived growth factor structure and and function Federation Proceedings 1983 42 Ross R The pathogenesis of arterosclerosis N Engl J Med 1976 295 Coughlin SR Serotonin mediated receptor stimulation of bovine smooth muscle cell prostacicline syntesis and its modulation by pdgf Proc Natl Acad Sci 1981 78 Tasjian A Platelet derived growth factor stimulates bone resorption via prostaglandin mediated mechanism Endocrinology 1982 11 Chait A Platelet derived growth factor stimulates activity of LDL receptors Proc Natl Acad Sci 1980 77 Witte LD Platelet derived growth factor stimulates low density lipoproteins receptor activity in fibroblasts Proc Natl Acad Sci 1980 77 Wrann M Modulation of epidermal growth factor receptors in on 3t3 cells by platelet derived growth factor Science 1980 210 Stover EF Introperatively prepared platelet gel as an alternative to fibrine glue in dural wound repair Transfusion 1996 36 Keating RF Tethered cord dural repair with intraoperative autologous fibrine glue Pesented at the American Association of Neurological Surgeons Tethered cord dural repair with intraoperative autologous fibrine glue Pesented at the American Association of Neurological Surgeons 1992 Vancouver Reisser H Control of hemorrage from wounds of the coronary vessels by the gelatin sponge technic Ann Surg 1949 129 Hansen JL Gross hemorrage from the aorta and the pulmonary artery Hemostasis by gelatin sponge Act Chir Scand 1953 19 06 Jampoli RW Control of the hemorrage of cardiac auricles by the gelatin sponge Surgery 1947 22 Fabri PS The use of Spongostan film in plastic surgery Minerva Chir 1976 21 Cobden RH Topical Hemostatic agents to reduce bleeding from cancelleous bone J Bone Joint Surg 1976 58 Wells SA Transfusion amd surgery Curr Probl Surg 1993 12 Sanchez W Hemodilucion isovolemica preoperatorio en pacientes con histerectomía radical por cancer de cervix Acta Medica Costarricense 2002 44 ^s4
S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100004 Incidencia de las cardiopatías congénitas en el menor de un año. Villa Clara, 1998 -2002 Martín Delgado Eusebio del Mar Llanes Camacho María del Carmen Castillo Vitlloch Alina González Ojeda Guillermo Torres Ruíz Daniel Vega Teresita ,Hospital Pediátrico Universitario José Luis Miranda Servicio de Cardiopediatría Villa Clara Cuba 04 2003 2003 5 19 24

Introducción: Se evaluó la incidencia de cardiopatías congénitas en 50.432 recién nacidos vivos en el período entre 1/1/1998 a 31/12/2002 en la provincia de Villa Clara, Cuba. Métodos: En todos los niños que se sospechó clínicamente la existencia de cardiopatía congénita se les realizó ecocardiograma. El cateterismo cardíaco y el tratamiento quirúrgico se realizó por determinación del cardiólogo pediatra del paciente. Se realizó necropsia a todos los fallecidos. Los niños con cardiopatía congénita fueron registrados en una base de datos computarizada y fueron seguidos durante su primer año de vida. Resultados: Se diagnosticaron 466 niños con cardiopatía congénita de un total de 50.432 para una incidencia de 9.24/1.000 nacidos vivos cercano a lo estimado mundialmente. Conclusiones: Esta incidencia se debe a la estructura y funcionamiento de nuestra red cardiopediátrica donde son evaluados todos los pacientes sospechosos y enviados a la consulta provincial de cardiología pediátrica y seguidos por el mismo grupo, los servicios gratuitos de salud y el examen ecocardiográfico a todo niño con diagnóstico clínico de cardiopatía congénita. La persistencia del conducto arterioso y la comunicación interventricular tuvieron una elevada incidencia debido a su temprano diagnóstico antes de su cierre espontáneo.

Background: We surveyed the incidence of congenital Heart disease en 50432 native live born children en the period between 1/1/98 to 31/12/2002 in Villa Clara, Cuba. Methods: Each child with clinically suspected congenital heart disease underwent echocardiographic examination. Cardiac cauterization and surgical intervention were carried out at the discretion of the patient's pediatric cardiologist. All postmortem examinations were performed. Children with congenital heart disease were registered in a computerized database and followed up for a year. Result: Congenital heart disease was diagnosed in 466 of the 50432 children for an incidence of 9.24/1000 live births. Conclusion: The reason for this incidence is due to the structure and function of our cardiopediatric net, where all suspicious patients are evaluated, referred to and followed up by a single group of pediatric cardiologists, freely available health care service and echocardiographic examination of every child with a clinical diagnosis of congenital heart disease. The patent ductus arteriosus and ventricular septal defects showed a high incidence due to early diagnosis before the moment of spontaneous closure.

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S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100005 Etiología de la insuficiencia mitral pura en Costa Rica: estudio ecocardiográfico Lidieth Esquivel M. Romero Luis Vásquez Gerardo Gutiérrez Oswaldo ,CCSS Hospital México Servicio de Cardiología San José Costa Rica 04 2003 2003 5 26 29

Introducción: Estudios internacionales recientes han mostrado que en la actualidad la insuficiencia valvular mitral se debe principalmente a degeneración mixomatosa de la válvula o a enfermedad arterial coronaria. Este estudio ecocardiográfico tiene como objetivo establecer la prevalencia de las diferentes causas de insuficiencia mitral pura en Costa Rica. Metodología: Se incluyeron a todos aquellos pacientes referidos a nuestro laboratorio de eocardiografía en el período comprendido entre el mes de julio de 1998 y julio del 2000 en quienes se detectó insuficiencia mitral de causa orgánica. Se realizó la exploración en modo M, bidimensional y con las técnicas de mapeo con doppler pulsado, continuo y color y se clasificó a los casos en reumática, prolapso de la válvula mitral por degeneración mixoide, isquémica, degenerativa, secundaria a endocarditis, por colagenopatía y otras, según definiciones convencionales. También se valoró semicuantitativamente la severidad de la regurgitación clasificándose en leve, moderada y severa. Resultados: Se incluyeron 82 pacientes, 48 mujeres (59.7%) y 34 hombres (37.8%) entre los 14 y 87 años (promedio 50.3 +/- 20.7). Se encontraron 27 casos de insuficiencia mitral pura reumática (32.9%), 25 por degeneración mixomatosa (30.5%), 12 de origen isquémico (14.6%), 9 con enfermedad degenerativa (11%), 4 por dilatación del anillo secundaria a miocardiopatía dilatada no sospechada (4.9%), 2 con valvulitis lúpica (2.4%), 2 que no se pudieron clasificar (2.4%) y una con endocarditis (1.2%). Sesenta y dos casos presentaron insuficiencia mitral leve a moderada (76.7%) y 18 severa (21.9%). Sesenta y un pacientes presentaban función sistólica ventricular izquierda normal (75.6%) y 21 con algún grado de deterioro. Conclusión: En esta serie encontramos prevalencia similar de la causa reumática y el prolapso de la valvula mitral mixoide, las más frecuentes de insuficiencia mitral pura a diferencia de otras series internacionales. La causa isquémica ocupó el tercer lugar. La mayoría de los casos fueron leves a moderadas y de los casos con insuficiencia mitral severa, se dió la misma proporción.

Introduction: International studies have demonstrated that mitral valve mixoid degeneration and coronary artery disease are the most frequent causes of pure mitral regurgitation. This cardiac ultrasound study was designed to know each cause prevalence in Costa Rica. Methods: We included all patients referred to our institution since July 1998 to July 2000 in whom was detected organic pure mitral regurgitation. We performed M-mode and bidimensional imaging and pulsed, continuous and colour flow mapping exploration. We classified patients in rheumatic disease, mixoid degenerative changes, secondary to coronary artery disease, to accelerated degenerative changes, to endocarditis, to collagen disease or other, regarding international criteria. We also assessed severity of mitral regurgitation classifying it in mild, moderate and severe. Results: We studied 82 patients, 48 females (59.7%) and 34 males (37.8%) between 14 and 87 years old (mean 50.3 +/- 20.7). There were 27 patients with pure mitral regurgitation of rheumatic origin (32.9%), 25 with mixoid degenerative valve disease (30.5%), 12 with coronary artery disease (14.6%), 9 with age-related changes (11%), 4 with mitral annulus elongation secondary to dilated cardiomyopathy not previously suspected (4.9%), 2 with systemic lupus erythematosus valve involvement (2.4%), 2 with no obvious cause (2.4%) and one with endocarditis (1.2%). Sixty-two cases had mild or moderate mitral regurgitation (76.7%) and 18 severe (21.9%). Sixty-one patients had left ventricle systolic function preserved (75.6%) and 21 with some degree of diminished function. Conclusion: In this study we find a similar prevalence of rheumatic disease and mixoid degenerative disease as most frequent causes of mitral regurgitation, a fact different from international series. Coronary artery disease was the third cause. Most cases were mild or moderate and severe cases had a similar distribution.

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S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100009 Reporte de 5 casos de Edema Pulmonar Post-obstructivo, secundario a Laringoespasmo Post Extubación Anestésica, en el Hospital San Rafael de Alajuela Porras Morales Guillermo E. ,C.C.S.S. Hospital San Rafael de Alajuela San José Costa Rica 04 2003 2003 5 51 55

El Edema Pulmonar Post-obstructivo (E.P.P.O), es un cuadro de inicio súbito de edema pulmonar como consecuencia de la obstrucción de las vías respiratorias superiores. Se han identificado dos formas de E.P.P.O. El tipo 1 es el que se presenta secundario a la obstrucción aguda de las vías respiratorias superiores. El tipo 2 ocurre posterior a la liberación quirúrgica de la obstrucción crónica de las vías respiratorias superiores. Su etiología es multifactorial. La incidencia y mortalidad no están bien establecidas. Las manifestaciones clínicas no son típicas en esta patología, pero pueden causar estados mórbidos importantes e incluso la muerte. El tratamiento para ambas condiciones es de soporte vital.

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S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100010 Rotura parcial de músculo papilar tricúspide en anomalía de Ebstein Lanzoni Rodríguez Allan Mauricio Saborío Mercado César Sánchez Acosta Carlos Luis ,CCSS Hospital Dr. R.A. Calderón Guardia Servicios de Cardiología San José Costa Rica ,CCSS Hospital Dr. R.A. Calderón Guardia Servicios de Neurología San José Costa Rica 04 2003 2003 5 57 60 Moss AJ Adams FH Pine JW Congenital stenosis and insufficiency of the tricuspid valve Herat disease in infants, children and adolescents Herat disease in infants, children and adolescents 1995 Baltimore Williams and Wilkins Zielinsky P Pilla CB Ebstein's anomaly with imperforate tricuspid valve: Prenatal diagnosis Arq Bras Cardiol 2000 75 Perloff JK Chile JS Congenital heart disease in adults Congenital heart disease in adults 1998 2da edición Los Angeles Saunders Attie F Rosas M Rijlaarsdam M Buendia A Zabal C Kuri L The adult patient with Ebstein anomaly. Outcome in 72 unoperated patients Medicine 2000 79 Van Son JA Konstantinov IE Zimmermann Y Wilhelm V Ebstein and Ebstein's malformation Eur J Cardiothorac Surg 2001 20 Knott-Craig CJ Overholt ED Ward KE Ringewald JM Baker SS Razook JD Repair of Ebstein's anomaly in the symptomatic neonate: an evolution of technique with 7 year follow-up Ann Thorac Surg 2002 73 McCarthy K Ho SY Cook AC Connell MG Smith A Anderson RH The atrioventricular junction in Ebstein malformation Heart 2000 83 Garrido A Oliver JM Domínguez FJ Gonzalez AE Sobrino JA Displasia congénita de la válvula tricuspide en un varón de 73 años con insuficiencia tricuspide severa Rev Esp Cardiol 2000 53 Cappato R Schlüter M Weiss C Antz M Koshyk D Hofmann T Radiofrecuency current catheter ablation of accessory atrioventricular pathways in Ebstein's anomaly Circulation 1996 94 Di Russo GB Gaynor JW Ebstein anomaly: indications for repair and surgical technique Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2000 2 Durán M Gómez I Palacio A Anomalía de Ebstein con hipoplasia pulmonar. Diagnóstico mediante ecocardiografía doppler color en el feto Rev Esp Cardiol 1992 45 Hong YM Moller JH Ebstein anomaly: a long-term study of survival Am Heart J 1993 125 Yetman AT Fredom RM Y Mc Crindle BW Outcome in cyanotic neonates with Ebstein´s anomaly Am J Cardiol 1998 81 Hetzer R Nagdyman N Ewert P Weng YG Alexi-Meshisvili V Berger F A modified repair technique for tricuspid incompetence in Ebstein anomaly J thorac Cardiovasc Surg 1998 115 Vargas FJ Mengo G Granja MA Gentile JA Rannzini ME Vasquez JC Ann Torca Surg 1998 65 Van Son JA Kinzel P Mohr FW Pericardial match augmentation of anterior tricuspid leaflet in Ebstein's anomaly Ann Thorac Surg 1998 66 Kiziltan HT Theodoro DA Warnes CA O'Leary PW Anderson BJ Danielson BK Late results of bioprosthetic tricuspid valve replacement in Ebstein's anomaly Ann Thorac Surg 1998 66
S1409-414220030001 Revista Costarricense de Cardiología Rev. costarric. cardiol 1409-4142 Asociación Costarricense de Cardiología S1409-41422003000100011 Araya Gómez Vivien ,Centro Cardiológico Integral 04 2003 2003 5 61 61