Monitoring complex secundum atrial septal defects percutaneous closure with real time three-dimensional echocardiography

Background: Atrial septal defect (ASD) is one of the most common congenital heart diseases. Nowadays, percutaneous closure is considered the treatment of choice in most of secundum ASDs. Assessment of the defect and procedure monitoring have been usually performed by angiographic balloon‐sizing and/or two‐dimensional (2D) transesophageal echocardiography. However, in complex ASDs these techniques might be inaccurate. Methods: From January 2009 to January 2011 all adult patients with complex ASDs submitted for percutaneous closure were selected. Those defects, where shunts were present through a device previously implanted on the atrial septum or through multiperforated septums, were considered complex ASDs. Two‐dimensional transesophageal echocardiography and real time three‐dimensional (3D) echocardiography were performed simultaneously during the percutaneous closure procedure. Number of orifices, relationships between the defect, catheter, and device, as well as residual shunt were assessed. Results: Seven patients were included. Five patients had a multiperforated septum and in two cases the defect in the septum was through a previously implanted device. In all cases, 3D echocardiography was superior to 2D echocardiography in relation to the assessment of the relationship between the defect and the catheter or the device. Mechanisms responsible for residual shunts through a device were also better assessed by 3D echocardiography. Conclusion: Three‐dimensional echocardiography is a safe and useful technique when monitoring percutaneous closure of ASDs, showing relevant advantages over 2D echocardiography. (Echocardiography 2012;29:729‐734)     

Abordaje ecoguiado a nivel antecubital para cirugía del síndrome del túnel del carpo

IntroductionThere are various anaesthetic techniques for ambulatory surgery of carpal tunnel release. The ultrasound-guided nerve blocks offer advantages compared to other techniques. The purpose of this study was to evaluate the efficacy using ultrasound-guided block at the antecubital fossa, as well as to evaluate complications, patient satisfaction and surgeon satisfaction with the block.Materials and methodsProspective observational study with 32 elective patients for carpal tunnel release in a one-day case unit. An ultrasound-guided block with mepivacaine 1% was performed at the antecubital fossa, aiming for the median, ulnar and the lateral and medial cutaneous nerves of the forearm. The measurements of the anteroposterior and laterolateral diameters of the median and ulnar nerves were recorded, before and after injection. Motor and sensory levels were evaluated for the median and ulnar nerves at 5 and 30 min post injection, and compared with the contralateral hand. Pain from the surgical incision time and recovery were recorded, together with complications, and patient and surgeon satisfaction with the block.ResultsThe antecubital fossa ultrasound-guided block was successful in 93.7% of the patients. No patients needed rescue analgesia in recovery and no complications were recorded. Patient satisfaction was 93.7% and surgeon satisfaction was 97%.ConclusionsA selective block of the medial, ulnar and medial and lateral cutaneous nerves of the forearm are effective and satisfactory anaesthetic techniques for carpal tunnel release in a one-day case unit. It allows early mobilization, minimises risks and amount of local anaesthetic used.     

Is “Intra–operating Room” Thromboelastometry Useful in Liver Transplantation? A Case-Control Study in 303 Patients

Coagulation monitoring during liver transplantation (LT) is, even today, fundamental to reduce blood loss during surgery. Thromboelastometry (TEM) is a proven technique for controlling the various parameters that influence coagulation. However, there are no studies linking “intra–operating room” TEM (orTEM) with LT outcomes. We describe a case-control study in 303 liver graft recipients analyzing variables associated with operative complications and long-term LT outcomes. The results showed that orTEM reduced the use of blood products in patients with Model for End-Stage Liver Disease scores of ≥21, retransplantation, and high surgical difficulty and important intraoperative bleeding. In addition, results in survival and postoperative complications were better when orTEM was used. In conclusion, we confirm that use of orTEM is associated with less use of blood products and a lower rate of complications after LT.     

Nuevas perspectivas de tratamiento con el fumarato de fesoterodina en pacientes con vejiga hiperactiva

ObjectiveEvaluate the effect of the treatment with fesoterodine fumarate in patients with overactive bladder, as an alternative in case of failure of the usual anticholinergic treatment, due to either lack of therapeutic efficacy or due to intolerance to side effects.Material and methodA retrospective review of 158 patients with overactive bladder was carried out. The patients were divided into two groups; the first group; 56 patients where the anticholinergic treatment showed to be ineffective, and the second group; 102 patients who presented intolerance to anticholinergic side effects.ResultsFor the first group where fesoterodine fumarate was used to improve effectiveness of the anticholinergics, improvement in the components of urinary urgency (p = 0.001), insufficient emptying (p = 0.001), incontinence (p = 0.009), and in the number of pads/day (p < 0.001) was detected. As to the second group where fesoterodine fumarate was used as an alternative to anticholinergics to avoid side effects, a high reduction in the incidence of dry mouth (p < 0.001) and constipation (p = 0.015) was seen, as well as a significant clinical improvement.ConclusionFesoterodine fumarate is an optimal treatment option when the clinical response to anticholinergics has not been satisfactory, either by the lack of therapeutic action or by intolerance to side effects, and especially when the treatment is expected to be long.     

Valor pronóstico de la invasión microvascular en la predicción de la supervivencia en el carcinoma de células renales

ObjectiveTo assess microvascular tumor invasion and other clinical and histological parameters as potential prognostic factors in surgically treated renal cell carcinoma.Materials and methodsSurgical specimens from 238 consecutive patients who underwent radical or partial surgery between 1990 and 2006 were retrospectively evaluated. The series included clinically localized or metastatic renal cell carcinoma (pT1-4; N0-1; M0-1). Disease-free and cancer-specific survival assessments were the end points with median follow-up of 75 months (range 1-189 months). Variables studied included: age, sex, tumor size, TNM 2010 classification, Fuhrman grade, histological subtype and microvascular tumor invasion.ResultsMicrovascular tumor invasion was observed in 79 patients (33,2%) and was significantly associated with age (P = .010), tumor size (P = .000), Fuhrman grade (P = .000), pT stage 2010 (P = .000), N stage 2010 (P = .000) and M stage 2010 (P = .000). Multivariate analyses determined that sex, Fuhrman grade, pT stage 2010 and histological subtipe were independent prognostic factors of disease-free survival, while sex, Fuhrman grade, pT stage 2010, M stage 2010, histological subtype and microvascular invasion were prognostic factors for cancer-specific survival.ConclusionsOur study shows that microvascular tumor invasion is an independent prognostic factor for cancer-specific survival in surgically treated patients with renal cell carcinoma.