{"id":106251,"date":"2011-12-01T00:00:00","date_gmt":"2011-12-01T00:00:00","guid":{"rendered":"https:\/\/www.deberes.net\/tesis\/sin-categoria\/estudio-de-la-morbi-mortalidad-de-la-ciruga%c2%ada-cardiaca-de-revascularizacion-coronaria-efectos-cla%c2%adnicos-y-repercusiones-de-la-circulacion-extracorporea\/"},"modified":"2011-12-01T00:00:00","modified_gmt":"2011-12-01T00:00:00","slug":"estudio-de-la-morbi-mortalidad-de-la-ciruga%c2%ada-cardiaca-de-revascularizacion-coronaria-efectos-cla%c2%adnicos-y-repercusiones-de-la-circulacion-extracorporea","status":"publish","type":"post","link":"https:\/\/www.deberes.net\/tesis\/cirugia-cardiaca\/estudio-de-la-morbi-mortalidad-de-la-ciruga%c2%ada-cardiaca-de-revascularizacion-coronaria-efectos-cla%c2%adnicos-y-repercusiones-de-la-circulacion-extracorporea\/","title":{"rendered":"Estudio de la morbi-mortalidad de la cirugia cardiaca de revascularizaci\u00f3n coronaria. efectos cl\u00ednicos y repercusiones de la circulaci\u00f3n extracorp\u00f3rea."},"content":{"rendered":"<h2>Tesis doctoral de <strong> Fernando Clau Terr\u00e9 <\/strong><\/h2>\n<p>Introducci\u00f3n la enfermedad coronaria isqu\u00e9mica representa una de las patolog\u00edas con m\u00e1s morbi-mortalidad. Hasta la fecha actual el tratamiento quir\u00fargico, con injertos arteriales, de las estenosis coronarias presenta la mejor tasa de supervivencia a largo plazo. La cirug\u00eda cardiaca sufri\u00f3 un desarrollo espectacular con la aparici\u00f3n de la circulaci\u00f3n extracorp\u00f3rea (cec) como soporte circulatorio durante los procedimientos en quir\u00f3fano. Este soporte circulatorio y respiratorio artificial ha permitido hacer frente a todo tipo de tratamientos quir\u00fargicos (cardiaco, vascular y tor\u00e1cico principalmente), as\u00ed como de patolog\u00edas m\u00e9dicas con dispositivos como la ecmo (extracorporeal membrane oxigenation).  sin embargo estos dispositivos de soporte generan en s\u00ed mismos una morbilidad no siempre bien valorada. Los efectos delet\u00e9reos, no secundarios a accidentes en su manipulaci\u00f3n, se centran en un s\u00edndrome inflamatorio con repercusi\u00f3n sist\u00e9mica y que se sobreponen a la inflamaci\u00f3n generada por la propia cirug\u00eda. En la mayor parte de pacientes el uso de la cec es imprescindible y sin alternativa, y el estudio de los efectos de la cec no ha podido realizarse, con una metodolog\u00eda aceptable, hasta la aparici\u00f3n de la cirug\u00eda coronaria sin el uso de la cec (opcabg). Esta cirug\u00eda nos permite comparar grupos de pacientes similares y delimitar el verdadero efecto de la cec.  material y m\u00e9todos se realiz\u00f3 un estudio de cohortes prospectivo, desde el a\u00f1o 2004 al 2007, donde se analiz\u00f3 las repercusiones de estar sometido a la circulaci\u00f3n extracorp\u00f3rea, siendo definido como el factor de riesgo a estudio. Los grupos de pacientes comparados deber\u00edan ser similares en caracter\u00edsticas y factores de riesgo. Se analizaron seg\u00fan hab\u00edan estado sometidos al factor de riesgo (cec vs opcabg), seg\u00fan el tiempo al que hab\u00edan sido sometidos al factor de riesgo (cec>120 minutos) y su nivel de riesgo quir\u00fargico seg\u00fan el euroscore (bajo riesgo <3, riesgo medio 3-7 y riesgo alto >7).  se recogieron los datos demogr\u00e1ficos, quir\u00fargicos y de evoluci\u00f3n durante su estancia en uci, con un seguimiento de mortalidad a los 28 d\u00edas. Como variables secundarias se recogieron: a) la afectaci\u00f3n cardiaca (da\u00f1o cardiaco e infarto perioperatorio), b) revascularizaci\u00f3n completa, c) afectaci\u00f3n respiratoria (protocolo fast-track, vm prolongada), d) afectaci\u00f3n renal (disfunci\u00f3n renal, da\u00f1o renal y necesidad de hemodi\u00e1lisis), e) alteraciones en la coagulaci\u00f3n y requerimientos trasfusiones (hemat\u00edes, plasma y plaquetas), f) afectaci\u00f3n neurol\u00f3gica (da\u00f1o neurol\u00f3gico tipo i) y g) consumo y recursos necesarios. resultados una muestra final de 322 pacientes fueron estudiados, siendo 237 pacientes sometidos al factor de riesgo estudiado (cec) y 88 pacientes sin factor de riesgo como control. Ambos grupos presentaron caracter\u00edsticas similares y sin diferencias estad\u00edsticas para poder comparar el efecto del factor de riesgo. la mortalidad de los pacientes de riesgo bajo fue de 0% en ambas t\u00e9cnicas; los pacientes de riesgo moderado la mortalidad fue de un 0% (no cec) vs 1.85% (cec); y en los pacientes de riesgo alto fue de un 9.1% (no cec) vs 8.9% (cec), sin diferencias entre los grupos. Se logr\u00f3 una revascularizaci\u00f3n completa en un 60% de los pacientes sin cec y en un 70.9% de los pacientes con cec sin diferencias entre grupos (p=0.035). La incidencia de iam diferenciada, fue un de 2.35% en los pacientes sin cec, frente a un 5.48% en los pacientes con cec sin diferencias estad\u00edsticamente significativas. Se pudo aplicar un protocolo de extubaci\u00f3n r\u00e1pida (fastrack) en un 65.9% de los pacientes sin cec y en un 42.7% de los pacientes con cec (51.7% de cec < a 120 minutos y 33.7% de cec > a 120 minutos), con diferencias estad\u00edsticamente significativa (p<0.001). El da\u00f1o renal afect\u00f3 al 9.4% de los pacientes sin cec y al 17.9% de los pacientes con cec (15.4% con cec < a 120 minutos y un 20% con cec > a 120 minutos), sin diferencias estad\u00edsticamente significativas entre grupos, ni en el tiempo de cec empleado. La incidencia de da\u00f1o neurol\u00f3gico tipo i se dio en el 1.17% de los pacientes sin cec y en el 2.81% de los pacientes con cec, con una relaci\u00f3n estad\u00edsticamente significativa (p<0.05). Se trasfundi\u00f3 un 31.76% de los pacientes sin cec y un 71.72% de los pacientes con cec, con diferencias estad\u00edsticamente significativas (p<0.001). estos resultados han supuesto un riesgo relativo asociado a la cec de 2.96 veces m\u00e1s en el da\u00f1o cardiaco de 2.96, de 2.4 veces m\u00e1s en el infarto perioperatorio, de 2.07 veces m\u00e1s en el da\u00f1o renal, de 2.55 veces m\u00e1s de da\u00f1o neurol\u00f3gico tipo i, de 5.45 veces m\u00e1s en la trasfusi\u00f3n de hemat\u00edes (9.55 veces m\u00e1s de politrasfusi\u00f3n), de 10.02 veces m\u00e1s de trasfusi\u00f3n de plaquetas, de 3.7 veces m\u00e1s de la trasfusi\u00f3n de plasma y de 1.26 veces m\u00e1s en el riesgo de muerte, siendo especialmente significativos este aumento del riesgo en el grupo de pacientes de alto riesgo. conclusiones la cirug\u00eda sin cec resulta tan segura y eficaz como la cirug\u00eda con cec, consiguiendo tasas equiparables de revascularizaci\u00f3n completa, por lo que, dada su menor morbi-mortalidad asociada deber\u00eda ser de preferida elecci\u00f3n ante los casos debidamente seleccionados.   la utilizaci\u00f3n de cec aumenta de manera estad\u00edsticamente significativa la aparici\u00f3n de complicaciones respiratorias, renales y neurol\u00f3gicas en pacientes con un riesgo quir\u00fargico preoperatorio alto. En pacientes con riesgo quir\u00fargico preoperatorio bajo o moderado el efecto de la cec en el \u00edndice de complicaciones no es estad\u00edsticamente significativo.  el tiempo de exposici\u00f3n a la cec es un factor clave en la aparici\u00f3n de complicaciones, como son la necesidad de trasfusiones (hemat\u00edes, plasma y plaquetas) y con una estancia prolongada en uci, pudiendo fijar en 120 minutos el l\u00edmite recomendable de exposici\u00f3n a la misma.  el uso de la cec conlleva un aumento de la mortalidad no estad\u00edsticamente significativo en todos los grupos de riesgo. Si la duraci\u00f3n de la cec supera los 120 minutos y se aplica a pacientes de alto riesgo la mortalidad aumenta m\u00e1s del doble, siendo este aumento estad\u00edsticamente significativo.  la cec consume m\u00e1s recursos econ\u00f3micos que la cirug\u00eda sin cec, pero son las complicaciones quir\u00fargicas las que realmente encarecen los tratamientos al perpetuar la estancia en uci, la ventilaci\u00f3n mec\u00e1nica, la necesidad de trasfusiones, etc., Por lo que es de crucial importancia adecuar la t\u00e9cnica quir\u00fargica a cada paciente para minimizar el riesgo de aparici\u00f3n de complicaciones.       introduction  ischemic heart disease is one of the diseases with more morbidity and mortality. To date the revascularization surgery with arterial grafts in coronary stenosis has the highest rate of long-term survival. Cardiac surgery underwent a spectacular development with the onset of cardiopulmonary bypass (cpb) and circulatory support during surgical procedures. This artificial respiratory and circulatory support has enabled it to front to all types of surgery (cardiac, vascular and thoracic particular) as well as specific medical diseases with devices such as ecmo (extracorporeal membrane oxigenation).  however, these support devices produce morbidity, themselves, and is not always well appreciated. The deleterious effects, no side accidents, focus on a systemic inflammatory syndrome and overlap to inflammation caused by the surgery itself. In the majority of patients the use of cpb is essential and no alternative is possible, so the study of the effects of cpb has not been possible, with an acceptable methodology till the appearance of coronary surgery without the use of cpb (opcabg). This type of surgery allows us to compare groups of similar patients and delineate the true effect of cpb.  material and methods  we conducted a prospective cohort study from 2004 to 2007, which analyzed the impact of being subjected to extracorporeal circulation, which was defined as the risk factor to study. The patient groups compared should be similar in characteristics and risk factors. They were analyzed depending if they had been subjected to the risk factor (cec vs opcabg), according to the time at which they were subjected to the risk factor (cpb> 120 minutes) and level of surgical risk according to euroscore (low risk <3, moderate risk 3-7 and high risk> 7).   we collected demographic data, surgical and development during their stay in icu, followed for mortality at 28 days. Secondary variables were collected: a) cardiac involvement (cardiac damage and perioperative infart), b) complete revascularization, c) respiratory impairment (fast-track protocol, prolonged mechanical ventilation), d) renal (renal failure, kidney damage and need of hemodialysis), e) changes in coagulation and transfusions requirements (red cells, plasma and platelets), f) neurological (neurologic damage type i) and g) economic cost and resources consume.  results  a final sample of 322 patients studied, 237 patients being subjected to the risk factor studied (cbp) and 88 patients without risk factors as control. Both groups were comparable and no statistical differences in order to compare the effect of risk factor.  mortality in low risk patients was 0% in both techniques, the moderate-risk patients mortality was 0% (cbp) vs 1.85% (non cbp); and high-risk patients mortality was from 9.1 % (non cbp) vs 8.9% (cbp) with no differences between groups. Complete revascularization was achieved in 60% of patients without cpb vs 70.9% of patients with cpb with no difference between groups (p = 0,035). The differential incidence of ami, was 2.35% in patients without cpb, compared to 5.48% in patients with cpb without significant differences. Be able to apply a rapid extubation protocol (fastrack) in 65.9% of patients without cpb vs in 42.7% of patients with cpb (51.7% of cbp <120 minutes and 33.7% of cpb> 120 minutes) these differences were statistically significant (p <0.001). Kidney damage affected 9.4% of patients without cpb and 17.9% of patients with cpb (15.4% with cbp <120 minutes and 20% with cpb> 120 minutes), no statistically significant differences between groups, nor cpb time employee. The incidence of type i neurologic damage occurred in 1.17% of patients without cpb and 2.81% of patients with scc, with a statistically significant (p <0.05). In the transfusion issues a 31.76% for patients without cpb vs a 71.72% of patients with cbp were trasfused, with statistically significant differences (p <0.001).  these results have led to a relative risk associated with the use of cbp of 2.96 times in cardiac damage, 2.4 times increase in perioperative myocardial infarction, a 2.07 increase in renal damage, a 2.55 times more neurological type i damage, a 5.45 times in the red blood cell transfusion (9.55 times more politrasfusi\u00f3n),a 10.02 times the transfusion of platelets, 3.7 times the transfusion of plasma and 1.26 times more at risk of death, this being especially significant increased in high risk group of patients.  conclusions  off-pump surgery is as safe and effective as surgery with cpb, achieving comparable rates of complete revascularization; therefore, given its lower morbidity and mortality should be surgery of choice in carefully selected cases.  cpb was statistically significant, increasing the occurrence of respiratory, renal and neurological complications in high risk patients. In low or moderate surgical risk patients the effect of cpb in the complication rate is not statistically significant.  the exposure time to the cbp is a key factor in the occurrence of complications, such as the need for transfusions (red cells, plasma and platelets) and a prolonged icu stay. A time of 120 minutes can be recommended as the limit of exposure.  the use of cpb leads to increased mortality but was not statistically significant in all risk groups. If the duration of cpb exceeded 120 minutes and is applied to high-risk patients increases mortality more than doubled, this increase being statistically significant.  the cbp uses more economical resources than off-pump surgery, but surgical complications are the really expensive treatments to perpetuate the icu stay, mechanical ventilation, the need for transfusions, etc., So it is crucial to adapt surgical technique for each patient to minimize the risk of complications.\n\n\n\n&nbsp;\n\n\n<h3>Datos acad\u00e9micos de la tesis doctoral \u00ab<strong>Estudio de la morbi-mortalidad de la cirugia cardiaca de revascularizaci\u00f3n coronaria. efectos cl\u00ednicos y repercusiones de la circulaci\u00f3n extracorp\u00f3rea.<\/strong>\u00ab<\/h3>\n<ul>\n<li><strong>T\u00edtulo de la tesis:<\/strong>\u00a0 Estudio de la morbi-mortalidad de la cirugia cardiaca de revascularizaci\u00f3n coronaria. efectos cl\u00ednicos y repercusiones de la circulaci\u00f3n extracorp\u00f3rea. <\/li>\n<li><strong>Autor:<\/strong>\u00a0 Fernando Clau Terr\u00e9 <\/li>\n<li><strong>Universidad:<\/strong>\u00a0 Zaragoza<\/li>\n<li><strong>Fecha de lectura de la tesis:<\/strong>\u00a0 12\/01\/2011<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h3>Direcci\u00f3n y tribunal<\/h3>\n<ul>\n<li><strong>Director de la tesis<\/strong>\n<ul>\n<li>Francisco Agustin Garcia Gil<\/li>\n<\/ul>\n<\/li>\n<li><strong>Tribunal<\/strong>\n<ul>\n<li>Presidente del tribunal: Miguel angel Suarez pinilla <\/li>\n<li>joan ramon Masclans enviz (vocal)<\/li>\n<li>Miguel Leon valles (vocal)<\/li>\n<li>raul Garisa rocha (vocal)<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Tesis doctoral de Fernando Clau Terr\u00e9 Introducci\u00f3n la enfermedad coronaria isqu\u00e9mica representa una de las patolog\u00edas con m\u00e1s morbi-mortalidad. Hasta [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-gradient":""}},"footnotes":""},"categories":[2189,28262,11824,13610],"tags":[213921,198747,180225,54329,54332,104744],"class_list":["post-106251","post","type-post","status-publish","format-standard","hentry","category-cirugia-cardiaca","category-morbilidad","category-mortalidad","category-zaragoza","tag-fernando-clau-terre","tag-francisco-agustin-garcia-gil","tag-joan-ramon-masclans-enviz","tag-miguel-angel-suarez-pinilla","tag-miguel-leon-valles","tag-raul-garisa-rocha"],"_links":{"self":[{"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/posts\/106251","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/comments?post=106251"}],"version-history":[{"count":0,"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/posts\/106251\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/media?parent=106251"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/categories?post=106251"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.deberes.net\/tesis\/wp-json\/wp\/v2\/tags?post=106251"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}