Mortality after surgery for congenital heart disease (CHD) in Mexico is significantly higher than in high-income countries due to structural, medical, and financial factors. In Mexico, public hospitals have a large volume of patients but inadequate quality control systems, whereas private hospitals, although having higher quality control systems, have an insufficient number of patients to build programs of excellence. We describe the creation of a novel hybrid private-public program in Mexico that leverages the advantages of both sectors while establishing an integrated multidisciplinary unit that has allowed us to improve the quality of care for patients with CHD.
Background: Although high altitude has been considered a risk factor for the Fontan operation, and an indication for fenestration, there is a paucity of data to support its routine use. Fenestration, with its necessary right to left induced shunt, together with the lower partial pressure of oxygen found with progressive altitude, can significantly decrease hemoglobin oxygen saturation, and therefore, it would be desirable to avoid it. Objective: To analyze immediate and medium-term results of the non-fenestrated, extracardiac, Fontan procedure at high altitude. Methods: Retrospective analysis of data from consecutive patients who underwent non-fenestrated, extracardiac, Fontan procedure at two institutions located in Mexico City at 2,312 m (7,585 ft) and 2,691 m (8,828 ft) above sea level. High altitude was not considered a risk factor. Results: Thirty-nine patients were included, with a mean age of 6.7 years. Mean preoperative indexed pulmonary vascular resistance was 1.7 Wood units. Seventy-nine percent of the patients extubated in the operating room. There was one in-hospital death (2.56%) and one at follow-up. Median chest tube drainage time was 6.5 and 6 days for the right and left pleural spaces. Median oxygen saturation at discharge was 90%. At a median follow-up of six months, all survivors, except one, had good tolerance to daily life activities. Conclusions: The present study shows good short- and medium-term results for the non-fenestrated, extracardiac, Fontan operation at altitudes between 2,300 and 2,700 m and might favor this strategy over fenestration to improve postoperative oxygen saturation. Further studies to examine the long-term outcomes of this approach need to be considered.
Reemplazo valvular mitral en edad pediátricaResumen ANTECEDENTES: el reemplazo valvular mitral en pediatría es un procedimiento raro asociado con dificultades técnicas y clínicas únicas. Estudios recientes reportan mejores resultados, a corto y largo plazo, posteriores al procedimiento.OBJETIVO: analizar la experiencia del reemplazo valvular mitral en el Instituto Nacional de Pediatría. MATERIALES Y MÉTODOS:se revisaron los expedientes de los pacientes con reemplazo valvular mitral, en el Instituto Nacional de Pediatría, entre agosto del 2002 y agosto del 2012. Las variables de evaluación primaria fueron mortalidad, complicaciones de la anticoagulación y resultados a largo plazo. Se incluyó a doce pacientes, con mediana de edad de 12.5 años (tres pacientes menores de 5 años).RESULTADOS: en 11 casos la anomalía mitral fue considerada congénita. La manifestación clínica más frecuente fue insuficiencia mitral. La mediana de la fracción de eyección del ventrículo izquierdo fue de 62% antes de la cirugía. Se colocó prótesis mecánica en 11 casos. Dos pacientes fallecieron en el postoperatorio inmediato, con supervivencia a 30 días de 83%, sin reporte de ninguna muerte en el periodo de seguimiento. Un paciente presentó sangrado de tubo digestivo leve y dos arritmia auricular. No se reportaron eventos tromboembólicos ni necesidad de nueva intervención. La mediana del tiempo de seguimiento fue de 16.6 meses.CONCLUSIÓN: en nuestras condiciones el reemplazo valvular mitral parece ser una buena opción para los pacientes que no pueden beneficiarse de la reparación, con resultados aceptables a corto y mediano plazos.PALABRAS CLAVE: válvula mitral, enfermedad congénita de la válvula mitral, implantación de prótesis valvular cardiaca.
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