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Toda especialidad médica, y en especial las quirúrgicas, necesitan, de alguna manera, vislumbrar el futuro que puedan ofrecer a los miembros más jóvenes de la especialidad y eventuales interesados en esta, de manera de asegurarles las mejores posibilidades de desarrollo profesional y personal, para, a su vez, poder reclutar a los mejores. Empero, para imaginar y forjar el futuro, es necesario vivir y enfrentar el presente. Pero, todo presente se asienta en un pasado, que es necesario conocer y meditar. Y de esto trata este artículo especial: pasado, presente y futuro de la cirugía de corazón, desde la particular visión de su autor.

Every medical specialty, mainly surgical specialties, needs to envision the future they can offer to the specialty's younger members and those eventually interested in it to assure them of the best possibilities for professional and personal development and, in turn, to be able to recruit the best one. However, it is necessary to live and face the present to imagine and forge the future. But every present is based on a past, which must be known and meditated upon. This article is about the past, present, and future of heart surgery, according to the particular vision of its author.

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Extracapsular dissection is an old technique use for the removal of benign parotid tumours, which is not generally chosen as the first treatment option due to the association of recurrences in the past but is currently considered again accord to the aesthetic requirements of the patients. The general trend in the last decade is to return to minimally invasive procedures for this type of lesions, which are mainly conditioned by the pleomorphic adenoma and its positive margins in its capsule. By this, the purpose of this case series study is to analyze those patients diagnosed with benign parotid tumors and treated by extracapsular dissection in a tertiary hospital in Chile between 2018-2020.

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BACKGROUND: The over prescription of antibiotics for acute respiratory infections is a major public health problem worldwide. Aim: To evaluate the frequency of prescription of antibiotics for non-pneumonia acute respiratory infections in private outpatient clinics in individuals without chronic diseases or immunosuppression. MATERIAL AND METHODS: All medical records of adult consultants in a national network of private ambulatory medical centers during May 2018 whose primary diagnosis corresponded to acute respiratory infections not pneumonia (ICD10) were identified and retrospectively analyzed, excluding those with chronic respiratory conditions or states of immunosuppression. RESULTS: Of the 38,072 consultants (aged 36 years, 63% women) who met this criterion, 54% (n = 20,499) received a prescription for at least one antibiotic. The diagnoses that most frequently received this prescription were acute bronchitis (28.7%), acute sinusitis (16.5%) and acute tonsillitis (16.2%). The most frequently prescribed antibiotic globally was azithromycin (37.4%), followed by amoxicillin (20.1%) and amoxicillin plus clavulanic acid (17.7%). Levofloxacin prescription reached 12.5% of total prescriptions. CONCLUSIONS: An antibiotic was prescribed in more than half of the non-pneumonia outpatient acute respiratory infections. Azithromycin was the most prescribed antibiotic, while levofloxacin exceeded 10% of prescriptions. These results reinforce the need to implement an antibiotic prescription surveillance system at the outpatient level.

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BACKGROUND: The over prescription of antibiotics for acute respiratory infections is a major public health problem worldwide. AIM: To evaluate the frequency of prescription of antibiotics for non-pneumonia acute respiratory infections in private outpatient clinics in individuals without chronic diseases or immunosuppression. MATERIAL AND METHODS: All medical records of adult consultants in a national network of private ambulatory medical centers during May 2018 whose primary diagnosis corresponded to acute respiratory infections not pneumonia (ICD10) were identified and retrospectively analyzed, excluding those with chronic respiratory conditions or states of immunosuppression. RESULTS: Of the 38,072 consultants (aged 36 years, 63% women) who met this criterion, 54% (n = 20,499) received a prescription for at least one antibiotic. The diagnoses that most frequently received this prescription were acute bronchitis (28.7%), acute sinusitis (16.5%) and acute tonsillitis (16.2%). The most frequently prescribed antibiotic globally was azithromycin (37.4%), followed by amoxicillin (20.1%) and amoxicillin plus clavulanic acid (17.7%). Levofloxacin prescription reached 12.5% of total prescriptions. CONCLUSIONS: An antibiotic was prescribed in more than half of the non-pneumonia outpatient acute respiratory infections. Azithromycin was the most prescribed antibiotic, while levofloxacin exceeded 10% of prescriptions. These results reinforce the need to implement an antibiotic prescription surveillance system at the outpatient level.

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Mucormycosis of the scalp is a rare cutaneous presentation of the disease. It is also an unusual infection in children. We present the case of a 4-year-old girl with acute lymphoblastic leukemia, who presented with atypical cutaneous mucormycosis simulating an ecthyma gangrenosum lesion. Risk factors for the infection are diabetes, neoplastic diseases, immunosuppression in organ transplant recipients, and neutropenia. The cutaneos forms have been associated with trauma, burns and surgical wounds. First line treatment is amphotericin B. Posaconazole was recently approved to treat invasive mucormycosis. Surgical removal of the infected tissue is indicated.

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INTRODUCTION: Autologous hematopoietic stem cell transplantation is the treatment of choice for high-risk Hodgkin's lymphoma and non-Hodgkin's lymphoma. OBJECTIVE: Compare the capacity to mobilize CD34+ cells for autologous hematopoietic stem cell transplantation using schemes with chemotherapy and without chemotherapy plus filgrastim in patients diagnosed with Hodgkin's lymphoma or non-Hodgkin's lymphoma. MATERIAL AND METHODS: The clinical records of patients with Hodgkin's lymphoma or non-Hodgkin's lymphoma who received an autologous hematopoietic stem cell transplant were analyzed retrospectively. Filgrastim alone or in combination with chemotherapy was used as mobilization scheme. Cell harvesting was classified as adequate when > 2 × 106 cells/kg were collected. RESULTS: Forty-seven patients (Hodgkin's lymphoma, 24; non-Hodgkin's lymphoma, 23) were included. Comparing groups of Hodgkin's lymphoma mobilized with chemotherapy (15 patients) and without chemotherapy (nine patients), one apheresis procedure was sufficient in 73 and 44% of patients, respectively (p = 0.04), the average of CD34 + cells/kg collected was 11 x 106 and 3 x 106, respectively (p = 0.017), and the collection was adequate in 100 and 55.6% of cases, respectively (p = 0.014). Comparing the groups of non-Hodgkin's lymphoma mobilized with chemotherapy (six patients) and without chemotherapy (17 patients), one apheresis procedure was sufficient in 33 and 65% of patients, respectively (p = 0.26), the average of CD34+ cells/kg was 3.56 x 106 and 3.41 x 106, respectively (p = 0.47), and collection was adequate in 66.6 and 59% of cases, respectively (p = 0.37). CONCLUSION: In Hodgkin's lymphoma patients, mobilization schemes with chemotherapy were more effective considering the number of cells collected, the number of apheresis required, and the percentage of successful cell collections. In non-Hodgkin's lymphoma patients, there were no significant differences between the two groups.

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Abstract: Introduction: Pulmonary thromboembolism (PTE) is a cardiovascular emergency threatening life. It is classified at low, intermediate and high risk of mortality. By the above, it allows to establishing conservative treatment for low-intermediate risk PTE and more intense treatment for high risk PTE. Objective: To report the number of cases of acute PTE, risk stratification and prognosis in those treated with adherence to clinical guidelines. Material and methods: Review of clinical records with a diagnosis of acute PTE by confirmatory diagnostic test. The type of treatment was determined by: oral anticoagulation (OAC) or parenteral anticoagulation (PAC), percutaneous thrombectomy, supraselective thrombolysis, systemic thrombolysis, surgical thrombectomy or combinations. The type of initial anticoagulation and maintenance therapy. Hard results: TIMI major bleeding, re-thrombosis, death and brain stroke (BS). Normality was verified by Kolmogorov-Smirnov test. Then was compared with Student t or U Mann-Whitney. Results: A sample of 36 patients was obtained, the mean age was 67.24 ± 18.83 years, 62.2% were females. The 29.7% were low-risk PTE, 51.4% were intermediate risk and 18.9% were high risk. The 70.3% received OAC, 8.1% percutaneous trombectomy, 8.1% systemic thrombolysis, 10.8% systemic thrombolysis + percutaneous thrombolysis, 2.7% percutaneous trombectomy + supraselective thrombolysis. There is increased risk of death in this group OR = 2.63 (95% CI 0.45-16.08) but not significant (p = 0.255). Conclusions: Lack of adherence to clinical guidelines confers increased risk of death in patients with acute PTE, this difference is not statistically significant.

Resumen: Introducción: La tromboembolia pulmonar (TEP) es una urgencia cardiovascular que pone en riesgo la vida. Se cataloga en riesgo bajo de mortalidad, intermedio y alto. Lo anterior permite establecer estrategias terapéuticas conservadoras para la TEP de riesgo bajo-intermedio y más intensas para alto riesgo. Objetivo: Reportar el número de casos de TEP aguda, la estratificación de riesgo y el pronóstico en quienes recibieron tratamiento con apego a guías clínicas. Material y métodos: Revisión de expedientes clínicos con diagnóstico de TEP aguda, mediante prueba diagnóstica confirmatoria. Se determinó el tipo de tratamiento: anticoagulación (ACO), oral o parenteral (ACP), trombectomía percutánea(TBTP), trombolisis supraselectiva (TBLSU), trombolisis sistémica (TBLSIS), trombectomía quirúrgica (TBTQ) o sus combinaciones. El tipo de anticoagulación inicial y de mantenimiento. Los resultados duros: sangrado TIMI mayor, retrombosis, muerte y evento vascular cerebral (EVC). Se verificó la normalidad mediante prueba de Kolmogorov-Smirnov. Posteriormente se comparó con t Student o U de Mann-Whitney. Resultados: Se obtuvo una muestra de 36 pacientes, la edad media fue 67.24 ± 18.83 años, el 62.2% fueron del género femenino. El 29.7% correspondía a TEP de riesgo bajo, 51.4% riesgo intermedio y 18.9% a riesgo alto. El 70.3% se dio ACO y ACP, 8.1% TBTP, 8.1% TBLSIS, 10.8% TBLSIS + TBTP y 2.7% TBTP + TBLSU. Existe mayor riesgo de muerte en el grupo de falta de apego a guías OR = 2.63 (IC 95% 0.45-16.08), sin embargo, no es significativo (p= 0.255). Conclusiones: La falta de apego a guías clínicas confiere mayor riesgo de muerte en pacientes con TEP aguda, esta diferencia no es estadísticamente significativa.

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BACKGROUND AND AIMS: FLT3-ITD mutations in acute myeloid leukemia (AML) are associated with a poor prognosis. In Latin America, little epidemiological data exist about these mutations and their influence on clinical evolution and prognosis. Standardization and well-established clinical correlation make FLT3 mutational analysis by molecular methods an invaluable tool to decide among treatment options and to determine AML prognosis. METHODS: We assessed the prevalence of FLT3-ITD mutations in 138 patients with AML at four hematology referral centers from Mexico and Colombia. Molecular methods based on polymerase chain reaction (PCR) were employed for determining FLT3-ITD status. RESULTS: Mutations were present in 28 patients indicating a prevalence of 20.28%. Median age was 47 years (5-96). The FLT3 mutation positive group was older, had higher WBC and hemoglobin values and lower platelet counts but without statistical significance. A not previously described mutation in the FLT3 gene was found in one patient involving a nucleotide exchange of timine for cytosine at the 66608 position. A high mortality was found in the FLT3-mutated group, 67.8 vs. 42.72% in the non-mutated group and median survival was 4.9 months vs. 20.4 months, p = 0.009. A mutated FLT3 did not confer poor prognosis to those with M3 AML. The mutated FLT3 population had poor overall survival (OS) despite hematoprogenitor stem cell transplantation (HSCT). CONCLUSION: Prevalence of FLT3-ITD mutation in AML was present in a proportion comparable to other populations and, when present, was associated with a very poor prognosis.

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Si bien pudiera parecer que desde siempre el corazón fue el centro de la vida y de la espiritualidad del hombre, esto no es exactamente así. A lo largo de la historia, debió competir con otros órganos por esta posición. Su primer competidor fue el hígado, especialmente en Babilonia. Para los babilonios, el hígado, una masa grande, inmóvil en la cavidad abdominal, era el órgano ideal para que los dioses hicieran saber el futuro. Sin embargo, los egipcios eligieron al corazón como el órgano central de la vida y asiento del alma y le atribuyeron toda clase de facultades. En Israel, es el pulmón donde radica la vida. La característica de este no son las palpitaciones, sino la respiración. Dios crea a Adán soplándole Su aliento en la nariz. Pero el competidor más serio fue el cerebro. Los filósofos y médicos griegos van a discrepar, dando origen a una larga controversia. La discusión se termina con Aristóteles, quien afirma que, al igual que el mundo tiene un punto central, también el hombre lo tiene, y este es el corazón. Y así es hasta cinco siglos más tarde, en que Galeno vuelve a sostener que la vida mental y espiritual del hombre se asienta en el cerebro. Sin embargo, hasta hoy, hombres y mujeres siguen sintiendo que su espíritu habita en el corazón y que el centro de la vida es el corazón, puesto que el corazón simboliza lo más propio del hombre, el amor.

Though it could seem that the heart has always been the center of life and spirituality of man, this is not exactly so. Along history the heart had to compete with other organs for this position. Its first competitor was the liver, specially in Babylonia. For the Babylonians, the liver, a big, immobile mass in the abdominal cavity, was the ideal organ for the gods to make the future known. On the other hand, the Egyptians chose the heart as the central organ of life and seat of the soul, and attributed to it all kinds of faculties. In Israel the lung was the site where life took root. The distinctive features of life were not the throbs but the breathing. God created Adam blowing His breath into Adam’s nose. But, the most serious competitor was the brain. The Greek philosophers and physicians had different opinions, giving origin to a long controversy. The discussion was settled by Aristotle, who stated that as the world has a central point, man also has one, and this is the heart. This remained so for five centuries until Galen declared that the brain is the seat of mental and spiritual life of man. However men and women up to today continue feeling that their spirit inhabits in the heart and that the center of their life is the heart, since it symbolizes love, an inherent faculty of man.

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Si bien 1953 fue el año del descubrimiento del ADN y de la conquista del Monte Everest, también lo fue de un gran invento tecnológico: la máquina corazón-pulmón, la que ofreció un tratamiento, y en muchos casos cura, a la mayoría de las enfermedades cardiovasculares. En efecto, el 6 de mayo de 1953 John Gibbon logró coronar con el éxito el trabajo de toda su vida al cerrar por primera vez una comunicación interauricular en una joven mujer utilizando una máquina corazón-pulmón de su invención. Sin embargo, previamente la cirugía exploró otros caminos para operar el corazón, como la hipotermia, la que consistía en bajar la temperatura del paciente introduciéndolo en una tina de agua fría para luego efectuar la corrección quirúrgica de una malformación del corazón, en el menor tiempo posible. Por otra parte, luego de su primer éxito, los 4 pacientes siguientes de Gibbon fallecieron, por lo que este abandonó todo intento ulterior, lo que fue seguido por un pesimismo generalizado sobre la circulación extracorpórea. Este fue revertido un año más tarde por Walton Lillehei con la introducción de la "circulación cruzada controlada" en la que un paciente, habitualmente un niño, era conectado a un "donante", habitualmente el padre o la madre, cuyo corazón y pulmón servían como un oxigenador para así efectuar la cirugía a corazón abierto del paciente. Finalmente, es el mismo Lillehei, quien un año más tarde introduce el oxigenador de burbujas, simple y de bajo costo, que abrió las puertas de la cirugía a corazón abierto a todos los cirujanos del mundo. Por esto, para muchos, Walton Lillehei es considerado el "Padre de la Cirugía a Corazón Abierto". Lillehei visitó Chile en 1963 y luego de operar en los pabellones del Hospital Clínico de la Universidad Católica fue nombrado Miembro Honorario de la Facultad de Medicina de dicha Universidad. Previamente, en 1957, Helmuth Jaeger había efectuado el primer cierre quirúrgico exitoso de una comunicación interauricular con circul...

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Background: When the ascending aorta and the femoral artery cannot be used for extracorporeal circulation, an emerging alternative is the use of axillary artery. Aim: To report the experience using the axillary artery for extracorporeal circulation. Patients and methods: Between November 1998 and May 2002, 22 patients (14 male) were operated with extracorporeal circulation, cannulating the axillary artery. Briefly, an incision is made below the middle third of the clavicle and a cut is made on major pectoris muscle. Minor pectoris muscle is retracted and axillary artery is exposed. It is cannulated directly or with the aid of a prosthesis. Results: Right axillary artery was used in 21 patients and in 20 it was cannulated with the aid of a prosthesis. Mean flow was 4.5 + 0.6 l/min. The most common indications were aortic dissection or aneurysms. The most common procedures done, were ascending aorta replacement in 8 cases and replacement of ascending aorta and aortic arch in 5. Thirty five percent of operations were emergencies and 32 percent were reoperations. In 15 patients (68 percent), a circulatory arrest was done. Of these, retrograde brain perfusion was used in 9, antegrade brain perfusion through the same axillary artery was used in 2 and mixed perfusion was used in 2. One patient had a complication related to the axillary cannulation. None had cerebrovascular accidents or thromboembolic complications. Two patients died in the postoperative period. Patients were followed up to 42 months after the procedure and no secondary complications of the cannulation were detected. Conclusions: When the ascending aorta and the femoral artery cannot be used, axillary artery is a good alternative for extracorporeal circulation

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Traumatic rupture of the aorta has a near 80 percent mortality. Most patients die on the site of the accident. Conventional surgical repair of these lesions has a high morbidity and mortality, generally associated to the severity of associated lesions. Over the last decade, endovascular treatment has become an effective therapeutic alternative. We report a 40 years old male, that suffered a traumatic rupture of the descending thoracic aorta in a car accident. A successful endovascular repair was performed, installing an endoprothesis on the site of the lesion, using a femoral artery approach. The patient had a good postoperative evolution and was discharged from the hospital once complete rehabilitation of his associated lesions was obtained

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Background: During the last five years, 65 patients with univentricular heart have been treated surgically in our institution, according to a protocol of staged operations that have been previously reported. Aim: To evaluate the early and mid-term outcome of those patients that have completed their staging protocol by means of a Fontan procedure. Patients and Methods: Between April 1996 and June 2001, 23 patients (age 16 to 223 months) underwent a Fontan procedure, 15 with an intracardiac lateral tunnel technique and 8 with an extracardiac conduit. A retrospective review of their clinical, surgical, echocardiographic, angiographic and hemodynamic data was performed, trying to identify risk factors for both mortality and functional capacity (FC). Follow up was complete in all survivors. Results: Three patients died early after surgery (13.04 percent). Excessive pulmonary blood flow was a risk factor for early death (p= 0.03). One patient died at 14 months. Follow up was 29.9 months (1-63). For those who survived the operation, five years survival was 93.3 percent. The majority of patients are in FC I or II, with no related risk factors. Conclusions: Our current results are comparable with those of larger series. Patients reach good FC and mid-term survival, irrespective of type of single ventricle or the surgical strategy

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Antecendentes: La cirugía es el tratamiento de elección de la coartación aórtica. Sus resultados deben evaluarse no sólo en base de morbimortalidad operatoria si no también en relación a la incidencia de coartación residual y recoartación, hecho que es más frecuente en recién nacidos. Actualmente, dado el interés progresivo en la angioplastia primaria como tratamiento de esta patología se hace necesario conocer los resultados actuales del tratamiento quirúrgico. Objetivo: Analizar y reportar nuestra experiencia en el subgrupo de pacientes de mayor riesgo. Método: Se analizaron retrospectivamente todos los pacientes de hasta 3 meses de edad (menores de 120 días) sometidos a cirugía de coartación aórtica en nuestra institución, entre enero de 1989 y agosto de 1999. Se efectuó un análisis descriptivo de las características generales y de la técnica quirúrgica, así como de los resultados inmediatos y alejados. Resultados: Cincuenta y nueve pacientes fueron sometidos a reparación quirúrgica de la coartación aótica. La edad fue de 35ñ33 días, correspondiendo un 57 por ciento a recién nacidos. Treinta y seis pacientes (61 por ciento) eran del sexo masculino. El peso fue de 3.650ñ1.057 g. La coartación aótica se presentó en forma aislada en 28 pacientes (47,5 por ciento), asociada a CIV en 7 (11,9 por ciento) y a otra patología intracardíaca en 24 (40,7 por ciento). Treinta y seis pacientes (61 por ciento) presentaron unarco aórtico normal, 17 hipoplasia del istmo (28,8 por ciento) y 6 hipoplasia del arco transverso (10 por ciento). La principal indicación de cirugía fue insuficiencia cardíaca. Al momento de la cirugía 17 pacientes (31,5 por ciento) se encontraban en ventilación mecánica y 20 (37 por ciento) habían recibido de protaglandinas. La técnica quirúrgica fue: anastomosis término-terminal en 31 (52,5 por ciento); anastomosis término-terminal extendida en 24 (40,7 por ciento) y colgajo subclavio en 4 (6,7 por ciento). El tiempo de clampeo aórtico fue de tomosis fue de 18,4ñ6,2 minutos. En siete pacientes (11.9 por ciento) se efectuó cirugía cardíaca adicional. Cuatro pacientes (6,7 por ciento) presentaron coartación aórtica residual la cual motivó cirugía en un caso (1,7 por ciento) y angioplastia en otro. Ningún paciente presentó paraplejia. La mortalidad quirúrgica a 30 días fue de 3,4 por ciento (2 casos). Siete pacientes (11,8 por ciento) fallecieron durante el seguimiento, obteniéndose una sobrevida actuarial a 5 años de 83,9 por ciento

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Background: The implantation of pacemakers improves cardiac function and quality of life, in particular with dual chamber DDD and DDDR modes. Aim: To evaluate our clinical experience and results on pacemaker implantation, from 1963 to 1998. Material and methods: Computerized data collected from 2,445 consecutive paced patients was reviewed. A total of 3,554 operative procedures were performed, including 412 procedures for complications and 697 pacemaker replacement. Patient survival was determined from clinical records, inquiry to pacemaker manufacturers and death certificates from Servicio de Registro Civil e Identificaci-n de Chile (Chilean Civil and Identification Registry). Results: Use of dual chamber (DDD and DDDR) pacemakers increased progressively up to 74 percent from 1988 to 1998. Complication rate was 42 percent in the 1963-1976 study period, it decreased to 10.6 percent in the 1977-1987 study period, and to 5.6 percent by 1988-1998. Only two patients died during surgery in the study period (0.08 percent). In the 1977-1987 period, pacemakers lasted 10.6 years. Survival rates were 52 percent at ten years, 33 percent at 15 years, and 21 percent at 20 years, with a median survival of 11.7 years, and 7.24 years in patients over 80 years old. Conclusions: Transvenous permanent pacing can be accomplished today with a low complication rate, mainly due to better technology and surgical procedures

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