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Biomedical subjects

J Ernesto Molina

Publications and source records attributed to J Ernesto Molina.

14 recordsLinked to original sources
PubMed2006

Treatment of postoperative sternal dehiscence with mediastinitis: twenty-four-year use of a single method.

OBJECTIVE: Postoperative deep sternal wound infection with dehiscence carries a high mortality rate, a high morbidity rate, and a poor cure rate. We developed a standard protocol of care to treat this complication, achieving primary closure and cure of the infection. METHODS: From January 1, 1981, through May 31, 2005 (24 years 5 months), we treated 114 patients with dehiscence and mediastinitis. The diagnosis was made from 4 to 56 days (mean, 14.5 days) after surgery. Mean age was 64.3 years (range, 38-84 years); 79 (69%) were obese, and 48 (42%) had diabetes. Ten had previous attempts (1-4) of repair with other methods. Treatment entailed (1) debridement without removal of bone, (2) bilateral dissection of skin and subcutaneous tissue as one layer, (3) implantation of a staggered double-tube irrigation-suction system posterior and another one anterior to the sternum, (4) lateral reinforcement of the sternum and reclosure with a double wire, and (5) a single-layer closure of the subcutaneous tissue and skin. RESULTS: Of 114 patients, 109 (96%) had mediastinitis, positive for Staphylococcus species in 101 (92.6%). The cure rate was 98% (112/114); hospital stay was 14 days (range, 12-16 days), with no deaths. CONCLUSIONS: Use of this standard protocol is effective and highly recommended. It spares the sternum, cures the infection, and leaves the patient physically functional without the use of soft tissue flaps.

Adult↗
PubMed2005

Evaluation and operative technique to repair isolated sternal fractures.

A series of 12 patients with traumatic sternal fractures without internal organ injury are reported to have had their fractures repaired with a standard operative technique that has proved to be effective up to 17 years of follow-up. Although sternal fractures are often seen in emergency departments of trauma centers, rarely are they recommended for correction. Often patients experience physical deformity, chronic pain, and abnormal physical habits. A standard operative technique is proposed with highly satisfactory results. Thoracic surgeons should be familiar with this problem and with available standard methods to correct it.

Adolescent↗
PubMed2004

Coronary bypass before simultaneous pancreas-kidney transplants for type 1 diabetics in renal failure.

Our study examined the results of coronary artery bypass (CAB) before simultaneous pancreas-kidney (SPK) transplant in type 1 diabetics in renal failure. Of 588 pancreas transplant patients from 1992 to 2002, 77 (24 females, 53 males) were candidates for SPK transplant. All 77 had coronary evaluation and were referred for pretransplant CAB. Among the 77 CAB patients, the mean age was 42 years (range: 30- 63 years), and the duration of diabetes was 28.52 years (range: 9-51 years). All had neuropathy, retinopathy, and nephropathy; 12.9% (n = 10) had angina; and 76% (n = 59) were on dialysis at the time of CAB. The creatinine level of the 18 nondialysis patients was 3.7 mg%; 42.8% (n = 33) had suffered myocardial infarction. The left ventricular ejection fraction (LVEF) was 49% (30-65%). At CAB surgery, 88% (n = 68) triple, 9% (n = 7) double, and 2.5% (n = 2) single arterial grafts were implanted. All 77 CAB patients had severe coronary artery disease (CAD); some vessels could not be bypassed in 9.8%. At surgery, 3.4 grafts/patient were implanted (range: 1-6 grafts). All 59 dialysis patients continued dialysis after CAB; 6 nondialysis patients required dialysis after CAB. The intensive care stay averaged 1.86 days (range: 1-10 days); the hospital stay averaged 10.5 days (range 6-28 days). There was no operative mortality. Eventually, 68 patients underwent SPK transplant; 9 await organs. The waiting period for 68 CAB patients who had SPK was 2 years, 5 months (range: 2 months to 10 years). The SPK operative mortality was 3.9% (n = 3). Significant CAD exists in patients > 30 years of age with type 1 diabetes and renal failure. Pretransplant CAB can be done safely and may reduce posttransplant mortality associated with cardiac events.

Acute Kidney Injury↗
PubMed2004

Postoperative sternal dehiscence in obese patients: incidence and prevention.

BACKGROUND: Obesity has been identified as the single most important risk factor for postoperative sternal infection in coronary bypass surgery patients. It is also a major risk factor for sternal dehiscence, with or without infection, for any type of cardiac operation. We assessed whether prophylactic measures could prevent this complication. METHODS: Two studies were conducted. In study A, 3,158 heart surgery patients were analyzed at 3 cardiac units. Obesity was defined as body mass index (BMI) more than 30. Group I (1,253 obese [39.7%]) was compared with group II (1,905 nonobese [60.3%]). Sternal closure was done at the surgeon's preference: (a) plain wires through and through the bone; (b) peristernal figure-of-eight wires; or (c) peristernal method, using stainless-steel cables. In study B, 123 obese patients were prospectively divided into 2 subgroups. Group B-1 (54 patients) underwent lateral prophylactic sternal reinforcement before placement of peristernal wires. Group B-2 (69 patients) had standard sternal closure, as in study A. RESULTS: In study A, group I had 81 dehiscences (6.46%); 78 also suffered deep sternal infection and mediastinitis (96%). Despite treatment, dehiscence recurred in 13, and mortality was 38.4%. In group II nonobese patients, 31 dehisced (1.6%, p = 0.000), with no mortality. In study B, group B-1 (54) had 0% dehiscence versus group B-2 (69) with 6 dehiscences (8.7%). CONCLUSIONS: In our study, the rate of obesity is high ( approximately 40%). Sternal dehiscence is real when the BMI is more than 30 (6.46%), and has high morbidity and mortality. Prophylactic sternal reinforcement seems to prevent this complication.

Adult↗
PubMed2004

Surgical options for endocardial lead placement when upper veins are obstructed or nonusable.

In 35 patients (24 adults, 11 children), two techniques were used to implant endocardial pacemaker or defibrillator leads in the presence of complete occlusion or nonusability of upper veins. The obstructed veins were the subclavian, innominate, and superior vena cava (SVC). Most of the obstructions occurred secondary to previous implant of multiple leads. Twenty-four patients had occlusion of the subclavian veins; 7 of both the subclavians and innominates; 4 had stenosis of the SVC. Twenty-seven patients with obstructed subclavian veins, but with patent innominates, underwent direct implants via cut-down internal jugular vein for one or two leads, as needed. Eight patients with obstructed innominate veins or SVC underwent a direct transthoracic transatrial approach (TTTA). This method involves a parasternal extrapleural route through the mediastinum to directly puncture the right atrium. The leads are then implanted endocardially, under fluoroscopy. There were no complications with either method, and the implanted units have been working well during up to 14 years follow-up. These two techniques circumvent the problem of obstructed upper veins--which limits the options for implanting endocardial pacing systems.

Adult↗
PubMed2004

An epicardial subxiphoid implantable defibrillator lead: superior effectiveness after failure of standard implants.

A single epicardial implantable lead using the subxiphoid approach is described in this article. It consists of a single halo-shaped coil that is implanted under the inferior surface of the heart, including the right and left inferior ventricular surfaces. It has been implanted in four patients who could not be defibrillated with a transvenous system, even with the adjunct use of subcutaneous leads or left chest wall patch. Three of the patients had progressive heart failure due to ischemic myocardiopathy; the fourth patient had a dilated idiopathic myocardiopathy. The approach is simple and appears to be effective due to its ability to encompass the left and right ventricles. This vector seems to significantly lower the threshold for defibrillation, and may offer substantial benefit in the setting of high defibrillation thresholds with conventional leads, or when conventional systems are inadequate to achieve consistent defibrillation.

Adult↗
PubMed2004

Occlusion of subclavian-innominate veins: the increasing problem of receiving improper care.

Acute upper vein obstruction necessitates emergency treatment and always requires surgery. However, it is not treated appropriately most of the time. Leaving this condition untreated, or treating it incorrectly, can result in permanent disability of the patient, as well as malpractice and negligence lawsuits against the treating physicians. Thus, all physicians must be familiar with the proper care of acute upper vein obstruction. We provide in this article an easy-to-follow algorithm and an outline of steps for successful treatment. We also discuss two situations that should not be confused: 1) the acute event involving the axillary-subclavian-innominate vein, which is called effort thrombosis or Paget-Schroetter syndrome, and 2) the chronic, more extensive obstruction caused by the intravenous placement of intraluminal devices.

Acute Disease↗
PubMed1978

RAPID HYPOTHERMIC CARDIOPLEGIA AND AIR VENTING WITH AN AORTIC ROOT CANNULA.

A newly designed aortic root perfusion cannula (ARC) is described that accomplishes a double purpose. Not only does it allow rapid inflow into the root of the aorta for induction of hypothermic cardioplegia, but it also provides an effective air vent after completion of the procedure. This technique simplifies air venting at the end of open heart operations.

Journal Article↗