Sincelejo Diaries, part 2


Sincelejo

Tuesday –  We drove back from Cartagena this morning before heading to surgery in the afternoon for a bypass grafting case.  For the first half of the way, I sat in the back and enjoyed looking out the window.  It’s amazing how dry parts of Bolivar are.

The drought has been responsible for the deaths of over 20,000 farm animals here in Colombia.  The small lakes are disappearing, from my first trip to Sincelejo to my most recent visit just a few weeks later.  The trees and bushes besides the roadways are completely coated with layers of dust from passing vehicles.  It gets greener as we pass into Sucre, but it’s a sad reminder of the devastating effects of climate change.

After stopping for breakfast along the way, where we met up with Dr. Melano, Iris went with Dr. Melano and I stayed with Dr. Barbosa.  We talked about music mostly.  At one point, a former patient from several years ago called, just to say hello.  The patient had recently heard that Dr. Barbosa now had a surgery program in Sucre. (The patient had previously traveled to Cartagena from a small town in Sucre for surgery.)

Once we got to Sincelejo, we headed to the hospital to see our patient before surgery and go over any last-minute questions or concerns.

(Of course) I was worried about finding vein but we easily found good quality conduit.  Dr. Salgua has been very nice about helping me with the saphenectomies.  The team teases me because I have a difficult time pronouncing her name.  We have a kind of system: While I finish closing the leg, she moves up the table to assist the surgeon in starting the grafts.  Then when I finish wrapping the leg, I stay at the back of the table with the instrumentadora, learning the Spanish names for all the instruments.  Once the chest is closed, she does a layer of fascia and I close the skin incision.

It’s a little crowded sometimes with the new instrumentadora learning the essentials of cardiac surgery, but the atmosphere at the back of the table is a lot different from the climate at the top.  (Dr. B is always calm, pleasant and entertaining – but Dr. Salgua is almost completely silent the whole time).  I am a lot quieter than my “out of OR self” when I am across the table from the surgeon too..

Wednesday – Another coronary case, on a fragile-ish patient (multiple co-morbidities including chronic kidney disease etc).  It was a long case and I was a little worried the whole time but the patient did well.  (I always worry about the frail patients).

I did okay too – performing a saphenectomy with Dr. Barbosa.  The patient had a vein stripping procedure previously (on one leg only) so I wanted to be sure to get a good segment of vein on the remaining vein.  I think Dr. Barbosa was worried about the quality of the conduit (because he kind of hovered – and didn’t relax until we started harvesting it.)

skip harvesting

Skip harvesting

I wish I would have more opportunities to perform a traditional saphenectomy (one very long incision).  I assisted on one several years ago – and I think if I had a chance to do a couple more, I would feel more comfortable skip harvesting.  Of course, a headlamp would also help.  (It’s kind of dark looking down the skip ‘tunnels’).  Then once I’ve mastered skip harvesting, I think it’s just another small jump to endo-harvesting with a scope.  I know a lot of people never bother learn to skip harvest, but I feel more comfortable building on the principles of open procedures first.  I might need them in an emergency case which is kind of why I wished I had more open saphenectomy experience.

Thursday – Saw three patients in the clinic today.  However, on reviewing the patient records and an intra-office echocardiogram, one of the patients definitely doesn’t need surgery at this point. (Asymptomatic with only moderate valvular disease).  We were happy to let him know he didn’t need surgery even if that means fewer cases.

Two surgeries today.  The first case was a bypass case for a patient with severe coronary disease and unstable angina.  Dr. Salgua and I did the harvest.  I think Dr. Barbosa is a little nervous about handing over the reins to me for harvest because he keeps a pretty close eye on me while I am doing it.  But then again, it might be because I am a little overly cautious and hesitant at this point.  If I didn’t have Dr. Salgua to look over my shoulder and encourage me onward, I’d put clips on everything and proceed at a snail’s pace to make sure I do it right.  But since it’s still my first week, maybe I shouldn’t be so hard on myself.

On the other hand, he must think my suturing is pretty good, because he just trusts me to do it correctly.

The second case was a patient from last week, who developed a large (symptomatic) pleural effusion and cardiac effusion (no tamponade or hemodynamic instability) which is a pretty common surgical complication.  The case proceeded well – I placed the chest tube, with Dr. Barbosa supervising.  Dr. Barbosa performed the cardiac window portion of the procedure.

Sadly, one of our patients from last week died today.  It was a fragile patient to begin with, and even though surgery proceeded well, the patient could never tolerate extubation and had to be re-intubated twice after initially doing well.  From there, the patient continued to deteriorate.

Friday

Today we had a beautiful aortic valve surgery.  This has always been one of my favorite cardiac procedures.  Somehow its elegant in the way the new valve slides down the carefully coördinated sutures.  (I don’t have pictures from this case – since I was first assisting – but I will post some from a previous case – so you can see what I mean).

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Dr. Salgua worked an overnight shift, so I was at the top of the table – (and yes, noticeably quieter than normal.)  I was surprised at how fast it seemed to go – but maybe that’s because everything went so smoothly.  Or maybe because we’ve done a lot of coronaries lately, which is a much more tedious and time-consuming process.

Iris and I are working on a patient education process – as a way to improve the continuum of care for patients (particularly after discharge).  I really enjoy working with Iris because I feel like we are always on the same page when it comes to patient care.

While it’s been a tiring week for the crew – I am, as always! exhilarated and happy to be here in Sincelejo.  Just knowing it’s the end of another week (and I am that much closer to going home) has me feeling a little sad.  But I guess I can’t stay forever, and I sure don’t want to take advantage of all the kindnesses that have been extended to me.

That being said:

At the end of every surgery, every day and every week in Sincelejo – I am grateful.  Grateful to Dr. Barbosa for being such a willing and patient teacher – grateful to the operating room crew (especially Iris Castro and Dr. Salgua) and particularly grateful to all the kind and generous patients I have met and helped take care of*.

The medical mission

This week I had another inquiry about ‘medical missions’.   I know people mean well when they ask about medical missions, or when they participate in these types of activities but…

Long time readers know my philosophy on this – don’t go overseas so you can pat yourself on the back over the ‘great deeds’ you performed ‘helping the poor’.  It’s patronizing to the destination country and its inhabitants – and generally not very useful anyway.  An awful lot of volunteers with real skills and talents go to waste on these so-called mission trips when their skills might be better served (in less exciting or glamorous ways) in free clinics in our own country.

But it does give everyone involved a chance to brag about how selfless and noble they have been; traveling thousands of miles, sleeping somewhere without 24/7 wi-fi (and who knows what other hardships).

Instead, change your orientation – and maybe challenge that assumption that everything you’ve learned about medicine, health care and taking care of people is better and superior.  Open your eyes and be willing to learn what others have to teach you instead.

* I always opt for full disclosure and transparency with the patients.  I introduce myself and explain that I am a studying with Dr. Barbosa, what my credentials and experience is to give them the opportunity to ‘opt out’.

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Iris & Ximena


Here in Cartagena, I have been fortunate enough to have two great roommates; Iris and Ximena.

Dr. Barbosa made all the arrangements for me, and I was a little nervous about bunking down with another nurse (we can be temperamental and territorial at times) but living with Iris has been absolutely wonderful.

I was kind of worried I’d be living with some young, possibly flighty nurse who might resent having a middle-age woman in her home, cramping her style.  Instead, it’s like having an instant best friend and I love it.

For starters – we have a lot in common:  we are both academically and professionally inclined.  Iris is the perfusionist for Dr. Barbosa’s cardiac surgery service and is extremely knowledgeable.

Part of the machinery that makes up Iriis' professional life: the heart-lung machine

Part of the machinery that makes up Iriis’ professional life: the heart-lung machine

(In Colombia, Perfusion is an advanced nursing degree.  Iris obtained her master’s degrees in both critical care (National University) and Perfusion at (CES.).   She is widely acknowledged as one of the best perfusionists (if not the best) in all of Colombia.   Her peers frequently consult her seeking advice for a variety of surgical circumstances.

She is the only nurse to collaborate (and be listed on the cover) of a comprehensive Colombian textbook on Cardiology.  Her name is listed along side such esteemed Colombian physicians as Pablo Guerra, Nestor Sandoval and Sergio Franco.

Cardiology textbook

She also serves as a reviewing editor of several Colombian medical journals.  Research articles are sent to Iris to review the methodology/ study design and overall quality.  Articles she rejects will not be accepted for publication.

In her free time, it’s not unusual to find her reading the latest journal articles on cardiac surgery or working on presentations for the latest meeting or international conference on perfusion.  In fact, she recently returned from the annual Colombian conference on cardiology and cardiac surgery in Medellin.  She is equally enthusiastic about all aspects of nursing and the position and rights of women (nurses) in Colombia and in medical society in general.

She is particularly outspoken against much of the machismo that dominates life here.  She is the one person I have learned to expect to never ask me the unpleasantly intrusive questions that seem to pass for almost introductory conversation here such as “Why don’t you have children?  Don’t you want them?  What does your husband think of that?  Your husband permits you to be here [in Colombia] without him?”*

Even when we don’t agree on all issues, she never judges my opinions or thoughts.  She endeavors to understand my reasoning instead.  It’s refreshing.

This combination of intellect, insight and experience makes for a lot of interesting and engaging discussions in the evenings as we relax and enjoy the fragrant breezes that bring daily relief to the sweltering city.

A strong woman in a culture of machismo

Iris is also extremely forthright and independent (traits that also resonate with me.)  She takes no ‘guff’ from anyone and lives how she pleases in a society that has a lot of difficulty accepting that (unmarried, no kids with Ximena as a part-time roommate.)

Even my professor, as charming and intelligent as he is, defaults into this kind of ‘macho’ thinking.  He tells me he worries about Iris, as “she is all alone” without a man to protect her.  He worries she is missing out on true happiness and is destined to be sad, alone.  Nothing could be further from the truth.

Rather, Iris has chosen to defy tradition, and live life on her terms.  She has friends, family and romantic attachments like anyone else.  She just maintains both her privacy and her independence despite that, sort of like Elizabeth I of England.

It is sometimes hard as an outsider to understand why this attracts some much attention – a single woman living quietly in her own apartment.  But then I think back to some of the comments I get from friends, acquaintances, co-workers and even strangers regarding locums life, and I realize, that as female professionals; whether the United States or Colombia, we still have a long way to go.

It’s just that as an American, I think I have fallen for the illusion of the possibility of female equality in way that women in other countries never have.  (The irony is that at this moment in my home country, women’s rights; to reproductive, financial and professional freedom are being eroded more that any other time in recent history.  Hard won battles of the 60’s and 70’s are being erased with nary an outcry.)

Here ‘paternalism’ rules the day – and no one pretends any different.

But there is more to Iris that a forthright, intelligent, independent individual.  She is also a nurturer, a caregiver, a nurse in the very sense of the word.

What could be more nurturing that offering up her home to an unknown stranger from another land?

“Ximena”

photo (38)

Iris and the other members of her apartment complex have adopted a white and orange stray cat that answers to a variety of affectionate terms.  One of these is “Nena”.  One my first day here, I confused “Nena” as a shortened version of Ximena, so Ximena she is.

This straggly looking, mangy little ball of fluff is adored by the residents of the small apartment building.  Typical of most cats, she is “owned”  by none, but owns each neighbor in turn.  But it was Iris who took up donations to get Ximena surgery she needed and routine veterinary care.  All the residents share in the feeding and care of the street cat – including applying a cream to her healing surgical scar, but it is Iris whom Ximena usually seeks.

While most of the residents leave their doors open during the afternoons to invite Ximena in, Ximena is most often found either inside our apartment, or bellowing outside the door (on the rare occasions that is is closed.)  She wanders in with the grace and arrogance that only a cat possesses.

She carries herself with a dignity that belies her ‘homeless’ state as to say she isn’t a vagabond but a seasoned traveler as she visits each apartment in turn – but always comes back to Iris to stay all afternoon and overnight.

Some of the neighbors our jealous of Ximena’s attention, but with our weekly journeys to Sincelejo, they always have an apportunity to host ‘Nena as their favored guest.

Iris loves to cook – and does so easily, deliciously.  She embraces a healthy lifestyle filled with daily exercise and fresh fruit and vegetables.

salad made of exotic fruits

salad made of exotic fruits

We talk about my love of Colombian food – and together one day in the kitchen, we make brevas.  She tells me with a smile that she has never made them, but used to watch her grandmother cook them for a sweet tweet.

Boiling brevas: Photo by Camila

Boiling brevas: Photo by Camila

We savor the sugary treat, one breva at a time over the next several days.

In  addition to learning how to perform saphenectomies from Dr. Barbosa, Iris is teaching me how to crochet.  My first project will be one of the small bags that is in a style typical for Colombia.  I think it is ironic that it seems easier to suture that it is to crochet.

Iris 003

But Iris is endlessly patient with me – and slowly, slowly as I unravel my mistakes and start again, I am making progress.  She has a blogspot where she showcases her latest creations.  She recently received national accreditation as a ‘native artist’ to participate in festivals and art fairs that specialize in traditional Colombia crafts.

Today, as we sit on the sofa, crocheting, we talk about plans for the Semana Santa (Easter Week).  The secretarial staff in Sincelejo has vacation plans and wants to keep the office closed all week so she can visit a boyfriend in Medellin – but Iris and I think it should remain open for the patients.  We plan to offer to staff the office, so that patients won’t have to wait a week to be seen.  We will have to navigate and negotiate carefully and diplomatically to prevent causing any hard feelings but as Iris points out, it’s the right thing to do for the patients – and the doctors, and that’s what matters. (My motives are admittedly more self-serving: more clinic = more surgery.)

*This type of questioning is fairly pervasive throughout Colombia, and is often performed as part of introductory conversation.  Once a taxi driver in Bogotá directed me to the nearest fertility clinic when I responded “No” to the question about children.  He wasn’t rude, on the contrary, he thought he was being helpful.

** Iris prefers not to have her picture taken.

Adventures in Sincelejo


If there is such thing as a perfect day, it would have been today.  The weather was still hot, humid and sticky.  I still have student loans and the world continues to have accidents, disasters and wars.  But for me, today was as good as it gets.

VSD patch400

I spent the morning in the operating room while Dr. Barbosa performed a septal patch, and repair of the tricuspid valve.  The case went well and the patient did beautifully.  Before I left the hospital, the patient was already awake, alert and awaiting extubation.  There was no hemodynamic instability or bleeding.

Barbosa1x400

The local cardiologist did several cardiac catheterizations today – and we were consulted on four of them.  3 of the patients have excellent targets for bypass grafts and normal heart function.  The fourth patient is a little more fragile, but is still a reasonable candidate for surgery.

Best way to see Sincelejo: On the back of a bike*

Lastly, I spent a nice, breezy hour touring the city on the back of a friend’s motorcycle.  (Yes, mom – I wore my helmet – and he didn’t drive like a maniac.)  We went all over Sincelejo; from the scenic overlook over the valley below, to the football stadium, past the University of the Caribbean, over to a public park with tennis courts, several pools and a small zoo. (I don’t have any pictures because I figured I’d probably drop it).

My guide was Omar, the spouse of my friend, Elena.  He works in the Parks & Recreation department of the Sucre.

photo (37)

After returning home, I took a walk down to the Plaza to buy some local cheese.  Then I spent the evening eating exotic fruits like guama, plums, uchuvas and fejoas.

*Also fairly dangerous..

All in all, it was a pretty awesome day.

Talking with Dr. Sergio Franco, Cardiac surgeon


Dr.  Sergio Franco wrote the book on heart surgery.

It was exciting and illuminating to talk to Dr. Sergio Franco, who is one of Colombia’s most prolific writers and professors of cardiac surgery.  The 50 year-old cardiac surgeon has authored multiple textbooks for surgeons and edited ten others, making him one of the nation’s definitive experts on cardiac surgery.

Dr. Franco stands near a collection of his textbooks

Dr. Franco stands near a collection of his textbooks

Currently he is the Medical Director of the Cardiopulmonary and Peripheral Vascular Center of the Fundacion San Vicente in Rio Negro, as well as Chief of Cardiothoracic Surgery at the Clinica de Medellin.  For the last 12 years, he has also been the program director for post-graduate studies at the Universidad CES medical school.  Between the two clinics, and the five other surgeons he works with (2 at Clinica de Medellin and 2 at Rionegro), he estimates that the cardiac programs see volumes of 700 – 750 cases per year.

For our first interview, we meet at the Clinica de Medellin to talk. He later invites me to see the hospital at Rionegro.

Education/ Training / Experience

Dr. Franco attended medical school, general surgery residency and cardiac surgery fellowship at the Universidad Pontifica Boliviarana.  He finished his fellowship in 1996.  As part of his fellowship, he spent nine months training in heart and lung transplantation at Loyola University Medical Center in Chicago, Il. During his heart and lung tranplantation training, he received an award as “Best Foreign Medical Fellow.”  He graduated with high honors due to his exemplary grade point average.

He has additional training in thoracic and thoracoabdominal aortic surgery (Missouri Baptist, 1998), and minimally invasive valvular surgery (Cleveland Clinic).

Selected awards and special recognition

He was also the first surgeon to perform endovascular harvesting of the saphenous vein in Colombia in 1997.  He received second place for a poster presentation based on this technique at the Colombian Congress of Cardiology and Cardiovascular Surgery, Cartagena, 8 to 11 February 2006.

He received the Cesar Uribe Piedrahita Medal from the Colombian Medical Federation and the Antioquia Medical College in 2003 for academic and clinical excellence, in addition to several other awards for academic achievement.

He was the chapter president of the Colombian Society of Cardiovascular Surgery and the Colombian Surgical Consensus for multiple terms. He was also the Chairman, and Medical Advisory of the first Latin American Forums on cardiovascular surgery.

He has received several awards including “The best of 2006” from Hospital General de Medellin for his assistance in the development, creation and commissioning of the cardiovascular services unit at that facility.  He has also presented his work at numerous national and international conferences.

He speaks English in addition to his native Spanish.

Dr Sergio Franco

San Vicente Fundacion

Cardiovascular Surgery

Medical Director, Cardiopulmonary and Vascular Surgery

Rionegro, Antioquia

Tele: 574 444 8717 Ext. 3502

Cell: 310 424 4884

Email: sfsx@sanvicentefundacion.com

Website: http://www.sanvicentefundacion.com

While I requested a visit to the operating room, an invitation was not forthcoming.

Selected writings of Dr. Sergio Franco

Book chapters:

1. Franco S., Restrepo G.  Momento Quirúrgico óptimo en el paciente con enfermedad valvular cardiaca. Libro Tópicos selectos en enfermedades cardiovasculares 2000. Unidad cardiovascular Clínica Medellín.  1 Edición. Página. 101-112.  ISBN 958-33-1541-9

2. Franco S.   Endocarditis Infecciosa: Visión Quirúrgica – Indicaciones de Cirugía. Libro Tópicos selectos en enfermedades cardiovasculares 2000. Unidad cardiovascular Clínica Medellín.  1 Edición.  Páginas 201-211. ISBN 958-33-1541-9

3. Franco, S. Estenosis Mitral – Tratamiento Quirúrgico.  En: Franco, S. (Ed) Enfermedad valvular cardiaca.  Sociedad Colombiana de Cardiología. Editorial Colina, 1 edición, Pgnas 111-116 Abril 2001. ISBN : 958-33-2244-X

4. Franco, S., Giraldo, N. , Vélez JF.  Uso e Indicaciones de Homoinjertos – Cirugía de Ross. En: Franco, S (Ed) Enfermedad Valvular Cardiaca.  Sociedad Colombiana de Cardiología.  Editorial Colina, 1 edición, Pgnas  70 – 77,  Abril 2001. ISBN : 958-33-2244-X

5. Alzate L., Franco SFactores hemodinámicos y físicos de las válvulas cardiacas artificiales. En: Franco, S. (Ed) Enfermedad Valvular Cardiaca – Sociedad Colombiana de Cardiología.  Editorial Colina, 1 edición, Pgnas 222 – 228 Abril 2001. ISBN : 958-33-2244-X

6. Franco, S., Vélez, J.  Revascularización Quirúrgica del Miocardio: Estado actual.  En: Tópicos selectos en terapéutica cardiaca y vascular 2001.  Cardiología Clínica Medellín. P: 108 –120. Primera edición, Octubre 2001. ISBN : 958-33-2607-0

7.  Vélez, JF,   Franco, S., Tamayo L. Tratamiento quirúrgico de la enfermedad coronaria.   En: Enfermedad Coronaria. Pineda M, Matiz H, Rozo R. (Ed), septiembre 2002.  Capitulo 36, pgnas 609-630. ISBN : 958-33-3945-8

8. Franco, S.  Intervencion Quirúrgica de los síndromes coronarios agudos. En: Tópicos selectos en enfermedades cardiovasculares, 2002. Pgna 177-192 (Velásquez D, Uribe W, editores) Ed. Colina, Departamento de Cardiología Clínica Medellín 2002.   ISBN 958-33-3663-7

9. Franco, S.  Cardiopatías Congénitas del Adulto.  En: Tópicos selectos en cardiología de consultorio  2003. Pgnas 193-211. (Restrepo G., Uribe W., Velásquez D., editores).  Ed. Colina, Cardiología Clínica Medellín, 2003.  ISBN : 958-33-4858-9

10. Franco, S.  Enfermedad Valvular Cardiaca: Indicaciones de Cirugía. En: Libro II Congreso medicina cardiovascular y torácica. .  Hospital Departamental Santa Sofía de Caldas,  2003 (Jaramillo O., Editor)    Editorial  Tizan.   Pgnas  87-104

11. Franco, S. Tratamiento Quirúrgico de la Fibrilación Atrial. En: Libro II Congreso medicina cardiovascular y torácica. Hospital Departamental Santa Sofía de Caldas,  2003. (Jaramillo O., Editor) Editorial  Tizan.  Pgnas  123-131

12. Franco, S.  Endocarditis Infecciosa. En: Enfermedad Valvular Cardiaca.  Pgnas 39 – 56.  (Franco, S., Editor). Editorial Colina.  Primera Edición 2004. 227 paginas.  ISBN 958-33-6218-2

13. Franco, S.  Estenosis Mitral. Tratamiento Quirúrgico. En: Enfermedad Valvular Cardiaca.   Paginas 70 – 74.  (Franco, S., Editor). Editorial Colina.  Primera Edición 2004. 227 paginas.  ISBN 958-33-6218-2

14. Franco, S., Giraldo, N.  Tratamiento Quirúrgico del Paciente Valvular en Falla Cardiaca. En: Enfermedad Valvular Cardiaca. Paginas 169 – 176.  (Franco, S., Editor). Editorial Colina.  Primera Edición 2004. 227 paginas.  ISBN 958-33-6218-2

15. Franco, S.  Jiménez A.  Factores Físicos y Hemodinámicos de las Prótesis Valvulares Cardiacas.  En: Enfermedad Valvular Cardiaca.  Pgnas 223-227.  (Franco, S., Editor). Editorial Colina.  Primera Edición 2004. 227 paginas. ISBN 958-33-6218-2

16. Franco, S. Guías de manejo de las valvulopatias aorticas.  En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2004.  Pgnas 143-149. (Uribe, W, Velásquez D, Restrepo G., Editores).  Editorial Colina.  Primera edición, 2004. 195 paginas.  ISBN 958-33-6285-9

17. Franco, S. Guías de manejo de las valvulopatias mitrales.  En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2004.  Pgnas 149-155. (Uribe, W, Velásquez D, Restrepo G., Editores).  Editorial Colina.  Primera edición, 2004. 195 paginas. ISBN 958-33-6285-9

18. Franco, S. Tratamiento Quirúrgico de la Fibrilación Atrial. En: Falla Cardiaca, Diagnostico y manejo Actual. 2004.  Pgnas  271- 287.. (Castro, H; Cubides, C.  Editores) Editorial  Blanecolor,  Primera edición, 2004.  431 pgnas. ISBN 33-6689-7

19. Escobar, A. Franco, S. Trauma de grandes vasos torácicos. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. (Velásquez D., Uribe W. editores) 1 Edición, editorial colina, 2005.  pgnas 160- 169. 193 paginas. ISBN : 958-33-7698-1

20. Franco, S., Vélez, A. Trauma cardiaco. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. (Velásquez D., Uribe W. editores)  1 Edición, editorial colina, 2005.  pgnas 154- 159. ISBN : 958-33-7698-1

21. Franco, S., Jaramillo, J. Tumores cardiacos. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. (Velásquez D., Uribe W. editores)  1 Edición, editorial colina, 2005.  pgnas 117 – 123. 193 paginas. ISBN : 958-33-7698-1

22. Franco, S., Vélez, A. Trauma cardiaco. En: Tópicos Selectos en guías de manejo en enfermedades cardiacas y vasculares – 2005. Manual Condensado. (Velásquez D., Uribe W. editores)  1 Edición, editorial colina, 2005.  pgnas 362- 366. 388 paginas. ISBN : 958-33-7698-1

23. Franco, S. Guías de manejo de las valvulopatias aorticas.  En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2005. Manual condensado.  Pgnas 177-182. (Uribe, W, Velásquez D, Restrepo G., Editores).  Editorial Colina.  Primera edición, 2005. 388 paginas. ISBN : 958-33-7698-1

24. Franco, S. Guías de manejo de las valvulopatias mitrales.  En: Tópicos Selectos en Guías de Manejo en Enfermedades Cardiacas y Vasculares 2005. Manual condensado.  Pgnas 183-188. (Uribe, W, Velásquez D, Restrepo G., Editores).  Editorial Colina.  Primera edición, 2005. 388 paginas. ISBN : 958-33-7698-1

25. Jaramillo, J.S., Franco, S. Implante Quirúrgico del Electrodo Epicárdico en el Ventrículo Izquierdo Mediante Cirugía. En: Duque, M., Franco, S.  Editores.  Tratamiento no Farmacológico de la Falla Cardiaca. Sociedad Colombiana de Cardiología y Cirugía Cardiovascular. Primera Edición, Editorial Colina, Pgnas 89-92, Abril 2006. ISBN : 958-33-8661-8

26. Franco, S. Cirugía de Remodelación Ventricular en Falla Cardiaca. En: Duque, M., Franco, S.  Editores.  Tratamiento no Farmacológico de la Falla Cardiaca. Sociedad Colombiana de Cardiología y Cirugía Cardiovascular. Primera Edición, Editorial Colina, Pgnas 168 – 182, Abril 2006. ISBN : 958-33-8661-8

27. Jaramillo, JS., Franco, S., Vélez, JF. Revascularización Coronaria Quirúrgica. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 559-576. ISBN : 958-33-9493-9

28. Franco, S., Vélez, JF, Jaramillo, JS., Cirugía en Enfermedad Valvular Aortica.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 588 – 595. ISBN : 958-33-9493-9

29. Franco, S., Vélez, JF, Jaramillo, JS., Valvulopatia Mitral.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 596 – 603. ISBN : 958-33-9493-9

30. Franco, S., Vélez, JF, Jaramillo, JS., Cirugía en Enfermedad Valvular Pulmonar y Tricúspidea.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 604 – 606. ISBN : 958-33-9493-9

31. Jaramillo, JS., Franco, S., Vélez, JF, Disección Aortica.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 607 – 617. ISBN : 958-33-9493-9

32. Franco, S., Vélez, A., Trauma de Corazón y Grandes Vasos.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 618 – 625. ISBN : 958-33-9493-9

33. Franco, S., Jaramillo, JS., Vélez, JF., Tumores Cardiacos.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 626 – 635. ISBN : 958-33-9493-9

34. Vélez, JF, Franco, S., Jaramillo, JS., Cardiopatías Congénitas del Adulto.   En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 649 – 659. ISBN : 958-33-9493-9

35. Uribe, W., Franco, S., Gil, E. Fibrilacion Auricular. En: Velásquez, D., Restrepo, G., Duque, M., Uribe, W., Franco, S. Editores.  Tópicos Selectos En Enfermedades Cardiacas y Vasculares – 2006, Estado del Arte.  Primera Ed, 2006, Editorial Colina. Pgnas 441 – 466. ISBN : 958-33-9493-9

36. Restrepo, G., Franco, S.  Endocarditis Infecciosa.  En :  Texto de Cardiologia.  Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular.  Legis, S.A. 1 Ed, 2007; Capitulo VI, pgnas 614-30. ISBN : 958-97065-7-6

37. Franco, S., Sandoval, N.  Tratamiento Quirurgico de la Fibrilacion Atrial.    En :  Texto de Cardiologia.  Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular.  Legis, S.A. 1 Ed, 2007; Capitulo IX, pgnas 835-842. ISBN : 958-97065-7-6

38. Franco, S., Jaramillo JS.  Trauma Cardiaco.  En :  Texto de Cardiologia.  Sociedad Colombiana de Cardiologia y Cirugia Cardiovascular.  Legis, S.A. 1 Ed, 2007;  Capitulo XVI, pgnas 1442-49. ISBN : 958-97065-7-6

39. Franco, S., Velez, A. Trauma Vascular Cervical.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007.  Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007.  Capitulo 31, P 425 – 433. ISBN : 979-958-98111-9-1

40. Franco, S., Velez, A., Jaramillo JS.  Trauma Cardiaco.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007.  Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007.  Capitulo 30, P 419 – 423. ISBN : 979-958-98111-9-1

41. Franco, S. Guias de Manejo de las Valvulopatias Aorticas.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007.  Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007.  Capitulo 25, P 379 – 385.  ISBN 978-958-98111-9-1

42. Franco, S. Guias de Manejo de las Valvulopatias Mitrales.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007.  Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin; 2007.  Capitulo 26, P 387 – 392. ISBN : 979-958-98111-9-1

43. Jaramillo, J.S., Franco, S. Guias de Manejo de la Revascularizacion Coronaria Quirurgica.   En : Guias de Manejo en Enfermedades Cardiacas y Vasculares 2007.  Manual Condensado, 3 Edicion, Cardiologia Clinica Medellin. Capitulo 24, P 369 – 377. ISBN : 979-958-98111-9-1

44. Franco, S.; Velez, JF.; Jaramillo,JS. Complicaciones mecanicas del infarto agudo del miocardio.  En : Topicos Selectos en Enfermedad Coronaria – 2008. Velasquez, D. ed; Distribuna Ed, Cardiologia Clinica Medellin, 2008. P. 115-126. ISBN 978-958-8379-09-8

45. Jaramillo,JS.;  Franco, S.; Velez, JF. Guias de manejo de la revascularizacion coronaria quirurgica.  En : Topicos Selectos en Enfermedad Coronaria – 2008. Velasquez, D. ed; Distribuna Ed, Cardiologia Clinica Medellin, 2008. P. 197- 218. ISBN 978-958-8379-09-8

46. Franco, S.; Jaramillo, J.S. Guías de Manejo de la revascularización Coronaria Quirúrgica. En: Guias de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edicion 2009, 503 paginas.  P. 429-440. ISBN : 978-958-8379-19-7

47. Franco, S.; Jaramillo, J.S. Guias de Manejo de las valvulopatias aorticas. En: Guias de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edicion 2009, 503 paginas.  P. 441-448. ISBN : 978-958-8379-19-7

48. Franco, S.; Jaramillo, J.S. Guias de Manejo de las valvulopatias mitrales. En: Guias de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edicion 2009, 503 paginas.  P. 449-456. ISBN : 978-958-8379-19-7

49. Franco, S.; Jaramillo, J.S. Trauma Cardiaco. En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edición 2009, 503 paginas.  P. 487-492. ISBN : 978-958-8379-19-7

50. Franco, S.; Jaramillo, J.S. Trauma Vascular Cervical. En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2009. Velásquez, D. Ed. Editorial Distribuna, 1 edición 2009, 503 paginas.  P. 493 – 503. ISBN : 978-958-8379-19-7

51. Franco, S.; Jaramillo, J.S. Trauma Vascular Cervical. En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas.  P. 501 – 511. ISBN : 978-958-8379-29-6

52. Franco, S.; Jaramillo, J.S. Trauma Cardiaco. En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edicion 2010, 511 paginas.  P. 495 – 500. ISBN : 978-958-8379-29-6

53. Franco, S.; Jaramillo, J.S. Guías de Manejo de las Valvulopatias Mitrales. En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas.  P. 457 – 463. ISBN : 978-958-8379-29-6

54. Franco, S.; Jaramillo, J.S. Guías de Manejo de las Valvulopatias Aorticas.  En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas.  P. 449 – 456. ISBN : 978-958-8379-29-6

55. Franco, S.; Jaramillo, J.S. Guías de Manejo de la Revascularización Coronaria Quirúrgica. En: Guías de manejo en enfermedades cardiacas y vasculares.  Manual Condensado 2010. Velásquez, D. Ed. Editorial Distribuna, 2 edición 2010, 511 paginas.  P. 437 – 447. ISBN : 978-958-8379-29-6

56. Franco, S.; Bucheli, V. Anatomía Quirúrgica de la Válvula Mitral. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas.  P. 26 – 31.  ISBN : 978-958-44-7706-4

57. Franco, S.; Bucheli, V. Anatomía Quirúrgica de la Válvula Aortica. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas.  P. 33 – 38.  ISBN : 978-958-44-7706-4

58. Franco, S.   Endocarditis Infecciosa. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas.  P. 85 – 113.  ISBN : 978-958-44-7706-4

59. Franco, S.   Criterios para la Selección de una Prótesis Cardiaca. En : Enfermedad Valvular Cardiaca. Franco, S. Ed., Editorial Colina, Primera Edición 2010, 440 paginas.  P. 433 – 440.  ISBN : 978-958-44-7706-4

60. Franco, S., Atehortua, M.    Endocarditis Infecciosa.  En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011.  Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas.   Pgna 153 – 184.  ISBN : 978-958-8379-46-3

61.  Franco, S., Atehortua, M.    Valvulopatia Mitral.  En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011.  Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas.   Pgna 717 – 727.  ISBN : 978-958-8379-46-3

62. Franco, S., Atehortua, M.    Cirugía Valvular Aortica.  En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011.  Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas.   Pgna 707 – 717.  ISBN : 978-958-8379-46-3

63.  Atehortua, M.,  Franco, SRevascularización Coronaria Quirúrgica.  En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011.  Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas.   Pgna 675 – 690.  ISBN : 978-958-8379-46-3

64. Atehortua, M.,  Franco, SEvaluación y Momento Optimo de Intervención en el Paciente con Enfermedad Valvular Cardiaca.  En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011.  Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas.   Pgna 691 – 707.  ISBN : 978-958-8379-46-3

65. Atehortua, M.,  Franco, SCirugía en Enfermedad Valvular y Tricuspidea.  En : Estado Actual en Enfermedades Cardiacas y Vasculares 2011.  Ed. Editorial Distribuna, 1 Edición 2011, 744 pnas.   Pgna 727 – 744.  ISBN : 978-958-8379-46-3

66. Atehortua, M.,  Franco, S., Velez, L.A.  Guias de Manejo de Revascularizacion Coronaria.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 619 – 630.  ISBN : 978-958-8379-60-9

67. Velez, L.A., Franco, S., Atehortua, M.  Guias de Manejo de las Valvulopatias Aorticas.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 631 – 642.  ISBN : 978-958-8379-60-9

68. Atehortua, M.,  Franco, S., Velez, L.A.  Guias de Manejo de las Valvulopatias Mitrales.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 643 – 653.  ISBN : 978-958-8379-60-9

69. Velez, L.A.,  Atehortua, M.,  Franco, S. Cirugia en Enfermedad Valvular Pulmonar y Tricuspidea.  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 655 – 661.  ISBN : 978-958-8379-60-9

70. Franco, S., Bucheli, V., Atehortua, M., Velez, L.A.  Guias de Manejo en Endocarditis Infecciosa  En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 671 – 690.  ISBN : 978-958-8379-60-9

71.  Franco, S., Bucheli, V., Atehortua, M., Velez, L.A.  Guias de Manejo de los Sindromes Aorticos Agudos.   En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 691 – 702.  ISBN : 978-958-8379-60-9

72. Franco, S., Atehortua, M., Velez, L.A.  Trauma Cardiaco.   En : Guias de Manejo en Enfermedades Cardiacas y Vasculares Estado Actual – 2012.  Ed. Editorial Distribuna, 3 Edición 2012, 708 pnas.   Pgna 703 – 708.  ISBN : 978-958-8379-60-9

Journal articles

1. Franco  Sergio, Hincapié  Miriam, Mejía  Olga.   Estudio Epidemiológico de Teníasis. Cisticercosis, San Vicente Antioquia – Colombia, 1985-1986.   En: Medicina Tropical y Parasitología Vol. 2 No 1, Ecuador, Diciembre 1985.

2. Franco Sergio, Hincapié  Miriam, Mejía  Olga.   Estudio Epidemiológico de Epilepsia y Neurocisticercosis.    En: “Revista Universidad Industrial de Santander –  Medicina¨ Vol. 14 No 1, Mayo 1986, p 143- 74.

3. Botero  D.,   Franco S.,   Hincapié  M., Mejía O.  Investigaciones Colombianas  Sobre Cisticercosis.  En: Acta Neurológica.   Vol. 2 No 2 Septiembre 1986, p. 3-6.

4. Franco Sergio; Londoño Juan.    Dermatopoliomiositis – Reporte de un caso – Revisión del Tema.    En: Medicina – U.P.B.   Vol.  7 No 2, Noviembre  1988. p. 115.

5. Franco Sergio;  Vásquez Jesús; Ortiz Jorge.     Infarto Segmentario Idiopático  del Epiplón Mayor – Presentación de dos casos y revisión del tema.    En: Medicina – U.P.B.  Vol. 10 No 2. Octubre. 1991, p. 109.

6. Franco Sergio.   Choque Hipovolémico.  Medicina  U.P.B., Vol. 13 No 2, Octubre, 1994.  P. 139-160.

7.  Montoya A.,   Franco S.,.   Lung Transplantation for Bronchoalveolar Cell Carcinoma.    First Case Report in the Word Literature.  1996 –  Loyola University Chicago Annual Report Magazine.

8. Franco S. Autopsy Results in Patients Following Lung Transplantation. Department of Pathology at Loyola University Medical Center. 1996 – Loyola University Chicago Annual Report Magazine.

  9.  Franco S.,  Giraldo N., Flórez M. Tratamiento Quirúrgico de la Coartación  Aórtica Seguimiento a Largo Plazo  – 8 años.     Revista Colombiana de Cardiología. Vol. 5 No 5, Diciembre 1996.

10.  Franco S,  Giraldo N.   Trauma Cardíaco: Revisión del Tema.    Revista Colombiana de Cardiología.  Marzo  de 1997.

11.  Franco  S., Giraldo N., Ramírez C., Vallejo C., Castro H. Revascularización Miocárdica en pacientes con fracción de eyección menor del 30%.  Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999.  Revista Colombiana de Cardiología, 1999, Vol. 7(6): 301.

12. Franco S., Giraldo N., Fernández H., Ramírez C., Vallejo C., Castro H.  Transección Aórtica Traumática: Presentación de tres casos, revisión de la literatura. Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 330.

13.  Franco S., Giraldo N., Vélez S. et al.  Fístula de la arteria coronaria derecha al tracto de salida del ventrículo derecho.   Reporte de un caso – revisión del tema.  Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999.  Revista Colombiana de Cardiología, 1999, Vol. 7(6): 319.

14. Giraldo N., Franco S., Ramírez C., Vallejo C., Castro H.   CIV y Banding de la arteria pulmonar en un paciente adulto.  Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.   Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 333.

15.   Giraldo N., Franco S., Ramírez C., Vallejo C., Castro H.   Ruptura Ventricular post implantación de válvula mitral.   Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999.  Revista Colombiana de Cardiología, 1999, Vol. 7(6): 340.

16. Castro H., Ramírez C., Franco S.,  Mesa J. et al.  Anestesia y técnica quirúrgica en pacientes sometidos a implantación percutánea de endoprótesis en aneurismas de la aorta abdominal.  Reporte de tres casos y revisión de la literatura.  Departamento de Cirugía y Anestesia Cardiovascular.  Departamento de Hemodinámica. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 331.

17. Vallejo C., Castro H., Ramírez C., Franco S., Duque M.  et al. Anestesia y técnica quirúrgica en pacientes sometidos a implante de cardiodesfibrilador automático.  Reporte de 20 casos.  Departamento de Cirugía y Anestesia Cardiovascular.  Departamento de Electrofisiología y Arritmias. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 336.

18. Ramírez C., Vallejo C., Castro H., Franco S., Giraldo N. et al.  Protección Miocárdica: Solución de HTK en Cirugía Cardiaca.   Departamento de Cirugía y Anestesia Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999.  Revista Colombiana de Cardiología, 1999, Vol. 7(6): 336.

19.   Ramírez C., Vallejo C., Castro H., Franco S., Giraldo N. et al.  Protección Miocárdica: Comparación entre la Solución de HTK y la Solución de Buckberg en Cirugía Cardiaca.   Departamento de Cirugía y Anestesia Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999.  Revista Colombiana de Cardiología, 1999, Vol. 7(6): 336.

20. Vallejo C., Ramírez C., Castro H., Giraldo N., Franco S.  Hipotiroidismo y enfermedad cardiaca: Administración de hormona tiroidea vía oral en pacientes sometidos a cirugía cardiaca.  Departamento de Cirugía y Anestesia Cardiovascular. Unidad Cardiovascular Clínica Medellín.  XVIII Congreso Colombiano de Cardiología.  Medellín, 1999. Revista Colombiana de Cardiología, 1999, Vol. 7(6): 334.

21. Franco, S., Giraldo, N., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H.   Revascularización miocárdica con arteria radial: Estudio de Casos y Controles.  Departamento de Cirugía Cardiotorácica, Clínica Medellín.  XIX Congreso Colombiano de Cardiología.  Noviembre 27 – Diciembre 1, 2001. Revista Colombiana de Cardiología, 2001, Vol. 9(2): 197.

22. Giraldo, N., Franco, S.,  Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H.   Revascularización miocárdica Off Pump: Requerimiento de derivados sanguíneos.  Departamento de Cirugía Cardiotorácica, Clínica Medellín.  XIX Congreso Colombiano de Cardiología.  Noviembre 27 – Diciembre 1, 2001. Revista Colombiana de Cardiología, 2001, Vol. 9(2): 238.

23. Giraldo, N., Franco, S.  Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H. Endarterectomia Coronaria del tronco principal izquierdo.  Departamento de Cirugía Cardiotorácica, Clínica Medellín.  CES Medicina Vol. 16  # 1, página 39-44.   Enero-Marzo  2002.

24. Franco, S., Giraldo, N., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H.   Cierre tardío del esternón en el manejo del sangrado mediastinal post cirugía cardiaca.  Departamento de Cirugía Cardiotorácica, Clínica Medellín.  CES –  Medicina.  Vol.  16 # 1, página 27-34.  Enero-Marzo 2002.

25. Franco, S., Giraldo, N., Fernández H., Escobar A., Ramírez, C., Vallejo, C., Castro H.   Cambio valvular mitral con preservación total del aparato valvular: Técnica quirúrgica, resultados y seguimiento.  Departamento de Cirugía Cardiotorácica, Clínica Medellín.  CES Medicina.  Volumen 16  # 1,  página 9-18.  Enero-Marzo 2002.

26. Franco S, Giraldo N, Escobar A, Fernández H, Vallejo C, Ramírez C. Cambio valvular mitral con preservación total del aparato valvular: técnica quirúrgica, resultados y seguimiento. Revista  Colombiana De Cardiología. 2003. pp. 368 – 74

27. Giraldo N, Franco S, Escobar A, Fernández H, Vallejo C, Ramírez C. Cierre    tardío del esternón en el manejo del sangrado mediastinal post cirugía cardiaca. Revista Colombiana De Cardiología 2003. pp.  95 – 99

28. Escobar A., Giraldo N., Franco S., Jaramillo J., Orozco A. Taquiarritmias supraventriculares postcirugia cardiaca con y sin el uso de circulación extracorpórea.  En : CES Medicina Volumen 17 # 1, Enero-julio 2003, Pgnas 23-31

29.  Echeverri JL, Gonzáles M, Franco S., Vélez LA.  Ruptura traumática de la aorta.  Reporte de dos casos y revisión de la literatura.  Medicina Crítica y Cuidados Intensivos.  Enero – Junio 2004, 2 (1) : 31-35

30. Franco, S. Giraldo, N., Gaviria, A. et al.  Aneurismas y seudoaneurismas de injertos venosos coronarios.  Revista Colombiana de cardiología, Vol. 11 # 8, Abril 2005. Pgna 401- 404.

31. Franco, S.; Uribe, W.; Velez, JF. et al.  Tratamiento quirurgico curativo de la fibrilacion atrial mediante tecnica de ablacion con radiofrecuencia monopolar irrigada : resultados a corto y mediano plazo.  Revista Colombiana de Cardiologia. 2007.  Vol 14, # 1.  Pnas 43 – 55.

32. Escobar, A., Franco,S., Giraldo,N., et al.  Tecnica de perfusion selectiva cerebral via subclavia para la correccion de patologias del arco aortico.  Revista Colombiana de Cardiologia Volumen 14, numero 4, agosto 2007.  P 232-237

33. Franco, S. Tratamiento quirurgico de la fibrilacion atrial. Revista Colombiana de Cardiologia – Guias de Diagnostico y Tratamiento de la Fibrilacion Auricular.   Vol 14,  Suplemento 3, Octubre 2007. P. 133 – 143.

34. Franco, S. Velez, A., Uribe, W., Duque, M., Velez, JF, et al.  Tratamiento quirurgico de la fibrilacion atrial mediante radiofrecuencia.  Revista Medica Sanitas 2008, Volumen 11, Numero 1, pgnas 8 – 20. Febrero –  Abril, 2008.

35. Franco,S., Herrera, AM., Atehortua, M. et al. Use of Steel bands in sternotomy closure : implications in high-risk cardiac surgical population. Interactive CardioVascular and Thoracic Surgery  8 (2009) : 200-205.

36. Franco, S. Tratamiento Quirurgico para el manejo de las arritmias ventriculares. Guias Colombianas de Cardiologia.  Artitmias Ventriculares y Muerte Subita.  Revista Colombiana de Cardiologia. Volumen 18, Suplemento 1. Pgnas  160 – 163.  Febrero 2011.

37. Miranda, A. ; Franco, S.,; Uribe, W. et al. Tromboembolismo Pulmonar Masivo de Alto Riesgo.  Medicina ( Buenos Aires),  72 :  2012; Pgnas 128-130.

38. Miranda, A., Duque, M., Franco, S., Velasquez, J. et al. Tromboembolismo Pulmonar Masivo.  Indicaciones de Cirugia – Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1.  Marzo de 2012.

39.  Franco, S.; Eusse, A.; Atehortua, M., Vélez, L., et al. Endocarditis Infecciosa : Análisis de Resultados del Manejo Quirúrgico Temprano. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 66.  Marzo de 2012.

40. Franco, S.; Bucheli, V.; Atehortua, M., Vélez, L.; Eusse, A et al. Tratamiento Quirurgico : El “Gold Estándar” en el manejo de los defectos del septum interauricular. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1.  Marzo de 2012.

41. Franco, S.; Atehortua, M., Vélez, L.; Castro, H., et al. Anomalías coronarias del Adulto. Origen anómalo de la arteria coronaria izquierda de la arteria pulmonar (ALCAPA).  Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 61.  Marzo de 2012.

42. Franco, S.; Atehortua, M., Vélez, L.; Castro, H., et al. Metástasis cardiaca de carcinoma anaplasico de tiroides. Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 70.  Marzo de 2012.

43. Franco, S.; Giraldo, N.; Atehortua, M., Vélez, L.; Castro, H., et al. Endarterectomia coronaria del tronco principal izquierdo : Seguimiento a 15 años.  Reporte de caso. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 66.  Marzo de 2012.

44. Franco, S.; Atehortua, M., Vélez, L.; Castro, H., Bucheli, V.; et al. Implante de válvulas biológicas : evaluación de libertad de reoperación por deterioro valvular estructural. Revista Colombiana de Cardiologia. Volumen 19, Suplemento 1, pgna 69.  Marzo de 2012.

45.  Miranda, A. Franco, S. Uribe, W., Duque, M. et al.  Tromboembolismo Pulmonar Masivo de Alto Riesgo Asociado a Foramen Ovale Permeable.  Medicina (Buenos Aires)  72 : 128 – 130.  2012.

46.  Franco, S.  Criterios Para la Selección de Una Protesis Cardiaca.  Rev Fed Arg Cardiol.  2012; 41(3): 156 – 160.

Special topics in Cardiac Surgery: (Monographs)

1. Franco Sergio Manejo Básico Inicial del Paciente Con Trauma CortoPunzante    En: Monografía. Hospital San Vicente de Paúl – Prado  (Tolima)  1989.

2. Franco S; Montoya A.    Transplante Pulmonar: Indicaciones, Criterios  de Selección y rechazo, Técnica Quirúrgica,  Manejo de Donante y receptor, Complicaciones.   Protocolo  para la realización de transplante  pulmonar en nuestro medio.   Comité  de transplantes de corazón y pulmón. 1996.  Clínica Cardiovascular Santa María,  Biblioteca Médica – Facultad de Medicina, Universidad  Pontificia Bolivariana

3.  Giraldo N., Franco S.,  Estudiantes X Semestre Instituto de Ciencias de la Salud  – CES.   Tratamiento Quirúrgico de la Endocarditis Infecciosa.  Monografía. Investigación realizada en la Clínica Cardiovascular Santa Maria.   Publicación Monográfica.   Enero 1997.

4.  Franco S. Safenectomía Videoendoscópica.  Realización de video  con descripción de la técnica quirúrgica. Descripción Monográfica.  Departamento de Cirugía Cardiovascular. Unidad Cardiovascular Clínica Medellín. Diciembre de 1997.

5. Franco S., Giraldo N., Fernández H.  Tratamiento Quirúrgico de la Enfermedad Pulmonar Obstructiva Crónica.  Cirugía de Reducción de Volumen Pulmonar.  Monografía, Departamento de Cirugía Cardiovascular  – Unidad Cardiovascular Clínica Medellín.  Octubre  1999.

6. Franco S., Escobar A.   Trauma de  Tórax.  Revisión  del  tema.  Monografía.  Departamento de Cirugía Cardiovascular / Unidad Cardiovascular Clínica Medellín.  Octubre de 1999.

7. Franco S., Jaramillo J.C.  Cirugía en el paciente con Angina. Consenso Nacional sobre el Manejo de la Angina de Pecho.  Sociedad  Colombiana de Cardiología.  Bogota, 11-12 agosto 2000.

8. Franco, SFibrilación Atrial: Tratamiento Quirúrgico. I Actualización del Consenso Nacional Sobre Fibrilación Atrial.  Capitulo de Electrofisiología, Sociedad Colombiana De Cardiología.  Abril 2002.

9. Franco, S, Jaramillo JS, Vélez JF, Castro H.  Infecciones Mediastinales.  Monografía.  Departamento de Cirugía Cardiovascular. Hospital Departamental Santa Sofía de Caldas, Manizales.  Mayo de 2003.

10. Guias Colombianas de Cardiologia.   Fibrilacion Atrial – Guias de bolsillo.

Duque, M, Marin, J, ed. Franco, S. Cirugia  de fibrilacion atrial.  Sociedad      Colombiana de Cardiologia y Cirugia Cardiovascular.   2008.

11.  Franco, S.  Long-Term Effectiveness of HIFU on Atrial Fibrillation in High Risk Valvular Surgery Patients. A Clinical Interview from Epicor- Cardiac Ablation System – St Jude Medical.  March 2009.

 

In the operating room with Dr. Meza at Hospital General de Medellin


Dr. Meza, closing the chest

Dr. Meza, closing the chest

I apologize for the wordiness of this post – but much of what we discuss below is covered in the Bogotá, Cartagena and Mexicali books – the essential mechanisms of cardiac surgery; how procedures work, what is off-pump surgery, when do we use the bypass pump and other explanatory information.  But since I have am not writing a full book on Medellin, I wanted to offer a bit of a primer for my new internet readers here.  

Dr. Luis Meza

Cardiac surgeon, Hospital General de Medellin

After interviewing Dr. Meza and meeting many of the staff at Hospital General de Medellin, it was a pleasure to be invited to observe Dr. Meza and Dr. Urequi , the head of the cardiac surgery department in the operating room. Despite the patient’s young age, the surgery (for me as an observer) was knuckle-biting.  While the surgery itself was a fast, straight-forward and uncomplicated repair of an interauricular septal defect – it was the patient’s fragile condition that had me on the edge of my seat.

Complex patients The case was typical of many of the cases they see at public hospitals.  It was a young patient with newly diagnosed right-sided heart failure due to an uncorrected congenital defect.  The patient had traveled from another part of Colombia (one of the poorer regions) to have surgery.  The patient had initially presented to a local doctor after a syncopal event (passing out) and was found to have an enlarged heart, with a moderate sized pericardial effusion (fluid in the sac around the heart.)  After arriving at HGM, the patient was also diagnosed with a serious acquired coagulopathy (bleeding disorder).

drawing courtesy of Wikipedia (Creative Commons licensing)

drawing courtesy of Wikipedia (Creative Commons licensing)

Since the patient had a hole between the left atrium leading into the right atrium, blood was being pushed from the left atrium (which is under higher pressure) to the low pressure right atrium.  Over the course of many years, this had caused the right atrium to enlarge massively.  As the right atrium was continuously being overfilled (from blood from the left side), the right side of the heart was being forced to work harder, and harder.  As the atrium continued to be overstretched, and enlarged – it also caused blood to be forced back into the pulmonary arteries – causing pulmonary hypertension.  While pre-surgical tests (echocardiogram, and cardiac catheterization) showed the patient to have (only) moderate pulmonary hypertension (with PA systolic pressures of 65mmHg).

Pre-operative testing is only part of the story

However, when we looked down, into the patient’s chest – it was obvious that the patient’s pulmonary vasculature was engorged and enlarged.  The patient’s heart was massive, and floppy (which is a sign the heart is working way too hard).  The patient also had peripheral edema which is another sign that the heart was not working well.

Potential for badness*

So even though, the surgery itself (described below) is not terribly technically challenging (‘like darning socks’ one surgeon used to say) – a lot can go wrong because the patient’s heart just doesn’t work that well to begin with.

* a not-so-scientific term to describe the likelihood of potential complications, problems or adverse outcomes.  These may be unavoidable circumstances in many cases – but the term is a reminder to remain vigilant even during so-called “simple” procedures.

Nitric oxide on hand

This OR does have nitric oxide  – (which we didn’t need), but was available nearby, just in case. Nitric oxide, milrinone and other medications are critical to have on hand in patients with pulmonary hypertension.  Some patients will never need it – others can’t survive without it – and sadly, (in patients with severe fixed pulmonary hypertension),  nothing – not even an assist device is going to make much difference.  While we can try to predict which patients are going to tolerate surgery, it’s not always clear-cut.  Tests (echocardiograms, right heart caths) can predict, tests can give probabilities – but sometimes tests are wrong, and patients who appear to have only ‘mild’ disease do very poorly (and visa versa). Sometimes, we just have to hold our breath as the patient comes off bypass and see.

canisters of nitric oxide in OR #1

canisters of nitric oxide in OR #1

As I mentioned in a previous post – cardiac surgery procedures can be a bit more complicated than many other surgical procedures, and while having something like nitric oxide on hand doesn’t seem like a big deal – it is.  (I have worked in several facilities without these capabilities).   It also speaks to the general preparedness of the staff. But despite the ‘potential for badness’ everything proceeded beautifully with  Drs. Urequi and Meza.  The case seemed to speed by despite the patient’s fragile health.  The entire CPB (cardiopulmonary bypass run) was just 26 minutes with a total cross-clamp time of 31 minutes.)

A little bit about cardiopulmonary bypass – the “heart-lung machine”

In comparison to the congenital repair above, average CPB times for valve replacement run around 100 minutes, 60 to 90 minutes for bypass surgery.  Patients have a higher risk of CPB related complications from hypo/ altered perfusion after long pump runs  .  As the clock begins to exceed 120 minutes, the risk of renal failure, cognitive changes and bleeding problems (as blood cells are continuous smashed/ broken / damaged within the pump) increase.

Perfusionist operating bypass pump aka "hart-lung machine"

Perfusionist operating bypass pump aka “heart-lung machine”

What is “Off-pump surgery”?  Nowadays, lots of people get real excited about “off-pump” surgery because they think that by not using the heart-lung machine, they can avoid a lot of the problems we mentioned above.  But that’s oversimplifying the entire scenario – and one that I find is often used to “sell” a particular surgeon or surgical program.  Off-pump can be safer than CPB cases, for some patients.  But these are usually not the patients that the surgery is sold to.. So it’s important to know what some of the terminology really means.  Just because Hospital X has billboards announcing that they now perform off pump surgery – doesn’t mean that it’s something you may even need or want.

Off pump is not for everyone

Patients have to be fairly healthy to tolerate cardiac surgery without the pump.  People with a lot of the problems that we thought were worsened by the pump, actually fare worse when we try to do surgery without the heart-lung machine. For example, we initially thought that Off-pump surgery would be great for people with renal insufficiency or ‘bad kidneys’ – particularly people who have kidney problems but aren’t quite sick enough to be on dialysis yet. The hope was that by avoiding the bypass pump we could avoid any damage to the kidneys from artificial flow/hypoperfusion because one of the biggest risks of cardiac surgery in patients with bad kidneys is that surgery will cause their kidneys to fail entirely, and make patients dialysis dependent.  Unfortunately, the research from all of the off-pump surgeries being done hasn’t really shown the benefits that we thought it would. So like most things in medicine, it’s not quite the panacea we had hoped it was.  But we did learn an incredible amount  of information once surgeons started trying off pump surgeries for coronary bypass.   Surprisingly, we learned that many of the complications, and conditions that we had long blamed on the CPB pump – weren’t related to the machine at all. But much of this is still being argued by cardiac surgeons every single day – each with different research studies giving different results..

More importantly, Off-pump not possible for many types of cardiac surgery

It’s technically impossible to do some types of cases without the bypass pump.  Coronary bypass surgery (CABG) is very different from other types of surgery, for example.  During bypass, the surgeon is only operating on the outside of the heart – attaching new conduit (arteries and veins) to arteries on the surface of the heart.  So – it isn’t absolutely essential to have the pump circulating blood for him while he’s operating – in some patients – we can let their body do it for us during surgery.

But replacing diseased heart valves, or the great vessels (aortic aneurysms etc) is a completely different entity.  In those surgeries – the surgeon is cutting into the heart or great vessels themselves.  It’s not possible to lop off the top of the aorta, operate on the aortic valve and not have blood being re-directed mechanically during this process.   Otherwise blood would just literally spill out into the chest and never oxygenate the brain and the rest of the body. (The only time we ever do this kind of procedure without a pump is during organ retrieval – for obvious reasons). It’s important to know these distinctions so people understand how the surgery actually proceeds.

For the case today – the surgeon has to make an incision through the side of the atria (wall of the heart chamber) to get to the hole on the inside wall of the heart.)  The surgeon then closes the hole with suture (and a patch, in some cases).  Some doctors do this in the cath lab without surgery – but that’s also controversal because the patch used in the cath procedures in the past has caused a high incidence of stroke.  In a young patient like the one here – you certainly wouldn’t want to risk it – particularly since we don’t know how well those patches hold up in the long term.

Cardiac surgeons operate at Hospital General de Medellin (HGM)

Cardiac surgeons operate at Hospital General de Medellin (HGM)

Overall evaluation of today’s case:

Safety checklists, and all pre-operative procedures were completed.  Patient was prepped and draped in an appropriate sterile fashion.  Antibiotics were administered within the recommended window (of time).  Appropriate records were maintained during the case.

Surgery proceeded normally and without incident.

Due to an underlying coagulopathy the patient did require administration of nonautologous blood products (4 units of packed red blood cells, 3 packets of platelets, and abumin) while on pump.  While the facility does not have a ‘cell-saver’ for washing and re-infusing shed blood, patient did receive autologous(their own) transfusion from the CPB pump. This blood, from the CPB circuit was returned to the patient to limit the amount of blood needed after surgery.  Hemoglobin at the conclusion of surgery was 9.6mg/dl, which is within acceptable parameters.

Hemostasis was obtained prior to chest closure, with only a small amount of chest tube drainage in the collection chamber at the time of transfer to the intensive care unit.

Surgical Apgarsdo not apply for cardiac cases due to the nature of the case, and use of CPB.  Mean pressure while on CPB was within an acceptable range.  Patient’s urinary output was less than anticipated during the case (150cc) despite the use of mannitol while on pump, but the patient responded well  (1000+) with volume infusion and the addition of furosemide.

The patient was hemodynamically stable during the entire case.  The was a very brief transitory period of hypotension (less than 5 minutes) near the conclusion of the case, which was immediately noted by anesthesia and treated with no recurrence.

On transfer to the unit, the patient was accompanied by several members of the OR staff, including Dr. Meza, the anesthesiologist, and the perfusionist, each of which did a face-to-face “hand-off” report of the patient (and medical history) including the course of the surgical procedure (including medications given, lab values, procedural details) to the Intensivist (physician), with ICU nursing staff attending to the patient.

Transesophageal echo (TEE) was not performed during this case, but was available if needed.

Also, I am happy to report there were no smartphones or “facebooking” in sight.  No one appeared engaged in anything other than the surgery at hand.

The cardiac OR


If you’ve never been to the cardiac operating room – it’s a completely different world, and not what most people expect.  For starters, unlike many areas of health care (particularly in the USA), the cardiac operating room is usually very well staffed.

 OR

Just a few of the people working in the OR. (photo edited to preserve patient privacy)

For example, there were eight people working in the operating room today:

Dr. Luis Fernando Meza, cardiac surgeon

Dr. Bernando Leon Urequi O., cardiac surgeon

Dra. Elaine Suarez Gomez, cardiac anesthesiologist

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient's privacy)

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient’s privacy)

Ms. Catherine Cardona, “Jefe”/ Nurse who supervises the operating room

Ms. Diana Isobel Lopez,  Perfusionist (In Colombia, all perfusionists have an undergraduate degree in nursing, before obtaining a postgraduate degree in Perfusion).  The perfusionist is the person who ‘runs’ the cardiac bypass machine.

Ms. Laura Garcia, Instrumentadora (First Assist)

Angel, circulating nurse

Olga, another instrumentadora, who is training to work in the cardiac OR.

This is fairly typical for most institutions.

Secondly – it’s always a regimented, and checklist kind of place.  (I wish I could say that about every operating room – but it just wouldn’t be true.)  But cardiac ORs (without exception) always follow a very strict set of accounting procedures..

For starters – there are labels.. For the patient (arm bands), for the equipment (medications, blood products etc..)  even the room is labeled.

Sign on operating room door (edited for patient privacy)

Sign on operating room door (edited for patient privacy)

Then come the checklists..

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

The general (WHO) operating room checklist.  The perfusionist’s checklist.. The anesthesiologist’s checklist.. and the big white cardiac checklist.

by then end of the case, this board will be full..

by the end of the case, this board will be full..

The staff attempts to anticipate every possible need and have it on hand ahead of time.  Whether it’s nitric oxide, blood, defibrillation equipment, or special medications – it’s already stocked and ready before the patient is ever wheeled in.

Most of these things are universal:

such as the principles of asepsis (preventing infection), patient safety and preventing intra-operative errors – no matter what hospital or country you are visiting (and when it comes to surgery – that’s the way it should be.)

Today was no exception..

In health care, we talk about “OR people” and “ER people”.. ER people are the MacGyvers of the world – people who thrive on adrenaline, excitement and the unexpected.  They are at their best when a tractor-trailer skids into a gas station, ignites and sets of a five-alarm fire that decimates a kindergarden, sending screaming children racing into the streets.. And God love them for having that talent..

But the OR.. that’s my personal area of tranquility.

This orderly, prepared environments is one of the reasons I love what I do.. (I am not a screaming, “by the seat-of-your-pants”/ ‘skin of your teeth’ kind of gal).  I don’t want to encounter surprises when it comes to my patient’s health – and I never ever want to be caught unprepared.   That’s not to say that I can’t handle an emergent cardiac patient crashing in the cath lab – it just means I’ve considered the scenarios before, (and have a couple of tricks up my sleeve) to make sure my patient is well taken care of (and expedite the process).

That logical, critical-thinking component of my personality is one of the reasons I am able to provide valuable and objective information when visiting hospitals and surgeons like Dr.  Urequi’s and Dr. Meza’s operating room at Hospital General de Medellin.

In OR #1 – cardiothoracic suite

As I mentioned in a previous post on Hospital General de Medellin, operating room suite #1 has been designated for cardiac and thoracic surgeries.  This works out well since the operating room itself, is modern and spacious (which is important because of the area needed when adding specialized cardiac surgery equipment like the CPB pump (aka heart-lung machine).  There are muliple monitors, which is important for the video-assisted thoracoscopy (VATS) thoracic cases but also helpful for the cardiac cases.  The surgeon is able to project the case as he’s performing it on a spare monitor, which allows everyone involved to see what’s going on during the case (and anticipate what he will need next) without shouting or crowding the operating room table.

Coordinating care by watching surgery

For instance, if the circulator looks up at the monitor and sees he is finishing (the bypasses for example), she can make sure both the instrumentadora and the anesthesiologist have the paddles and cables ready to gently defibrillate the heart if it needs a little ‘jump start’ back into normal rhythm..or collect lab samples, or double check medications, blood products or whatever else is needed at specific points during the surgery.

More on today’s case in our next post.

the Drs. Meza and Suarez


Dr. Luis Fernando Meza Valencia, cardiac surgeon and his wife, Dra. Elaine Suarez Gomez, anesthesiologist have a terrific partnership as part of the Cardiac Surgery program at Hospital General de Medellin (HGM). (Hospital General de Medellin is one of just a few public hospitals that have heart surgery programs.)

Dr. Meza, a Cali native who trained at Fundacion Cardioinfantil under the instruction of Dr. Pablo Umana, Dr. Nestor Sandoval along with Dr. Maldonado now performs coronary bypass, valve replacement, surgery on the great vessels (such as ascending arch replacement, aortic aneurysm repair) at the Hospital General de Medellin as well as several smaller, private facilities like Clinica Las Vegas.

He has worked at HGM for 2 1/2 years since he moved from the public hospital in Manizales (in the coffee-growing region of central Colombia).

Dra. Elaine Suarez is a anesthesiologist who has specializes in cardiothoracic anesthesia.  She has been practicing for five years and is fluent in English and German in addition to her native Spanish.

High risk patients

Because HGM serves the public and many of their patients are impoverished, Dr. Meza and Dra. Suarez see a large number of rheumatic heart disease and endocarditis patients.  Many of these patients have had very limited preventative care or medical management of their underlying chronic health conditions.  A large number of these patients have significant co-morbid conditions such as diabetes,  chroic pulmonary disease, hypertension, hyperlipidemia, and nephropathies (kidney damage).  This subset of patients almost always presents in the midst of a cardiac emergency.

In the Consulta Externa

Dr. Meza reports that he usually spends at least an hour with his patients during the initial consultation, gathering information, examining the patient and explaining the necessary tests and treatments.

In the Operating Room

Haven’t had an opportunity to follow Dr. Meza to the operating room yet, but we did get to see Dra. Suarez in action.