RESUMEN
BACKGROUND: Currently, several anatomical approaches and intervention sites can be used to perform transcatheter aortic valve implantations (TAVIs), often with no clinical indications for choosing one or another. While these choices can have an impact on resource consumption, no costing study is available in the European context to provide information on resource use and assist decision-making. AIMS: To provide comparative data on the cost of the TAVI procedure, depending on anatomical approach and intervention site used, from a hospital perspective, and to analyze factors associated with cost of hospital stay. METHODS: Multicentre national registry data were collected in 16 centres between January and October 2009. For 287 patients, a descriptive costing study and a multivariable analysis of hospital stay cost were performed. RESULTS: The mean cost of the TAVI procedure was 22,876 and the mean initial hospital stay cost was 35,164. The procedure cost, excluding valve cost, did not differ between anatomical approaches and was highest in the hybrid room and lowest in the catheterization laboratory. Factors associated with higher hospital stay cost were transapical approach, Society of Thoracic Surgeons score>10%, warfarin use at inclusion, complications during procedure and pacemaker implantation following valve implantation. CONCLUSIONS: If clinical considerations do not interfere, hospital staff may find it economically favorable to opt for the catheterization laboratory and against the hybrid room. The mean hospital stay cost is higher than the tariff paid in 2011, a difference that has grown since the change in tariff in 2012, representing an economic disincentive for the uptake of TAVI in France.
Asunto(s)
Cateterismo Cardíaco/economía , Implantación de Prótesis de Válvulas Cardíacas/economía , Costos de Hospital , Tiempo de Internación/economía , Anciano , Anciano de 80 o más Años , Anticoagulantes/economía , Anticoagulantes/uso terapéutico , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Estimulación Cardíaca Artificial/economía , Ahorro de Costo , Costos de los Medicamentos , Femenino , Francia , Prótesis Valvulares Cardíacas/economía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Modelos Lineales , Masculino , Modelos Económicos , Análisis Multivariante , Marcapaso Artificial/economía , Admisión y Programación de Personal/economía , Diseño de Prótesis , Sistema de Registros , Factores de Tiempo , Resultado del Tratamiento , Warfarina/economía , Warfarina/uso terapéuticoRESUMEN
AIMS: The SYNTAX Score (SXscore) has established itself as an important prognostic tool in patients undergoing percutaneous coronary intervention (PCI). A limitation of the SXscore is the inability to differentiate outcomes in patients who have undergone prior coronary artery bypass graft (CABG) surgery. The CABG SXscore was devised to address this limitation. METHODS AND RESULTS: In the SYNTAX-LE MANS substudy 115 patients with unprotected left main coronary artery disease (isolated or associated with one, two or three-vessel disease) treated with CABG were prospectively assigned to undergo a 15-month coronary angiogram. An independent core laboratory analysed the baseline SXscore prior to CABG. The 15-month CABG SXscore was calculated by a panel of three interventional cardiologists. The CABG SXscore was calculated by determining the standard SXscore in the "native" coronary vessels ("native SXscore") and deducting points based on the importance of the diseased coronary artery segment (Leaman score) that have a functioning bypass graft anastomosed distally. Points relating to intrinsic coronary disease, such as bifurcation disease or calcification, remain unaltered. The mean 15-month CABG SXscore was significantly lower compared to the mean baseline SXscore (baseline SXscore 31.6, SD 13.1; 15-month CABG SXscore 21.2, SD 11.1; p<0.001). Reproducibility analyses (kappa [k] statistics) indicated a substantial agreement between CABG SXscore measurements (k=0.70; 95% CI [0.50-0.90], p<0.001), with the points deducted to calculate the CABG SXscore the most reproducible measurement (k=0.74; 95% CI [0.53-0.95], p<0.001). Despite the limited power of the study, four-year outcome data (Kaplan-Meier curves) demonstrated a trend towards reduced all-cause death (9.1% vs. 1.8%, p=0.084) and death/CVA/MI (16.4% vs. 7.0%, p=0.126) in the low compared to the high CABG SXscore group. CONCLUSIONS: In this pilot study the calculation of the CABG SXscore appeared feasible, reproducible and may have a long-term prognostic role in patients with complex coronary disease undergoing surgical revascularisation. Validation of this new scoring methodology is required.
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Angiografía Coronaria , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/cirugía , Técnicas de Apoyo para la Decisión , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/mortalidad , Estudios de Factibilidad , Humanos , Estimación de Kaplan-Meier , Infarto del Miocardio/etiología , Variaciones Dependientes del Observador , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Rotura de la Aorta/etiología , Rotura de la Aorta/cirugía , Procedimientos Quirúrgicos Cardiovasculares , Intervención Coronaria Percutánea/efectos adversos , Seno Aórtico/lesiones , Angina Inestable/terapia , Oclusión Coronaria/terapia , Ecocardiografía Transesofágica , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada Multidetector , Seno Aórtico/diagnóstico por imagenRESUMEN
AIMS: The SYNTAX-LE MANS substudy prospectively evaluated 15-month angiographic and clinical outcomes in patients with treated left main (LM) disease. METHODS AND RESULTS: In the SYNTAX trial, 1,800 patients with three-vessel and/or LM disease were randomised to either CABG or PCI; of these, 271 LM patients were prospectively assigned to receive a 15-month angiogram. The primary endpoint for the CABG arm was the ratio of ≥50% to <100% obstructed/occluded grafts bypassing LM lesions to the number placed. The primary endpoint for the PCI arm was the proportion of patients with ≤50% diameter stenosis ('patent' stents) of treated LM lesions. Per protocol, no formal comparison between CABG and PCI arms was intended based on the differing primary endpoints. Available 15-month angiograms were analysed for 114 CABG and 149 PCI patients. At 15 months, 9.9% (26/263) of CABG grafts were 100% occluded and an additional 5.7% (15/263) were ≥50% to <100% occluded. Overall, 27.2% (31/114) of patients had ≥1 obstructed/occluded graft. The 15-month CABG MACCE rate was 8.8% (10/114) and MACCE at 15 months was not significantly associated with graft obstruction/occlusion (p=0.85). In the PCI arm, 92.4% (134/145) of patients had ≤50% diameter LM stenosis at 15 months (89.7% [87/97] distal LM lesions and 97.9% [47/48] non-distal LM lesions). The 15-month PCI MACCE rate was 12.8% (20/156) and this was significantly associated with lack of stent patency at 15 months (p<0.001), mainly due to repeat revascularisation. CONCLUSIONS: At 15 months, 15.6% (41/263) of grafts were at least 50% obstructed but this was not significantly associated with MACCE; 92.4% (134/145) of patients had stents that remained patent at 15 months, and stent restenosis was significantly associated with MACCE, predominantly due to revascularisation.
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Angioplastia Coronaria con Balón/instrumentación , Fármacos Cardiovasculares/administración & dosificación , Angiografía Coronaria , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/diagnóstico por imagen , Stents Liberadores de Fármacos , Oclusión de Injerto Vascular/diagnóstico por imagen , Paclitaxel/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Reestenosis Coronaria/etiología , Reestenosis Coronaria/fisiopatología , Europa (Continente) , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Diseño de Prótesis , Sistema de Registros , Análisis de Regresión , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos , Grado de Desobstrucción VascularAsunto(s)
Estenosis de la Válvula Aórtica/patología , Válvula Aórtica/patología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Ventrículos Cardíacos/patología , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Ecocardiografía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Masculino , Ultrasonografía DopplerRESUMEN
AIMS: Transcatheter aortic valve implantation is a therapeutic alternative for high-surgical-risk patients with severe symptomatic aortic stenosis. Two models of prosthesis are currently commercialized in France, which can be implanted either via a transarterial or a transapical approach. The aim of the study was to evaluate in a national French registry the early safety and efficacy of transcatheter aortic valve replacement (AVR) using either the Edwards SAPIEN™ or CoreValve™ in high-surgical-risk patients with severe aortic stenosis. METHODS AND RESULTS: The multicentre national registry was conducted in 16 centres between February 2009 and June 2009, under the authority of the French Societies of Cardiology and Thoracic and Cardio-Vascular Surgery. The primary endpoint was mortality at 1 month. Two hundred and forty-four high-surgical-risk patients (logistic EuroSCORE ≥20%, STS ≥10%, or contra-indication to AVR) were enrolled. Mean age was 82 ± 7 years and 43.9% were female. Edwards SAPIEN and CoreValve were implanted in 68 and 32% of patients, respectively. The approaches used were transarterial (transfemoral: 66%; subclavian: 5%) or transapical in 29%. Device success rate was 98.3% and 30-day mortality was 12.7%. Severe complications included stroke (3.6%), tamponade (2%), acute coronary occlusion (1.2%), and vascular complications (7.3%). Pacemaker was required in 11.8%. At 1 month, 88% of patients were in NYHA class II or less. CONCLUSION: This prospective registry reflects the real-life experience of transcatheter aortic valve implantation in high-risk elderly patients in France. The early results are satisfactory in terms of feasibility, short-term haemodynamic and functional improvement, and safety. Longer term follow-up will be further assessed.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Complicaciones Posoperatorias/etiología , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Femenino , Francia , Humanos , Masculino , Persona de Mediana Edad , Sistema de Registros , Resultado del TratamientoRESUMEN
AIMS: Transcatheter aortic valve implantation (TAVI) is performed through a transarterial approach with encouraging results in "one-type valve" registries. We report 30-day data from a mixed population of patients treated with either Medtronic CoreValve (MCV) or Edwards SAPIEN (ES) valves. METHODS AND RESULTS: Forty-five patients had TAVI via the transarterial approach (21 MCV and 24 ES). Mean age was 81.8+/-4.2 years, Logistic EuroSCORE was 25.2+/-8.4%. Procedural success rate was 97.8%. In-hospital death rate was 4.4%. Vascular complication rate was 8.9%. Of MCV patients, 28.6% had a permanent pacemaker vs. 4.2% of ES patients; p=0.02. No additional deaths were observed between discharge and 30 days. NYHA functional class was improved at 30-days: 2.07+/-0.4 vs. 3.09+/-0.05, p<0.0001. Mean transvalvular gradient was lower: 9.5+/-3.28 mmHg vs. 41.9+/-14 mmHg, p<0.0001. Overall 30-day MACE rate was 8.9%, similar between MCV and ES patients. CONCLUSION: A routine policy of TAVI using both MCV and ES valves is feasible without any worsening of procedural success rates and 30-day outcomes. A wider population of high risk patients with aortic stenosis can be offered a transarterial treatment. This could be the next standard of care for teams performing TAVI.
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Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Enfermedades Vasculares/etiología , Anciano de 80 o más Años , Angiografía , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/epidemiología , Cateterismo Cardíaco/métodos , Ecocardiografía Transesofágica , Femenino , Estudios de Seguimiento , Francia , Implantación de Prótesis de Válvulas Cardíacas/métodos , Mortalidad Hospitalaria , Humanos , Incidencia , Tiempo de Internación , Masculino , Estudios Prospectivos , Diseño de Prótesis , Factores de Tiempo , Resultado del Tratamiento , Enfermedades Vasculares/epidemiologíaAsunto(s)
Estenosis de la Válvula Aórtica/cirugía , Cateterismo , Arteria Femoral , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Válvula Mitral/cirugía , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico , Ecocardiografía Transesofágica , Medicina Basada en la Evidencia , Femenino , Arteria Femoral/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/diagnóstico , Humanos , Radiografía Intervencional , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
OBJECTIVES: The study aim was to evaluate the safety and feasibility of radiofrequency ablation for the surgical treatment of permanent atrial fibrillation in patients with degenerative mitral valve disease. DESIGN: From August 2000 to August 2003, 40 consecutive patients (mean age 69.0 +/- 9.3 years) with permanent atrial fibrillation and degenerative mitral valve disease underwent surgical radiofrequency ablation in conjunction with 22 mitral valve repairs and 18 mitral valve replacements. The mean duration of chronic AF was 5.1 +/- 3.4 years. The completeness of follow-up was 100%. The mean follow-up time was 4.6 +/- 2.0 years (range 0 to 7.8 years). RESULTS: Thirty-day mortality was 2.5% (1 patient), the cause of death was cardiac failure. Cardiac failure and temporary A-V block were the most common postoperative complications. Both occurred in 10% (4 patients). No complication was related to the ablation procedure. At discharge, 65% (26/40) of the patients were in sinus rhythm. Overall incidence of sinus rhythm at the end of the follow-up was 56.4% (22/39).The 1-, 3- and 5-year survival was 97.5%, 91.8% and 85.9%, respectively. CONCLUSION: Mitral valve surgery combined with radiofrequency ablation is a safe and effective procedure in patients with permanent atrial fibrillation and degenerative mitral valve disease. The result is encouraging in restoring sinus rhythm, and an excellent postoperative survival rate can be achieved.
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Fibrilación Atrial/epidemiología , Fibrilación Atrial/cirugía , Ablación por Catéter , Enfermedades de las Válvulas Cardíacas/epidemiología , Enfermedades de las Válvulas Cardíacas/cirugía , Anciano , Procedimientos Quirúrgicos Cardíacos , Comorbilidad , Estudios de Factibilidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana EdadRESUMEN
AIMS: To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development. METHODS AND RESULTS: A committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation. CONCLUSION: Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.
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Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/normas , Estenosis de la Válvula Aórtica/epidemiología , Contraindicaciones , Europa (Continente) , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Factores de RiesgoRESUMEN
AIMS: To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development. METHODS AND RESULTS: A committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation. CONCLUSION: Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Cateterismo Cardíaco/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Cateterismo Cardíaco/normas , Europa (Continente) , Implantación de Prótesis de Válvulas Cardíacas/normas , Humanos , Sociedades MédicasRESUMEN
AIMS: To critically review the available transcatheter aortic valve implantation techniques and their results, as well as propose recommendations for their use and development. METHODS AND RESULTS: A committee of experts including European Association of Cardio-Thoracic Surgery and European Society of Cardiology representatives met to reach a consensus based on the analysis of the available data obtained with transcatheter aortic valve implantation and their own experience. The evidence suggests that this technique is feasible and provides haemodynamic and clinical improvement for up to 2 years in patients with severe symptomatic aortic stenosis at high risk or with contraindications for surgery. Questions remain mainly concerning safety and long-term durability, which have to be assessed. Surgeons and cardiologists working as a team should select candidates, perform the procedure, and assess the results. Today, the use of this technique should be restricted to high-risk patients or those with contraindications for surgery. However, this may be extended to lower risk patients if the initial promise holds to be true after careful evaluation. CONCLUSION: Transcatheter aortic valve implantation is a promising technique, which may offer an alternative to conventional surgery for high-risk patients with aortic stenosis. Today, careful evaluation is needed to avoid the risk of uncontrolled diffusion.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Cateterismo Cardíaco , Medicina Basada en la Evidencia , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Selección de Paciente , Radiografía , Resultado del TratamientoRESUMEN
The outcome of patients with Ebstein's malformation depends mainly on the severity of the tricuspid valve malformation. Accurate description of the tricuspid anatomy by two-dimensional echocardiography remains difficult. We applied real-time three-dimensional echocardiography to 3 patients with Ebstein's anomaly. Preoperative and postoperative descriptions of the tricuspid valve were obtained from views taken inside the right ventricle. Surface of the leaflets as well as the commissures were obtained by three-dimensional echocardiography. Real time three-dimensional echocardiography is a promising tool, providing new views that will help to evaluate the ability and efficiency of surgical valve repair in patient with Ebstein's malformation.
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Anomalía de Ebstein/diagnóstico por imagen , Ecocardiografía Tridimensional , Adolescente , Niño , Femenino , Humanos , MasculinoRESUMEN
Adipose tissue is now considered as an endocrine organ implicated in energy regulation, inflammation and immune response, and as a source of multipotent cells with a broad range of differentiation capacities. Some of these cells are of a mesenchymal type which can -- like their bone marrow (BM) counterpart -- support hematopoiesis, since in a previous study we were able to reconstitute lethally irradiated mice by cells isolated from adipose tissue. In the present study, we established that cells derived from the stroma-vascular fraction of human subcutaneous fat pads support the complete differentiation of hematopoietic progenitors into myeloid and B lymphoid cells. However, these cells are unable to maintain the survival and self-renewal of hematopoietic stem cells. These features, similar to those of BM adipocytes, are the opposite of those of other cell types derived from mesenchymal progenitors such as BM myofibroblasts or osteoblasts. Because it is abundant and accessible, adipose tissue could be a convenient source of cells for the short-term reconstitution of hematopoiesis in man.
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Adipocitos/citología , Adipocitos/fisiología , Diferenciación Celular , Células Madre Hematopoyéticas/citología , Adulto , Anciano , Antígenos CD34/metabolismo , Linfocitos B/citología , Técnicas de Cultivo de Célula , Células Cultivadas , Técnicas de Cocultivo , Medios de Cultivo/química , Citocinas/análisis , Femenino , Humanos , Persona de Mediana Edad , Células Mieloides/clasificación , Células Mieloides/citología , Células del Estroma/citologíaRESUMEN
A simple and quick technique to fashion a mitral ring was developed using a stainless steel wire covered by a Gore-Tex strip. This technique allows a 15-fold reduction in the cost of a mitral ring compared with commercially available rings. As such, cardiac surgery becomes more readily available to patients in developing countries such as Africa and Asia. These homemade rings were implanted in 6 patients with similar results to commercially available rings.
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Válvula Mitral/cirugía , Diseño de Prótesis , Países en Desarrollo , Humanos , Lactante , Insuficiencia de la Válvula Mitral/cirugía , Diseño de Prótesis/economíaRESUMEN
Aortoesophageal and aortobronchial fistulas constitute a problem in therapy because of the high rates of morbidity and mortality associated with operation. From May 1996 to March 2000, we treated by an endovascular procedure one aortoesophageal and three aortobronchial fistulas. There was no postoperative death. We noted one peripheral vascular complication that required a surgical procedure, one postoperative confusion, and one inflammatory syndrome. In one case, because of a persistent leakage after 21 months, we had to implant a second endovascular stent graft. A few weeks later the reopening of this patient's esophageal fistula led to his death by mediastinitis 25 months after the first procedure. The few cases published seem to bear out the interest, observed in our 4 patients, of an endovascular approach to treat complex lesions such as fistulas of the thoracic aorta especially in emergency or palliative cases.
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Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular , Fístula Bronquial/cirugía , Fístula Esofágica/cirugía , Fístula Vascular/cirugía , Anciano , Anciano de 80 o más Años , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , StentsRESUMEN
When the port of entry of acute type-A aortic dissection is at the level of the horizontal portion of the aortic arch, the latter should be replaced by a prosthesis. To avoid performing this difficult procedure in an emergency situation, we place a stent in the aortic arch. Then we replace the ascending aorta by a prosthesis.