RESUMO
BACKGROUND: Socioeconomic deprivation (SED) has been associated with increased 30-day mortality and reduced long-term survival after surgical repair of acute type A aortic dissection (ATAAD). The study aimed to determine the incidence rate ratio of ATAAD in New Zealand population with higher and lower SED indices and to evaluate any association between SED and outcomes after ATAAD repair. METHODS: This was a retrospective cohort study. Patients who underwent ATAAD repair from March 2003 to May 2020 were identified. Overseas patients, those with chronic aortic dissection, and those who died in hospital before the operation were excluded. The total number of New Zealand residents was estimated based on the national 2018 Census. RESULTS: A total of 363 ATAAD patients met the eligibility criteria. The incidence of ATAAD was 70% greater in those who were more socioeconomically deprived (higher SED) compared with less socioeconomically deprived (lower SED) New Zealanders (odds ratio = 1.7; 95% confidence interval [CI] = 1.4-2.1; p < .0005). Postoperative cardiogenic shock, renal failure, pulmonary embolism, and respiratory failure were more common in the higher than in the lower SED group. Both groups had similar operative and in-hospital mortality and time intervals in the intensive care unit and hospital. Both groups had similar freedom from reoperation (hazards ratio [HR] = 1.1; 95% CI = 0.5-2.6; p = .746) and long-term survival (HR = 0.73; 95% CI = 0.5-1.1; p = .115). CONCLUSION: The incidence of ATAAD is greater in more socioeconomically deprived New Zealand residents. Following ATAAD repair, SED is not associated with worse short- or long-term outcomes in the universal health care system.
Assuntos
Dissecção Aórtica , Dissecção Aórtica/epidemiologia , Dissecção Aórtica/cirurgia , Humanos , Incidência , Nova Zelândia/epidemiologia , Estudos Retrospectivos , Fatores SocioeconômicosRESUMO
BACKGROUND: The current management of acute type A aortic dissection (ATAD) repair does not consider the safe duration of cardiac ischaemia as an operative strategy. We aimed to evaluate whether the duration of cardiac ischaemia during ATAD repair can predict operative mortality and to determine the optimum cardiac ischaemia time that is associated with better outcomes. METHODS: This was a retrospective observational study. Patients who underwent ATAD repair from 2003 to 2020 were identified from our hospital records. RESULTS: Three hundred and sixty three (363) ATAD patients met eligibility criteria. The median patient age was 61 years, 221 (61%) patients were male. Duration of cardiac ischaemia was associated with operative mortality (Odds ratio [OR] =1.01; p<0.0005). Its optimal cut-off point was equal to or above 149.5 minutes (95% CI: 126.2-172.8). In patients with a shorter period (less than 150 mins) of cardiac ischaemia, a valve-sparing root repair was used more often (OR=2.5; 95% CI: 1.6-3.9; p<0.001). Procedures that had the longer period of cardiac ischaemia included the Bentall procedure (OR=10.9; 95% CI: 4.9-27.4; p<0.001), descending thoracic aorta replacement (OR=4.3; 95% CI: 1.007-18.7; p=0.049) and concomitant cardiac surgery (OR=4.7; 95% CI: 2-11.1; p<0.001). Operations associated with shorter cardiac ischaemia were associated with lower in-hospital mortality and better long-term survival. CONCLUSION: This study determined that the duration of cardiac ischaemia in ATAD repair is linked to operative mortality. Further studies are required to confirm that ATAD patients with surgical repair involving less than 150 minutes of cardiac ischaemic time have lower in-hospital mortality and better long-term survival.
Assuntos
Aneurisma da Aorta Torácica , Dissecção Aórtica , Procedimentos Cirúrgicos Cardíacos , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/cirurgia , Humanos , Isquemia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Endocardite Bacteriana , Infecções por Bactérias Gram-Positivas , Transplante de Coração , Próteses Valvulares Cardíacas , Infecções Relacionadas à Prótese , Endocardite Bacteriana/cirurgia , Infecções por Bactérias Gram-Positivas/diagnóstico , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Infecções por Bactérias Gram-Positivas/cirurgia , Transplante de Coração/efeitos adversos , Próteses Valvulares Cardíacas/efeitos adversos , Valvas Cardíacas , Humanos , Propionibacterium acnes , Infecções Relacionadas à Prótese/diagnósticoAssuntos
Implante de Prótese Vascular , Procedimentos Endovasculares , Traumatismos Torácicos , Ferimentos não Penetrantes , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Humanos , Estudos Retrospectivos , Traumatismos Torácicos/diagnóstico por imagem , Traumatismos Torácicos/cirurgia , Resultado do Tratamento , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem , Ferimentos não Penetrantes/cirurgiaRESUMO
BACKGROUND: Acute cholangitis (AC) after liver transplantation occurs in 8-12% patients and remains a significant cause of patients' morbidity and mortality. The 2018 Tokyo guidelines use white blood cell count and C-reactive protein (CRP) as diagnostic criteria in AC. However, these and other common inflammatory markers have not been assessed in immunosuppressed liver transplant (LT) recipients with AC. The aims of this study were to compare the discriminative powers of common inflammatory markers, define the best inflammatory marker and determine the diagnostic cut-off values for the inflammatory markers in LT recipients with AC. METHODS: This was a retrospective cohort study. Over 16 years 212 LT recipients who underwent endoscopic biliary decompression were identified from hospital records. Thirty LT recipients with AC and 30 LT recipients without AC were randomly drawn in a 1:1 ratio. RESULTS: Among inflammatory markers, CRP had the highest discriminative power for diagnosing AC. The areas under the receiver operating characteristics curves for CRP, white blood cell count, lymphocyte count and neutrophil-to-lymphocyte ratio were 95% (95% confidence interval (CI): 91-98), 59% (95% CI: 50-68), 65% (95% CI: 53-77) and 70% (95% CI: 59-80), respectively. The cut-off value of CRP for diagnosing AC was equal to or above 9.5 mg/L. CONCLUSION: CRP has the best discriminative power compared with other commonly used inflammatory markers for diagnosing AC in LT recipients. The optimal cut-off value for CRP concentration in diagnosing AC is equal to or above 9.5 mg/L.
Assuntos
Colangite , Transplante de Fígado , Proteína C-Reativa/análise , Colangite/diagnóstico , Colangite/etiologia , Humanos , Contagem de Leucócitos , Transplante de Fígado/efeitos adversos , Contagem de Linfócitos , Estudos RetrospectivosRESUMO
A 74-year old female patient presented with a 3-week history of fever, general weakness, and later developed complete heart block. On admission, the patient was febrile (temperature of 39°C) and tachypnoeic (respiratory rate of 29/min) with oxygen saturation of 95% on 2 L of oxygen. Her heart rate was 60 beats/min (VVI pacing), arterial blood pressure was 135/60 mm Hg and the Glasgow Coma Scale was 15. On chest auscultation, she had a harsh systolic murmur over her left precordium and bilateral rales. Blood tests demonstrated moderate anemia (hemoglobin of 95 g/L), leucocytosis (white blood cell count of 13.13 x 10^9/L), hypoalbuminemia (albumin concentration of 18 g/L), normal liver function tests and creatinine clearance of 45 ml/min. Computed tomography aortography demonstrated an irregular mass arising from the aortic root that extended into the right atrium (RA) and a fistulous tract (the Gerbode defect) between the left ventricular outflow tract (LVOT) and the right ventricle (RV). Transoesophageal echocardiography showed large vegetation in the RA and left to right cardiac shunt through the Gerbode defect from the LVOT to the RA and the RV. Using cardiopulmonary bypass, the patient underwent resection of the aortic cusps, debridement of the aortic root, septal and anterior leaflets of the tricuspid valve, and the membranous septum. The Gerbode defect was closed with an autologous pericardial patch, then a sliding annuloplasty of the septal leaflet of the tricuspid valve was performed. Finally, the aortic root was replaced with a 23 mm Freestyle xenograft.
Assuntos
Aorta/cirurgia , Implante de Prótese Vascular/métodos , Comunicação Interventricular/cirurgia , Xenoenxertos , Idoso , Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca , Desbridamento , Ecocardiografia Transesofagiana , Endocardite/complicações , Endocardite/diagnóstico por imagem , Feminino , Comunicação Interventricular/diagnóstico por imagem , Comunicação Interventricular/etiologia , Septos Cardíacos/cirurgia , Humanos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Valva Tricúspide/cirurgiaAssuntos
Falso Aneurisma/etiologia , Aorta/cirurgia , Aneurisma Aórtico/etiologia , Valva Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Síndrome de Marfan/complicações , Adulto , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/cirurgia , Aorta/diagnóstico por imagem , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Masculino , Síndrome de Marfan/diagnóstico , Resultado do TratamentoAssuntos
Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/cirurgia , Comunicação Interventricular/diagnóstico por imagem , Comunicação Interventricular/cirurgia , Idoso , Aorta/diagnóstico por imagem , Aorta/cirurgia , Implante de Prótese Vascular/métodos , Anuloplastia da Valva Cardíaca , Ecocardiografia , Ecocardiografia Transesofagiana , Endocardite Bacteriana/complicações , Feminino , Comunicação Interventricular/etiologia , Humanos , Monitorização Intraoperatória , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/cirurgiaRESUMO
The Bentall procedure using a bioprosthesis-containing conduit carries the risk of structural valve deterioration within the patients' lifetime. Failed aortic bioprosthesis replacement requires a redo aortic root replacement that is associated with significant morbidity and mortality. We describe an original "neo-annulus" technique of aortic valve replacement (AVR) within the Bentall graft. This technique involves an incision of the Bentall valve-containing aortic root conduit, cutting the stainless wireform stent and the inner plastic stent of the bioprosthetic valve at the tips of commissure posts with a wire cutter, removal of semilunar fragments of the remaining stainless wire, division of the fabric of the valve between the valve sewing cuff and the Elgiloy alloy base ring leaving the sewing cuff of the excised aortic valve bioprosthesis attached to the Bentall conduit as a "neo-annulus". Subsequently, this neo-annulus is stitched with interrupted 2/0 Ticrone sutures and another prosthetic aortic valve implanted inside of the old Bentall conduit. The graft incision is closed with a continuous 4/0 polypropylene suture.
Assuntos
Valva Aórtica/lesões , Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Idoso , Humanos , Masculino , Resultado do TratamentoAssuntos
Lipoma/cirurgia , Neoplasias Vasculares/diagnóstico , Veia Cava Superior/patologia , Assistência ao Convalescente , Angiografia por Tomografia Computadorizada/métodos , Feminino , Humanos , Lipoma/diagnóstico , Lipoma/patologia , Pessoa de Meia-Idade , Veia Cava Superior/diagnóstico por imagemRESUMO
BACKGROUND: Socio-economic deprivation (SED) is emerging as a risk factor for acute graft rejection (AR) and reduced survival of heart transplant (HT) recipients. The study aim was to evaluate any association between SED status of HT recipients and the development of early AR and long-term survival in New Zealand. METHODS: This was a retrospective cohort study. Over a 30-year period, 329 HT recipients were identified from the Australian and New Zealand Heart Transplant Registry. All patients were divided into two groups according to the 2013 New Zealand Deprivation Index (NZDep2013) Score. Heart transplant recipients with NZDep2013 scores of 1,030 and above that corresponded to the eighth, ninth and tenth NZDep2013 deciles were allocated to the higher SED group and those with NZDep2013 scores below 1,030 to the lower SED group. RESULTS: The incidence of early AR in the higher SED group was 1.158/person-years and in the lower SED group 1.156/person-years. The crude incidence rate ratio was 1.0 (95% CI: 0.71-1.44; p = 0.9997). The prevalence of early AR in the higher SED group was 1.13/person-years and 1.15/person-years in the lower SED group. The crude prevalence rate ratio was 0.98/person-year (95% CI: 0.68-1.41/person-years; p = 0.468). In the higher SED group, mortality was 5.6/100 person-years (95% CI: 4.3-7.4/100 person-years) and 5.2/100 person-years (95% CI: 4.3-6.3/100 person-years) in the lower SED group. The adjusted mortality rate ratio estimate was 1.2 (95% CI: 0.8-1.7; p = 0.426). The higher and lower SED groups had similar survival (p = 0.196). CONCLUSION: Socio-economic disparity in New Zealand HT recipients has no negative impact on the development of AR or survival.
Assuntos
Rejeição de Enxerto/economia , Transplante de Coração , Sistema de Registros , Doença Aguda , Adolescente , Adulto , Fatores Etários , Idoso , Criança , Pré-Escolar , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Fatores Socioeconômicos , Taxa de Sobrevida/tendências , Transplantados , Adulto JovemAssuntos
Aneurisma Aórtico , Valva Aórtica , Próteses Valvulares Cardíacas , Seio Aórtico , Tomografia Computadorizada por Raios X , Idoso , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Humanos , Masculino , Seio Aórtico/diagnóstico por imagem , Seio Aórtico/cirurgiaRESUMO
BACKGROUND: Acute cholangitis (AC) complicated by septic shock is associated with 40% mortality. The best screening method for diagnosing sepsis in patients with AC is unknown. In this study, we aimed to compare the discriminative powers of systemic inflammatory response syndrome criteria (SIRS test) and the 2018 Tokyo Guidelines for moderate cholangitis (TG18 test) in screening AC patients for sepsis and to estimate their predictive abilities. METHODS: This was a retrospective diagnostic accuracy study in which the TG18 and SIRS tests were applied to two groups of patients; 52 patients with 70 hospital admissions had AC with shock index ≥0.7 and 46 patients with 57 hospital admissions had AC with shock index <0.7, uncomplicated choledocholithiasis, obstructive jaundice and biliary stent removal. RESULTS: The sensitivity and specificity for the TG18 test in identifying AC patients with sepsis were 69% and 68%, respectively. The SIRS test applied to the same patient cohort yielded 93% sensitivity and 79% specificity. The SIRS test had a larger area under the receiver operating characteristic curve, 86% and 69%, respectively (P = 0.0004). With a sepsis prevalence of 23% in patients with biliary tract infections, the positive predictive value (PPV) for the SIRS test was 57% (95% confidence interval (CI) 44-69%) and the negative predictive value was 97% (95% CI 94-99%). The PPV and negative predictive value for the TG18 criteria were 39% (95% CI 30-50%) and 88% (95% CI 83-92%), respectively. CONCLUSION: The SIRS test had better discriminative power in identifying AC patients with sepsis than the TG18 criteria, but had a low PPV.
Assuntos
Colangite/complicações , Sepse/diagnóstico , Sepse/etiologia , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Síndrome de Resposta Inflamatória Sistêmica/diagnósticoAssuntos
Embolia Aérea/etiologia , Biópsia Guiada por Imagem/efeitos adversos , Neoplasias Pulmonares/patologia , Tomografia Computadorizada por Raios X/instrumentação , Idoso , Aorta/diagnóstico por imagem , Aorta/fisiopatologia , Embolia Aérea/diagnóstico por imagem , Embolia Aérea/terapia , Decúbito Inclinado com Rebaixamento da Cabeça , Humanos , Oxigenoterapia Hiperbárica/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Masculino , Resultado do Tratamento , Veia Cava Superior/diagnóstico por imagem , Veia Cava Superior/fisiopatologiaRESUMO
BACKGROUND: Important risk factors for long-term survival of lung transplant (LT) recipients are infection, acute graft rejection (AR) and chronic lung allograft dysfunction (CLAD). Socioeconomic deprivation (SED) is associated with increased graft failure rate after heart and kidney transplantation, but has not been investigated in LT recipients. The aim of this study was to evaluate an association between LT recipients' SED status and development of AR, CLAD, and long-term survival. METHODS: This was a retrospective cohort study. Over a 23 y period, 233 patients were identified from the Auckland City Hospital Lung Transplant Registry, Auckland, New Zealand. All patients were divided into two groups according to the 2013 New Zealand Deprivation Index Score. RESULTS: The incidence of AR in the higher SED group was 34.0/100 person-y (95% confidence interval [CI]: 24.7-46.7/100 person-y) and in the lower SED group 40.2/100 person-y (95% CI: 33.5-48.3/100 person-y) (P = 0.373). The incidence of CLAD in the higher SED group was 10.7/100 person-y (95% CI: 6.2-18.4/100 person-y) and 9.3 (6.9-12.5/100 person-y) in the lower SED group (P = 0.645). Mortality in the higher SED group was 12.9/100 person-y (95% CI: 9.2-17.9/100 person-y) and 12.4/100 person-y (95% CI: 10.0-15.3/100 person-y) in the lower SED group (P = 0.834). CONCLUSIONS: SED status of LT recipients in New Zealand has no negative effect on development of AR, CLAD, and patients' survival.