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1.
Cardiovasc Revasc Med ; 33: 7-12, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34078581

RESUMO

BACKGROUND: Prospective bicuspid low-risk transcatheter aortic valve replacement (TAVR) registries' data demonstrated encouraging short-term results. Detailed data on transcatheter heart valve (THV) geometry after deployment using contemporary devices are lacking. This study sought to examine valve geometry after TAVR in patients with bicuspid aortic stenosis (AS). METHODS: The study population was patients from the LRT (Low Risk TAVR) trial who underwent TAVR using the SAPIEN 3 THV for bicuspid and tricuspid AS. THV geometry measured on 30-day computed tomography (CT) included valve height, angle, depth, and eccentricity. Additionally, THV hemodynamics and outcomes post-TAVR were compared among patients with bicuspid and tricuspid AS. RESULTS: A total of 107 patients from the LRT trial using the SAPIEN 3 THV were included in our analysis. On 30-day CT, the valve height ratio (1.07 vs. 1.07; p = 0.348), depths (right [5.6 mm vs. 6.2 mm; p = 0.223], left [5.3 mm vs. 4.4 mm; p = 0.082] and non [4.8 mm vs. 4.5 mm; p = 0.589] coronary cusps), eccentricities (1.08 vs. 1.07; p = 0.9550), and angles (except the right [3.9 degrees vs. 6.3 degrees; p = 0.003] and left [3.6 degrees vs. 6.0 degrees; p = 0.007]) were similar between bicuspid and tricuspid patients. Hemodynamics, stroke, and mortality were similar at 1 year. CONCLUSION: Despite challenging bicuspid anatomy of the aortic valve, our comprehensive CT analysis supports similar THV geometry between patients with bicuspid and tricuspid AS undergoing TAVR using the SAPIEN 3 THV in low-risk patients. This translated to excellent short-term clinical outcomes and THV hemodynamics in both aortic valve morphologies. TRIAL REGISTRY: NCT02628899, https://clinicaltrials.gov/ct2/show/NCT02628899.


Assuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Humanos , Estudos Prospectivos , Desenho de Prótese , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
2.
Circ Cardiovasc Interv ; 14(1): e009983, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33423540

RESUMO

BACKGROUND: The optimal antithrombotic regimen after transcatheter aortic valve replacement remains unclear. METHODS: In this randomized open-label study, low-risk patients undergoing transfemoral transcatheter aortic valve replacement at 7 centers in the United States were randomized 1:1 to low-dose aspirin or warfarin plus low-dose aspirin for 30 days. Patients who could not be randomized were enrolled in a separate registry. Computed tomography or transesophageal echocardiography was performed at 30 days. The primary effectiveness end point was a composite of the following at 30 days: hypoattenuated leaflet thickening, at least moderately reduced leaflet motion, hemodynamic dysfunction (mean aortic valve gradient ≥20 mm Hg, effective orifice area ≤1.0 cm2, dimensionless valve index <0.35, or moderate or severe aortic regurgitation), stroke, or transient ischemic attack. RESULTS: Between July 2018 and October 2019, 94 patients were randomly assigned, 50 to aspirin and 44 to warfarin plus aspirin, and 30 were enrolled into the registry. In the intention-to-treat analysis of the randomized cohort, the composite primary effectiveness end point was met in 26.5% for aspirin versus 7.0% for warfarin plus aspirin (P=0.014; odds ratio, 4.8 [95% CI, 1.3-18.3]). The rate of hypoattenuated leaflet thickening was 16.3% for aspirin versus 4.7% for warfarin plus aspirin (P=0.07; odds ratio, 4.0 [95% CI, 0.8-20.0]). There was no excess bleeding at 30 days with anticoagulation. In the as-treated analysis of pooled randomized and registry cohorts, the rate of hypoattenuated leaflet thickening was 16.7% for aspirin versus 3.1% for warfarin plus aspirin (P=0.011; odds ratio, 6.3 [95% CI, 1.3-30.6]). CONCLUSIONS: In low-risk transcatheter aortic valve replacement patients, anticoagulation with warfarin may prevent transcatheter heart valve dysfunction in the short term without excess bleeding. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03557242.


Assuntos
Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Aspirina/efeitos adversos , Humanos , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento , Estados Unidos , Varfarina/efeitos adversos
3.
Transfusion ; 57(10): 2483-2489, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28714229

RESUMO

BACKGROUND: Blood transfusions are a common and costly intervention for cardiac surgery patients. Evidence suggests that a more restrictive transfusion strategy may reduce costs and transfusion-related complications without increasing perioperative morbidity and mortality. STUDY DESIGN AND METHODS: A transfusion-limiting protocol was developed and implemented in a cardiovascular surgery unit. Over a 5-year period, data were collected on patient characteristics, procedures, utilization of blood products, morbidity, and mortality, and these were compared before and after the protocol was implemented. RESULTS: After the protocol was put in place, fewer patients required transfusions (38.2% vs. 45.5%, p = 0.004), with the greatest reduction observed in postoperative blood use (29.1% vs. 37.2%, p = 0.001). In-hospital morbidity and mortality did not increase. When patients who received transfusions were stratified by procedure, the protocol was most effective in reducing transfusions for patients undergoing isolated coronary artery bypass grafting (CABG; 4.09 units vs. 2.51 units, p = 0.009) and CABG plus valve surgery (10.32 units vs. 4.77 units, p = 0.014). A small group of patients were disproportionate recipients of transfusions, with approximately 6% of all patients receiving approximately half of the blood products. CONCLUSION: A protocol to limit transfusions decreased the proportion of cardiothoracic surgery patients who received blood products. A very small group of patients received a large number of transfusions, and within that group the observed mortality was significantly higher than in the general patient population. Current protocols cannot possibly account for these patients, and this should be considered when analyzing the performance of protocols designed to reduce unnecessary transfusions.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/economia , Protocolos Clínicos , Transfusão de Sangue/economia , Comorbidade , Ponte de Artéria Coronária , Mortalidade Hospitalar , Humanos , Cuidados Pós-Operatórios/métodos
4.
Eur J Cardiothorac Surg ; 51(2): 368-375, 2017 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-28186272

RESUMO

OBJECTIVES: Utilization of bilateral internal mammary arteries (BIMAs) has been shown to improve long-term outcomes in patients undergoing coronary artery bypass grafting. To achieve complete revascularization, BIMAs may be used as either sole conduits for revascularization through a Y-graft configuration (BIMA-Y) or deployed with additional grafts used in conjunction with BIMAs. The purpose of this study was to compare the long-term outcomes of two institutions that predominantly used either the BIMA-Y configuration or BIMA plus additional grafts to achieve optimal revascularization. METHODS: From 1 January 2000 to 31 December 2010, 436 patients were revascularized using a non-sequential BIMA grafting at one institution (Group A), with veins being used for additional targets. At the second institution (Group B), 771 patients were revascularized using a BIMA-Y graft for all distal targets. Kaplan­Meier analysis was used to compare unadjusted survival between the groups. Cox proportional hazards regression modelling was used to provide an adjusted comparison of survival between the groups. RESULTS: There was no statistically significant difference between the average number of anastomotic sites used in Group A and Group B (A = 4.0 ± 0.7 vs B = 4.0 ± 0.7; P = 0.24). Group A did not have a significantly greater in-hospital mortality (0.7% vs 1.0% P = 0.39), stroke (0.5% vs 0.8% P = 0.40), deep sternal wound infection (0.0% vs 0.6% P = 0.11) or reoperation for bleeding (1.6% vs 0.6% P = 0.10) than Group B. Cox proportional hazards analyses demonstrated that at 14 years, Group B had a significantly improved survival compared to Group A (Group B = 88% vs Group A = 81%) with an overall reduction in mortality (adjusted hazard ratio 0.780, 95% confidence interval 0.448­0.849; P = 0.043). CONCLUSION: Utilization of the BIMA-Y configuration was associated with improved survival when compared to BIMA grafting with additional vein grafts. Further studies are necessary to evaluate the efficacy of BIMA-Y grafting against other means of providing complete arterial revascularization.


Assuntos
Anastomose de Artéria Torácica Interna-Coronária/métodos , Idoso , Bélgica/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Anastomose de Artéria Torácica Interna-Coronária/mortalidade , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , New Jersey/epidemiologia , Modelos de Riscos Proporcionais , Reoperação , Estudos Retrospectivos , Fatores de Risco , Veia Safena/transplante , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia , Resultado do Tratamento
5.
Eur J Cardiothorac Surg ; 49(1): 350-1, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25669643

RESUMO

Performing a reoperative root replacement in cases of prosthetic valve endocarditis (PVE) can often be challenging due to significant inflammation and scarring. During these cases, surgeons may decide to utilize an interpositional graft when mobilization of the coronary ostia becomes too hazardous. The authors describe their experience performing a reoperative root replacement on a patient with PVE. In this case, the authors utilize a segment of the homograft left subclavian artery as an interpositional graft to provide an infection-resistant bioprosthetic graft that maintains coronary anatomy.


Assuntos
Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Vasos Coronários/cirurgia , Infecções Relacionadas à Prótese/cirurgia , Idoso , Valva Aórtica/cirurgia , Bioprótese/efeitos adversos , Endocardite Bacteriana/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Reoperação/métodos , Infecções Estafilocócicas/cirurgia
6.
Eur J Cardiothorac Surg ; 49(1): 203-10, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26003960

RESUMO

OBJECTIVES: Recent studies have demonstrated the superiority of bilateral internal mammary arteries (BIMAs) as conduit material for coronary artery bypass grafting (CABG) surgery. However, there is limited research on the effects of other graft conduits used in patients who require additional bypasses. The goal of this study was to evaluate the impact of the radial artery (RA) when used in conjunction with the BIMAs. METHODS: From the beginning of 2000 to the end of 2013, 4370 patients underwent CABG for three or more vessels at our institution. There were 568 and 183 patients who received BIMA + saphenous vein graft (SVG) and BIMA + radial ± SVG, respectively. Propensity matching was used to create a balanced cohort from these patients, which resulted in two groups of 183 patients. Thirty-day outcomes and long-term survival were compared between the two groups. Long-term follow-up was generated using the Social Security Death Index. RESULTS: There were no significant differences in preoperative characteristics. For 30-day outcomes, the BIMA + radial ± SVG group had more postoperative atrial fibrillation (24.6 vs 12.0%; P = 0.001) and a longer median postoperative length of stay (6 vs 5 days; interquartile range = 2; P = 0.016) than BIMA + SVG patients. There was no significant difference in long-term survival between the two groups over the 14-year period. However, before year 10, the BIMA + SVG group had a trend towards higher survival, whereas on follow-up after 10 years, there was a trend that favoured the BIMA + radial ± SVG patients. Cox regression analysis using a time-dependent covariate demonstrated that when the groups were split at 10 years, there was a statistically significant improvement in survival of the BIMA + radial ± SVG group [adjusted hazard ratio 0.254 95% confidence interval (CI) 0.062-0.977; P = 0.048] over BIMA + SVG patients between 10 and 14 years. CONCLUSIONS: Overall, there were no statistically significant differences in survival between the BIMA + SVG and BIMA + radial ± SVG groups over the 14 years. However, further analysis demonstrated that while the BIMA + radial ± SVG group had a trend towards decreased survival before 10 years, use of the RA in conjunction with BIMAs was associated with significantly increased survival in the later years. A larger cohort of patients with longer follow-up is needed to assess the outcomes of CABG using BIMA + radial ± SVG.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna/transplante , Artéria Radial/transplante , Adulto , Idoso , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
7.
J Surg Res ; 197(2): 265-9, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25963164

RESUMO

BACKGROUND: Ascending aortic dissections (AADs) require prompt diagnosis and surgical treatment. We present the results of implementing a multidisciplinary aortic dissection protocol on the outcomes of AAD treatment at a nonteaching hospital. METHODS: From January 2002-December 2013, 54 patients with the diagnosis of AAD were treated at our institution. Thirty-seven (68.5%) were male with a mean age of 62.3 y. Cardiogenic shock was present in 25.9% of patients. An AAD protocol, focused on educating physicians on presenting signs and symptoms, adequate triaging, and the need for immediate surgical intervention, was implemented, alongside the standardization of surgical treatment. We divided the cohort into two eras, based on AAD program's implementation in 2006, to better assess the impact of this protocol. RESULTS: Patients from the early era had significantly longer time from Emergency Department to the operating room, more postoperative occurrence of prolonged ventilation, and a longer postoperative hospital stay at 8.7 ± 8 versus 3.1 ± 2.6 h (P = 0.002), 63% versus 18% (P = 0.002), and 63% versus 18% (P = 0.002), respectively. The overall mortality for the cohort was 9.3%, decreasing from 12.5% before 2006 to 7.9% after 2006. CONCLUSIONS: The implementation of a multidisciplinary aortic dissection protocol has resulted in faster diagnosis and transport of AAD cases from the emergency room to the operating room, improving outcomes. Our data support the concept that nonteaching institutions can deliver excellent care to patients with acute aortic emergencies.


Assuntos
Algoritmos , Aneurisma Aórtico , Dissecção Aórtica , Técnicas de Apoio para a Decisão , Procedimentos Cirúrgicos Vasculares , Adulto , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/mortalidade , Dissecção Aórtica/cirurgia , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/mortalidade , Aneurisma Aórtico/cirurgia , Protocolos Clínicos , Emergências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
8.
J Thorac Cardiovasc Surg ; 149(4): 1027-33.e2, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25648476

RESUMO

OBJECTIVE: Previous studies have demonstrated that bilateral internal mammary artery (BIMA) grafts lead to superior outcomes compared with single internal mammary artery grafts. This study examines whether cardiopulmonary bypass affects conduit-dependent outcomes of coronary artery bypass grafting (CABG) surgery. METHODS: From 1994 to 2013, a total of 6666 patients underwent isolated CABG surgery at our institution. Of these procedures, 3548 (53.2%) were performed off pump. A BIMA-saphenous vein graft (SVG) was used in 1544, and 5122 had left internal mammary artery-SVGs. These 2 conduit groups differed significantly in baseline characteristics. Propensity matching based on 22 preoperative variables and using a nearest-neighbor matching algorithm was used to make balanced cohorts, resulting in 2 groups of 1006. To account for the influence of pump status on conduit selection, a second propensity score was developed for pump use. These cases were matched to create 4 patient cohorts of 353 patients each (a total of 1412), balanced for both conduit use and pump status. Late mortality was determined using the Social Security Death Index. RESULTS: No difference was found in survival between patients receiving BIMA-SVGs on or off pump (78.9% vs 79.1%). BIMA-SVGs outperformed the left internal mammary artery-SVGs regardless of whether the procedure was performed off pump (73.9%) or on pump (69.9%). CONCLUSIONS: This study demonstrates that the use of cardiopulmonary bypass does not significantly affect the long-term outcomes in these patients as long as full revascularization is achieved. In addition, these results are consistent with prior research showing that the use of BIMAs produces better outcomes than use of a single internal mammary artery when performing CABG.


Assuntos
Ponte Cardiopulmonar , Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna/cirurgia , Veia Safena/transplante , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Masculino , New Jersey , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
Asian Cardiovasc Thorac Ann ; 22(5): 566-73, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24867031

RESUMO

BACKGROUND: Elderly patients with aortic stenosis are under-referred for aortic valve replacement surgery. This study investigated the perioperative factors associated with midterm outcomes in a consecutive series of patients undergoing aortic valve replacement with or without coronary artery bypass graft surgery. METHODS: From 2006 to 2010, 509 patients having aortic valve replacement or aortic valve replacement with coronary artery bypass were grouped according to age (<80 years and ≥80 years) and procedure (aortic valve replacement ± coronary artery bypass). Patient survival was followed up for 5 years (mean 2.6 years). Midterm survival was evaluated using Kaplan-Meier and Cox proportional hazards regression model statistics. RESULTS AND CONCLUSIONS: 5-year survival among octogenarians was 59.2% with an observed 30-day mortality of 1% for aortic valve replacement and 3% for aortic valve replacement with coronary artery bypass. Kaplan-Meier survival analysis showed that age ≥80 years, New York Heart Association functional class III/IV, and left ventricular ejection fraction <35% were significantly associated with increased midterm mortality. Cox regression modeling demonstrated that age ≥80 years was the only significant independent factor associated with midterm mortality; older patients had a 3-fold increase in mortality (adjusted hazard ratio = 3.231, 95% confidence interval: 1.764-5.920, p < 0.0001). While hospital and 30-day mortality were not statistically different between age groups, age ≥80 years was the most powerful predictor of midterm death. These results support early aortic valve replacement with or without coronary artery bypass in aortic stenosis management.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/cirurgia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda
10.
Genomics ; 104(1): 36-44, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24858532

RESUMO

In coronary artery bypass grafting (CABG), the combined use of left and right internal mammary arteries (LIMA and RIMA) - collectively known as bilateral IMAs (BIMAs) provides a survival advantage over the use of LIMA alone. However, gene expression in RIMA has never been compared to that in LIMA. Here we report a genome-wide transcriptional analysis of BIMA to investigate the expression profiles of these conduits in patients undergoing CABG. As expected, in comparing the BIMAs to the aorta, we found differences in pathways and processes associated with atherosclerosis, inflammation, and cell signaling - pathways which provide biological support for the observation that BIMA grafts deliver long-term benefits to the patients and protect against continued atherosclerosis. These data support the widespread use of BIMAs as the preferred conduits in CABG.


Assuntos
Artéria Torácica Interna/metabolismo , Transcriptoma , Idoso , Aorta/metabolismo , Ponte de Artéria Coronária/métodos , Feminino , Perfilação da Expressão Gênica , Genoma Humano , Humanos , Masculino , Pessoa de Meia-Idade , Especificidade de Órgãos
11.
Transfusion ; 54(4): 1106-13, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23909477

RESUMO

BACKGROUND: Studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality during the first year after surgery, but risk appears to decrease after the first year. This study compared 5-year mortality in a propensity-matched cohort of cardiac surgery patients. STUDY DESIGN AND METHODS: Between July 1, 2004, and June 30, 2011, 3516 patients had cardiac surgery with 1920 (54.6%) requiring blood transfusion. Propensity matching based on 22 baseline characteristics yielded two balanced groups (blood transfusion group [BTG] and nontransfused control group [NCG]) of 857 patients (1714 in total). The type and number of blood products were compared in the BTG. RESULTS: Operative mortality was higher in BTG versus NCG (2.3% vs. 0.4%; p < 0.0001). Kaplan-Meier analysis of 5-year survival demonstrated no difference between groups in the first 2 years (BTG 96.3% and 93.0% vs. NCG 96.4% and 93.9%, respectively). There was a significant divergence during Years 3 to 5 (BTG 82.0% vs. NCG 89.3% at 5 years; p < 0.007). Five-year survival was significantly lower in patients who received at least 2 units of blood (79.6% vs. 88.0%; p < 0.0001). In multivariate Cox regression analyses, transfusion was independently associated with increased risk for 5-year mortality. Patients receiving cryoprecipitate products had a twofold mortality risk increase (adjusted hazard ratio, 2.106; p = 0.002). CONCLUSION: Blood transfusion, specifically cryoprecipitates, was independently associated with increased 5-year mortality. Transfusion during cardiac surgery should be limited to patients who are in critical need of blood products.


Assuntos
Transfusão de Sangue/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Mortalidade , Fatores de Risco , Análise de Sobrevida
12.
Innovations (Phila) ; 8(5): 371-5, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24346587

RESUMO

OBJECTIVE: The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our double LAA ligation (LLAA) technique was shown to be 96% successful in a small study. However, the outcomes of these patients have yet to be compared with a set of nonligated patients. METHODS: From 2005 to 2012, a total of 808 patients received LAA using our double ligation technique using both a polydioxanone (PDS) II endosnare and a running 4-0 Prolene pledgeted suture. The 30-day outcomes of these patients were compared with that of nonligated patients. Fifty-six of the ligated patients had a postoperative transesophageal echocardiography (TEE). An echocardiographer reviewed the follow-up TEEs for LAA remnant and/or residual flow into the LAA using color Doppler imaging. The patients with LAA flow and/or remnant depth of 1 cm or greater were deemed to have an unsuccessful exclusion. RESULTS: The ligated group had a trend of less postoperative atrial fibrillation (19.4% vs 22.9%, P = 0.07) and an overall significantly lower in-hospital mortality (0.7% vs 3.0%, P < 0.001) and lower 30-day mortality (0.7% vs 3.4%, P < 0.0001). The LAA was successfully excluded in 53 (94.7%) of the 56 patients with TEE. CONCLUSIONS: Double LAA ligation correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in perioperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared with LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi perioperatively and in the long-term.


Assuntos
Apêndice Atrial/cirurgia , Ecocardiografia Transesofagiana , Pericárdio/cirurgia , Idoso , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/cirurgia , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Ligadura/métodos , Masculino , Pessoa de Meia-Idade , Pericárdio/diagnóstico por imagem , Técnicas de Sutura/instrumentação , Suturas , Resultado do Tratamento
13.
Genomics ; 101(6): 313-7, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23462555

RESUMO

Clopidogrel is an oral antiplatelet pro-drug prescribed to 40 million patients worldwide who are at risk for thrombotic events or receiving percutaneous coronary intervention (PCI). However about a fifth of patients treated with clopidogrel do not respond adequately to the drug. From a cohort of 105 patients on whom we had functional data on clopidogrel response, we used ultra-high throughput sequencing to assay mutations in CYP2C19 and ABCB1, the two genes genetically linked to respond. Testing for mutations in CYP2C19, as recommended by the FDA, only correctly predicted if a patient would respond to clopidogrel 52.4% of the time. Similarly, testing of the ABCB1 gene only correctly foretold response in 51 (48.6%) patients. These results are clinically relevant and suggest that until additional genetic factors are discovered that predict response more completely, functional assays are more appropriate for clinical use.


Assuntos
Membro 1 da Subfamília B de Cassetes de Ligação de ATP/genética , Ponte de Artéria Coronária , Análise Mutacional de DNA/métodos , Inibidores da Agregação Plaquetária/farmacologia , Ticlopidina/análogos & derivados , Subfamília B de Transportador de Cassetes de Ligação de ATP , Idoso , Hidrocarboneto de Aril Hidroxilases/genética , Plaquetas/fisiologia , Estudos de Casos e Controles , Clopidogrel , Citocromo P-450 CYP2C19 , Resistência a Medicamentos/genética , Feminino , Estudos de Associação Genética , Cardiopatias/sangue , Cardiopatias/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Mutação , Agregação Plaquetária/efeitos dos fármacos , Agregação Plaquetária/genética , Inibidores da Agregação Plaquetária/uso terapêutico , Testes de Função Plaquetária , Ticlopidina/farmacologia , Ticlopidina/uso terapêutico
14.
Interact Cardiovasc Thorac Surg ; 17(1): 96-102, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23537850

RESUMO

OBJECTIVES: Prior studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality and morbidity following surgery. It is not clear whether this increased risk occurs across all haematocrit (HCT) levels. The goal of this study was to compare operative mortality in propensity-matched cardiac surgery patients based on stratification of the preoperative HCT levels. METHODS: Between 1 August 2004 and 30 June 2011, 3516 patients had cardiac surgery. One thousand nine hundred and twenty-two (54.5%) required blood transfusion during or after surgery. A propensity score for transfusion was developed based on 22 baseline variables. One thousand seven hundred and fourteen patients were matched: 857 in the transfusion group (TG) and 857 in the non-transfused control group (CG). Univariate analyses demonstrated that, after propensity matching, the groups did not differ on any baseline factors included in the propensity model. Operative mortality was defined as death within 30 days of surgery. Preoperative HCT was stratified into four groups: <36, 36-39, 40-42 and ≥ 43. RESULTS: For HCT <36%, 30-day mortality was higher in the TG than that in the CG (3.0 vs 0.0%). For HCT 36-39, operative mortality was similar between TG (1.1%, N = 180) and CG (0.8%, N = 361; P = 0.748). For HCT 40-42, operative mortality was significantly higher in the TG compared with that in the CG (1.9 vs 0%, N = 108 and 218, respectively; P = 0.044). For HCT of ≥ 43, there was a trend towards higher operative mortality in the TG vs the CG (2.0 vs 0%, N = 102 and 152, respectively; P = 0.083). Other surgical complications followed the same pattern with higher rates found in the transfused group at higher presurgery HCT levels. HCT at discharge for the eight groups were similar, with an average of 29.1 ± 1.1% (P = 0.117). CONCLUSIONS: Our study indicates that a broad application of blood products shows no discernible benefits. Furthermore, patients who receive blood at all HCT levels may be placed at an increased risk of operative mortality and/or other surgical complications. Paradoxically, even though patients with low HCTs theoretically should benefit the most, transfusion was still associated with a higher complication and mortality rate in these patients. Our results indicate that blood transfusion should be used judiciously in cardiac surgery patients.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hemorragia Pós-Operatória/terapia , Reação Transfusional , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Perda Sanguínea Cirúrgica/mortalidade , Transfusão de Sangue/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Feminino , Hematócrito , Hemoglobinas/metabolismo , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Seleção de Pacientes , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/mortalidade , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
15.
Arch Intern Med ; 172(15): 1154-60, 2012 Aug 13.
Artigo em Inglês | MEDLINE | ID: mdl-22751620

RESUMO

BACKGROUND: Jehovah's Witness patients (Witnesses) who undergo cardiac surgery provide a unique natural experiment in severe blood conservation because anemia, transfusion, erythropoietin, and antifibrinolytics have attendant risks. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions. METHODS: A total of 322 Witnesses and 87 453 non-Witnesses underwent cardiac surgery at our center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38 467 did not receive blood transfusions and 48 986 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival. RESULTS: Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% vs 2.8% (P = . 01); additional operation for bleeding, 3.7% vs 7.1% (P = . 03); prolonged ventilation, 6% vs 16% (P < . 001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 vs 24, 48, and 162 hours (P < . 001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 vs 6, 8, and 16 days (P < . 001). Witnesses had better 1-year survival (95%; 95% CI, 93%-96%; vs 89%; 95% CI, 87%-90%; P = . 007) but similar 20-year survival (34%; 95% CI, 31%-38%; vs 32% 95% CI, 28%-35%; P = . 90). CONCLUSIONS: Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.


Assuntos
Anemia , Transfusão de Sangue , Procedimentos Cirúrgicos Cardíacos , Testemunhas de Jeová/psicologia , Complicações Pós-Operatórias , Recusa do Paciente ao Tratamento , Idoso , Anemia/etnologia , Anemia/etiologia , Anemia/psicologia , Anemia/terapia , Antifibrinolíticos/uso terapêutico , Transfusão de Sangue/psicologia , Transfusão de Sangue/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Eritropoetina/uso terapêutico , Feminino , Hematínicos/uso terapêutico , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Assistência Perioperatória/métodos , Assistência Perioperatória/psicologia , Complicações Pós-Operatórias/etnologia , Complicações Pós-Operatórias/psicologia , Complicações Pós-Operatórias/terapia , Projetos de Pesquisa , Análise de Sobrevida , Fatores de Tempo , Reação Transfusional , Recusa do Paciente ao Tratamento/etnologia , Recusa do Paciente ao Tratamento/psicologia , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia , Estados Unidos/etnologia
16.
Interact Cardiovasc Thorac Surg ; 15(3): 371-6, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22665381

RESUMO

OBJECTIVES More elderly patients (>80 years of age) are being referred for aortic valve replacement (AVR) with or without CABG. Current risk stratification models may not accurately predict the preoperative risk in these patients. We sought to determine which perioperative variables were relevant in determining short-term (30-day to in-hospital) outcomes in our intuition's series of consecutive AVR and AVR+CABG surgeries. We constructed a novel variable, patient-prosthesis mismatch (PPM) in the presence of diminished functional status (NYHA) classification, and studied its role as a predictor of mortality risk. METHODS From 2006 to 2010, 509 patients undergoing AVR or AVR+CABG were evaluated. We created four groups based on the age and procedure (AVR >80, AVR+CABG >80, AVR <80 and AVR+CABG <80). PPM was defined as a calculated effective orifice area index value of ≤ 0.85, and it was calculated from manufacturer-generated charts. In-hospital and 30-day outcomes were assessed using the Chi-square and logistic regression analyses. RESULTS Overall observed 30-day mortality for all groups was lower (n = 8, 1.6%) than the STS-predicted mortality. Reoperation and PPM+NYHA class III-IV were associated with short-term mortality, but age >80 years was not. Octogenarians referred for surgery often had advanced heart failure. CONCLUSIONS Overall, short-term outcomes after AVR with or without CABG were excellent and lower than predicted by the STS model. The low risk of AVR with CABG supports the consideration for earlier surgical referral and intervention for patients with a high likelihood of aortic stenosis progression before the onset of advanced heart failure ensues, regardless of the age. This should help further decrease the already very low mortality observed in these series. Efforts to avoid PPM in the setting of advanced heart failure may improve short-term results in this subset of patients.


Assuntos
American Heart Association , Estenose da Valva Aórtica/cirurgia , Insuficiência Cardíaca/cirurgia , Próteses Valvulares Cardíacas/classificação , Falha de Prótese , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/mortalidade , Feminino , Seguimentos , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Masculino , New York , Estudos Prospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
17.
J Invasive Cardiol ; 24(2): 49-52, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-22294531

RESUMO

BACKGROUND: The current standard of care is to delay coronary surgery 5-7 days after clopidogrel exposure to prevent bleeding complications. We sought to determine the utility of an objective tool (ie, the VerifyNow assay) to measure platelet inhibition (PI) in patients receiving preoperative clopidogrel prior to off-pump coronary artery bypass grafting surgery (OPCABG). PATIENTS AND METHODS: Between June 2007 and July 2009, a total of 482 isolated OPCABG procedures were performed at our institution. In 160 patients, the VerifyNow assay results were used to determine timing of the OPCABG. These patients were compared to the remaining 322 patients. We divided the cohort into 4 subgroups: Group 1 patients (n = 205) were not taking clopidogrel; Group 2 patients (n = 117) were taking clopidogrel, but the test was not performed; Group 3 patients (n = 122) were taking clopidogrel and had a preoperative PI result of ≤20%; and Group 4 patients (n = 38) had ≥21% preoperative PI. RESULTS: Demographic and clinical factors were compared in all groups. The median waiting time for surgery from the last dose of clopidogrel was 6 days for the control groups and 3 days for the groups where the test was performed (P<.001). Reoperation for bleeding occurred most often in Group 4 (7.9%; P=.003). Blood utilization was lower in Group 1 (24.4%) than in Groups 2 (34.2%), 3 (40.2%), or 4 (55.3%) (P<.001). Major complications and postoperative length of stay were similar in all groups. CONCLUSIONS: Utilization of a PI tool in the preoperative assessment of OPCABG patients exposed to clopidogrel can provide valuable information to guide the timing of coronary surgery and may lead to a decrease in reoperation for bleeding and blood usage.


Assuntos
Testes de Coagulação Sanguínea , Perda Sanguínea Cirúrgica/prevenção & controle , Ponte de Artéria Coronária sem Circulação Extracorpórea , Inibidores da Agregação Plaquetária/administração & dosagem , Agregação Plaquetária/efeitos dos fármacos , Ticlopidina/análogos & derivados , Difosfato de Adenosina/farmacologia , Idoso , Transfusão de Sangue , Clopidogrel , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Cuidados Pré-Operatórios , Reoperação , Ticlopidina/administração & dosagem
18.
Eur J Cardiothorac Surg ; 41(4): 770-5; discussion 776, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22290908

RESUMO

OBJECTIVES: Bilateral internal mammary arteries (BIMA) remains widely underutilized in coronary artery bypass grafting (CABG). Although prior research has demonstrated a long-term benefit of the use of BIMA over left internal mammary artery (LIMA)-only, validation of these results is lacking in a contemporary surgical experience. We compared complications and survival at 17-year follow-up in a large series of consecutive CABG patients from a single institution that underwent BIMA grafting with a propensity-matched group where LIMA only was used. METHODS: Propensity scores representing the estimated probabilities of patients receiving either BIMA or LIMA alone were developed based on 22 observed baseline covariates in a logistic regression model with procedure group as the dependent variable. The nearest-neighbour-matching algorithm with Greedy 5-1 Digit Matching was used to produce two patient cohorts of 928 patients each balanced for baseline factors. We compared 30-day morbidity and mortality, as well as long-term survival at 5-year intervals up to 17-year follow-up. RESULTS: In-hospital and 30-day mortality was 0.8% for the BIMA group and 1.1% for the LIMA-saphenous vein grafting (SVG). No significant difference was found in complications, mortality and/or length-of-stay between these two groups. Off-pump was done in 48.9% of BIMA cases and 51.3% of LIMA cases. Regardless of the types of grafts used, on-pump patients were more likely to have postoperative permanent strokes and longer postoperative lengths of stay. Use of the BIMA over LIMA-only had a statistically significant impact conferring a 10% survival advantage at 10-year and 18% at 15-year follow-up. The Kaplan-Meier survival curves comparing off-/on-pump BIMA and off-/on-pump LIMA-SVG patients demonstrated a 22% survival advantage for off-pump BIMA patients when compared with on-pump LIMA-SVG patients at 15-year follow-up. CONCLUSIONS: Perioperative complications do not increase with the use of BIMAs. Long-term survival is optimized with off-pump CABG and BIMA grafting. The low morbidity and mortality rates in this series are likely due to the continuous evolution of technology and the adoption of less invasive options for CABG patients. A more widespread use of BIMAs in CABG patients would continue to improve the overall excellent short- and long-term results of this operation.


Assuntos
Doença das Coronárias/cirurgia , Anastomose de Artéria Torácica Interna-Coronária/métodos , Fatores Etários , Idoso , Índice de Massa Corporal , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença das Coronárias/mortalidade , Feminino , Seguimentos , Humanos , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Anastomose de Artéria Torácica Interna-Coronária/mortalidade , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , New Jersey/epidemiologia
20.
Rev Cardiovasc Med ; 12 Suppl 1: S40-6, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22080987

RESUMO

Antiplatelet therapy is widely accepted in the contemporary management of patients with coronary syndromes. Effective platelet inhibition can cause an increased risk of bleeding, which is more evident when patients are referred to surgical coronary revascularization. The cardiac surgeon should be familiar with all new antiplatelet drugs. In this article we compile the latest information about antiplatelet therapy and its impact on cardiac surgery.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Cardiopatias/terapia , Inibidores da Agregação Plaquetária/efeitos adversos , Hemorragia Pós-Operatória/etiologia , Plaquetas/efeitos dos fármacos , Cardiopatias/sangue , Cardiopatias/tratamento farmacológico , Cardiopatias/cirurgia , Humanos , Testes de Função Plaquetária , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/prevenção & controle , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco
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