RESUMO
OBJECTIVE: To assess differences in mitral regurgitation (MR) grade between the preoperative and the intraoperative evaluations. DESIGN: Systematic review and meta-analysis of 6 observational studies found from MEDLINE and EMBASE. SETTING: Cardiac surgery. PARTICIPANTS: One hundred thirty-seven patients. INTERVENTION: Comparison between the preoperative MR assessment and the intraoperative evaluation conducted under general anesthesia (GA), with or without "hemodynamic matching" (HM) (artificial increase of afterload). MEASUREMENTS AND MAIN RESULTS: The primary outcome was the difference between the preoperative and intraoperative MR grade under "GA-only" or "after-HM." Secondary analyses addressed differences according to effective regurgitant orifice area (EROA), regurgitant volume (RVol), color-jet area, and vena contracta width. Risk of MR underestimation was found under "GA-only" (SMD: 0.55; 95% confidence interval [CI], 0.31-0.79, p < 0.00001), but not "after-HM" (SMD: -0.16; 95% CI, -0.46 to 0.13, p = 0.27). Under "GA-only", EROA had a trend toward underestimation (p = 0.07), RVol was reliable (p = 0.17), while reliance on color-jet area and vena contracta width incur risk of underestimation (both p = 0.003). After HM, EROA accurately reflected preoperative MR (p = 0.68) while RVol had a trend toward overestimation (p = 0.05). The overall reported incidence of misdiagnoses was slightly more common under "GA-only" (mean 48%, 39% underestimation, 9% overestimation; range: 32%-57%) than "after-HM" (mean 41%, 12% underestimation, 29% overestimation; range: 33%-50%). Only the minority of misdiagnoses were clinically relevant: underestimation was around 10% (both approaches), but 18% had clinically significant overestimation "after-HM" as compared with 3% under GA-only. CONCLUSIONS: Intraoperative assessment under "GA-only" significantly underestimated MR. A more accurate intraoperative evaluation can be obtained with afterload manipulation, although HM strategy carries high risk of clinically significant overestimation.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cuidados Intraoperatórios/métodos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/cirurgia , Salas Cirúrgicas/métodos , Cuidados Pré-Operatórios/métodos , Humanos , Insuficiência da Valva Mitral/classificação , Estudos Prospectivos , Estudos RetrospectivosRESUMO
: Images and movie clips documenting the rare occurrence of a percutaneous prosthesis embolization into the left ventricle are presented. The case outcome and the circumstances leading to the event are discussed.
Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Embolia/etiologia , Migração de Corpo Estranho/etiologia , Próteses Valvulares Cardíacas , Ventrículos do Coração , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Valvuloplastia com Balão , Cineangiografia , Remoção de Dispositivo , Embolia/diagnóstico por imagem , Embolia/cirurgia , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/cirurgia , Humanos , Desenho de Prótese , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
During aortic arch replacement, construction of the distal anastomosis represents the crucial step because of the time limit of circulatory arrest. If the aneurysmal neck is located at the level of the 5(th) thoracic vertebra, it becomes difficult to carry out through a sternotomy approach. We describe a case in which an interrupted suture technique, similar to that used for valve replacement, was employed to maximize the limited exposure and achieve a water-tight anastomosis.
