RESUMEN
Transcatheter valve implantation in the mitral position with severe calcific mitral stenosis has been described in patients who are at an increased risk for conventional mitral valve surgical procedures. We report the direct deployment of the Sapien 3 valve in the mitral position with severe mitral annular calcification through a sternotomy in an arrested heart in two cases.
Asunto(s)
Calcinosis/complicaciones , Cardiomiopatías/complicaciones , Implantación de Prótesis de Válvulas Cardíacas/métodos , Estenosis de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Anciano de 80 o más Años , Calcinosis/diagnóstico , Calcinosis/cirugía , Cardiomiopatías/diagnóstico , Cardiomiopatías/cirugía , Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Femenino , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/diagnóstico , Estenosis de la Válvula Mitral/etiología , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: The study objective was to determine the effects of implementing a blood conservation algorithm on blood product use and outcomes in a community cardiac surgery program. METHODS: A blood management strategy including lower hemoglobin transfusion threshold and algorithm-driven decisions was adopted. Intraoperatively, point-of-care testing was used to avoid inappropriate component transfusion. A low prime perfusion circuit was adopted. Blood was withdrawn from patients before initiating bypass when possible. Patients undergoing coronary and valve procedures were included. Outlier patients receiving more than 10 units packed red blood cells were excluded. Data were collected for 6 months as a baseline group (group I). A 3-month period of program implementation was allotted. Data were subsequently collected for 6 months and comprised the study patients (group II). Prospective data were collected on demographics, blood use, and outcomes. RESULTS: Group I comprised 481 patients, and group II comprised 551 patients. Group II received fewer units of packed red blood cells, fresh-frozen plasma, and cryoprecipitate than group I. There was no difference in platelets transfused. Total blood product use was reduced by 40% in group II (P < .001). The overall 30-day mortality was 1.3%. There were no differences in mortality, reoperation for bleeding, or other postoperative outcomes between the groups. CONCLUSIONS: Implementation of a comprehensive blood conservation algorithm can be rapidly introduced, leading to reductions in blood and component use with no detrimental effect on early outcomes. Point-of-care testing can direct component transfusion in coagulopathic cases, with most coagulopathic patients requiring platelets. Further research will determine the effects of reduced transfusions on long-term outcomes.
Asunto(s)
Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Procedimientos Quirúrgicos Cardíacos , Servicios de Salud Comunitaria/organización & administración , Hemorragia Posoperatoria/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Biomarcadores/sangre , Pruebas de Coagulación Sanguínea , Transfusión Sanguínea/mortalidad , Transfusión Sanguínea/estadística & datos numéricos , Transfusión de Sangre Autóloga , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Distribución de Chi-Cuadrado , Técnicas de Apoyo para la Decisión , Femenino , Hemoglobinas/análisis , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , New Jersey , Recuento de Plaquetas , Sistemas de Atención de Punto , Hemorragia Posoperatoria/etiología , Valor Predictivo de las Pruebas , Evaluación de Programas y Proyectos de Salud , Estudios Prospectivos , Reoperación , Factores de Tiempo , Reacción a la Transfusión , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Previous studies have reported an 11% to 75% incidence of postoperative cognitive decline among cardiac surgery patients. The INVOS Cerebral Oximeter (Somanetics Corp, Troy, MI) is a Food and Drug Administration approved device that measures regional cerebral oxygen (rSo(2)) saturation. The purpose of this study is to examine whether decreased rSo(2) predicts cognitive decline and prolonged hospital stay after coronary artery bypass grafting (CABG). METHODS: The rSo(2) was monitored intraoperatively in a cohort of primary CABG patients. Patients were prospectively randomized to a blinded control group or an unblinded intervention group. Cognitive function was assessed preoperatively, postoperatively, and at 3 months using a battery of standardized neurocognitive tests. Cognitive decline was defined as a decrease of one standard deviation or more in performance on at least one neurocognitive measure. The rSo(2) desaturation score was calculated by multiplying rSo(2) below 50% by time (seconds). Multivariate logistic regression models were used to assess cognitive decline and hospital stay. The change in cognitive performance was also assessed using a multivariate linear regression model. RESULTS: Patients with rSo(2) desaturation score greater than 3,000%-second had a significantly higher risk of early postoperative cognitive decline [p = 0.024]. Patients with rSo(2) desaturation score greater than 3,000%-second also had a near threefold increased risk of prolonged hospital stay (>6 days) [p = 0.007]. CONCLUSIONS: Intraoperative cerebral oxygen desaturation is significantly associated with an increased risk of cognitive decline and prolonged hospital stay after CABG.
