RESUMO
OBJECTIVES: To assess the feasibility and safety of uniportal video-assisted thoracoscopic pulmonary segmentectomy compared with lobectomy by studying early postoperative outcomes. METHODS: We included all patients who underwent uniportal segmentectomy and lobectomy between 2017 and 2022 at Karolinska University Hospital. Early clinical outcomes were compared between the uniportal segmentectomy and lobectomy groups. Differences in baseline characteristics were addressed using inverse probability of treatment weighting. RESULTS: A total of 833 patients (232 segmentectomy, 601 lobectomy) were included. The number of uniportal operations increased during the study period. Patients in the segmentectomy and lobectomy groups, respectively, had stage I lung cancer in 65% and 43% of the cases; 97% and 94% had no postoperative complications, the median number of lymph node stations sampled was 4 vs 5, and non-radical microscopic resection occurred in 1.7% vs 1.8%. The drains were removed on postoperative day 1 in 75% vs 72% of the patients following segmentectomy and lobectomy, respectively, and 90% vs 89% were discharged directly home. CONCLUSIONS: Uniportal video-assisted segmentectomy was performed with similar early postoperative clinical results compared with uniportal lobectomy in patients with benign, metastatic or early-stage lung cancer.
Assuntos
Neoplasias Pulmonares , Cirurgia Torácica Vídeoassistida , Humanos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodos , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Neoplasias Pulmonares/patologia , Pulmão/cirurgia , Complicações Pós-Operatórias/etiologiaRESUMO
OBJECTIVES: The objective of this cohort study was to analyse long-term relative survival in patients with bicuspid aortic valve (BAV) who underwent aortic valve surgery. METHODS: We studied 865 patients with BAVs who participated in three prospective cohort studies of elective, open-heart, aortic valve surgery at the Karolinska University Hospital, Stockholm, Sweden, between 2007 and 2020. The expected survival for the age, sex and calendar year-matched general Swedish population was obtained from the Human Mortality Database. The Ederer II method was used to calculate relative survival, which was used as an estimate of cause-specific survival. RESULTS: No differences were found in the observed versus expected survival at 1, 5, 10 or 12 years: 99%, 94%, 83% and 76% vs 99%, 93%, 84% and 80%, respectively. The relative survival at 1, 5, 10 and 12 years was 100% (95% CI 99% to 100%), 101% (95% CI 99% to 103%), 99% (95% CI 95% to 103%) and 95% (95% CI 87% to 102%), respectively. The relative survival at the end of follow-up tended to be lower for women than men (86% vs 95%). The mean follow-up was 6.3 years (maximum 13.3 years). CONCLUSIONS: The survival of patients with BAV following aortic valve surgery was excellent and similar to that of the general population. Our results suggest that the timing of surgery according to current guidelines is correct and provide robust long-term survival rates, as well as important information about the natural history of BAV in patients following aortic valve surgery.
Assuntos
Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Implante de Prótese de Valva Cardíaca , Efeitos Adversos de Longa Duração , Adulto , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Doença da Válvula Aórtica Bicúspide/diagnóstico , Doença da Válvula Aórtica Bicúspide/epidemiologia , Doença da Válvula Aórtica Bicúspide/fisiopatologia , Doença da Válvula Aórtica Bicúspide/cirurgia , Estudos de Coortes , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Humanos , Estimativa de Kaplan-Meier , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/etiologia , Efeitos Adversos de Longa Duração/mortalidade , Masculino , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Fatores Sexuais , Suécia/epidemiologiaRESUMO
BACKGROUND: Prior reports on a possible female survival advantage in both surgical and nonsurgical cohorts of patients with lung cancer are conflicting. Previously reported differences in survival after lung cancer surgery could be the result of insufficient control for disparities in risk factor profiles in men and women. RESEARCH QUESTION: Do women who undergo pulmonary resections for lung cancer have a better prognosis than men when taking a wide range of prognostic factors into account? STUDY DESIGN AND METHODS: We performed a nationwide population-based observational cohort study analyzing sex-specific survival after pulmonary resections for lung cancer. We identified 6356 patients from the Swedish National Quality Register for General Thoracic Surgery and performed individual-level record linkage to other national health-data registers to acquire detailed information regarding comorbidity, socioeconomic status, and vital status. Inverse probability of treatment weighting was used to account for differences in baseline characteristics. The association between female sex and all-cause mortality was assessed with Cox regression models, and flexible parametric survival models were used to estimate the absolute survival differences with 95% CIs. We also estimated the difference in restricted mean survival time. RESULTS: We observed a lower risk of death in women compared with men (hazard ratio, 0.73; 95% CI, 0.67-0.79). The absolute survival difference at 1, 5, and 10 years was 3.0% (95% CI, 2.2%-3.8%), 10% (95% CI, 7.0%-12%), and 12% (95% CI, 8.5%-15%), respectively. The restricted mean survival time difference at 10 years was 0.84 year (95% CI, 0.61-1.07 years). The findings were consistent across several subgroups. INTERPRETATION: Women who underwent pulmonary resections for lung cancer had a significantly better prognosis than men. The survival advantage was evident regardless of age, common comorbidities, socioeconomic status, lifestyle factors, physical performance, type and extent of surgery, tumor characteristics, and stage of disease. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT03567538; URL: www.clinicaltrials.gov.
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Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/cirurgia , Idoso , Feminino , Humanos , Masculino , Prognóstico , Sistema de Registros , Fatores Sexuais , Análise de Sobrevida , Suécia/epidemiologiaRESUMO
INTRODUCTION: Socioeconomic disparities have been linked to survival differences in patients with lung cancer. Swedish healthcare is tax-funded and provides equal access to care, therefore, survival following lung cancer surgery should be unrelated to household income. The aim of this study was to investigate the association between household disposable income and survival following surgery for lung cancer in Sweden. METHODS: We conducted a nationwide population-based cohort study including all patients who underwent pulmonary resections for lung cancer in Sweden 2008-2017. Individual-level record linkages between national quality and health-data registers were performed to acquire information regarding socioeconomic status and medical history. Cox regression by quintiles of household disposable income was used to estimate the adjusted risk for all-cause mortality. RESULTS: We included 5500 patients and the age-adjusted and sex-adjusted incidence rate of death per 100 person-years was 15 and 9.4 in the lowest and highest income quintile, respectively (mean follow-up time 3.2 years). Deprived patients were older, had more comorbidities and were less likely to have preoperative positron emission tomography or minimally invasive surgery, compared with patients with higher income. The adjusted HR for death was 0.77 (95% CI: 0.62 to 0.96) for the highest income quintile compared with the lowest. CONCLUSIONS: We found an association between household disposable income and survival in patients who underwent surgery for lung cancer in Sweden, despite tax-funded universal health coverage. The association remained after adjustment for differences in baseline characteristics.
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Renda/estatística & dados numéricos , Neoplasias Pulmonares/mortalidade , Idoso , Estudos de Coortes , Feminino , Humanos , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Pneumonectomia , Modelos de Riscos Proporcionais , Sistema de Registros , Taxa de Sobrevida , Suécia/epidemiologia , Fatores de TempoRESUMO
BACKGROUND: Contemporary data on loss in life expectancy after aortic valve replacement (AVR) are scarce, particularly in younger patients. OBJECTIVES: The purpose of this national, observational cohort study was to analyze long-term relative survival and estimated loss in life expectancy after AVR. METHODS: The study included 23,528 patients who underwent primary surgical AVR with or without concomitant coronary artery bypass grafting in Sweden between 1995 and 2013 from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. Individual level linking with other national health-data registers was performed to obtain baseline characteristics and vital status. The expected survival from the general Swedish population matched by age, sex, and year of surgery was obtained from the Human Mortality Database. The relative survival was used as an estimate of cause-specific mortality. Flexible parametric models based on relative survival were used to estimate the loss in life expectancy. RESULTS: The mean follow-up was 6.8 years. The 19-year observed, expected, and relative survival was 21%, 34%, and 63% (95% confidence interval [CI]: 59% to 67%), respectively. The loss in life expectancy was 1.9 years (95% CI: 1.2 to 2.6 years) in the total study population. The estimated loss in life expectancy increased with younger age: 0.4 years (95% CI: 0.3 to 0.5 years) versus 4.4 years (95% CI: 1.5 to 7.2 years) in patients ≥80 and <50 years of age, respectively. There was no difference in loss in life expectancy between men and women. CONCLUSIONS: This study found a shorter life expectancy in patients after AVR compared with the general population. The estimated loss in life expectancy was substantial, and increased with younger age. These results provide important information to quantify disease burden after AVR, and are relevant for clinicians counseling patients before and after AVR. (HeAlth-data Register sTudies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).
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Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Expectativa de Vida , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , SuéciaRESUMO
Background: In many parts of the world, stark racial disparities in human immunodeficiency virus (HIV) prevalence, incidence, prevention, and care outcomes persist among gay, bisexual, and other men who have sex with men (MSM), with Black MSM significantly impacted in the United States (U.S.). Individual-level characteristics, including sexual behaviors and socioeconomic status, do not fully account for racial/ethnic disparities in HIV among MSM. We hypothesize that neighborhood contexts and network characteristics influence risk for HIV infection as well as HIV-related prevention and care behaviors. As such, the study design includes the use of real-time geospatial methods and in-depth assessments of multiple network typologies to investigate the impact of neighborhood and network-level factors on HIV prevention and treatment among Black MSM residing in longstanding priority HIV elimination areas in the U.S., namely Chicago, Illinois and in the Deep South (Jackson, Mississippi and New Orleans, Louisiana) (n = 450, n = 50, and n = 100, respectively). We describe the design, sampling methods, data collection, data management methods, and preliminary findings of the ongoing 'Neighborhoods and Networks (N2) Cohort Study'. Methods/Design: N2 employs a prospective longitudinal design. The sample includes Black MSM participants in Chicago recruited via respondent-driven sampling and assessed every six months over two years of follow-up. Participants enrolled in Jackson and New Orleans are being recruited through existing health and community services and assessed every six months over one year of follow-up. Mobility within and between neighborhoods is being assessed using global positioning system (GPS) technology. Social and sexual networks among Black MSM are being studied through egocentric network inventories as well as newer methods of creating meso-level networks that involve social media (Facebook) and mobile phone contacts. Key HIV prevention outcomes such as pre-exposure prophylaxis (PrEP) care engagement, and HIV/STI (sexually transmitted infections) biomarkers will be examined at baseline and follow-up. Results: As of 31 December 2018, a total of 361 men were enrolled across all study sites: 259 in Chicago and 102 in the Deep South (75 in New Orleans and 27 in Jackson). At baseline, participants ranged in age from 17 to 65 years old (mean = 34.3, standard deviation = 5.1) with 123 men (34.1%) self-reported as HIV positive. While HIV treatment levels were similar between sites, men in the Deep South reported higher rates of adherence than men in Chicago (63.3% versus 49.4%, p = 0.03). Sexual risk profiles were mainly the same between men from different study sites, with 22.9% of men in Chicago and 28.9% in the Deep South reporting consistent condom use during vaginal and anal sex (p = 0.26). Regarding their home neighborhoods, men in the Deep South were more likely than those in Chicago to characterize theirs as having a good reputation (43.1% versus 24.7%, p < 0.001) and as being safe (37.3% versus 21.2%, p = 0.002). Conclusions: The focus on Black MSM in the N2 Study will allow for a nuanced exploration of the attitudes, beliefs, behaviors, and practices of a diverse group of Black MSM. The study is also positioned to provide novel insight about neighborhood and network characteristics that influence HIV-related behaviors. A health equity framework ensures that Black MSM are not explicitly or implicitly deemed as deviant, disordered, or the non-reference group. Findings from N2 will provide guidance for the implementation of more impactful HIV prevention interventions that engage a diverse population of Black MSM as we work toward HIV elimination in the U.S.
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Negro ou Afro-Americano/estatística & dados numéricos , Infecções por HIV , Homossexualidade Masculina , Características de Residência , Adolescente , Adulto , Idoso , Chicago/epidemiologia , Estudos de Coortes , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Infecções por HIV/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Mississippi/epidemiologia , Nova Orleans/epidemiologia , Comportamento Sexual , Meio Social , Adulto JovemRESUMO
BACKGROUND: Bovine and porcine bioprostheses are commonly used for surgical aortic valve replacement. It is unknown if the long-term survival differs between the two valve types.We performed a systematic review and meta-analysis to compare survival in patients who underwent aortic valve replacement and received a bovine or a porcine prosthesis. METHODS: We performed a systematic search of Medline, Embase, Web of Science, and the Cochrane Library. Cohort studies that compared survival between patients who underwent aortic valve replacement and received either a bovine or a porcine bioprosthesis and that reported overall long-term survival with hazard ratio (HR) and 95% confidence interval (CI) were included. Two authors independently reviewed articles considered for inclusion, extracted the information from each study, and performed the quality assessment. We performed a meta-analysis using a random effects model to calculate the pooled HR (95% CI) for all-cause mortality. We did sensitivity analyses to assess the robustness of our findings. RESULTS: Seven studies published between 2010 and 2015 were included, and the combined study population was 49,190 patients. Of these, 32,235 (66%) received a bovine, and 16,955 (34%) received a porcine bioprosthesis. There was no significant difference in all-cause mortality between patients who received a bovine compared with a porcine bioprosthesis (pooled HR 1.00, 95% CI: 0.92-1.09). Heterogeneity between studies was moderate (55.8%, p = 0.04). CONCLUSIONS: This systematic review and meta-analysis suggest no difference in survival between patients who received a bovine versus a porcine bioprosthesis after aortic valve replacement. Our study provides valuable evidence for the continuing use of both bovine and porcine bioprosthetic valves for surgical aortic valve replacement.
Assuntos
Valva Aórtica/cirurgia , Bioprótese , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Hemodinâmica , Animais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Bovinos , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Xenoenxertos , Humanos , Recuperação de Função Fisiológica , Fatores de Risco , Sus scrofa , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Video-assisted thoracic surgery (VATS) lobectomy is the recommended surgical approach for patients with stage I lung cancer. Whether a multiportal or a uniportal approach is preferable remains unclear. The aim of this study was to evaluate the safety of implementing uniportal VATS lobectomy into the treatment program of lung cancer patients. METHODS: We used the national quality register for general thoracic surgery in Sweden and included all patients who underwent VATS lobectomy for lung cancer at the Karolinska University Hospital between 2016-2018. Early postoperative complications were compared in patients undergoing uniportal (n=122) and multiportal (n=211) VATS lobectomy for lung cancer. Inverse probability of treatment weighting and standardized mean differences were used to limit differences in baseline characteristics and to assess balance after weighting. RESULTS: The proportion of uniportal VATS lobectomies increased during the study period and the conversion rates declined significantly. Baseline characteristics were similar in the two groups with the exception of a higher percentage of patients without any comorbidity in the uniportal group (59.8% vs. 44.5%, P=0.010). After inverse probability of treatment weighting the groups were well balanced. Postoperative complications were rare regardless of surgical approach, 94% in both groups had no complications. The 30-day mortality and overall survival at 1 year was 0% and 97% in the uniportal group, and 0.5% and 98% in the multiportal group (P=0.71). Patients undergoing uniportal VATS lobectomy were discharged directly to home to a higher extent than multiportal VATS patients (76.2% vs. 62.1%, P=0.008). CONCLUSIONS: We found that uniportal VATS lobectomy was feasible and safe, and might entail advantages in terms of a faster recovery after surgery as compared to multiportal VATS lobectomy in patients with lung cancer.
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Valva Aórtica/cirurgia , Endocardite Bacteriana/cirurgia , Endocardite/cirurgia , Infecções Relacionadas à Prótese/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação/métodosRESUMO
BACKGROUND: The influence of moderately reduced kidney function on late survival after surgical aortic valve replacement (AVR) is unknown. We analyzed survival after AVR in patients with moderately reduced kidney function. METHODS AND RESULTS: All patients who underwent primary AVR in Sweden 1997-2013 were identified from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register. Patients were categorized according to estimated glomerular filtration rate (eGFR). Of 13 102 patients, 9836 (75%) had normal kidney function (eGFR >60 mL/min per 1.73 m2) and 3266 (25%) had moderately reduced kidney function (eGFR 30-60 mL/min per 1.73 m2). Mean follow-up time was 6.2 years. Mortality was higher in patients with moderately reduced kidney function; 5-, 10-, and 15-year survival was 76%, 48%, and 25% versus 89%, 73%, and 55% (adjusted hazard ratio [HR], 1.28; 95% CI, 1.18-1.38; P<0.001). Patients with moderately reduced kidney function had a nonsignificantly higher risk of major bleeding (HR, 1.18; 95% CI, 1.00-1.39; P=0.051) and a lower risk for aortic valve reoperation (HR, 0.54; 95% CI, 0.38-0.79; P=0.001) compared to those with normal kidney function. In patients with moderately reduced kidney function, survival was similar in those who received bioprostheses compared to those who received mechanical valves (HR, 0.85; 95% CI, 0.70-1.03; P=0.094). CONCLUSIONS: Moderately reduced kidney function was strongly associated with increased mortality after AVR. These results have important implications for preoperative risk stratification, and suggest that patients with eGFR 30 to 60 mL/min per 1.73 m2 warrant careful observation after AVR. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02276950.
Assuntos
Estenose da Valva Aórtica/mortalidade , Valva Aórtica , Próteses Valvulares Cardíacas , Nefropatias/mortalidade , Idoso , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Bioprótese , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/mortalidade , Hemorragia/etiologia , Hemorragia/mortalidade , Humanos , Nefropatias/complicações , Masculino , Pessoa de Meia-Idade , Prognóstico , Reoperação/estatística & dados numéricos , Fatores de Risco , Suécia/epidemiologiaRESUMO
AIMS: The objective was to investigate the long-term all-cause mortality in patients aged 50-69 years after aortic valve replacement (AVR) with bioprosthetic or mechanical valves. METHODS AND RESULTS: All patients aged 50-69 years who had undergone AVR in Sweden 1997-2013 were identified from the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register. Subsequent patient-level record linkage with national health-data registers provided patient characteristics, vital status, and clinical outcomes. Of the 4545 patients, 60% (2713/4545) had received mechanical valves and 40% (1832/4545) bioprostheses. In 1099 propensity score-matched patient pairs, 16% (180/1099) had died in the mechanical valve group and 20% (217/1099) in the bioprosthetic group; mean follow-up 6.6 (maximum 17.2) years. Survival was higher in the mechanical than in the bioprosthetic group: 5-, 10-, and 15-year survival 92, 79, and 59% vs. 89, 75, and 50%; hazard ratio 1.34; 95% confidence interval (CI) 1.09-1.66; P = 0.006. There was no difference in stroke [subdistribution hazard ratio (sHR) 1.04; 95% CI 0.72-1.50, P = 0.848]; however, the risk for aortic valve reoperation was higher (sHR 2.36; 95% CI 1.42-3.94, P = 0.001), and for major bleeding lower (sHR 0.49; 95% CI 0.34-0.70, P < 0.001), in patients who had received bioprostheses than in those with mechanical valves. CONCLUSION: Patients aged 50-69 years who received mechanical valves had better long-term survival after AVR than those with bioprostheses. The risk of stroke was similar; however, patients with bioprostheses had a higher risk of aortic valve reoperation and a lower risk of major bleeding. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov/show/NCT02276950. CLINICALTRIALSGOV IDENTIFIER: NCT02276950.
Assuntos
Implante de Prótese de Valva Cardíaca , Idoso , Valva Aórtica , Bioprótese , Próteses Valvulares Cardíacas , Humanos , Pessoa de Meia-Idade , Reoperação , SuéciaRESUMO
OBJECTIVE: Differences in clinical presentation between patients with tricuspid aortic valves (TAVs) or bicuspid aortic valves (BAVs) and aortic valve disease are evident. Whether these differences can be attributed to differences in cardiovascular risks remains uncertain. METHODS: Patient characteristics, echocardiographic findings, medical history, medication, and laboratory findings were evaluated in 702 patients with aortic valve and/or ascending aortic pathology; 202 also had concomitant coronary artery disease. RESULTS: A BAV was commonly found in patients with isolated valve disease (BAV 47%, TAV 53%) and frequently associated with ascending aortic dilatation (BAV 80%, TAV 20%). In patients with coronary artery disease, a TAV was commonly found (TAV 84%, BAV 16%). The combination of ascending aortic dilatation and coronary artery disease was markedly rare regardless of valve morphology (TAV, 7 out of 38; BAV, 6 out of 127). The distribution of valve pathology and clinical parameters was similar in patients with TAV and BAV with coronary artery disease (P ≥ .12). Without coronary artery disease, parameters associated with cardiovascular risks were more often seen in patients with TAV than in patients with BAV (P ≤ .0001). CONCLUSIONS: Coronary artery disease is uncommon in surgical patients with BAV, but it is associated with TAV, advanced age, and male gender. Coronary artery disease and ascending aortic dilatation rarely coexist, regardless of valve phenotype. Differences in the prevalence of coronary artery disease or ascending aortic dilatation between patients with TAV and BAV are not explained by differences in cardiovascular risks or the distribution of valve pathology.
Assuntos
Aneurisma Aórtico/epidemiologia , Valva Aórtica/anormalidades , Doença da Artéria Coronariana/epidemiologia , Doenças das Valvas Cardíacas/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/diagnóstico , Aneurisma Aórtico/cirurgia , Valva Aórtica/cirurgia , Doença da Válvula Aórtica Bicúspide , Implante de Prótese Vascular , Ponte de Artéria Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Dilatação Patológica , Feminino , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Suécia/epidemiologiaRESUMO
BACKGROUND AND AIM OF THE STUDY: The relationship between aortic valve pathology and the aortic root and ascending aortic dimensions in cardiac surgery patients is unclear, and its clarification was the objective of this study. METHODS: The severity of valve pathology, whether aortic valve stenosis (AS) or aortic valve regurgitation (AR), and the aortic dimensions (aortic root and ascending aorta) were prospectively evaluated with echocardiography in 500 consecutive patients with tricuspid aortic valve (TAV) or bicuspid aortic valve (BAV) who had undergone surgery due to aortic valve and/or ascending aortic disease. RESULTS: The distribution of valve pathology was similar in TAV and BAV patients when the aorta was non-dilated. However, when the aorta was dilated, AS was seen predominantly in BAV patients (n = 76) compared to TAV patients (n = 2). In TAV and BAV patients with non-dilated aortas, an increased severity of valve pathology was associated with smaller dimensions of the aortic root and the ascending aorta. In TAV and BAV patients with dilated aortas, an increase in the severity of AR was associated with a decreasing dimension of the ascending aorta but an increasing dimension of the aortic root. In BAV patients with aneurysm, the severity of AS was associated with a decreased dimension of the aortic root and the ascending aorta. CONCLUSION: Patients with AS and ascending aortic dilatation almost exclusively have a BAV. An increasing severity of valve pathology was related to decreasing dimensions of the aortic root and the ascending aorta, and the pattern was strikingly similar in TAV and BAV patients. The high frequency of ascending aortic dilatations in BAV patients cannot be explained by the valve pathology.
Assuntos
Aorta/patologia , Valva Aórtica/anormalidades , Doenças das Valvas Cardíacas/patologia , Valva Tricúspide/patologia , Idoso , Aorta/diagnóstico por imagem , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/patologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/patologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/patologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/patologia , Doença da Válvula Aórtica Bicúspide , Dilatação Patológica/diagnóstico por imagem , Feminino , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Valva Tricúspide/cirurgia , UltrassonografiaRESUMO
OBJECTIVE: Whether patients with bicuspid aortic valves are susceptible not only to ascending aortic dilatation but also to dilatation of the remaining aorta is uncertain. This study evaluated the possible correlation between ascending aortic dilatation and dilatation of the remaining aorta in patients with bicuspid and tricuspid aortic valves, respectively. METHODS: The entire aortas of 97 patients (bicuspid in 62, tricuspid in 35) undergoing replacement of the ascending aorta because of ascending aortic pathology (78 with and 19 without concurrent valve pathology) were preoperatively evaluated using computed tomography scanning. RESULTS: Aortic dimensions distal to the ascending aorta were smaller in patients with bicuspid aortic valves than in patients with tricuspid aortic valves (P < .001): proximal arch: 3.20 ± 0.60 cm/3.80 ± 0.68 cm; distal arch: 2.90 ± 0.60 cm/3.40 ± 0.50 cm; isthmus, 2.95 ± 0.60 cm/3.50 ± 0.60 cm; descending aorta: 2.70 ± 0.50 cm/3.20 ± 0.65 cm; suprarenal aorta: 2.30 ± 0.40 cm/2.70 ± 0.43 cm; infrarenal aorta: 1.90 ± 0.48 cm/2.20 ± 0.35 cm, respectively. Concomitant pathologic dilatation of the descending aorta was more common in patients with tricuspid aortic valves (37%) than in patients with bicuspid aortic valves (5%) (P < .001). Neither valvular pathology nor bicuspid aortic valve phenotype influenced the aortic dimensions in the bicuspid group (P > .2). CONCLUSIONS: Patients with bicuspid aortic valves and dilatation of the ascending aorta consistently had smaller dimensions of the remaining aorta compared with patients with tricuspid aortic valves. Concomitant dilatation of the descending aorta was predominantly found in patients with tricuspid aortic valves.
Assuntos
Aorta/patologia , Aneurisma Aórtico/etiologia , Valva Aórtica/anormalidades , Cardiopatias Congênitas/complicações , Doenças das Valvas Cardíacas/complicações , Idoso , Aorta/cirurgia , Aorta Abdominal/diagnóstico por imagem , Aorta Abdominal/patologia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/patologia , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/cirurgia , Valva Aórtica/diagnóstico por imagem , Aortografia/métodos , Doença da Válvula Aórtica Bicúspide , Implante de Prótese Vascular , Dilatação Patológica , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios XRESUMO
This article presents the findings of a collaborative effort between the Georgetown University Student Consulting Team and Booz Allen Hamilton to interview healthcare providers undergoing the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS). The goals of this study were to extract a common set of trends, challenges, and lessons learned surrounding the implementation of the ICD-10-CM/PCS code set and to produce actionable information that might serve as a resource for organizations navigating the transition to ICD-10-CM/PCS. The selected survey sample focused on a subset of large hospitals, integrated health systems, and other national industry leaders who are likely to have initiated the implementation process far in advance of the October 2013 deadline. Guided by a uniform survey tool, the team conducted a series of one-on-one provider interviews with department heads, senior staff members, and project managers leading ICD-10-CM/PCS conversion efforts from six diverse health systems. As expected, the integrated health systems surveyed seem to be on or ahead of schedule for the ICD-10-CM/PCS coding transition. However, results show that as of April 2010 most providers were still in the planning stages of implementation and were working to raise awareness within their organizations. Although individual levels of preparation varied widely among respondents, the study identified several trends, challenges, and lessons learned that will enable healthcare providers to assess their own status with respect to the industry and will provide useful insight into best practices for the ICD-10-CM/PCS transition.
Assuntos
Setor de Assistência à Saúde/legislação & jurisprudência , Classificação Internacional de Doenças/classificação , Gerenciamento da Prática Profissional/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Registros Eletrônicos de Saúde , Pessoal de Saúde , Humanos , Classificação Internacional de Doenças/legislação & jurisprudência , Estados UnidosRESUMO
OBJECTIVE: It is hypothesized that an altered turnover of extracellular matrix mediated by matrix metalloproteinases (MMPs) is present in thoracic aortic aneurysms. Here, we analyzed the occurrence of MMPs and MMP inhibitors in ascending aortic aneurysms in patients with bicuspid and tricuspid aortic valves. METHODS: Expression of 23 MMPs and their inhibitors was measured in aortic intima/media and adventitia in 109 patients (40 tricuspid, 69 bicuspid, 68 with aortic diameter≥4.5 cm, and 41 with ≤4.0 cm) using Affymetrix Exon arrays (Affymetrix, Santa Clara, Calif). Gene expression was confirmed by quantitative real-time polymerase chain reaction. Principal components analysis was used to study differences in gene expression. Immunohistochemistry was used to study protein expression. RESULTS: We detected messenger RNA expression for gelatinases (MMP2 and MMP9), stromelysin 3 (MMP11), all membrane bound MMPs (MMP14, MMP15, MMP16, MMP17, MMP24, MMP25), MMP19, MMP21, and MMP28 in ascending aorta. No expression of collagenases was detected. Principal components analysis showed that changes in mRNA expression between dilated and nondilated aorta were mainly detected in patients with tricuspid aortic valves. MMP14 and MMP19 showed higher expression in dilated aortas and MMP19 expression correlated positively to maximal aortic diameter in patients with tricuspid aortic valves (Rho=0.61, P=.004, and Rho=0.57, P=.008, using raw and body surface area-corrected aortic diameter, respectively). Immunohistochemical staining demonstrated increased medial expression of MMP14 and MMP19 in dilated aorta. CONCLUSIONS: The present study identifies MMP14 and MMP19 as proteolytic enzymes potentially involved in aneurysm formation in the ascending aorta of patients with tricuspid aortic valves.