RESUMO
BACKGROUND: Patients requiring coronary artery bypass grafting (CABG) are often loaded with antithrombotic drugs (AT) and are at an increased risk for perioperative bleeding complications. Active AT removal by a hemoadsorption cartridge integrated in the cardiopulmonary bypass circuit is increasingly used in this setting to reduce bleeding, and herein we describe the extension of this application in patients on AT undergoing off-pump coronary artery bypass (OPCAB). METHODS: Ten patients (80% male; mean age: 67.4 ± 9.2years) were treated with ticagrelor (eight patients), rivaroxaban and ticagrelor (one patient), and rivaroxaban (one patient) prior to OPCAB surgery. AT's were discontinued one day before surgery in nine patients and on the day of surgery in one patient, and all patients were also on aspirin. The cohort mean EuroSCORE-II was 2.9 ± 1.5%. A hemoadsorption cartridge was integrated into a dialysis device (n=4) or a stand-alone apheresis pump (n=6) periprocedural, for a treatment time of 145 ± 33 min. Outcome measures included bleeding according to Bleeding Academic Research Consortium (BARC)-4 and 24-hour chest-tube-drainage (CTD). RESULTS: Mean operation time was 184 ± 35 min. All patients received a left internal thoracic artery with a mean of 2.3 ± 0.9 total grafts. One patient had a BARC-4 bleeding event and there were no surgical re-explorations for bleeding. Mean 24-hours CTD was 680 ± 307mL. During follow-up of 19.5 ± 17.0 months, none of the patients died or required further reinterventions. No device-related adverse events were reported. CONCLUSIONS: Hemoadsorption via a stand-alone apheresis pump during OPCAB surgery was feasible and safe. This innovative and new approach showed favorable bleeding rates in patients on antithrombotic drugs requiring bypass surgery.
Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea , Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Feminino , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Fibrinolíticos , Ticagrelor , Rivaroxabana , Ponte de Artéria Coronária , Resultado do TratamentoRESUMO
Background and Objectives: The hemoadsorption device CytoSorb® (CytoSorbents Inc., Princeton, NJ, USA) has been shown to efficiently remove ticagrelor from whole blood in vitro. A promising clinical experience was made with the integration of the hemoadsorption cartridge on the cardiopulmonary bypass (CPB) circuit during cardiac surgery to reduce adverse events. Materials and Methods: In this report, we describe a novel approach using a new apheresis platform, PUR-01 (Nikkisio Co., Ltd., Tokyo, Japan), which was used as the extracorporeal circuit where CytoSorb® could be installed for the removal of ticagrelor during off-pump coronary artery bypass (OPCAB) procedures. Results: In a 74-year-old male (index case) with coronary artery disease and dual antiplatelet therapy, hemoadsorption was initiated with a skin incision for OPCAB surgery and was continued for 221 min to eliminate ticagrelor. The blood volume that had circulated through the CytoSorb® was 39.04 L in total. Thus far, this treatment strategy has been used in four cases with CHD and DAPT who needed OPCAB surgery. The intraoperative and postoperative courses were uneventful in all patients. No device-related adverse events occurred. Conclusions: The combination of the PUR-01 apheresis pump and hemoadsorption with the CytoSorb® column during OPCAB procedures appears to be safe and effective in eliminating antiplatelet drugs.
Assuntos
Remoção de Componentes Sanguíneos , Ponte de Artéria Coronária sem Circulação Extracorpórea , Masculino , Humanos , Idoso , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Inibidores da Agregação Plaquetária/uso terapêutico , Fibrinolíticos , Ticagrelor/uso terapêutico , Ponte Cardiopulmonar/efeitos adversosRESUMO
Objectives: Postoperative atrial fibrillation (POAF) is a frequent complication following cardiac surgery. This study examined the safety and efficacy of the new DefiPace TM system consisting of two bi-atrial temporary pacing and cardioversion electrodes, a ventricular electrode and the DefiPace TM device (combined external pacemaker and cardioverter) for low-energy atrial cardioversion. Methods: The temporary electrodes were placed on the left and right atrium during open heart surgery. Pacing thresholds and sensing were measured up to the 6th postoperative day. The satisfactory handling of the electrodes was measured with a visual analog scale (VAS) 1-10, with 10 being the best and 1 being the lowest. In case of POAF, R-wave synchronous low-energy shocks (0.5-10 J) were applied for cardioversion. Results: Temporary electrodes were implanted in 29 patients (age 65.6 ± 10.4 years; 21 males, 14 OPCAB, 15 on-pump cardiac operations). Left or right atrial pacing thresholds ranged from 1.9 ± 1.3 V/ms to 5.0 ± 3.3 V/ms and P-wave sensing from 0.9 ± 0.6 mV to 1.5 ± 0.7 mV. VAS for handling of electrodes: implantation 7.1 ± 0.8 and removal 8.4 ± 1.0. POAF was observed in four patients. Two patients had successful atrial cardioversion with 3.5 J and 4.5 J. One patient converted spontaneously, and one patient remained in PAOF. There were no device-related adverse events. Conclusions: The DefiPace TM system can be used safely in patients undergoing cardiac surgery.
RESUMO
CytoSorb hemoadsorption (CytoSorbents Inc, Monmouth Junction, NJ) was performed shortly before an urgent off-pump coronary artery bypass operation in a 58-year-old man at high risk of bleeding as a result of treatment of coronary artery disease with ticagrelor and treatment of atrial fibrillation with rivaroxaban. The patient experienced dissection of the left anterior descending artery during a percutaneous coronary intervention. Preoperatively, CytoSorb hemoadsorption was applied to eliminate the coagulative active medications. His intraoperative and postoperative courses were uneventful, with adequate bleeding control. This case highlights a promising approach for managing antiplatelet drugs and anticoagulant agents such as ticagrelor and rivaroxaban before off-pump coronary artery bypass.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Hemoperfusão/métodos , Rivaroxabana/sangue , Ticagrelor/sangue , Humanos , Masculino , Pessoa de Meia-Idade , Rivaroxabana/isolamento & purificação , Ticagrelor/isolamento & purificaçãoRESUMO
BACKGROUND: Lack of autologous graft material restricts the ability to treat patients requiring coronary artery bypass surgery (CABG). An off the shelf tissue engineered small diameter vascular graft is the holy grail of cardiovascular surgery. METHODS: Allograft saphenous veins were harvested from organ donors, cryopreserved, deendothelialized and then seeded with autologous endothelial cells prior to implantation during coronary artery bypass surgery. All patients treated were followed-up until death and angiographic results were collected. Grafts were explanted during autopsy and immunohistochemistry was performed. RESULTS: Twelve patients received 15 engineered grafts. Mean patient survival was 9.1⯱â¯1.8 years. Six month graft patency was 80 (95% CI: 59-100) and 9 month graft patency was 50 (95% CI: 27-93) - graft patency detected up to 32 months after surgery. Immunohistochemistry in grafts explanted showed a presence of CD31 and CD68 positive cells in the luminal region of the vessel walls and layers of Collagen Type I in the abluminal vessel walls. CONCLUSIONS: Our small diameter tissue engineered vascular graft shows openness up to 32 months after implantation. Immunohistochemistry suggests that monocyte activation may lead to vessel remodeling with thickening of the vessel wall. Research should concentrate on a manipulation of remodeling processes.
Assuntos
Aloenxertos/fisiologia , Prótese Vascular , Ponte de Artéria Coronária , Endotélio/fisiologia , Idoso , Prótese Vascular/efeitos adversos , Morte Celular , Determinação de Ponto Final , Feminino , Seguimentos , Oclusão de Enxerto Vascular/etiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Complicações Pós-Operatórias/etiologia , Fatores de TempoRESUMO
PURPOSE: The HEARTSTRING Proximal Seal System is used to avoid aortic clamping to insert the intraaortic balloon pump (IABP) in the ascending aorta or the aortic arch. This technique is used when calcification or atheroma prevents side clamping of the ascending aorta or the aortic arch. DESCRIPTION: A vein graft or a small-caliber vascular prosthesis for the later insertion of the IABP is sewn to the ascending aorta or the aortic arch using the HEARTSTRING Proximal Seal System. EVALUATION: In our department, this technique is applied whenever insertion of the IABP is not feasible via the femoral arteries. CONCLUSION: The technique allows the safe insertion of the IABP via the ascending aorta or the aortic arch.
Assuntos
Aorta Torácica/cirurgia , Aorta/cirurgia , Balão Intra-Aórtico/métodos , Implante de Prótese Vascular , Humanos , Veias/transplanteRESUMO
OBJECTIVE: This study aimed to investigate the influence of the flavonoid oxerutin (Venoruton®, Novartis, Basel, Switzerland) on endothelial cell apoptosis and transendothelial migration of peripheral blood mononuclear cells and to elucidate the potential mechanisms affecting these processes. METHODS: Human endothelial cells were treated with Venoruton to assess the potential effect on apoptosis and on the transendothelial migration process. Endothelial nitric oxide synthase and inducible nitric oxide synthase expression in endothelial cell after Venoruton treatment as well as reactive oxygen species levels were analyzed. RESULTS: Low-dose Venoruton shows a protective effect on endothelial cells and inhibits transendothelial migration of peripheral blood mononuclear cells through an endothelial monolayer, but high-dose Venoruton inversely elevated transendothelial migration of peripheral blood mononuclear cells. Meanwhile, a dose-dependent action of Venoruton on endothelial cell apoptosis could be observed. Endothelial nitric oxide synthase and inducible nitric oxide synthase expression were gradually increased in endothelial cells with increasing Venoruton dosage. In addition, reactive oxygen species were significantly reduced by 0.1 mM and 0.5 mM Venoruton and elevated after high dose treatment. CONCLUSION: These data suggest that the increased transendothelial migration of peripheral blood mononuclear cells is related to the excessive activation of the nitric oxide-axis and subsequent relaxation of the endothelial cells.
Assuntos
Apoptose/efeitos dos fármacos , Células Endoteliais/metabolismo , Flavonoides/farmacologia , Hidroxietilrutosídeo/análogos & derivados , Leucócitos Mononucleares/metabolismo , Migração Transendotelial e Transepitelial/efeitos dos fármacos , Linhagem Celular , Células Endoteliais/citologia , Feminino , Humanos , Hidroxietilrutosídeo/farmacologia , Leucócitos Mononucleares/citologia , Masculino , Óxido Nítrico Sintase Tipo III/metabolismoRESUMO
OBJECTIVES: Osteosynthetic closure of the chest after median sternotomy is usually performed with steel wires. We describe, for the first time, a case series in which titanium hooks were implanted from the sternal surface in patients who required secondary or additional stabilization. In comparison to the classic wires, the diameters of the hooks are approximately three times bigger and therefore reduce the risk of cutting through the bones. Additionally, there is no need to dissect retrosternal adhesions, which may reduce the risk of injuring mediastinal tissues. METHODS: The hooks are shaped like fishing hooks and can be inserted parasternally into the intercostal spaces. They can be pulled to the contralateral side of the sternum by the attached wires and then intertwined with a second hook. RESULTS: In 13 patients, the system was used to provide additional stabilization, while in two patients the hooks were implanted for exclusive stabilization of sternal fractures. In all cases but one, the implantation was able to eliminate the sternal problems. No infections, necrosis or bleeding of neighbouring tissues occurred. One patient developed chronic sternal infection, which necessitated explantation of the hooks. CONCLUSIONS: This sternal closure system using titanium hooks inserted parasternally is an effective alternative to conventional techniques and may increase stability of the breastbone and reduce the risk of injury to retrosternal tissues.
Assuntos
Fios Ortopédicos , Procedimentos Ortopédicos/instrumentação , Esternotomia , Titânio , Técnicas de Fechamento de Ferimentos/instrumentação , Humanos , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Desenho de Prótese , Resultado do Tratamento , Técnicas de Fechamento de Ferimentos/efeitos adversosRESUMO
BACKGROUND: Since 2002 MI and stroke, not cancer, are leading causes of death in women. We studied 30-days and 1 year mortality of 3441 patients undergoing coronary artery bypass grafting (CABG) operations in our institution performed either conventionally or off pump (OPCAB). Our objective was to investigate the gender-related mortality in both groups. PATIENTS AND METHODS: Between 2004 and 2008, 3441 patients (733 women, 2708 men) underwent CABG. 252 women and 854 men were operated using OPCAB, 481 women and 1854 men using extracorporeal circulation (ECC). Medical data was prospectively entered and retrospectively reviewed. 30-days and one year mortality rates were analyzed with Kaplan-Meier estimates and Cox proportional hazards models. Linear and logistic regression models were used to test gender differences. RESULTS: a) 30-day mortality using ECC: 5.2% in women vs. 2.5% in men (p = 0.001). One year ECC mortality: 8.7% in women vs. 4.8% in men (p = 0.0008). b) OPCAB: 30-days and 1 year mortality in women measured 1.7%. Mortality in men was 2.1% after 30 days and 3.7% after one year c) gender specific mortality: 30 days mortality in women was 1.7% using OPCAB and 5.2% using ECC (p = 0.002), one year mortality in women was 1.7% using OPCAB vs. 8.7% using ECC (p = 0.0004). In men, 30-days mortality in OPCAB was 2.1%, one year mortality was 3.7%; using ECC early and late mortality was 2.5% and 4.8%. CONCLUSIONS: Female gender is a strong independent predictor and risk factor of increased early and midterm postoperative mortality rates when ECC is used. OPCAB significantly reduces early and midterm postoperative mortality in women and may therefore be proposed as the preferred revascularization technique in female patients.
Assuntos
Ponte de Artéria Coronária/mortalidade , Idoso , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Circulação Extracorpórea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Taxa de SobrevidaRESUMO
The number of percutaneous coronary interventions (PCI) prior to coronary artery bypass grafting (CABG) increased drastically during the last decade. Patients are referred for CABG with more severe coronary pathology, which may influence postoperative outcome. Outcomes of 200 CABG patients, collected consecutively in an observational study, were compared (mean follow-up: 5 years). Group A (n = 100, mean age 63 years, 20 women) had prior PCI before CABG, and group B (n = 100, mean age 66, 20 women) underwent primary CABG. In group A, the mean number of administered stents was 2. Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 54 vs 34 (P = 0.007), distribution of CAD (P < 0.0001), unstable angina: 27 vs 5 (P < 0.0001). For intraoperative data, the total number of established bypasses was 2.43 +/- 1.08 vs 2.08 +/- 1.08 (P = 0.017), with the number of arterial bypass grafts being: 1.26 +/- 0.82 vs 1.07 +/- 0.54 (P = 0.006). Regarding the postoperative course, significant results could be demonstrated for: adrenaline dosage (0.83 vs 0.41 mg/h; [p is not significant (ns)]) administered in 67 group A vs 47 group B patients (P = 0.006), and noradrenaline dosage (0.82 vs 0.87 mg/h; ns) administered in 46 group A vs 63 group B patients (P = 0.023), CK/troponine I (P = 0.002; P < 0.001), postoperative resuscitation (6 vs 0; P = 0.029), intra aortic balloon pump 12 vs 1 (P = 0.003), and 30-day mortality (9% in group A vs 1% in group B; P = 0.018). Clopidogrel was administered in 35% of patients with prior PCI and in 19% of patients without prior PCI (P = 0.016). Patients with prior PCI presented for CABG with more severe CAD. Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI.
Assuntos
Angioplastia Coronária com Balão/estatística & dados numéricos , Ponte de Artéria Coronária/estatística & dados numéricos , Doença das Coronárias/cirurgia , Idoso , Angina Instável/prevenção & controle , Angioplastia Coronária com Balão/mortalidade , Estudos de Casos e Controles , Clopidogrel , Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/mortalidade , Epinefrina/uso terapêutico , Feminino , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/prevenção & controle , Norepinefrina/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Cuidados Pós-Operatórios , Estatísticas não Paramétricas , Stents/estatística & dados numéricos , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Resultado do TratamentoRESUMO
OBJECTIVE: To evaluate the feasibility and outcomes of protocol-driven noninvasive mechanical ventilation in patients with acute respiratory failure (ARF) after cardiac surgery. METHODS: From 2001 to 2004, a total of 2428 cardiac surgery patients admitted to our intensive care unit were observed. After exclusion of patients who received tracheostomy or were discharged while still on mechanical ventilation, 2261 patients with spontaneous breathing were further evaluated for ARF. Patients diagnosed with ARF were treated with intermittent noninvasive mechanical ventilation (NIV) if possible. Risk factors for the development of postoperative ARF as well as outcomes in patients with and without ARF were analyzed. RESULTS: In 2261 spontaneously breathing postoperative cardiac surgical patients after primarily successful extubation, 799 patients (35%) were diagnosed with ARF. Fifty-six patients (7%) did not tolerate NIV treatment. In 743 patients (33%) intermittent NIV was performed. In patients with ARF, ejection fraction was lower, combined cardiac surgical procedures were more frequent, postoperative mechanical ventilation time was longer, and the severity of illness score (SAPS II) was higher (P < .05). The duration of catecholamine support was longer, and the transfusion rate was higher in the NIV group (P < .05); however, mortality did not differ between patients with ARF treated by NIV and patients without ARF. CONCLUSION: Our study demonstrates the feasibility of NIV in patients after cardiac surgery. These results might suggest that NIV should be considered as first-line ventilatory support in ARF after cardiac surgery. A large randomized trial is warranted to confirm these findings.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Respiração Artificial/métodos , Insuficiência Respiratória/terapia , Idoso , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Fatores de Risco , Resultado do TratamentoRESUMO
The HEARTSTRING Proximal Seal System (Guidant Corp, Santa Clara, CA) is used to avoid aortic clamping while the proximal anastomoses are sewn. To protect surgeons from spurting blood while the device is used, we use a see through plastic sheet to cover the area being operated on. This modified technique is applied whenever the system is used and allows the safe use of the device even in high-risk patients with hepatitis or human immunodeficiency virus.
Assuntos
Anastomose Cirúrgica/instrumentação , Aorta Torácica/cirurgia , Perda Sanguínea Cirúrgica/prevenção & controle , Hemostasia Cirúrgica/instrumentação , Ponte de Artéria Coronária/instrumentação , Ponte de Artéria Coronária/métodos , Desenho de Equipamento , Segurança de Equipamentos , Humanos , Plásticos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Severe systemic inflammation (systemic inflammatory response syndrome) associated with cardiac surgery often leads to a worse short-term and long-term outcome. Stress doses of hydrocortisone have been successfully used to improve outcome of CS. The interleukin (IL)-6 to IL-10 ratio is associated with outcome after trauma and major surgery. OBJECTIVE: To evaluate immunologic effects (especially IL-6 to IL-10 ratio) of stress doses of hydrocortisone in a high-risk group of patients after cardiac surgery with cardiopulmonary bypass. DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Cardiovascular intensive care unit of a university hospital. PATIENTS: High-risk patients (n = 36) undergoing CS. INTERVENTION: Stress doses of hydrocortisone or placebo. MAIN OUTCOME MEASURES: IL-6 to IL-10 ratio and other markers of systemic inflammation at predefined time points; short-term clinical outcome. RESULTS: The two study groups did not differ with regard to demographic data. The patients from the hydrocortisone group (n = 19) had significantly lower levels of IL-6 and higher levels of IL-10, resulting in an attenuated change in IL-6/IL-10 ratio (28.7 [6.4/128.7] vs. 292.8 [6.5/534.6] 4 hours after cardiopulmonary bypass; p < 0.001). Patients in the hydrocortisone group had a shorter duration of catecholamine support (1 [1/2] vs. 4 [2/4.5] days; p = 0.02), a shorter length of stay in the intensive care unit (2 [2/3] vs. 6 [4/8] days; p = 0.001), and a lower incidence of postoperative atrial fibrillation (26% vs. 59%; p = 0.04). CONCLUSIONS: Stress doses of hydrocortisone attenuate the evolution of IL-6/IL-10 ratio in patients with systemic inflammatory response syndrome after CS, which seems to be associated with an improved outcome. The immunologic effects of hydrocortisone may thus be both, inhibitory (IL-6) and permissive (IL-10), regarding the immune response.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Mortalidade Hospitalar/tendências , Hidrocortisona/administração & dosagem , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Idoso , Biomarcadores/sangue , Institutos de Cardiologia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Relação Dose-Resposta a Droga , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Injeções Intravenosas , Unidades de Terapia Intensiva , Interleucina-10/sangue , Interleucina-6/sangue , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios , Estudos Prospectivos , Valores de Referência , Medição de Risco , Análise de Sobrevida , Síndrome de Resposta Inflamatória Sistêmica/mortalidade , Resultado do TratamentoRESUMO
For implantable cardioverter defibrillator a 10 J safety margin between the defibrillation threshold (DFT) and the maximum output of the device is intended. In complex cases, the additional placement of a subcutaneous array lead is a common strategy for lowering the DFT. We report the successful use of transvenous coil electrodes as single element subcutaneous array leads in order to lower the DFT.
Assuntos
Fibrilação Atrial/prevenção & controle , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Eletrodos Implantados , Adulto , Idoso , Feminino , Humanos , MasculinoRESUMO
OBJECTIVE: Microwave ablation has been reported as efficient for the surgical treatment of long-standing atrial fibrillation. However, the influence of ablation lesions on long-term results is not known. METHODS: From August of 2000 to November of 2003, 41 patients underwent a left atrial endocardial microwave ablation procedure after a Cox-Maze-like lesion set for long-standing atrial fibrillation concomitant to surgery for valvular or coronary artery disease. Mitral valve surgery alone or combined was performed in 31 cases (75.6%). The mean diameter of the left atrium was 7.19 +/- 1.44 cm. The mean duration of preoperative atrial fibrillation was 4.7 +/- 3.6 years. Patient follow-up was conducted by means of direct clinical examination, electrocardiography, and transthoracic echocardiography. The mean follow-up was 5.37 +/- 0.91 years. RESULTS: Patient follow-up was achieved in 82% of cases (n = 28). Seven patients (17%) died during follow-up. Stroke was the cause of death in 1 patient with persistence of atrial fibrillation. Major complications occurred in 4 (14.3%) of the patients that were related to the persistence of atrial fibrillation. At 5 years follow-up, 39.3% of patients (11/28) were in sinus rhythm. Seventeen patients (60.7%) were in New York Heart Association classes I and II, and 11 patients (39.3%) were in New York Heart Association class III at the time of follow-up. CONCLUSION: In our experience, left atrial endocardial microwave ablation for long-standing atrial fibrillation after a Cox-Maze-like ablation lesion set during surgery for organic heart disease is not a reliable method of achieving long-term conversion to sinus rhythm.
Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Doença da Artéria Coronariana/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Micro-Ondas/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
A 71-year-old woman, who had undergone mitral valve replacement procedure 2 years previously, presented with aortic and mitral prosthetic valve endocarditis. Preoperative examination demonstrated a wire-like structure coursing from the aortic bulb to the right carotid artery. The wire-like structure was removed during the mitral and aortic valve reoperation, and identified as an epicardial pacing wire, which was placed during the patients' first mitral valve operation. We suspect that the contaminated pacing wire migrated via the left atrium and left ventricle into the right carotid artery causing an infective endocarditis of the prosthetic mitral valve and the native aortic valve.
Assuntos
Eletrodos Implantados/efeitos adversos , Endocardite/diagnóstico , Endocardite/etiologia , Migração de Corpo Estranho/diagnóstico , Migração de Corpo Estranho/etiologia , Marca-Passo Artificial/efeitos adversos , Adulto , Feminino , HumanosRESUMO
OBJECTIVE: Fibrin sealants are frequently used in aortocoronary bypass operations. Although they are considered to be clinically safe, we performed a retrospective analysis of our data to examine the possible side effects of Tissucol fibrin sealant, namely the acute thrombosis of grafts and native coronary arteries resulting in severe myocardial damage and patient deaths. METHODS: The data of 2716 patients (2001 male, 715 female) who received an aortocoronary bypass operation from November 1995 to December 1999 were studied retrospectively. Two groups (group 1: received Tissucol, group 2: no sealant used) were compared with respect to an a priori selected set of demographic and clinical variables and with respect to their effect on the outcome using bivariate tabulation. Multiple exploratory assessments of factors possibly related to fatal outcome were done by multiple logistic regression. RESULTS: Nine hundred ninety patients (group 1) received Tissucol, 1726 patients (group 2) did not receive it. Mean patient age was 64+/-9.1 years. Group 1 had a higher risk of death (7.8% vs 2.8%, p<0.001). The peak values of creatine kinase >500 and creatine kinase-myocardial band >50 were higher in group 1 than in group 2, p<0.001. Adjusted odds ratios for the risk of fatal outcome were: 2.01 for the use of Tissucol, 2.71 for patient age >70 years, 2.02 for aortic cross clamp time >90 min, 3.95 for postoperative ventricular fibrillation, 6.35 for postoperative cardiopulmonary resuscitation, 4.55 for postoperative aortocoronary reoperation. CONCLUSION: In our analysis an increased risk of myocardial injury or even death was found in coronary artery bypass grafting patients when Tissucol fibrin sealant was used intraoperatively.
Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Doença das Coronárias/cirurgia , Adesivo Tecidual de Fibrina/efeitos adversos , Adesivos Teciduais/efeitos adversos , Idoso , Feminino , Adesivo Tecidual de Fibrina/administração & dosagem , Seguimentos , Hemostáticos/administração & dosagem , Humanos , Complicações Intraoperatórias/induzido quimicamente , Masculino , Estudos Retrospectivos , Fatores de Risco , Trombina/administração & dosagem , Adesivos Teciduais/administração & dosagem , Resultado do TratamentoRESUMO
Primary pheochromocytomas located outside the adrenal glands account for only 10% of all pheochromocytomas. Mediastinal pheochromocytomas are even rarer and usually represent a therapeutic challenge as they often infiltrate adjacent structures. We report the case of a large primary mediastinal pheochromocytoma in a 65-year-old patient presenting with a sudden angina-like chest pain and dyspnea. Thoracic multislice computed tomography showed an 8 x 5 x 6-cm retrocardiac mass causing compression of both atria and infiltrating the left superior pulmonary vein. The tumor was highly vascularized and presented a blood supply derived from the circumflex artery. The mass was successfully removed by open heart surgery, and the patient was discharged 10 days postoperatively.
Assuntos
Anomalias dos Vasos Coronários/diagnóstico por imagem , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Mediastino/diagnóstico por imagem , Mediastino/cirurgia , Feocromocitoma/diagnóstico por imagem , Feocromocitoma/cirurgia , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Angiografia Coronária , Humanos , Masculino , Resultado do TratamentoRESUMO
OBJECTIVE: We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. DESIGN AND SETTING: Single-center clinical study with a historical control group at an university hospital. PATIENTS: Forty cardiac bypass surgery patients were included prospectively and compared with a control group. INTERVENTIONS: In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m2, cardiac index above 2.5 l/min/m2, and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. RESULTS: In the GDT group duration of catecholamine and vasopressor dependence was shorter (187+/-70 vs. 1458+/-197 min), and fewer vasopressors (0.73+/-0.32 vs. 6.67+/-1.21 mg) and catecholamines (0.01+/-0.01 vs. 0.83+/-0.27mg) were administered. They received more colloids (6918+/-242 vs. 5514+/-171ml). Duration of mechanical ventilation (12.6+/-3.6 vs. 15.4+/4.3 h) and time until achieving status of fit for ICU discharge (25+/-13 vs. 33+/-17h) was shorter in the GDT group. CONCLUSIONS: Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery.