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1.
J Surg Case Rep ; 2022(7): rjac330, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35919691

RESUMO

Hostile vascular disease can pose a challenge for transcatheter aortic valve replacement, for which the preferred access is via a common femoral artery. However, extensive peripheral arterial disease may also preclude traditional points of alternative access in some patients. Herein, we describe two patients in whom successful transcatheter aortic valve replacement was performed via direct innominate artery access.

2.
Intern Med ; 60(4): 517-523, 2021 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-33028765

RESUMO

Objective Aortic stenosis (AS) is common among elderly patients. Since transcatheter aortic valve replacement (TAVR) is a less invasive procedure than surgical aortic valve replacement for symptomatic severe AS, super-elderly patients have tended to undergo TAVR. We retrospectively investigated the post-TAVR outcome in super-elderly patients with severe AS. Methods This analysis included 433 patients who underwent TAVR in the University of Wisconsin Hospital and Clinics from 2012 to 2017. Post-TAVR mortality, complications in-hospital, rehospitalization, the New York Heart Association (NYHA) functional class and echocardiographic parameters were compared between patients <85 years old (n = 290) and ≥85 years old (n = 143). Results The patients ≥85 years old less frequently had a history of coronary artery disease (73.1% vs. 62.2%, p=0.026) and hypertension (87.2% vs. 77.6%, p=0.012) than younger patients. Furthermore, the patients ≥85 years old had moderate-severe mitral regurgitation more frequently (19.3% vs. 28.7%, p=0.037) at baseline than younger patients. There was no significant difference in in-hospital outcomes between the age groups. The 30-day mortality was worse in patients ≥85 years old than in younger ones (0.7% vs. 3.5%, p=0.042). While there was no significant difference in the long-term mortality between the 2 groups, the estimated 1-year mortality from Kaplan-Meier curves were 9.6% in patients <85 years old and 14.9% in patients ≥85 years old. The rate of in-hospital complications, rehospitalization rate, improvement in the NYHA functional class and echocardiographic parameters were comparable between the two groups. Conclusion The outcomes of super-elderly patients after TAVR were acceptable, suggesting that these patients could benefit from TAVR.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
3.
J Cardiovasc Med (Hagerstown) ; 22(6): 486-491, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33229861

RESUMO

AIMS: In paradoxical low-flow low-gradient severe aortic stenosis (PLFLG AS) patients, stroke volume index (SVI) is reduced despite preserved left ventricular ejection fraction (LVEF). Although reduced SVI is already known as a poor prognostic predictor, the outcomes of PLFLG AS patients after transcatheter aortic valve replacement (TAVR) have not been clearly defined. We retrospectively investigated the post-TAVR outcomes of PLFLG AS patients in comparison with normal-flow high-gradient aortic stenosis (NFHG AS) patients. METHODS: The current observational study included 245 patients with NFHG AS (mean transaortic pressure gradient ≥40 mmHg and LVEF ≥ 50%) and 48 patients with PLFLG AS (mean transaortic pressure gradient <40 mmHg, LVEF ≥ 50% and SVI < 35 ml/m2). The endpoints were all-cause mortality, hospitalization for valve-related symptoms or worsening congestive heart failure and New York Heart Association functional class III or IV. RESULTS: PLFLG AS patients had a significantly higher proportion with a history of atrial fibrillation/flutter as compared with NFHG AS patients. All-cause mortality of PLFLG AS patients was worse than that of NFHG AS patients (P = 0.047). Hospitalization for valve-related symptoms or worsening congestive heart failure was more frequent in PLFLG AS patients than in NFHG AS patients (P = 0.041). New York Heart Association functional class III-IV after TAVR was more frequently observed in PLFLG AS patients (P = 0.019). CONCLUSION: The outcomes of PLFLG AS patients were worse than those of NFHG AS patients in this study. Preexisting atrial fibrillation/flutter was frequent in PLFLG AS patients, and may affect their post-TAVR outcomes. Therefore, closer post-TAVR follow-up should be considered for these patients.


Assuntos
Estenose da Valva Aórtica , Valva Aórtica , Insuficiência Cardíaca , Hemodinâmica/fisiologia , Substituição da Valva Aórtica Transcateter , Idoso , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/cirurgia , Progressão da Doença , Ecocardiografia Doppler/métodos , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Readmissão do Paciente/estatística & dados numéricos , Período Pós-Operatório , Prognóstico , Índice de Gravidade de Doença , Volume Sistólico , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Estados Unidos/epidemiologia , Função Ventricular Esquerda
4.
Catheter Cardiovasc Interv ; 96(7): E723-E734, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32243048

RESUMO

OBJECTIVE: To evaluate the impact of increased pulmonary artery systolic pressure (PASP) on outcomes after transcatheter aortic valve replacement (TAVR). METHODS: A total of 242 patients who underwent TAVR were retrospectively reviewed. Transthoracic echocardiography estimated PASP. The cohorts were divided into three groups according to the numerical change of PASP; Increased (post-TAVR PASP at 1 month minus pre-TAVR PASP, ≥ + 5 mmHg; n = 52), No change (-5 to +5 mmHg; n = 86) and Decreased (≤ -5 mmHg; n = 104). Patient demographics and clinical outcomes until 1 year were evaluated. Logistic regression model was used for multivariate risk analysis. RESULTS: At 1 year, the Increased group showed higher mortality (21 ± 6%) than the No change group (5 ± 2%) (hazard ratio [HR]: 4.8, 95% confidence interval [CI]: 1.7-13.5; p < .01) and the Decreased group (8 ± 3%) (HR: 2.8, 95% CI: 1.1-6.7; p = .02). Rehospitalization rate for valve-related or heart failure was also higher in the Increased group (21 ± 6%) than the No change group (10 ± 3%) (HR: 2.4, 95% CI: 1.1-6.0; p = .04). Predictors of PASP deterioration were hypertension (odds ratio [OR]: 3.9, 95% CI: 1.1-13.8; p = .04) and left ventricular end-diastolic diameter >50 mm (OR: 2.2, 95% CI: 1.1-4.6; p = .04), and the increased PASP remained an independent predictor of 1-year all-cause mortality (HR; 2.7, 95% CI: 1.0-6.8; p = .04). CONCLUSIONS: Regardless of the baseline PASP, patients with increased PASP at 1 month after successful TAVR were at higher risk of mortality and rehospitalization within 1 year. Strict medical management should be considered for patients who showed dilated left ventricle preoperatively.


Assuntos
Estenose da Valva Aórtica/cirurgia , Pressão Arterial , Hipertensão Arterial Pulmonar/fisiopatologia , Artéria Pulmonar/fisiopatologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Hipertensão Arterial Pulmonar/diagnóstico por imagem , Artéria Pulmonar/diagnóstico por imagem , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
6.
J Card Surg ; 34(6): 503-505, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31021012

RESUMO

The anomalous left circumflex artery can be a risk for coronary stenosis or obstruction during transcatheter aortic valve replacement; however, the best procedural management has not been clarified. We describe three patients with severe aortic valve stenosis as well as anomalous left circumflex artery. In the first patient, a coronary guidewire with balloon was placed before deploying a SAPIEN 3 transcatheter heart valve, as protection from the coronary occlusion or stenosis. For the second and third patients, no coronary protection was used. All procedures were completed safely and no complications were detected at one-year follow-up.


Assuntos
Estenose da Valva Aórtica/cirurgia , Anomalias dos Vasos Coronários/complicações , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Oclusão Coronária/etiologia , Oclusão Coronária/prevenção & controle , Estenose Coronária/etiologia , Estenose Coronária/prevenção & controle , Seguimentos , Próteses Valvulares Cardíacas , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
7.
J Thorac Dis ; 10(7): 4042-4051, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30174847

RESUMO

BACKGROUND: Mixed aortic valve disease (MAVD) is associated with a poorer natural history compared with isolated lesions. However, clinical and echocardiographic outcomes for aortic valve replacement (AVR) in mixed disease are less well understood. METHODS: Retrospective review of AVRs (n=1,011) from 2000-2016. Isolated AVR, AVR + coronary bypass, and AVR + limited ascending aortic replacement were included. Predominant aortic stenosis (AS) group was stratified into group 1 (n=660) with concomitant mild or less aortic insufficiency (AI), and group 2 (n=197) with accompanying moderate or greater AI. Predominant AI group was stratified using the same schema for concomitant AS into groups 3 (n=143) and 4 (n=53). Median follow-up was 3.1 and 4.4 years respectively for AS and AI groups. RESULTS: For the predominant AS group (n=857) preoperatively, group 2 had a larger preoperative left ventricular end diastolic diameter (LVESD) (51.0±8.4 vs. 48.6±7.2, P=0.02) and lower preoperative left ventricular ejection fraction (LVEF) (57.6% vs. 60.2%, P=0.043). No differences in left ventricular (LV) dimensions, LV or right ventricular (RV) function was evident at follow up (P>0.05). After propensity matching for age, operation, and comorbidities, there was no difference in survival (P=0.19). After propensity matching for the predominant AI group (n=196), survival was lower for group 4 compared to 3 (P=0.02). There were no differences in LV dimensions, LV or RV function preoperatively or on follow-up (P>0.05). CONCLUSIONS: Predominant AS associated with higher AI grades had larger LV dimensions and worse LV function preoperatively. These differences resolve after AVR with equivalent survival. However, predominant AI with more severe AS had reduced survival despite AVR.

8.
Eur J Radiol ; 105: 209-215, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30017282

RESUMO

OBJECTIVES: To investigate intra- and inter-observer repeatability of aortic annulus CT measurements for transcatheter aortic valve replacement (TAVR) by readers with different levels of experience and evaluate the impact of different multi-reader paradigms to improve prosthesis sizing. METHODS: 82 TAVR screening CTAs were evaluated twice by three raters with six (R1 = radiologist), three (R2 = 3D-laboratory technician) or zero (R3 = medical student) years of experience. Results were translated into hypothetical TAVR size recommendations. Intra- and inter-observer repeatability between single readers and three different multi-reader paradigms ([A]: two readers, [B]: three readers, or [C]: two readers + an optional third reader) were evaluated. RESULTS: Intra-observer variability did not differ significantly (range: 50.1-67.8mm2). However, we found significant differences in mean inter-observer variance (p = 0.001). Multi-reader paradigms led to significantly increased precision (lower variability) for scenarios [B] and [C] (p = 0.03, p < 0.05). Compared to single readers, all multi-reader strategies clearly lowered the rate of discrepant device size categorization between repeated measurements (22-26% to 5-10%). CONCLUSIONS: Aortic annulus CT measurements for TAVR are highly reproducible. Multi-reader strategies provide higher precision than evaluations from single readers with different levels of experience and could effectively be implemented with two readers and an optional third reader (Paradigm C) in a clinical setting.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Desenho de Prótese , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Interpretação de Imagem Radiográfica Assistida por Computador , Reprodutibilidade dos Testes , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
9.
Ann Thorac Surg ; 105(3): 757-762, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29174777

RESUMO

BACKGROUND: Cardiovascular disease is a cause of morbidity and mortality in organ transplant recipients. Cardiac surgery after organ transplantation is not uncommon in this population. We evaluated 30-day outcomes and long-term survival of abdominal transplant recipients undergoing cardiac surgery at our institution. METHODS: In all, 138 patients with previous kidney, kidney-pancreas, and liver transplants underwent cardiac surgery from 2000 to 2016. Propensity score (ratio 1:3) matched 115 abdominal transplant with 345 patients undergoing cardiac surgery without a history of abdominal transplant. They were matched for type and year of cardiac surgery, age, sex, body mass index, history of diabetes mellitus, and creatinine level before cardiac surgery. RESULTS: Median time from abdominal transplant to cardiac surgery was 7 years (interquartile range, 3 to 12 years). Perioperative variables, including surgery and cardiopulmonary bypass time, aortic cross-clamp and intubation time, and intensive care unit stay did not differ between the groups. Hospital length of stay and rate of 30-day hospital readmissions did not differ between the groups. Patients with abdominal transplants had more strokes (4% versus 0.6%; p = 0.005) within 30 days after surgery. There were no differences in renal failure, bleeding, site infections, atrial fibrillation, and pneumonia between the groups. Five patients (4%) died within 30 days after surgery in the abdominal transplant group (4 kidneys, 1 liver, 0 kidney-pancreas), and 7 patients (2%) died in the nontransplanted group (p = 0.24). CONCLUSIONS: Previous history of abdominal transplant is associated with an increased 30-day incidence of stroke after cardiac surgery. Abdominal transplant does not affect 30-day mortality after cardiac surgery, whereas long-term survival is significantly reduced. Regular patient follow-up and prevention and early treatment of postoperative complications are key to patient survival.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Doenças Cardiovasculares/cirurgia , Transplante de Órgãos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
10.
Asian Cardiovasc Thorac Ann ; 25(9): 586-593, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29153000

RESUMO

Background We aimed to examine the efficacy of surgical revascularization with respect to improvement in ventricular function and survival in patients with ischemic cardiomyopathy and poor left ventricular function. Methods We retrospectively analyzed the data of 429 patients (median age 64.6 years, 81.1% male) with ejection fractions <40% undergoing isolated primary coronary artery bypass grafting from 2000 to 2016. Techniques included on-pump cardioplegic arrest ( n = 312), off-pump ( n = 75), and on-pump beating heart ( n = 42). Propensity matching was performed to compare the cardioplegic arrest group ( n = 114) with the combined off-pump and beating heart groups ( n = 114). Results Postoperatively, ejection fraction increased by 10.1% ± 13.1% (from 31.4% ± 7.1% to 41.6% ± 13.6%; p < 0.001) and mitral regurgitation grade improved ( p < 0.001) but right ventricular function on echocardiographic assessment worsened over time ( p = 0.04). No difference in ejection fraction improvement was seen in the time periods <1 (9.8% ± 11.2%), 1-5 (11.6% ± 14.5%), and >5 (8.8% ± 14.2%) years ( p = 0.442). Following propensity matching, there was no significant difference between the combined off-pump/beating heart and cardioplegic arrest groups with respect to survival or postoperative complications. Conclusions Patients with moderate to severe left ventricular dysfunction experience long-term improvement in left ventricular ejection fraction after coronary artery bypass. However, right ventricular function often continues to decline, contributing to persistent or worsening heart failure symptoms and late mortality. No difference in survival was seen between the 2 techniques.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Idoso , Ponte Cardiopulmonar , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Feminino , Parada Cardíaca Induzida , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/fisiopatologia , Função Ventricular Direita
11.
Innovations (Phila) ; 12(3): 221-223, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28549025

RESUMO

Transcatheter aortic valve replacement is a less invasive alternative for high-risk patients. However, valve embolization is a rare but dreaded complication. We report the successful off-pump retrieval of an embolized valve after transfemoral transcatheter aortic valve replacement through a left anterior thoracotomy. We maintained the embolized valve on the guidewire and snared it using a transapical approach. We then deployed a valve in an adequate position to ensure hemodynamic stability before transapical removal of the embolized valve. Transapical exteriorization of the femoral guidewire offers additional support, particularly in patients with a horizontal aortic annulus.


Assuntos
Valva Aórtica/cirurgia , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Remoção de Dispositivo/métodos , Embolia/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade
12.
Aorta (Stamford) ; 5(3): 71-79, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29675439

RESUMO

BACKGROUND: Preoperative coronary angiography is often not performed in acute Type A dissection. We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair. METHODS: From 2000 to 2015, there were 154 acute Type A dissection repairs and 457 elective proximal aortic aneurysm repairs. We performed a retrospective review to evaluate preoperative coronary disease and postoperative coronary interventions such as percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG). RESULTS: A total of 31 (20%) dissection patients and 123 (27%) elective surgery patients had preoperative evidence of coronary artery disease (p = 0.094). All elective surgery patients but only six (4%) dissection patients had preoperative coronary catheterization. More CABGs were performed in the elective surgery group (19%) than in the dissection group (3%, p < 0.001). There were no differences in the incidence of prior PCI, CABG, or myocardial infarction between groups. Following dissection repair, four patients required coronary interventions. Of these, two (1.3%) experienced chest pain and underwent PCI at 4.7 and 4.3 months postoperatively, respectively, and another two experienced symptoms and required PCI at 5 and 7 years, respectively. The 30-day and 14-year mortality rates after dissection repair were 13% and 24%, respectively. Although the dissection group had poorer survival than the elective surgery group (p < 0.001), there was no difference in conditional survival after aortic-related deaths over the first year were censored (p = 0.104). CONCLUSIONS: Given the low incidence of missed significant coronary disease (1.3%), it is reasonable to perform Type A dissection repair without coronary angiography.

13.
Ann Thorac Surg ; 103(5): 1460-1466, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-27863732

RESUMO

BACKGROUND: This study investigates the efficacy of aortic valve (AV) resuspension with preservation of the native aortic root in maintaining AV competence during type A dissection repair. METHODS: A total of 154 acute type A dissection repairs were performed from January 2000 to July 2015. AV resuspension was performed in 120 patients to address AV insufficiency (AI). Survival data were derived from 120 patients who had AV resuspensions and all 154 acute type A dissection repairs. RESULTS: Of the 70 patients who presented initially with moderate-to-severe AI, 43 underwent AV resuspension. Echocardiographic data for analysis were available in 40 of these 43 patients. In the group with moderate-to-severe AI at presentation, AV resuspension was able to achieve mild or less AI in 38 of 40 patients (95%) and trivial or no AI in 29 of 40 patients (73%) after weaning from cardiopulmonary bypass. The presence of moderate-to-severe preoperative AI did not predict the ability to achieve trivial or no AI with resuspension immediately after coming off cardiopulmonary bypass (p = 0.3) or on subsequent follow-up (p = 0.8). Mean echocardiographic follow-up for AV resuspension was 1.21 ± 2.57 years. Three patients who underwent AV resuspension required AV reoperation at follow-up. There was no survival difference between patients who did or did not have AV resuspension (p = 0.3). CONCLUSIONS: AV resuspension is able to improve valve competency with good outcomes even in patients with moderate or severe AI at presentation. Overall long-term survival is unchanged compared with other operative strategies for the AV.


Assuntos
Aneurisma da Aorta Torácica/fisiopatologia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/fisiopatologia , Dissecção Aórtica/cirurgia , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Doença da Válvula Aórtica Bicúspide , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Fatores de Risco , Taxa de Sobrevida , Tomografia Computadorizada por Raios X , Resultado do Tratamento
14.
Surgery ; 161(5): 1273-1278, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-27876282

RESUMO

BACKGROUND: Amiodarone frequently is used in patients with heart failure. Concerns still exist about possible complications related to its lingering effect during and after heart transplantation. METHODS: We selected all consecutive patients who received a heart transplant at our institution between January 2004 and December 2015 (n = 220) and compared the peri- and postoperative outcomes of patients who were taking amiodarone for at least 120 days before heart transplant (n = 127) with patients who did not take amiodarone prior to heart transplant (n = 93). RESULTS: Compared with patients with no amiodarone use prior to transplant, those who had used amiodarone were similar in age, body mass index, sex, cause of cardiomyopathy, prevalence of diabetes, hypertension, presence of defibrillator, and had similar donor ischemic times during transplant (all P > .05). Median operative time, aortic cross clamp time, mechanical ventilation and median hospital duration of stay did not differ between the 2 groups (P > .05). Patients exposed to amiodarone had fewer cellular rejections (5% vs 20%; P = .001) but more primary graft dysfunction (4% vs 0%; P = .025) and post-transplant pneumonia (P = .047) compared with patients not taking amiodarone prior to transplant. Both groups had similar rate of atrial fibrillation, 30-day readmission, and 30-day mortality (P > .05). Even though 1-year survival was not affected by amiodarone use (P = .51), long-term (5-year) survival was significantly less in patients exposed to amiodarone (P = .03). CONCLUSION: Amiodarone use did not affect the incidence of atrial fibrillation nor 30-day and 1-year survival post-transplantation. Nevertheless, post-transplant pulmonary complications were significantly greater and 5-year survival was less among patients treated with amiodarone prior to transplant.


Assuntos
Amiodarona/uso terapêutico , Antiarrítmicos/uso terapêutico , Insuficiência Cardíaca/terapia , Transplante de Coração , Adulto , Idoso , Estudos de Coortes , Esquema de Medicação , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios , Taxa de Sobrevida , Resultado do Tratamento
15.
Sarcoidosis Vasc Diffuse Lung Dis ; 33(3): 235-241, 2016 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-27758988

RESUMO

BACKGROUND: Survival for patients with idiopathic pulmonary fibrosis (IPF) and high lung allocation score (LAS) values may be significantly reduced in comparison to those with lower LAS values. OBJECTIVES: To evaluate outcomes for high-risk IPF patients as defined by LAS values ≥46 (N=42) versus recipients with LAS values <46 (N=89). METHODS: We retrospectively reviewed records of 131 consecutive patients with IPF who received lung transplants at our institution between 1999 and 2013. RESULTS: The mean LAS was significantly higher (59.5, interquartile range 43.9-75.9 vs. 39.3, interquartile range 37.7-44.3; p<0.01) for the high-risk cohort. The higher LAS cohort had significantly lower percent predicted forced vital capacity (FVC) versus recipients with LAS <46 (41.3±14.1% vs. 53.2±16.2%; p<0.01) and required more supplemental oxygen (7±5 vs. 4±2 L/min, p<0.01) prior to transplant versus recipients with LAS <46. Although the incidence of early post-LTX pulmonary complications was increased for the higher LAS group versus recipients with LAS <46, 30-day mortality and actuarial survival did not differ between the two cohorts. CONCLUSIONS: Although lung transplantation in patients with IPF and high LAS values is associated with increased risk of early post-transplant complications, long-term post-transplant survival for our high-LAS cohort was equivalent to that for the lower LAS recipients.


Assuntos
Fibrose Pulmonar Idiopática/cirurgia , Transplante de Pulmão , Pulmão/cirurgia , Idoso , Feminino , Humanos , Fibrose Pulmonar Idiopática/diagnóstico , Fibrose Pulmonar Idiopática/mortalidade , Fibrose Pulmonar Idiopática/fisiopatologia , Estimativa de Kaplan-Meier , Pulmão/fisiopatologia , Transplante de Pulmão/efeitos adversos , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Oxigenoterapia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Capacidade Vital , Wisconsin
16.
Thorax ; 71(5): 478-80, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-26621135

RESUMO

Advanced lung disease (ALD) that requires lung transplantation (LTX) is frequently associated with pulmonary hypertension (PH). Whether the presence of PH significantly affects the outcomes following single-lung transplantation (SLT) remains controversial. Therefore, we retrospectively examined the outcomes of 279 consecutive SLT recipients transplanted at our centre, and the patients were split into four groups based on their mean pulmonary artery pressure values. Outcomes, including long-term survival and primary graft dysfunction, did not differ significantly for patients with versus without PH, even when PH was severe. We suggest that SLT can be performed safely in patients with ALD-associated PH.


Assuntos
Hipertensão Pulmonar/cirurgia , Transplante de Pulmão , Rejeição de Enxerto/prevenção & controle , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/fisiopatologia , Estimativa de Kaplan-Meier , Pneumopatias/cirurgia , Transplante de Pulmão/métodos , Transplante de Pulmão/mortalidade , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento
17.
Int J Surg ; 20: 135-9, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26118604

RESUMO

INTRODUCTION: Patients with postoperative ileus (POI), a common post-surgical event, experience intense discomfort. Various treatments targeting prevention of POI have shown to have an unpredictable effect. We introduced a novel postoperative bowel management protocol in patients implanted with a continuous-flow left ventricular assist device (CF-LVAD). The effect of this protocol on POI was evaluated. METHODS: Patients receiving an old bowel management protocol (OBMP; 01/2007-03/2009) were compared with those receiving a new bowel management protocol (NBMP; 04/2009-12/2013). The OBMP consisted of advancing the diet as tolerated, bisacodyl suppositories and enemas with the goal of a bowel movement (BM) every 3 days. The NBMP consisted of clear liquids until first BM is achieved, then full liquids until the second BM, then advancing to goal diet. Docusate is given on postoperative day (POD) 1 and bisacodyl PR on POD2 with enemas if ileus develops. Enemas are added POD3 if no BM has occurred. Polyethylene glycol is considered daily for patients prone to constipation. The goal is a BM every 2 days. Patients were made nil per os (NPO) with any signs of ileus. RESULTS: One hundred eighteen patients were implanted with CF-LVADs during the study period. The incidence of ileus significantly decreased from 19% in the OBMP group to 4% percent in the NBMP group (p < 0.05). In-hospital mortality was not different between the two groups (6% vs. 2% p = 0.35). CONCLUSIONS: A novel postoperative bowel management protocol successfully decreased the incidence of POI following CF-LVAD implant surgery at our institution.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Coração Auxiliar , Íleus/prevenção & controle , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Implantação de Prótese , Adulto , Idoso , Feminino , Humanos , Íleus/epidemiologia , Íleus/etiologia , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
18.
Ann Thorac Surg ; 100(3): 884-9, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26095106

RESUMO

BACKGROUND: We investigated the incidence and causes of unplanned hospital readmissions after continuous-flow (CF) left ventricular assist device (LVAD) implantation. We also analyzed the impact of unplanned readmissions on post-CF-LVAD survival and the costs associated with each cause of readmission. METHODS: We retrospectively reviewed 126 patients who underwent implantation with a CF-LVAD from January 2007 to December 2013. The timing of readmissions, hospital length of stay, and total length of device support were evaluated. Patients were followed up while receiving support, until transplantation, or until death. Direct hospital costs associated with each readmission were analyzed. RESULTS: In all, 103 patients underwent implantation for bridge to transplantation and 19 patients for destination therapy; 68 patients were readmitted 156 times (2.2 times/patient) as of the end of follow-up. The median follow-up period was 11 months. While receiving device support, patients spent 93% of their time out of the hospital. The causes of readmission included gastrointestinal bleeding (19%), driveline infection (13%), and stroke (8%). The median time to first readmission was 35 days. Thirty (44%) patients were readmitted within 30 days after discharge. The median direct hospital cost of a single readmission was $7,546. Device malfunction and arrhythmias were the most costly causes of readmission. There was no significant difference in long-term survival between readmitted patients and those who were not readmitted. CONCLUSIONS: Gastrointestinal bleeding and CF-LVAD-related infections were the leading causes of readmission. Patients with a CF-LVAD spent 93% of their time out of hospital after implantation, and readmissions did not have a negative impact on long-term survival. New approaches to minimize these adverse events will continue to improve the efficacy and decrease the cost of CF-LVAD therapy.


Assuntos
Coração Auxiliar , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Implantação de Prótese , Custos e Análise de Custo , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Taxa de Sobrevida
19.
Interact Cardiovasc Thorac Surg ; 20(6): 743-8, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25770085

RESUMO

OBJECTIVES: The goal of our study was to analyse the impact of age on outcomes in patients who underwent continuous-flow left ventricular assist device (CF-LVAD) placement at our institution. METHODS: One hundred and twenty-eight patients were implanted with a CF-LVAD between January 2008 and June 2014. Eighty-five patients were implanted with the device as a bridge to transplant (BTT); the remaining (n = 43) were on destination therapy (DT). Each group was divided into patients <65 years old and ≥ 65 years old at device implantation. Patients were followed up for at least 24 months or until transplant or death. RESULTS: Eighty-five patients (66%) received a CF-LVAD as BTT. Patients ≥ 65 years old (n = 8) had a lower preoperative cardiac index and prothrombin time-international normalized ratio (P = 0.009), and a longer stay in the intensive care unit (P = 0.008). Adverse events including infections, re-exploration for bleeding, ischaemic and haemorrhagic stroke, renal failure and right heart failure were comparable in both age groups. Eighty-two percent (n = 63) of the young patients and 75% (n = 6) of the older patients, who were on LVAD as BTT, underwent heart transplant within the first 24 months of LVAD implantation. Overall survival at 3, 6, 12 and 24 months were 95, 95, 77 and 70%, respectively, post-CF-LVAD implantation as BTT for the younger group and 73% for the older group at 3, 6 and 12 months (P = 0.35). Forty-three patients (34%) received a CF-LVAD as DT. Patients ≥ 65 years old (n = 14) on DT had a higher incidence of peripheral vascular disease (P = 0.048), higher serum sodium (P = 0.004) and serum creatinine values (P = 0.002), preoperatively. There were more strokes in the older patients post-LAVD implantation (14 vs 0%; P = 0.048). Overall survival at 3, 6, 12 and 24 months were 85, 79, 75 and 62%, respectively, for the younger group and 93, 77, 67 and 34% for the older group, respectively (P = 0.26). CONCLUSIONS: This study demonstrates that LVAD therapy can be used in the older patients with acceptable mortality and morbidity, and age alone should not be used as the sole criterion for exclusion from LVAD implantation.


Assuntos
Insuficiência Cardíaca/terapia , Coração Auxiliar , Função Ventricular Esquerda , Fatores Etários , Idoso , Comorbidade , Progressão da Doença , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Modelos de Riscos Proporcionais , Desenho de Prótese , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
20.
J Thorac Cardiovasc Surg ; 148(3): 1123-30; discussion 1130, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25129607

RESUMO

OBJECTIVE: To investigate the resuscitation potential and contractile function in adult human donation after cardiac death (DCD) hearts by ex vivo perfusion. METHODS: With institutional review board approval and under the DCD protocol at the University of Wisconsin (UW) Organ Procurement Organization, 5 brain dead (BD) and 5 DCD donor hearts were evaluated. All BD hearts were declined for clinical transplantation because of coronary artery disease, advanced age, or social history. All hearts were preserved by flushing and cold storage with UW solution. By using our ex vivo perfusion system, the left ventricular end systolic pressure-volume relationship (LV-ESPVR) was assessed for 2 hours of oxygenated blood reperfusion. RESULTS: All BD (n = 5) and 4 DCD hearts were successfully resuscitated. One DCD heart was unable to be resuscitated due to prolonged warm ischemic time (WIT; 174 minutes). Mean WIT for resuscitated DCD hearts (from extubation to flushing with cold UW solution) was 34 ± 3 minutes (range, 26 to 40 minutes); mean cold ischemic time for BD donors was 211 ± 31 minutes compared with 177 ± 64 minutes for DCD donors. The calculated LV-ESPVRs for BD hearts after 1 and 2 hours of reperfusion were 6.9 ± 0.7 and 5.7 ± 1.0 mm Hg/mL, respectively; LV-ESPVRs for DCD hearts after 1 and 2 hours of reperfusion were 5.6 ± 1.5 (P = .45) and 3.0 ± 0.7 mm Hg/mL (P = .07), respectively. CONCLUSIONS: We successfully resuscitated and measured ex vivo cardiac function in human DCD and BD donor hearts. Resuscitation potential in DCD hearts was achieved when the WIT was less than 40 minutes. Contractile performance in DCD hearts tended to be lower compared with BD hearts. Further investigation with longer reperfusion periods seems warranted.


Assuntos
Morte Encefálica , Cardiopatias/mortalidade , Transplante de Coração , Soluções para Preservação de Órgãos/farmacologia , Perfusão/métodos , Doadores de Tecidos/provisão & distribuição , Coleta de Tecidos e Órgãos/métodos , Adenosina/efeitos adversos , Adenosina/farmacologia , Adulto , Alopurinol/efeitos adversos , Alopurinol/farmacologia , Isquemia Fria , Feminino , Glutationa/efeitos adversos , Glutationa/farmacologia , Humanos , Insulina/efeitos adversos , Insulina/farmacologia , Masculino , Pessoa de Meia-Idade , Contração Miocárdica , Soluções para Preservação de Órgãos/efeitos adversos , Perfusão/efeitos adversos , Rafinose/efeitos adversos , Rafinose/farmacologia , Fatores de Tempo , Coleta de Tecidos e Órgãos/efeitos adversos , Função Ventricular Esquerda , Pressão Ventricular , Isquemia Quente , Wisconsin
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