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1.
Am J Transplant ; 9(2): 389-96, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19120076

RESUMO

Primary graft dysfunction (PGD) after lung transplantation causes significant morbidity and mortality. We aimed to determine the role of cytokines and chemokines in PGD. This is a multicenter case-control study of PGD in humans. A Luminex analysis was performed to determine plasma levels of 25 chemokines and cytokines before and at 6, 24, 48 and 72 h following allograft reperfusion in 25 cases (grade 3 PGD) and 25 controls (grade 0 PGD). Biomarker profiles were evaluated using a multivariable logistic regression and generalized estimating equations. PGD cases had higher levels of monocyte chemotactic protein-1 (MCP-1)/chemokine CC motif ligand 2 (CCL2) and interferon (IFN)-inducible protein (IP-10)/chemokine CXC motif ligand 10 (CXCL10) (both p < 0.05), suggesting recruitment of monocytes and effector T cells in PGD. In addition, PGD cases had lower levels of interleukin (IL-13) (p = 0.05) and higher levels of IL-2R (p = 0.05). Proinflammatory cytokines, including tumor necrosis factor (TNF)-alpha, and IFN-gamma decreased to very low levels after transplant in both PGD cases and controls, exhibiting no differences between the two groups. These findings were independent of clinical variables including diagnosis in multivariable analyses, but may be affected by cardiopulmonary bypass. Profound injury in clinical PGD is distinguished by the upregulation of selected chemokine pathways, which may useful for the prediction or early detection of PGD if confirmed in future studies.


Assuntos
Biomarcadores/sangue , Quimiocinas/sangue , Citocinas/sangue , Transplante de Pulmão/efeitos adversos , Disfunção Primária do Enxerto/etiologia , Adulto , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Rejeição de Enxerto , Humanos , Mediadores da Inflamação , Masculino , Pessoa de Meia-Idade , Disfunção Primária do Enxerto/sangue , Estudos Prospectivos , Adulto Jovem
2.
Am J Transplant ; 6(9): 2191-201, 2006 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16827792

RESUMO

A fundamental goal of lung transplantation is the regaining of functional capacity, yet little is known about what factors are associated with the achievement of this goal. The aim of this study is to test the association of clinical risk factors with functional status 1 year following lung transplantation. We conducted a cohort study of 321 lung transplants and assessed functionality by the distance achieved during a standard 6-min walk test (6MWT). Preoperative recipient risk factors were evaluated for association with functional status and adjusted for confounding using multivariable linear regression models. In these multivariable analyses, recipient female gender (p<0.001), recipient pretransplant body mass index (BMI) of greater than 27 kg/m2 (p=0.017) and shorter pretransplant 6MWT distances (p=0.006) were independently associated with shorter distances achieved during 6MWT after lung transplant, while cystic fibrosis (CF) (p=0.003), and bilateral lung transplant (p=0.014) were independently associated with longer distances achieved. Approximately 51% of the variance in 6MWT distance was explained by these risk factors in the linear regression models (R2=0.51). These findings may have implications in patient counseling, selection, procedure choice, and may lead to interventions aimed at improving the functional outcomes of lung transplantation.


Assuntos
Tolerância ao Exercício , Pneumopatias/fisiopatologia , Transplante de Pulmão , Pulmão/fisiopatologia , Adolescente , Adulto , Estudos de Coortes , Teste de Esforço , Feminino , Humanos , Pneumopatias/sangue , Pneumopatias/terapia , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Valor Preditivo dos Testes , Fatores de Risco
3.
J Thorac Cardiovasc Surg ; 131(5): 1087-94, 2006 May.
Artigo em Inglês | MEDLINE | ID: mdl-16678594

RESUMO

OBJECTIVE: Six years ago an endovascular program for repair of descending thoracic aneurysms was established at the University of Pennsylvania. We report on the hypothesis that results are improving with new stent design iterations and describe our experience and lessons learned. METHODS: From April 1999 to March 2005, 99 patients with descending thoracic aneurysms underwent repair with a first or second-generation commercially produced endograft; 24 patients had an early-generation device, and 75 patients had a late-generation device. Each patient was enrolled as part of 3 distinct Phase I or Phase II Food and Drug Administration-approved clinical trials in accordance with strict inclusion and exclusion criteria. RESULTS: Mean age was 73.1 years. Symptomatic aneurysms accounted for 42% of the cohort. Mean aneurysm size was 63.7 mm (range: 30-105 mm). Twenty percent of the patients underwent a subclavian carotid transposition or bypass preoperatively to obtain an adequate proximal landing zone. No procedures had to be aborted. In-hospital or 30-day mortality was 5.0%. The incidence of permanent spinal ischemia was 2%. Perioperative vascular complications requiring interposition graft, stent repair, or patch angioplasty occurred in 27% and seemed to be less frequent in the late-generation cohort than the early-generation cohort (22.7% vs 41.7%, respectively, P = .069). At the 30-day follow-up, 23 endoleaks were detected in 22 patients (14.7% in late-generation cohort vs 45.8% in early-generation cohort, P = .001). During the follow-up period, 3 new endoleaks were detected, 3 patients died of aortic rupture, and 10 patients underwent aneurysm-related reintervention. Kaplan-Meier estimated 1, 3, and 5-year survival was 84.5%, 70.5%, and 52.4%, respectively. Freedom from aneurysm-related event, defined as freedom from endoleak, aortic rupture, dissection, or any reintervention on the aorta, was 73%, 69%, and 64% at 1, 3, and 5 years, respectively. CONCLUSION: Thoracic aortic stent grafting is a safe procedure in selected patients with the added benefit of a low incidence of paraplegia. However, there is an incidence of late complications and reinterventions. This risk requires further quantification and must be balanced against the benefits of a minimally invasive approach with low perioperative morbidity and mortality. Results are improving as technology evolves and our level of experience increases. Radiologic follow-up is mandatory.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Idoso , Ensaios Clínicos como Assunto , Desenho de Equipamento , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Stents
4.
J Heart Lung Transplant ; 20(10): 1044-53, 2001 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11595559

RESUMO

BACKGROUND: Malignancy is a well-recognized complication of solid-organ transplantation. Although a variety of malignancies have been reported in lung transplant recipients, a paucity of information exists regarding the incidence and clinical course of bronchogenic carcinoma in this patient population. METHODS: We conducted a retrospective cohort study of our lung transplant experience at the University of Pennsylvania. RESULTS: We identified 6 patients with bronchogenic carcinoma detected at the time of, or developing after, transplantation. The incidence of bronchogenic carcinoma was 2.4%. All patients with lung cancer had a history of smoking, with an average of 79 +/- 39 pack-years. A total of 5 patients had chronic obstructive pulmonary disease, and 1 had idiopathic pulmonary fibrosis. Lung cancers were all of non-small-cell histology and first developed in native lungs. Three patients had bronchogenic carcinoma at the time of surgery. The remaining 3 patients were diagnosed between 280 and 1,982 days post-transplantation. Of the 6 patients, 4 presented with a rapid course suggestive of an infectious process. The 1- and 2-year survival rates after diagnosis were 33% and 17%, respectively. CONCLUSION: Lung transplant recipients are at risk for harboring or developing bronchogenic carcinoma in their native lungs. Rapid progression to locally advanced or metastatic disease commonly occurs, at times mimicking an infection. Bronchogenic carcinoma should be considered in the differential diagnosis of pleuroparenchymal processes involving the native lung.


Assuntos
Carcinoma Broncogênico/etiologia , Carcinoma Pulmonar de Células não Pequenas/etiologia , Imunossupressores/efeitos adversos , Neoplasias Pulmonares/etiologia , Transplante de Pulmão , Fumar/efeitos adversos , Carcinoma Broncogênico/diagnóstico , Carcinoma Broncogênico/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Estudos de Coortes , Feminino , Humanos , Incidência , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Análise de Sobrevida
5.
Chest ; 120(3): 873-80, 2001 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-11555523

RESUMO

STUDY OBJECTIVES: To characterize the course of patients with advanced sarcoidosis who have been listed for lung transplantation and to identify prognostic factors for death while they are on the waiting list. DESIGN: Retrospective cohort study. SETTING: Tertiary-care university hospital. PATIENTS: Forty-three patients with sarcoidosis who have been listed for lung transplantation at the University of Pennsylvania Medical Center. METHODS: A multivariable explanatory analysis using a Cox proportional hazards model was performed to determine risk factors that are independently associated with mortality while patients await transplantation. RESULTS: Twenty-three of the 43 patients (53%) died while awaiting transplantation. The survival rate of listed patients (as determined by the Kaplan-Meier method) was 66% at 1 year, 40% at 2 years, and 31% at 3 years. In a univariate analysis, the following factors were significantly associated with death on the waiting list: PaO(2) < or = 60 mm Hg (relative risk [RR], 3.4; 95% confidence interval [CI], 1.2 to 9.3); mean pulmonary artery pressure > or = 35 mm Hg (RR, 3.2; 95% CI, 1.1 to 9.5); cardiac index < or = 2 L/min/m(2) (RR, 2.8; 95% CI, 1.2 to 6.6), and right atrial pressure (RAP) > or = 15 mm Hg (RR, 7.6; 95% CI, 3.0 to 19.3). Multivariable analysis revealed that RAP > or = 15 mm Hg was the only independent prognostic variable (RR, 5.2; 95% CI, 1.6 to 16.7; p = 0.006). Twelve patients underwent lung transplantation. Survival after transplantation determined by the Kaplan-Meier method was 62% at both 1 and 2 years, and 50% at 3 years. CONCLUSIONS: Patients with advanced sarcoidosis awaiting lung transplantation have a high mortality rate with a median survival of < 2 years. Mortality is most closely linked to elevated RAP. While earlier referral may diminish the mortality rate of patients on the waiting list for transplantation, further improvements in posttransplantation outcomes will be necessary to ensure that this procedure truly bestows a survival benefit.


Assuntos
Transplante de Pulmão , Sarcoidose Pulmonar/mortalidade , Listas de Espera , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Sarcoidose Pulmonar/cirurgia
6.
Ann Surg ; 234(3): 336-42; discussion 342-3, 2001 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-11524586

RESUMO

OBJECTIVE: To examine the effect of an integrated surgical approach to the treatment of acute type A dissections. SUMMARY BACKGROUND DATA: Acute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. METHODS: From January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). RESULTS: Mean age was 59 +/- 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 +/- 50 minutes. Mean HCA with RCP time was 42 +/- 12 minutes (range 19-84). Mean cardiac ischemic time was 140 +/- 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n = 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. CONCLUSION: The authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.


Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Prótese Vascular , Ponte Cardiopulmonar , Ecocardiografia Transesofagiana , Eletroencefalografia , Feminino , Humanos , Hipotermia Induzida , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Estudos Retrospectivos
7.
Ann Thorac Surg ; 72(1): 86-90, 2001 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-11465236

RESUMO

BACKGROUND: In patients with acute profound cardiogenic circulatory failure unresponsive to conventional resuscitation, we instituted immediate aggressive application of extracorporeal membrane oxygenation (ECMO) to restore circulatory stability. Long-term hemodynamic support was accomplished with an early "bridge" to ventricular assist device (VAD) before definitive treatment with cardiac transplantation. METHODS: A respective review of ECMO and VAD data registries was instituted. RESULTS: From May 1996 to July 2000, 23 patients were placed on ECMO support for profound cardiogenic circulatory failure. Eleven patients (47%) were withdrawn from support due to severe neurologic injury or multisystem organ failure. Three patients (13%) were weaned off ECMO with good outcome. Nine patients (39%) were transferred to a VAD. Two patients expired while on VAD support, and 7 of the VAD-supported patients (78%) survived to transplantation. Overall survival was 43%. CONCLUSIONS: Emergent ECMO support is a salvage approach for cardiac resuscitation once conventional measures have failed. In neurologically intact patients, the early transfer to a VAD quickly stabilizes hemodynamics, avoids complications, and is essential for long-term circulatory support before definitive treatment with cardiac transplantation.


Assuntos
Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Transplante de Coração , Coração Auxiliar , Choque Cardiogênico/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Exame Neurológico , Sistema de Registros , Estudos Retrospectivos , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Resultado do Tratamento
9.
Ann Thorac Surg ; 71(1): 14-21, 2001 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-11216734

RESUMO

BACKGROUND: Deep hypothermia is an important cerebral protectant and is critical in procedures requiring circulatory arrest. The purpose of this study was to determine the factors that influence the neurophysiologic changes during cooling before circulatory arrest, in particular the occurrence of electrocerebral silence. METHODS: In 109 patients undergoing hypothermic circulatory arrest with neurophysiologic monitoring, five electrophysiologic events were selected for detailed study. RESULTS: The mean nasopharyngeal temperature when periodic complexes appeared in the electroencephalogram after cooling was 29.6 degrees C +/- 3 degrees C, electroencephalogram burst-suppression appeared at 24.4 degrees C +/- 4 degrees C, and electrocerebral silence appeared at 17.8 degrees C +/- 4 degrees C. The N20-P22 complex of the somatosensory evoked response disappeared at 21.4 degrees C +/- 4 degrees C, and the somatosensory evoked response N13 wave disappeared at 17.3 degrees C +/- 4 degrees C. The temperatures of these various events were not significantly affected by any patient-specific or surgical variables, although the time to cool to electrocerebral silence was prolonged by high hemoglobin concentrations, low arterial partial pressure of carbon dioxide, and by slow cooling rates. Only 60% of patients demonstrated electrocerebral silence by either a nasopharyngeal temperature of 18 degrees C or a cooling time of 30 minutes. CONCLUSIONS: With the high degree of interpatient variability in these neurophysiologic measures, the only absolute predictors of electrocerebral silence were nasopharyngeal temperature below 12.5 degrees C and cooling longer than 50 minutes.


Assuntos
Eletroencefalografia , Potenciais Somatossensoriais Evocados , Parada Cardíaca Induzida , Hipotermia Induzida , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nasofaringe/fisiologia
10.
Ann Thorac Surg ; 71(1): 22-8, 2001 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-11216751

RESUMO

BACKGROUND: Electrophysiologic studies during rewarming after deep hypothermic circulatory arrest probe the state of the brain during this critical period and may provide insight into the neurological effects of circulatory arrest and the neurologic outcome. METHODS: Electroencephalogram (EEG) and evoked potentials were monitored during rewarming in 109 patients undergoing aortic surgery with hypothermic circulatory arrest. RESULTS: The sequence of neurophysiologic events during rewarming did not mirror the events during cooling. The evoked potentials recovered first followed by EEG burst-suppression and then continuous EEG. The time to recovery of the evoked potentials N20-P22 complex was significantly correlated with the time of circulatory arrest even in patients without postoperative neurologic deficits (r = 0.37, (p = 0.002). The nasopharyngeal temperatures at which continuous EEG activity and the N20-P22 complex returned were strongly correlated (r = 0.44, p = 0.0002; r = 0.41, p = 0.00003) with postoperative neurologic impairment. Specifically, the relative risk for postoperative neurologic impairment increased by a factor of 1.56 (95% CI 1.1 to 2.2) for every degree increase in temperature at which the EEG first became continuous. CONCLUSIONS: No trend toward shortened recovery times or improved neurologic outcome was noted with lower temperatures at circulatory arrest, indicating that the process of cooling to electrocerebral silence produced a relatively uniform degree of cerebral protection, independent of the actual nasopharyngeal temperature.


Assuntos
Eletroencefalografia , Potenciais Somatossensoriais Evocados , Parada Cardíaca Induzida , Hipotermia Induzida , Reaquecimento , Idoso , Transtornos Cognitivos/etiologia , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Nasofaringe/fisiologia
11.
Circulation ; 102(19 Suppl 3): III35-9, 2000 Nov 07.
Artigo em Inglês | MEDLINE | ID: mdl-11082359

RESUMO

BACKGROUND: Bicuspid aortic valves (BAVs) are associated with premature valve stenosis, regurgitation, and ascending aortic aneurysms. We compared aortic size in BAV patients with aortic size in control patients with matched valvular lesions (aortic regurgitation, aortic stenosis, or mixed lesions) to determine whether intrinsic aortic abnormalities in BAVs account for aortic dilatation beyond that caused by valvular hemodynamic derangement alone. METHODS AND RESULTS: Diameters of the left ventricular outflow tract, sinus of Valsalva, sinotubular junction, and proximal aorta were measured from transthoracic echocardiograms in 118 consecutive BAV patients. Annular area was measured by planimetry, and BAV eccentricity was expressed as the ratio of the right leaflet area to the total annular area. Seventy-seven control patients with tricuspid aortic valves were matched for sex and for combined severity of regurgitation and stenosis. BAV patients (79 men and 39 women, aged 44.1+/-15.5 years) had varying degrees of regurgitation (84 patients [71%]) and stenosis (48 patients [41%]). Within the bicuspid group, multivariate analysis demonstrated that aortic diameters increased with worsening aortic regurgitation (P:<0.001) and advancing age (P:<0.05) but not with the severity of aortic stenosis. BAV patients had larger aortic diameters than did control patients at all ascending aortic levels measured (P:<0.01), despite advanced age in the control patients. CONCLUSIONS: Aortic dimensions are larger in BAV patients than in control patients with comparable degrees of tricuspid aortic valve disease. Although more severe degrees of aortic regurgitation are associated with aortic dilatation in BAV patients, intrinsic pathology appears to be responsible for aortic enlargement beyond that predicted by hemodynamic factors.


Assuntos
Aorta/patologia , Insuficiência da Valva Aórtica/complicações , Estenose da Valva Aórtica/complicações , Valva Aórtica/anormalidades , Dilatação Patológica/etiologia , Adulto , Distribuição por Idade , Aorta/diagnóstico por imagem , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Superfície Corporal , Demografia , Dilatação Patológica/diagnóstico , Ecocardiografia , Feminino , Humanos , Modelos Lineares , Masculino , Análise Multivariada , Estudos Retrospectivos , Índice de Gravidade de Doença , Distribuição por Sexo , Grau de Desobstrução Vascular
12.
Semin Thorac Cardiovasc Surg ; 12(4): 309-15, 2000 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11154726

RESUMO

Surgery on the central blood pump, the heart, is performed either to prevent homeostatic compromise (ie, coronary artery disease potentially causing myocardial infarction and heart failure) or to treat actual homeostatic imbalance (ie, valvular disease causing heart failure). The cardiovascular homeostatic state is what we generally define as hemodynamics. The heart must deliver adequate oxygen and nutrients to all organs at appropriate pressures to allow optimal organ function. We monitor hemodynamic variables to assess the adequacy of a given cardiac repair and to detect any organ dysfunction that may independently coexist or be intimately related with the cardiac disease or its surgical repair. Hemodynamic monitoring initially relied on vital signs and periodic physical examination. The current monitoring capabilities have field expanded to include systemic and pulmonary arterial pressures, central venous pressures, cardiac output, systemic and pulmonary vascular resistance, and systemic and mixed venous oxygen saturation. These variables reflect a synthesis of global cardiac function and the peripheral or pulmonary vascular state. Arterial blood gas analysis further assesses the adequacy of overall oxygen delivery, carbon dioxide removal and acid-base balance. Echocardiography allows a qualitative and quantitative description of both global and regional cardiac function to better define the cardiac components of any hemodynamic state.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Testes de Função Cardíaca , Cuidados Pós-Operatórios , Adulto , Cateterismo de Swan-Ganz , Ecocardiografia Transesofagiana , Hemodinâmica , Humanos , Monitorização Fisiológica
13.
Ann Thorac Surg ; 70(6): 1813-8; discussion 1818-9, 2000 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11156077

RESUMO

BACKGROUND: There is controversy regarding the transplant procedure of choice in chronic obstructive pulmonary disease. We reviewed our intermediate-term outcomes with single lung transplantation (SLT) versus bilateral lung transplantation (BLT). METHODS: We retrospectively reviewed 130 patients with chronic obstructive pulmonary disease: 84 underwent SLT, 46 BLT. The mean age was 51.1 +/- 1.2 years for those who underwent BLT and 56.2 +/- 0.7 years for those who underwent SLT (p < 0.0001). Male patients represented 65% of the BLT group and 46% of the SLT group (p = 0.04). Spirometry and 6-minute walk tests were obtained preoperatively and at 3- to 6-month intervals. Posttransplant survival and survival from time of onset of bronchiolitis obliterans syndrome were calculated by Kaplan-Meier method. The mean follow-up was 32.4 months. RESULTS: The 90-day mortality rate was 13.0% For BLT and 15.5% for SLT (p = 0.71). Actuarial survival rates at 1, 3, and 5 years were 82.6%, 74.6%, and 61.9% for BLT and 72.2%, 63.4%, and 57.4% for SLT; the favorable survival trend with BLT did not achieve statistical significance. There were no differences in preoperative spirometry or 6-minute walk tests. The improvements in forced expiratory volume in one second, forced vital capacity (FVC), and 6 MWT were significantly greater following BLT. The incidence of bronchiolitis obliterans syndrome was 22.4% in SLT and 22.2% in BLT; survival following onset of bronchiolitis obliterans syndrome was similar. CONCLUSIONS: For patients with chronic obstructive pulmonary disease, BLT is associated with superior lung function, exercise tolerance, and a trend toward enhanced survival. Younger candidates may be best suited for BLT. Given the limited donor lungs, SLT remains the preferred alternative for all other patients.


Assuntos
Pneumopatias Obstrutivas/cirurgia , Transplante de Pulmão/métodos , Complicações Pós-Operatórias/etiologia , Bronquiolite Obliterante/etiologia , Bronquiolite Obliterante/mortalidade , Teste de Esforço , Feminino , Seguimentos , Volume Expiratório Forçado , Humanos , Pneumopatias Obstrutivas/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Espirometria , Taxa de Sobrevida , Capacidade Vital
14.
J Vasc Surg ; 30(6): 996-1003, 1999 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-10587383

RESUMO

OBJECTIVE: The objective of this report was the study of the clinical outcome of emergently repaired thoracoabdominal aortic aneurysms (TAAAs). METHODS: We retrospectively reviewed our experience with TAAA repairs from 1990 to 1998. During this interval, 110 TAAA procedures were performed, 33 (30%) of which were for immediate presentations. The chi(2) test and regression analysis were used for the analysis of mortality, paraplegia, and renal failure (hemodialysis) rates and of factors that predict these complications, respectively. RESULTS: There were no significant differences between the elective and immediate presentations with respect to the use of adjunctive procedures (lumbar drain, hypothermia, and bypass grafting). The overall mortality rate was 13%. There were no statistically significant differences between the 30-day mortality rates or the complication rates in elective versus immediate presentations. Subgroup analysis results showed a significantly higher in-hospital mortality rate in type II TAAA with immediate presentation and free rupture presentation as compared with the overall mortality rate (50% vs 13%, P <.05, and 67% vs 13%, P <.01, respectively). Multiple regression analysis results identified the use of bypass grafting (atrial-femoral or cardiopulmonary) and lumbar drain and shorter bypass grafting time as significant predictors of decreased overall mortality (P <.05). The mortality rates were not significantly different among aneurysm types and were not significantly decreased with the use of hypothermia. Paraplegia (5%) and renal failure (9%) rates were not predicted with aneurysm type, immediate versus elective presentation, or the adjunctive use of hypothermia, lumbar drain, or bypass grafting. CONCLUSION: The emergency repair of TAAA with immediate presentation can be performed with mortality and morbidity rates that approach those of elective presentations, except in the setting of free rupture or symptomatic type II TAAA. Adjunctive circulatory management techniques and lumbar drains may reduce mortality in TAAA repair.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Emergências , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/mortalidade , Ruptura Aórtica/mortalidade , Ruptura Aórtica/cirurgia , Causas de Morte , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
15.
Anesth Analg ; 88(1): 8-15, 1999 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9895058

RESUMO

UNLABELLED: Retrograde cerebral perfusion (RCP) potentially delivers metabolic substrate to the brain during surgery using hypothermic circulatory arrest (HCA). Serial measurements of O2 extraction ratio (OER), PCO2, and pH from the RCP inflow and outflow were used to determine the time course for O2 delivery in 28 adults undergoing aortic reconstruction using HCA with RCP. HCA was instituted after systemic cooling on cardiopulmonary bypass for 3 min after the electroencephalogram became isoelectric. RCP with oxygenated blood at 10 degrees C was administered at an internal jugular venous pressure of 20-25 mm Hg. Serial analyses of blood oxygen, carbon dioxide, pH, and hemoglobin concentration were made in samples from the RCP inflow (superior vena cava) and outflow (innominate and left carotid arteries) at different times after institution of RCP. Nineteen patients had no strokes, five patients had preoperative strokes, and four patients had intraoperative strokes. In the group of patients without strokes, HCA with RCP was initiated at a mean nasopharyngeal temperature of 14.3 degrees C with mean RCP flow rate of 220 mL/min, which lasted 19-70 min. OER increased over time to a maximal detected value of 0.66 and increased to 0.5 of its maximal detected value 15 min after initiation of HCA. The RCP inflow-outflow gradient for PCO2 (slope 0.73 mm Hg/min; P < 0.001) and pH (slope 0.007 U/min; P < 0.001) changed linearly over time after initiation of HCA. In the group of patients with preoperative or intraoperative strokes, the OER and the RCP inflow-outflow gradient for PCO2 changed significantly more slowly over time after HCA compared with the group of patients without strokes. During RCP, continued CO2 production and increased O2 extraction over time across the cerebral vascular bed suggest the presence of viable, but possibly ischemic tissue. Reduced cerebral metabolism in infarcted brain regions may explain the decreased rate of O2 extraction during RCP in patients with strokes. IMPLICATIONS: Examining the time course of oxygen extraction, carbon dioxide production, and pH changes from the retrograde cerebral perfusate provided a means to assess metabolic activity during hypothermic circulatory arrest.


Assuntos
Encéfalo/fisiologia , Circulação Cerebrovascular , Oxigênio/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta/cirurgia , Encéfalo/irrigação sanguínea , Encéfalo/metabolismo , Dióxido de Carbono/sangue , Infarto Cerebral/sangue , Infarto Cerebral/metabolismo , Potenciais Somatossensoriais Evocados , Circulação Extracorpórea/métodos , Feminino , Parada Cardíaca Induzida/métodos , Humanos , Concentração de Íons de Hidrogênio , Hipotermia Induzida/métodos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Oxigênio/sangue , Pressão Parcial , Perfusão/métodos , Procedimentos de Cirurgia Plástica
17.
J Thorac Cardiovasc Surg ; 115(1): 9-17; discussion 17-8, 1998 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-9451040

RESUMO

BACKGROUND: End-stage chronic obstructive pulmonary disease has traditionally been treated with lung transplantation. For 2 years, our lung transplantation program has placed patients with appropriate criteria for lung transplantation and volume reduction into a prospective management algorithm. These patients are offered the lung volume reduction option as a "bridge" to "extend" the eventual time to transplantation. We examine the results of this pilot program. METHODS: From October 11, 1993, to April 17, 1997, 31 patients were evaluated for lung transplantation who also had physiologic criteria for volume reduction (forced expiratory volume in 1 second < or = 25%; residual volume > 200%; significant ventilation/perfusion heterogeneity). All patients completed 6 weeks of pulmonary rehabilitation and then had baseline pulmonary function and 6-minute walk tests. These patients were then offered volume reduction as a "bridge" and were simultaneously listed for transplantation. Postoperatively, these 31 patients were then divided into two groups: Those with satisfactory results at 4 to 6 months after volume reduction and those with unsatisfactory results. Volume reduction was performed through a video thoracic approach in 87% of the patients and bilateral median sternotomy in the remaining 13%. The condition of the patients was monitored after the operation with repeated pulmonary function tests and 6-minute walk tests at 3-month intervals. RESULTS: Twenty-four of 31 patients (77.4%) had primary success (at 4 to 6 months) results after lung volume reduction and 7 patients (22.6%) had primary failure, including 1 patient who died in the perioperative period (3.2%). Four patients (16.7%) from the primary success cohort had significant deterioration in their pulmonary function during intermediate-term follow-up and were then reconsidered for lung transplantation. Two of them have subsequently undergone transplantation with good postoperative pulmonary function results. Interestingly, three patients had alpha 1-antitrypsin deficiency; two had a poor outcome of lung volume reduction and primary failure. CONCLUSIONS: Lung volume reduction in these patients is safe. Seventy-seven percent of otherwise suitable candidates for lung transplantation achieved initial good results from volume reduction and were deactivated from the list (placed on status 7). Most patients entering our prospective management algorithm have either significantly delayed or completely avoided lung transplantation after volume reduction. Lung volume reduction has substantially affected the practice, timing, and selection of patients for lung transplantation. Our waiting list now has a reduced percentage of patients with a diagnosis of chronic obstructive pulmonary disease compared with 3 years ago. Our experience suggests that lung volume reduction may be limited as a "bridge" in alpha 1-antitrypsin deficiency.


Assuntos
Pneumopatias Obstrutivas/cirurgia , Transplante de Pulmão , Pneumonectomia , Algoritmos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Projetos Piloto , Estudos Prospectivos , Testes de Função Respiratória , Fatores de Tempo , Listas de Espera , Deficiência de alfa 1-Antitripsina/cirurgia
18.
Semin Thorac Cardiovasc Surg ; 9(3): 222-32, 1997 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-9263341

RESUMO

Retrograde cerebral perfusion (RCP) was first introduced to treat air embolism during cardiopulmonary bypass (CPB). Its use was reintroduced to extend the safety of hypothermic circulatory arrest (HCA) during operations involving an open aortic arch. RCP seems to prevent cerebral rewarming during HCA. Both clinical and animal data suggest that RCP provides between 10% and 30% of baseline cerebral blood flow when administered through the superior vena cava (SVC) at jugular pressures of 20 to 25 mm Hg. RCP flows producing jugular venous pressures higher than 30 mm Hg may cause cerebral edema. Cerebral blood flow generated by RCP is able to sustain some cerebral metabolic activity, yet is not able to fully meet cerebral energy demands even at temperatures of 12 degrees to 18 degrees C. RCP may further prevent embolic events during aortic arch surgery when administered at moderate jugular vein pressures (< 40 mm Hg). Clinical results suggest that RCP, when applied during aortic arch reconstruction, may extend the safe HCA period and improve morbidity and mortality, especially when HCA times are more than 60 minutes. RCP applied in patients and severe carotid and brachiocephalic occlusive disease may be ineffective, and caution is in order when RCP times are greater than 90 minutes.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Encéfalo/irrigação sanguínea , Parada Cardíaca Induzida , Hipotermia Induzida , Perfusão , Dissecção Aórtica/cirurgia , Animais , Aorta Torácica/cirurgia , Circulação Cerebrovascular , Parada Cardíaca Induzida/efeitos adversos , Humanos , Hipotermia Induzida/efeitos adversos , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/prevenção & controle
19.
Ann Thorac Surg ; 64(6): 1846-8, 1997 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-9436593

RESUMO

We have been using an anterior axillary muscle-sparing thoracotomy to perform single-lung transplantation in patients with chronic obstructive pulmonary disease. The incision allows excellent exposure and may lead to improved chest wall and shoulder girdle mechanics, which may allow for a faster recovery. This incision has become our preferred approach in patients with chronic obstructive pulmonary disease requiring single-lung transplantation who have not had a previous ipsilateral thoracic operation.


Assuntos
Transplante de Pulmão/métodos , Toracotomia/métodos , Axila , Humanos , Músculo Esquelético
20.
Ann Thorac Surg ; 57(4): 912-20, 1994 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-8166540

RESUMO

Skeletal muscle ventricles (SMVs) were constructed either extrathoracically or intrathoracically in 44 dogs using the left latissimus dorsi muscle. These SMVs functioned as aortic counterpulsators for from several hours to 216 days. In this study, the relationship between the morphologic changes in the SMVs and their time course in the circulation was evaluated retrospectively. The average volume of the SMV chamber after it had been excised and fixed in formalin was 21.3 +/- 11.0 mL (mean +/- the standard deviation) for extrathoracic SMVs and 20.0 +/- 7.5 mL for intrathoracic SMVs. The volume of the SMV chamber did not correlate with the time course in the circulation. The SMV wall was mainly composed of three components: muscular, fibrous, and fatty aspects. The overall thickness of the wall appeared to be preserved over time in the circulation. However, the thickness of the muscular component tended to decrease over time. SMV rupture occurred in 15 dogs between postoperative days 4 and 39. All ruptures occurred at the suture line between the SMV and the vascular conduits. There was some degree of thrombus in 24 SMVs. Before SMVs can be applied clinically for the purpose of cardiac assist, problems with rupture and thrombus formation must be solved. A better understanding of the morphologic changes that take place in the SMV over time also is needed.


Assuntos
Contrapulsação/métodos , Ventrículos do Coração/cirurgia , Hemodinâmica , Músculos/transplante , Doenças Musculares/patologia , Complicações Pós-Operatórias/patologia , Retalhos Cirúrgicos/métodos , Trombose/patologia , Animais , Dorso , Causas de Morte , Modelos Animais de Doenças , Cães , Estimulação Elétrica , Estudos de Avaliação como Assunto , Doenças Musculares/etiologia , Doenças Musculares/mortalidade , Doenças Musculares/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Ruptura Espontânea , Índice de Gravidade de Doença , Trombose/classificação , Trombose/etiologia , Trombose/mortalidade , Trombose/fisiopatologia , Fatores de Tempo
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