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OBJECTIVE: Trans-catheter aortic valve implantation inside a failing surgical aortic valve bio-prosthesis has become an alternative for patients at high risk for redo surgical aortic valve replacement. However, the correlation between the size of the failing surgical aortic valve and the occurrence of prosthesis-patient mismatch after trans-catheter implantation is still controversial. The aim of this study is to analyze and report the results in Japanese patients. METHODS: Thirty patients who underwent trans-catheter aortic valve implantation inside a failing surgical aortic valve at our hospital were retrospectively reviewed with results from echocardiography and computed tomography. RESULTS: The patients' mean age was 84.5 ± 4.8 years. The mean body surface area was 1.42 ± 0.13 m2. The cohort was divided into two groups according to the size of the failing bio-prosthesis: small (â¦19 mm) and large (> 19 mm). There were no significant differences in mean pressure gradient (12.2 ± 4.0 mmHg vs. 11.1 ± 1.2 mmHg; p = 0.54) and effective orifice area index (1.00 ± 0.26 cm2/m2 vs. 0.99 ± 0.25 cm2/m2; p = 0.92) between the groups at 6 months after trans-catheter implantation. The incidence of moderate (38.5% vs. 28.6%; p = 0.59) and severe (0% vs. 7.1%; p = 0.33) prosthesis-patient mismatch was equivalent. There was no significant difference in survival between the two groups (log-rank test p-value = 0.08). CONCLUSIONS: Trans-catheter implantation inside a failing small aortic valve did not increase the frequency of prosthesis-patient mismatch in this Japanese cohort.
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Aneurisma da Aorta Torácica , Ruptura Aórtica , Implante de Prótese Vascular , Humanos , Adulto , Polietilenotereftalatos , Prótese Vascular/efeitos adversos , Ruptura , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/etiologia , Ruptura Aórtica/cirurgia , Aneurisma da Aorta Torácica/cirurgiaRESUMO
Objective: In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. Methods: We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. Results: The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. Conclusions: In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.
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Mesenteric malperfusion is a fatal complication of acute aortic dissection, which should rapidly be repaired. However, the optimal treatment strategy remains controversial in patients with type A aortic dissection. We report on a case with aortic bare stenting for visceral and lower limb malperfusion prior to the proximal repair. The visceral and limb reperfusion was obtained after aortic bare stenting and proximal repair was successfully performed. This technique can be an alternative option for visceral malperfusion due to type A aortic dissection. However, careful patient selection is required considering the risk of new dissection and rupture.
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BACKGROUND: There have been few reports on the mid- to long-term safety and efficacy validation of the INSPIRIS RESILIA aortic bioprosthesis (Edwards Lifesciences LLC, Irvine, CA, USA) in Japan. Herein, we report the mid-term results of surgical aortic valve replacement (AVR) for aortic stenosis using INSPIRIS and evaluate the hemodynamics compared to the CEP Magna series from the multicenter AVR registry (the ACTIVIST registry). METHODS: Of the 1967 patients who underwent surgical or transcatheter AVR from the ACTIVIST registry, 66 patients who underwent isolated surgical AVR with INSPIRIS by December 2020 were included in this study, and the early and mid-term results were evaluated. Hemodynamics were evaluated by comparing 272 patients undergoing isolated surgical AVR with the Magna group using propensity score matching. RESULTS: The mean age was 74.0⯱â¯7.8â¯years, and 48.5â¯% were women. In-hospital mortality was 1.5â¯%, and the survival rates at 1- and 2-years were 95.2â¯% and 95.2â¯%, respectively. After propensity score matching, echocardiographic findings at discharge demonstrated that peak velocity and mean pressure gradient in the INSPIRIS group were comparable, while the effective orifice area in the INSPIRIS group was significantly larger than those in the Magna group (pâ¯=â¯0.048). A patient-prosthesis mismatch at discharge was significantly lower in the INSPIRIS group (11.8â¯%) than in the Magna group (36.4â¯%) (pâ¯=â¯0.004). CONCLUSIONS: Surgical AVR with INSPIRIS was performed safely and the mid-term results were satisfactory. The hemodynamics of INSPIRIS were comparable to those of Magna.
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Estenose da Valva Aórtica , Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Humanos , Feminino , Idoso , Idoso de 80 Anos ou mais , Masculino , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Resultado do Tratamento , Estenose da Valva Aórtica/cirurgia , Sistema de Registros , Hemodinâmica , Desenho de Prótese , Estudos RetrospectivosRESUMO
BACKGROUND: Late open conversion has sometimes been required for sac enlargement after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. Though the open repair with endograft preservation is considered less invasive compared to endograft removal, the mid-term outcomes are still unclear. The aim of this study is to evaluate the mid-term outcomes of late open conversion with endograft preservation after EVAR. METHODS: We reviewed patients who underwent late open conversion with endograft preservation for sac enlargement or rupture in our institution from May 2007 to December 2020. The open repair mainly consisted of ligation of lumber arteries or the median sacral artery and sacotomy. We additionally performed wrapping of plicated aneurysm with equine pericardium as much as possible. Patients were followed-up by a computed tomography scan and duplex ultrasound 1 and 6 months postoperatively, and each year thereafter. RESULTS: Of the 1,087 patients who underwent EVAR, 23 patients with a mean age of 81.5 years were included in this study. The mean duration post-EVAR was 35.6 months. Sac wrapping with equine pericardium was performed in 14 patients (60.9%). We additionally performed wrapping of the endograft junction by a Dacron knitted fabric in 1 case with type III endoleak and aortic neck banding in 4 cases with type I endoleak. The 30-day mortality was 0% and the rate of major complications was 4%. All-cause mortality was 21.7% which included 1 aneurysm-related death during a mean follow-up of 38.5 months. Sac re-enlargement was observed in 4 patients without the wrapping method. At 3 years, the aneurysmal diameter in the nonwrapping group significantly increased, compared with the wrapping group (P = 0.011). CONCLUSIONS: Late open conversion with endograft preservation is a feasible treatment; however, at times re-enlargement of the sac aneurysm occurs. The wrapping method has the potential to prevent sac re-enlargement after open conversion.
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Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Cavalos , Animais , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/complicações , Endoleak/diagnóstico por imagem , Endoleak/etiologia , Endoleak/cirurgia , Procedimentos Endovasculares/efeitos adversos , Resultado do Tratamento , Estudos Retrospectivos , Fatores de Risco , Prótese Vascular/efeitos adversosRESUMO
BACKGROUND: Postoperative cognitive dysfunction (POCD) is widely recognized and reported, but the lack of a uniform definition makes it difficult to evaluate its clinical impact. The aim of this study is to establish the optimal neuropsychological tests and definition of POCD relevant to clinical outcomes in heart valve surgeries.MethodsâandâResults: Between June 2015 and December 2019, 315 patients undergoing elective heart valve surgeries (age ≥65 years) were enrolled. The Mini-Mental Status Examination, Montreal Cognitive Assessment (MoCA), and the Trail Making Test A and B were performed to evaluate cognitive function. Clinical endpoints were defined as readmission and death. The postoperative readmission and death rate were 17% and 3% (54/315 and 8/315; follow-up 266-1,889 days). By multivariable Cox hazard analysis, Short Physical Performance Battery (adjusted hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.49-0.98, P=0.001), MoCA change rate (adjusted HR: 0.64, 95% CI: 0.01-1.22, P=0.024), and intensive care unit stay (adjusted HR: 0.55%, 95% CI: 0.99-1.12, P=0.054) were detected as independent risk factors for combined events. The cutoff value was -12% in the change rate of MoCA. CONCLUSIONS: MoCA was the only neuropsychological test that predicted the clinical impact on complex events and has the potential to define POCD.
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Procedimentos Cirúrgicos Cardíacos , Disfunção Cognitiva , Complicações Cognitivas Pós-Operatórias , Humanos , Idoso , Complicações Cognitivas Pós-Operatórias/diagnóstico , Complicações Cognitivas Pós-Operatórias/etiologia , Testes Neuropsicológicos , Testes de Estado Mental e Demência , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Valvas Cardíacas/cirurgia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Disfunção Cognitiva/psicologiaRESUMO
BACKGROUND AND AIM: After repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes. METHODS: Three hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV. RESULTS: Common mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients' age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038-0.068] vs. 0.041 mmHg/ml, [0.031-0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = -0.37, p < .001). CONCLUSIONS: Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.
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Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Estenose da Valva Mitral , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/etiologia , Estenose da Valva Mitral/etiologia , Estenose da Valva Mitral/cirurgia , Estudos Retrospectivos , Volume Sistólico , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
Downsizing of mitral annulus due to mitral annuloplasty for ischemic functional mitral regurgitation (FMR) raises a new issue, functional mitral stenosis (FMS), defined as a decline of mitral hemodynamics. However, common mitral hemodynamic parameters are influenced by transmitral flow, therefore, the clinical impacts are still controversial. The aim of this study is to seek mitral hemodynamic indices (including transmitlra pressure gradient [TMPG] adjusted by left ventricular stroke volume [LVSV]) relevant to the mid-term outcomes after annuloplasty for ischemic functional mitral regurgitation (FMR). This study is a retrospective evaluation of mitral valve hemodynamic status by resting echocardiogram at several weeks after surgery. Eighty-one patients underwent mitral annuloplasty for ischemic FMR between September 2012 and June 2019. Postoperative adverse events occurred in 28 patients (34.6%), and the overall 5-year freedom from adverse events rate was 55.9%. Common mitral hemodynamic parameters were not associated with adverse events, but flow adjusted TMPG can be a correlative factor. By multivariable analysis, postoperative systolic pulmonary artery pressure and peak TMPG/LVSV were detected as independent predictors (adjusted hazard ratio 1.07 and 1.08, P < 0.001 and < 0.001). Additionally, risk stratification by peak TMPG (cut-off: 10 mm Hg) and LVSV (cut-off: 35 mL/m2) reflected the mid-term outcomes, perceptively (Pâ¯=â¯0.007). Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after annuloplasty for ischemic FMR. However, flow adjusted TMPG was identfied as an independent predictor, and risk stratification by peak TMPG and LVSV reflected the mid-term outcomes, perceptively.
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Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Isquemia Miocárdica , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia , Isquemia Miocárdica/complicações , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Anomalous systemic arterial supply to the left basal lung is a rare congenital lung malformation, and its optimal treatment strategy is not well defined. We present a case of a 61-year-old man who underwent thoracic endovascular aortic repair (TEVAR) for anomalous systemic arterial supply to the left basal lung complicated with aneurysmal dilatation of the aberrant feeding artery. Computed tomography angiography after TEVAR revealed significant shrinkage of the aneurysmal portion as well as complete occlusion of the aberrant feeding artery. TEVAR proved to be a safe and efficient treatment for this rare arterial abnormality.
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BACKGROUND: This study retrospectively examined the association between elevated trans-pulmonary gradient (TPG), which reflects pre-capillary contribution to pulmonary hypertension (PH), and postoperative pulmonary hemodynamics and outcomes following restrictive mitral annuloplasty (RMA) in patients with pre-existing PH. METHODS: Pre- and postoperative (1 month) cardiac catheterization was performed in 64 patients with severely impaired left ventricular function (i.e., ejection fraction ≤40%) and pre-existing PH (mean pulmonary artery pressure (PAP) ≥25 mmHg) who underwent RMA. Patients were segregated into two groups: low TPG (≤12 mmHg) and elevated TPG (>12 mmHg). The mean follow-up period was 54±27 months. The primary outcome seen was a change in pulmonary hemodynamics after RMA; secondary outcomes were composite adverse events, including all-cause mortality and readmission for heart failure. RESULTS: Compared to the low TPG group, patients in the elevated TPG group were more likely to show a postoperative mean PAP of ≥25 mmHg (84% vs. 38%), TPG of >12 mmHg (79% vs. 11%), and pulmonary vascular resistance of ≥240 dynes/sec/cm-5 (84% vs. 6.7%) (all P<0.001), although both groups showed comparable degrees of mitral regurgitation improvement. Serial echocardiography demonstrated that Doppler-derived systolic PAP, which once decreased in both groups, remained stable in the low group while steadily increasing in the elevated group (group effect P<0.001). Patients with elevated TPG had lower freedom from composite adverse events (5-year, 20% vs. 70%, P=0.003). After adjusting for baseline covariates, the elevated TPG was independently associated with increased risk of adverse events (adjusted hazard ratio 2.9, 95% CI: 1.2-6.9, P=0.017). CONCLUSIONS: Elevated TPG negatively affects postoperative pulmonary hemodynamics and late outcomes in patients with advanced cardiomyopathy and pre-existing PH who have undergone RMA. These findings suggest that the assessment of TPG should be included in post-RMA risk stratification.
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BACKGROUND: In patients with severe left ventricular (LV) dysfunction requiring coronary artery bypass grafting (CABG), the association between diabetic status and outcomes after surgery, as well as with survival benefit following bilateral internal thoracic artery (ITA) grafting, remain largely unknown.MethodsâandâResults:Patients (n=188; mean [±SD] age 67±9 years) with LV ejection fraction ≤40% who underwent isolated initial CABG were classified into non-diabetic (n=64), non-insulin-dependent diabetic (NIDM; n=74), and insulin-dependent diabetic (IDM; n=50) groups. During follow-up (mean [±SD] 68±47 months), the 5-year survival rate was 84% and 65% among non-diabetic and diabetic patients, respectively (P=0.034). After adjusting for all covariates, both NIDM and IDM were associated with increased mortality, with hazard ratios (HRs) of 1.9 (95% confidence interval [CI] 1.0-3.7; P=0.049) and 2.4 (95% CI 1.2-4.8; P=0.016), respectively. Among non-diabetic patients, there was no difference in the 5-year survival rate between single and bilateral ITA grafting (86% vs. 80%, respectively; P=0.95), whereas bilateral ITA grafting increased survival among diabetic patients (57% vs. 81%; P=0.004). Multivariate analysis revealed that bilateral ITA was significantly associated with a decreased risk of mortality (HR 0.3; 95% CI 0.1-0.8; P=0.024). CONCLUSIONS: NIDM and IDM were significantly associated with worse long-term clinical outcome after CABG for severe LV dysfunction. Bilateral ITA grafting has the potential to improve survival in diabetic patients with severe LV dysfunction.
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Doença da Artéria Coronariana , Diabetes Mellitus , Artéria Torácica Interna , Disfunção Ventricular Esquerda , Idoso , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/cirurgia , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Disfunção Ventricular Esquerda/cirurgiaRESUMO
OBJECTIVES: This retrospective study aimed to clarify the incidence, determinants and clinical impact of left ventricular (LV) function non-recovery after coronary artery bypass grafting (CABG) in patients with ischaemic cardiomyopathy. METHODS: A total of 490 patients with ischaemic cardiomyopathy (LV ejection fraction ≤ 40%) undergoing CABG were analysed. Follow-up echocardiography was performed at 1 month, 1 year, and annually thereafter. LV function recovery was defined as ejection fraction (EF) ≥40% at least once during follow-up. LV function non-recovery was defined as EF <40% at any follow-up. The primary and secondary end points were changes in LV function and all-cause mortality, respectively. Clinical follow-up was completed in 461 patients (94.1%; mean follow-up: 64.5 ± 45.5 months). RESULTS: During follow-up, echocardiographic assessments were performed 1863 times (mean, 3.8 ± 2.4), and 193 patients (39.4%) exhibiting LV function non-recovery were identified. Overall survival was significantly higher in the recovery group (53.9%) than in the non-recovery group (31.4%) at 10 years (P < 0.001). Independent predictors of LV function non-recovery were preoperative LV end-systolic diameter [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.04-1.10; P < 0.001] and bilateral internal thoracic artery grafting (OR 0.61, 95% CI 0.39-0.95; P = 0.028). In a multivariable Cox proportional hazards model, LV function non-recovery was significantly associated with all-cause mortality (hazard ratio 2.14, 95% CI 1.60-2.86; P < 0.001). CONCLUSIONS: Almost 40% of patients with ischaemic cardiomyopathy undergoing CABG did not achieve LV function recovery and were associated with poor prognosis. To achieve LV function recovery, CABG with bilateral internal thoracic artery may be recommended before excessive LV remodelling occurs. CLINICAL TRIAL REGISTRATION NUMBER: Institutional review board of Osaka University Hospital, number 16105.
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Cardiomiopatias , Disfunção Ventricular Esquerda , Cardiomiopatias/epidemiologia , Cardiomiopatias/cirurgia , Seguimentos , Humanos , Incidência , Estudos Retrospectivos , Volume Sistólico , Resultado do Tratamento , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/cirurgia , Função Ventricular EsquerdaRESUMO
BACKGROUND: Consensus regarding an optimal atrial fibrillation (AF) ablation lesion set concomitant with aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG) has not been established. METHODS: We enrolled 125 consecutive patients (89 men; 70 ± 8 years old) with persistent AF who underwent radiofrequency-based pulmonary vein isolation (PVI) (PVI group, n = 53) or a Cox-Maze procedure (Maze group, n = 72) with AVR and/or CABG. To reduce the impact of treatment bias and potential confounding in the direct comparisons between patients who underwent Cox-Maze with and those who underwent PVI, we established weighted Cox proportional-hazards regression models with inverse probability of treatment weighting. Mean follow-up was 63 ± 34 months (maximum, 154 months). RESULTS: There was 1 in-hospital death in each group. Patients who underwent Cox-Maze showed a higher freedom from AF at all follow-up examinations. After the operation, there were 32 deaths, 13 thromboembolisms, 8 hemorrhagic events, and 22 heart failure readmissions. The Maze group had higher rates for 5-year survival (88% vs 64%, P = .013) and freedom from composite events (74% vs 42%, P < .001). After adjustment with inverse probability of treatment weighting, the Cox-Maze procedure still showed a lower risk of overall mortality (adjusted hazard ratio, 0.38; 95% confidence interval, 0.21-0.66; P = .001) and composite adverse events (adjusted hazard ratio, 0.52; 95% confidence interval, 0.35-0.76; P = .001). CONCLUSIONS: In patients with persistent AF indicated for nonmitral valve surgery, a concomitant Cox-Maze procedure resulted in superior AF- and event-free survival compared with PVI, without increased risk of early mortality. These findings may assist decision making for surgical management of persistent AF concomitant with AVR and/or CABG.
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Valva Aórtica/cirurgia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Idoso , Fibrilação Atrial/complicações , Feminino , Seguimentos , Doenças das Valvas Cardíacas/complicações , Mortalidade Hospitalar/tendências , Humanos , Japão/epidemiologia , Masculino , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
BACKGROUND AND AIM: Leaflet resection and chordal reconstruction are established repair techniques for posterior mitral valve (MV) prolapse. This study aimed to compare the clinical results of the resect and respect approaches, with a particular focus on MV hemodynamics. METHODS: Overall, 291 patients who underwent elective MV repair for isolated posterior leaflet prolapse between 2012 and 2020 were enrolled. Patients who underwent leaflet resection alone were classified as the "resection" group (n = 166), while patients who underwent neochordal replacement with/without limited leaflet resection were classified as the "respect" group (n = 125). Early postoperative MV hemodynamics and midterm repair durability were compared between the groups. RESULTS: The annuloplasty ring size was significantly larger in the respect group than in the resection group (31.0 ± 2.1 vs. 30.4 ± 2.0 mm, p = .028). The respect group showed significantly lower mean MV gradient (2.6 ± 1.1 vs. 3.0 ± 1.4 mmHg, p = .03) and larger effective orifice area (EOA) (1.86 ± 0.48 vs. 1.66 ± 0.47 cm2 , p < .001) than the resection group. Multivariable analysis identified the respect approach, younger age, female sex, larger ring size, and partial band as independent determinants of larger EOA. The rate of freedom from moderate or greater recurrent mitral regurgitation 5 years postoperatively was 90.9% in both groups. CONCLUSIONS: The respect approach allowed for a lower MV gradient and a larger EOA than the resection approach, which is possibly due to the capability of implanting a larger annuloplasty ring.
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Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Prolapso da Valva Mitral , Cordas Tendinosas/cirurgia , Feminino , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Prolapso da Valva Mitral/cirurgia , Prolapso , Respeito , Resultado do TratamentoRESUMO
Objective: We investigated whether or not a history of multiple percutaneous coronary interventions (PCIs) is associated with clinical outcomes after surgery for ischemic mitral regurgitation. Methods: A total of 309 patients with chronic ischemic mitral regurgitation and left ventricular ejection fraction ≤40% who underwent restrictive mitral annuloplasty were classified as follows: patients with no or 1 previous PCI (nonmultiple PCI group [n = 211]) and patients with 2 or more previous PCIs (multiple PCIs group [n = 98]). Mean follow-up duration was 53 ± 40 months. Results: Before surgery, there were no intergroup differences in patient demographic characteristics except for lower estimated glomerular filtration rate in patients with multiple PCIs. These patients underwent concomitant coronary artery bypass grafting less frequently with a lower number of distal anastomoses (P < .05 for both). The 30-day mortality was 3.3% and 2.0% in the nonmultiple and multiple PCIs group, respectively (P = .72). During follow-up, there were 157 deaths. Patients with multiple PCIs showed lower 5-year survival rate (44% vs 64%; P = .002). After adjustments with inverse-probability-of-treatment weighting, multiple PCIs history was an independent risk factor for mortality (adjusted hazard ratio, 1.4; 95% confidential interval, 1.1-1.7; P = .002). Patients with multiple PCIs showed less improvement in left ventricular ejection fraction (interaction effect P < .001). Conclusions: In patients with ischemic mitral regurgitation, a history of previous multiple PCIs was associated with increased risk of long-term postoperative mortality, with less improvement in left ventricular ejection fraction.
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OBJECTIVE: Silent brain lesions are known to occur after coronary artery bypass grafting (CABG). The aim of this study was to seek the incidence rate, the influence of procedures, and their impact on the postoperative course. METHODS: From July 2016 to April 2018, 104 consecutive patients undergoing elective and isolated first-time CABG (65 off-pump and 39 on-pump) were enrolled. New brain lesions were evaluated by brain magnetic resonance imaging both before and after CABG. Postoperative outcomes, including cognitive function, were compared between patients with and without brain lesions. RESULTS: The overall incidence of new brain lesions was 20.1% (21/104). Excluding one symptomatic stroke case, silent brain lesions were revealed in the remaining patients. The percentage of on-pump CABG (61.9% [13/21] vs 31.3% [26/83], P = .019) and aortic clamp (52.4% [11/21] vs 24.1% [20/83], P = .014) were significantly greater in patients with brain lesions. Brain lesions were observed in 12.3% and 15.8% of patients in the off-pump and anaortic CABG. The Katz Index of Independence in Activities of Daily Living was significantly lower in patients with brain lesions (from 5.8 ± 0.9 to 5.4 ± 1.2 vs from 5.9 ± 0.5 to 5.9 ± 0.6, P = .013). In patients with new lesions, postoperative cognitive dysfunction (POCD) was observed only in multiple lesions, and the maximum size was significantly greater in patients with POCD. CONCLUSIONS: Magnetic resonance imaging of the brain frequently detected postoperative silent brain lesions after CABG in off-pump and aorta non-touch groups. Multiple and larger new brain lesions were associated with the development of POCD.
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Encefalopatias/etiologia , Ponte de Artéria Coronária/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Encefalopatias/diagnóstico por imagem , Encefalopatias/epidemiologia , Feminino , Humanos , Incidência , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , NeuroimagemRESUMO
OBJECTIVES: Chronic disseminated intravascular coagulation is a rare complication of aortic dissection, and its optimal treatment remains controversial. METHODS: We present a 78-year-old man with repeated hemorrhagic events by disseminated intravascular coagulation due to chronic aortic dissection treated by thoracic endovascular aortic repair. RESULTS: Computed tomography angiography at three months revealed a completely thrombosed false lumen from the distal aortic arch to the descending aorta at the celiac artery level. Platelets and D-dimer levels remained stable, and the patient was doing well without hemorrhagic complications. CONCLUSIONS: Endovascular repair was effective for disseminated intravascular coagulation due to chronic type B aortic dissection.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Coagulação Intravascular Disseminada/etiologia , Procedimentos Endovasculares , Idoso , Dissecção Aórtica/complicações , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Doença Crônica , Coagulação Intravascular Disseminada/diagnóstico , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Stents , Resultado do TratamentoRESUMO
Background The aim of this study was to compare the predictive accuracy of acute kidney injury (AKI) after cardiac surgery using cardiopulmonary bypass for the largest area under the curve (AUC) below the oxygen delivery (DO2) threshold and the cumulative AUC below the DO2 threshold. Methods and Results From March 2017 to October 2019, 202 patients who had undergone cardiac surgery with cardiopulmonary bypass were enrolled. The perfusion parameters were recorded every 20 seconds, and the DO2 (10×pump flow index [L/min per m2]×[hemoglobin (g/dL)×1.36×arterial oxygen saturation (%)+partial pressure of arterial oxygen (mm Hg)×0.003]) threshold of 300 mL/min per m2 was considered to define sufficient DO2. The nadir DO2, the cumulative AUC below the [Formula: see text], and the largest AUC below the [Formula: see text] were used to predict the incidence of AKI. Postoperative AKI was observed in 12.4% of patients (25/202). By multivariable analysis, the largest AUC below the [Formula: see text] ≥880 (odds ratio [OR], 4.9; 95% CI, 1.2-21.5 [P=0.022]), preoperative hemoglobin concentration ≤11.6 g/dL (OR, 7.6; 95% CI, 2.0-32.3 [P=0.004]), and red blood cell transfusions during cardiopulmonary bypass ≥2 U (OR, 3.3; 95% CI, 1.0-11.1 [P=0.041]) were detected as independent risk factors for AKI. Receiver operating curve analysis revealed that the largest AUC below the [Formula: see text] was more accurate to predict postoperative AKI compared with the nadir DO2 and the cumulative AUC below the [Formula: see text] (differences between areas, 0.0691 [P=0.006] and 0.0395 [P=0.001]). Conclusions These data suggest that a high AUC below the [Formula: see text] is an important independent risk factor for AKI after cardiopulmonary bypass, which could be considered for risk prediction models of AKI.