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BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.
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COVID-19 , Cirurgiões , Adulto , Descontaminação , Humanos , Pandemias , Percepção , SARS-CoV-2RESUMO
BACKGROUND: Little is known about emotional quality-of-life in paediatric heart disease in low- and middle-income countries where the prevalence of uncorrected lesions is high. Research on emotional quality-of-life and its predictors in these settings is key to planning interventions. METHODS: Ten-year retrospective cross-sectional study of children aged 6-17 years with uncorrected congenital or acquired heart disease in 12 low- and middle-income countries was conducted. Emotional functioning score of the PedsQL TM 4.0 generic core scale and data on patient-reported limitation in sports participation were collected via in-person interview and analysed using regression analyses. RESULTS: Ninety-four children reported mean emotional functioning scores of 71.94 (SD 25.32) [95% CI 66.75-77.13] with lower scores independently associated with having a parent with a chronic illness or who had died (p = 0.005), having less than three siblings (p = 0.007), and reporting a subjective limitation in carrying an item equivalent to a 4 lb load (p = 0.021). Patient-reported limitation in sports participation at least "sometimes" was present in 69% and was independently associated with experiencing symptoms at least once a month (p < 0.001). CONCLUSION: Some of the factors which were associated with better emotional quality-of-life were similar to those identified in previous studies in patients with corrected defects. Patient-reported limitation in sports participation is common. In addition to corrective surgery and exercise, numerous other interventions which are practicable during surgical missions might improve emotional quality-of-life.
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Países em Desenvolvimento , Emoções , Cardiopatias Congênitas/fisiopatologia , Cardiopatias Congênitas/psicologia , Qualidade de Vida , Esportes , Adolescente , Criança , Estudos Transversais , Feminino , Cardiopatias/fisiopatologia , Cardiopatias/psicologia , Humanos , Modelos Lineares , Masculino , Estudos Retrospectivos , Autorrelato , Irmãos , Fatores SocioeconômicosRESUMO
INTRODUCTION: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic. METHODS: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms "(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)". Additionally, the webpages of relevant medical societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information. RESULTS: Whereas cardiac surgery and cardiology practices were reduced by 50-75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19. CONCLUSION: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients - which accounts for patient's clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic - is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.
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COVID-19 , Procedimentos Cirúrgicos Cardíacos , Cardiologia , Criança , Humanos , Pandemias/prevenção & controle , SARS-CoV-2RESUMO
BACKGROUND: Many online resources currently provide healthcare information to the public. In 2015, the Society of Thoracic Surgeons (STS) created a multimedia web portal (ctsurgerypatients.org) to educate the public regarding cardiothoracic surgery and provide an informative tool to which cardiothoracic surgeons could refer patients. METHODS: A patient education task force was created, and disease-specific content was created for 25 pathological conditions. After launching the website online, a marketing campaign was initiated to make STS members aware of its availability. Website visits were monitored, and an online survey for public users was created. An email survey was sent to STS members to evaluate awareness and content. Surveys were analyzed for effectiveness and utilization by both public users and STS member surgeons. RESULTS: From 2016 to 2018, the website had more than 1 million visits, with visits increasing yearly. Surveyed user ratings of the website were positive regarding quality and utility of the information provided. STS member response was poor (379 responses of 6347 emails), and 78.3% of responders were unaware of the website. Surgeon responders were positive about the content, though many still refrain from referring patients. CONCLUSIONS: Online education for cardiothoracic surgery is seeing increased public use, with high ratings for content and utility. Despite aggressive marketing to STS members, most remain unaware of this website's existence. Those who are aware approve of its content, but adoption of referring patients to it has been slow. Improved strategies are necessary to make surgeons aware of this STS-provided service and increase patient referrals to it.
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Educação a Distância/estatística & dados numéricos , Internet , Educação de Pacientes como Assunto/estatística & dados numéricos , Cirurgia Torácica/educação , Utilização de Instalações e Serviços , Humanos , Aceitação pelo Paciente de Cuidados de Saúde , Sociedades Médicas , Cirurgiões , Inquéritos e QuestionáriosRESUMO
Surgical therapy for the treatment of heart failure is a relatively young solution to a problem that has overwhelmed civilizations dating back to the First Dynasty. Despite centuries of enormous multidisciplinary medical and technological advance, nearly 2000 people in the USA died of cardiovascular disease every day in 2006, averaging one death every 35 seconds, and claiming more lives than the next four leading causes of death combined. In 2007, one in 30 female deaths will be from breast cancer, while one in 2.6 will be from cardiovascular disease. The prevalence of heart failure in our population is a staggering 5 million in the USA and 6.5 million in Europe per year. Furthermore, based on the 44-year follow-up of the National Heart, Blood, and Lungs Institute Framingham Heart Study, 80% of men and 70% of women under the age of 65 years who have heart failure will die within 8 years. The focus of this article will be to review the history and future of the Novacor Left Ventricular Assist System as it relates to the failing heart; the story of how the innovator, the researcher, the engineer and the surgeon have come together to offer a surgical solution to a medical problem of inconceivable scope.
Assuntos
Circulação Assistida/instrumentação , Ventrículos do Coração/fisiopatologia , Coração Auxiliar , Feminino , Coração Auxiliar/história , Coração Auxiliar/tendências , História do Século XX , História do Século XXI , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Próteses e Implantes , Acidente Vascular Cerebral/epidemiologia , Função VentricularRESUMO
ABSTRACT Introduction: The primary aim of this systematic review is to provide perioperative strategies to help restore or preserve cardiovascular services under threat from financial and personnel constraints imposed by the coronavirus disease 2019 (COVID-19) pandemic. Methods: The Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane Central Register of Controlled Trials/CCTR, and Google Scholar were systematically searched using the search terms "(cardiac OR cardiology OR cardiothoracic OR surgery) AND (COVID-19 or coronavirus OR SARS-CoV-2 OR 2019-nCoV OR 2019 novel coronavirus OR pandemic)". Additionally, the webpages of relevant medical societies, including the World Federation Society of Anesthesiologists, the Cardiothoracic Surgery Network, and the Society of Thoracic Surgeons, were screened for relevant information. Results: Whereas cardiac surgery and cardiology practices were reduced by 50-75% during the pandemic, mortality of patients with COVID-19 increased significantly. Healthcare workers are among those at high risk of infection with COVID-19. Conclusion: Hospitals must provide maximum protective equipment and training on how to use it to healthcare workers for their mutual protection. Triage management of patients — which accounts for patient's clinical status and risk-factor profile relatable to which services are available during the COVID-19 pandemic — is recommended. A strict reorganization of the hospital resources including preoperative, intraoperative, and postoperative detailed protective measures is necessary to reduce probability of vector contamination, to protect patients and the cardiovascular teams, and to permit safe resumption of cardiological and cardiac surgical activity.
RESUMO
Airway complications following pulmonary resection remain a challenging problem. A high degree of clinical suspicion, contrasted CT imaging, and early reoperation are crucial in preserving viable lung parenchyma following the anatomic compromise of lobar torsion. Likewise, early recognition and expeditious drainage of the pleural space in the setting of bronchial dehiscence may help prevent the aspiration pneumonia and consequent respiratory failure that is the leading cause of death in this patient population; A variety of interventions to manage stump dehiscence are possible, but successful management still remains difficult and requires an individualized approach. Attention to technical details and avoidance of extensive dissection and tension should yield acceptably low rates of postoperative stenosis following bronchoplastic resection. These common themes of precise surgical technique, vigilance in the perioperative period, and classic sound judgment in addressing problems effectively and expeditiously remain pivotal in the minimization of sequelae from morbid airway complications.
Assuntos
Pneumonectomia/efeitos adversos , Brônquios/cirurgia , Broncopatias/diagnóstico , Broncopatias/etiologia , Broncopatias/terapia , Constrição Patológica/diagnóstico , Constrição Patológica/etiologia , Constrição Patológica/terapia , Humanos , Incidência , Pneumopatias/diagnóstico , Pneumopatias/etiologia , Pneumopatias/terapia , Fatores de Risco , Deiscência da Ferida Operatória/diagnóstico , Deiscência da Ferida Operatória/etiologia , Deiscência da Ferida Operatória/terapia , Anormalidade Torcional/diagnóstico , Anormalidade Torcional/etiologia , Anormalidade Torcional/terapiaRESUMO
Noncommunicable diseases account for 38 million deaths each year, and approximately 75% of these deaths occur in the developing world. The most common causes include cardiovascular diseases, cancer, respiratory diseases, and diabetes mellitus. Many adults with acquired cardiothoracic disease around the world have limited access to health care. In addition, congenital heart disease is present in approximately 1% of live births and is therefore the most common congenital abnormality. More than one million children in the world are born with congenital heart disease each year, and approximately 90% of these children receive suboptimal care or have no access to care. Furthermore, many children affected by noncongenital cardiac conditions also require prevention, diagnosis, and treatment. Medical and surgical volunteerism can help facilitate improvement in cardiothoracic health care in developing countries. As we move into the future, it is essential for physicians and surgeons to be actively involved in political, economic, and social aspects of society to serve health care interests of the underprivileged around the world. Consequently, in developing countries, a critical need exists to establish an increased number of reputable cardiothoracic programs and to enhance many of the programs that already exist. The optimal strategy is usually based on a long-term educational and technical model of support so that as case volumes increase, quality improves and mortality and morbidity decrease. Humanitarian outreach activities should focus on education and sustainability, and surgical tourism should be limited to those countries that will never have the capability to have free-standing cardiothoracic programs.
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Procedimentos Cirúrgicos Cardíacos , Procedimentos Cirúrgicos Torácicos , Países em Desenvolvimento , Humanos , Papel do Médico , CirurgiõesRESUMO
Patients with a clinically concerning dominant thyroid nodule have been managed by lobectomy or total thyroidectomy at our institution. We determined the complications associated with both approaches and the ability of thyroid lobectomy to avoid the need for thyroid hormone replacement therapy. Records of all patients with a dominant thyroid nodule managed with surgery from August 1993 through December 2000 were reviewed for demographics, history of head and neck radiation, indication for surgery, preoperative fine-needle aspirate results, final pathologic evaluation, perioperative complications, determinations of need for subsequent thyroid surgery after lobectomy, and need for thyroid hormone replacement therapy after surgery. Patients with a preoperative diagnosis of malignancy or bilateral or diffuse disease were excluded because these conditions would uniformly be managed by bilateral thyroidectomy. The complications for the lobectomy group (n = 131) compared with the total thyroidectomy group (n = 84) were: recurrent laryngeal nerve paresis (4.6% vs 2.4%), recurrent laryngeal nerve injury (0.8% vs 0), and transient hypoparathyroidism (1.5% vs 9.5%; P = 0.007). No permanent hypoparathyroidism was identified in either group. Postoperative thyroid hormone replacement was required in 64 of 131 lobectomy patients (48.8%). Complications associated with either surgery were low. Total thyroidectomy was not associated with clinically significant additive morbidity. Patients treated by lobectomy should be aware of a nearly 50 per cent chance of requiring thyroid hormone replacement. Total thyroidectomy avoids future thyroid surgery; lobectomy patients remain at risk. When complications can be minimized total thyroidectomy should be considered an option in the management for patients with dominant thyroid nodules that require surgery.
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Nódulo da Glândula Tireoide/cirurgia , Tireoidectomia , Adenocarcinoma/cirurgia , Adenoma/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tireoidectomia/métodosRESUMO
The saphenous vein has been the principal conduit for coronary bypass grafting from the beginning, circa 1970. This report briefly traces this history and concomitantly presents one surgeons experience and personal views on use of the vein graft. As such it is not exhaustive but meant to be practical with a modest number of references. The focus is that of providing guidance and perspective which may be at variance with that of others and recognizing that there may be many ways to accomplish the task at hand. Hopefully the surgeon in training/early career may find this instructive on the journey to surgical maturity.
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BACKGROUND: Valve-preserving aortic root reconstruction is being performed with increasing frequency. Independent of durability concerns, enthusiasm for retaining the native valve is often championed on the presumption that composite graft replacement of the aorta will be complicated by thromboembolism and bleeding. Our goal in this late follow-up study is to determine if thromboembolism or bleeding, or both, are indeed problematic after composite aortic root replacement. METHODS: Between 1995 and 2011, 306 patients (mean age, 56±14 years) underwent composite graft replacement of the aorta. St. Jude mechanical valve conduits (St. Jude Medical, St Paul, MN) were used in 242 patients, and 64 received a biologic conduit. Long-term postoperative follow-up (mean, 56 months; range, 1 to 97 months) was performed through our Aortic Database, supplemented by patient interviews and use of the Social Security Death Index. RESULTS: Hospital mortality was 2.9% overall and 1.4% in the last 8 years. Kaplan-Meier curves showed freedom (±standard deviation) from bleeding, stroke, and distal embolism as 94.3%±1.7% at 5 years and 91.3%±2.4% at 10 years. Survival was 93.5%±1.8% at 5 years and 80.9%±4.6% at 10 years, which was not statistically different from that for an age- and sex-matched population in Connecticut. Freedom from reoperation of the aortic root was 99% at 10 years. CONCLUSIONS: Patients had excellent survival and few thromboembolic and bleeding complications after composite aortic root replacement. These data supporting minimal morbidity in the setting of well-established durability should be used to put alternative procedures, such as valve-preserving aortic root reconstruction, into context.
Assuntos
Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/efeitos adversos , Próteses Valvulares Cardíacas , Hemorragia Pós-Operatória/mortalidade , Tromboembolia/mortalidade , Adulto , Idoso , Análise de Variância , Valva Aórtica/fisiopatologia , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Estudos de Coortes , Feminino , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Hemorragia Pós-Operatória/etiologia , Prognóstico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Gestão da Segurança , Análise de Sobrevida , Tromboembolia/etiologia , Resultado do Tratamento , UltrassonografiaRESUMO
Although well established for the treatment of intracranial and prostatic pathology, stereotactic radiosurgery has only recently emerged as a modality for the treatment of malignant lung lesions. Utilization of radio-opaque markers, called fiducials, facilitate dose-intensive radiation focused on the tumor with sparing of surrounding normal tissue. There is a paucity of literature regarding complications that occur secondary to placement of these fiducials. The following report details a case in which intracoronary migration resulted in a hemodynamically significant acute coronary syndrome.
Assuntos
Síndrome Coronariana Aguda/etiologia , Carcinoma de Células Escamosas/cirurgia , Embolização Terapêutica/métodos , Marcadores Fiduciais/efeitos adversos , Migração de Corpo Estranho/terapia , Neoplasias Pulmonares/cirurgia , Segunda Neoplasia Primária/cirurgia , Radiocirurgia/efeitos adversos , Síndrome Coronariana Aguda/terapia , Idoso , Carcinoma de Células Escamosas/diagnóstico por imagem , Carcinoma de Células Escamosas/patologia , Cateterismo Cardíaco/métodos , Feminino , Seguimentos , Migração de Corpo Estranho/diagnóstico , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Segunda Neoplasia Primária/diagnóstico , Tomografia por Emissão de Pósitrons/métodos , Radiocirurgia/métodos , Medição de Risco , Tomografia Computadorizada por Raios X/métodos , Resultado do TratamentoAssuntos
Altruísmo , Procedimentos Cirúrgicos Cardíacos , Missões Médicas , Atitude do Pessoal de Saúde , Procedimentos Cirúrgicos Cardíacos/educação , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Humanos , Missões Médicas/organização & administração , Missões Médicas/estatística & dados numéricosRESUMO
The fundamental requirements for a meaningful biomarker have not been met in the prediction of the aneurysm trait, the progression of the aneurysm disease state, or the prevention of catastrophic aortic complications. Aortic aneurysm is a worthy opponent on all fronts, and clinicians should continue actively to evaluate all potential diagnostic and therapeutic adjuncts with high levels of scientific scrutiny and rigor, so that the understanding and management of this disease process evolves in a complementary, rather than duplicative, manner. In the meantime, proteomics, genomics, and metabolomics continue to represent a muse of sorts in scientific circles, but clinicians are responsible for verifying the relevance and meaningful application of its postulates as they apply to individual patients within the context of efficient and effective global health care delivery.
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Aneurisma da Aorta Torácica/diagnóstico , Biomarcadores/análise , Aneurisma da Aorta Torácica/genética , Aneurisma da Aorta Torácica/metabolismo , Diagnóstico Diferencial , Testes Genéticos/métodos , Humanos , Reprodutibilidade dos Testes , Índice de Gravidade de DoençaRESUMO
This paper addresses clinical controversies and uncertainties regarding thoracic aortic aneurysm and its treatment. 1) Estimating true aortic size is confounded by obliquity, asymmetry, and noncorresponding sites: both echocardiography and computed tomography/magnetic resonance imaging are necessary for complete assessment. 2) Epidemiology of thoracic aortic aneurysm. There has been a bona fide increase in incidence of aortic aneurysm making aneurysm disease the 18th most common cause of death. 3) Aortic growth rate. Although a virulent disease, thoracic aortic aneurysm is an indolent process. The thoracic aorta grows slowly-0.1 cm/year. 4) Evidence-based intervention criteria. It is imperative to extirpate the thoracic aorta before rupture or dissection occurs; surgery at 5.0- to 5.5-cm diameter will prevent most adverse natural events. Symptomatic (painful) aneurysms must be resected regardless of size. 5) Development of nonsize criteria. Mechanical properties of the aorta deteriorate at the same 6 cm at which dissection occurs; elastic properties of the aorta may soon become useful intervention criteria. 6) Medical treatment of aortic aneurysm. Medical treatment is of unproven value, even beta-blockers and angiotensin-receptor blockers. 7) A genetic disease. Even non-Marfan aneurysms have a strong genetic basis. 8) Need for biomarkers. Virulent but silent, TAA cries out for a biomarker that can predict the onset of adverse events. Pathophysiologic understanding has led to identification of promising biomarkers, especially metalloproteinases. 9) Endovascular therapy for aneurysms. Endovascular therapy has burgeoned, despite the fact that the EVAR-2, DREAM, and INSTEAD trials showed no benefit at mid-term over medical or conventional surgical therapy. We must avoid "irrational exuberance." 10) Inciting events for acute aortic dissection. Recent evidence shows that dissections are preceded by a specific severe exertional or emotional event. 11) "Silver lining" of aortic disease. Proximal aortic root disease seems to protect against arteriosclerosis.
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Aneurisma da Aorta Torácica , Procedimentos Cirúrgicos Vasculares/métodos , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/epidemiologia , Aneurisma da Aorta Torácica/cirurgia , Aortografia , Ecocardiografia , Humanos , Incidência , Taxa de Sobrevida , Tomografia Computadorizada por Raios X , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: The three methods of brain preservation for aortic arch surgery--straight deep hypothermic circulatory arrest (DHCA) without perfusion adjuncts, retrograde cerebral perfusion, and antegrade cerebral perfusion--remain controversial. Patients in this report underwent surgery solely with DHCA. METHODS: Straight DHCA at 19 degrees C was used in 394 patients (267 males, 127 females) during a 10-year period. Mean age was 61.3 years (range, 15 to 88 years). Eighty-seven cases (22.1%) were urgent or emergencies. Thirty-eight (9.6%) were performed for descending or thoracoabdominal pathology and the rest for ascending/arch (102 hemiarch, 49 total arch). Ninety-one patients (23.1%) had dissections. The head was packed in ice. No barbiturate coma was used. RESULTS: DHCA lasted a mean of 31.0 minutes (range, 10 to 66 minutes). Reexploration for bleeding was required in 4.5% (18/394). Overall mortality was 6.3% (25/394). Mortality was 3.6% (11/307) for elective cases and 16% (14/87) for emergency cases. The stroke rate was 4.8% (19/394). The seizure rate was 3.1% (12/394). Forty-five patients with high professional cognitive demands (MD, PhD, attorney, etc) performed without detriment postoperatively. Among patients with DHCA exceeding 40 minutes, the stroke rate was 13.1% (8/61); a neuroradiologist's review of brain computed tomography scans found 62.5% of these strokes (5/8) to be embolic and 37.5% (3/8) hypoperfusion related. By multivariable logistic regression, emergency operation and descending location increased morbidity and mortality. CONCLUSIONS: Straight DHCA without adjunctive perfusion suffices as a sole means of cerebral protection. Stroke and seizure rates are low. Cognitive function, by clinical assessment, is excellent. Especially for straightforward ascending/arch reconstructions, there is little need for the added complexity of brain perfusion strategies.