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Background and Objectives: The aim of this study was to evaluate the clinical outcomes of patients suffering from chronic limb-threatening ischemia (CLTI) and tissue loss treated with primary isolated femoral bifurcation endarterectomy (FBE) or with FBE combined with bypass surgery. Materials and Methods: This retrospective study was performed in a tertiary university-based care centre. Between January 2008 and December 2019, a prospectively collected database of patients suffering from CLTI and tissue loss and undergoing either primary FBE (group A) or FBE in combination with bypass surgery (group B) was analysed. Study endpoints were ulcer healing, primary and secondary patency rate, limb salvage, and survival. Results: In total, FBE was performed in 73 patients and FBE with bypass in 60 patients. Between both groups, there were no significant differences regarding demographic data or the Global Limb Anatomic Staging System (GLASS) grade III and IV of femoropopliteal lesions. After 3 years, ulcer healing could be achieved in 72% of FBE and in 75% of FBE with bypass patients. The primary patency rate was 95% and 91% for FBE and 83% and 80% for FBE with bypass after one and three years, respectively. The 3-year limb-salvage rate was 78% for FBE and 84% for FBE with bypass. The secondary patency rate after one and three years was 99% and 97% for FBE and 93% and 88% for FBE with bypass. Conclusions: FBE and FBE with bypass are equally effective for ulcer healing in cases of combined CFA and superficial femoral artery lesions. There was no significant difference between both groups regarding primary and secondary patency rates, limb salvage rates and ulcer healing. Isolated FBE could be an alternative strategy in patients with higher operative risk.
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Doença Arterial Periférica , Enxerto Vascular , Humanos , Isquemia Crônica Crítica de Membro , Estudos Retrospectivos , Úlcera/etiologia , Endarterectomia/efeitos adversos , Enxerto Vascular/efeitos adversos , Resultado do Tratamento , Grau de Desobstrução Vascular , Doença Arterial Periférica/cirurgia , Fatores de RiscoRESUMO
BACKGROUND: Carotid bifurcation revascularization using interposition grafts is rare. While internal carotid artery (ICA) revascularization is regarded as mandatory, the external carotid artery (ECA) is severed in most instances. Long-term results of an autologous bifurcated carotid artery reconstruction are discussed. METHODS: Single-center, retrospective analysis of a consecutive series of patients treated at an academic vascular surgery center. RESULTS: From December 2006 to November 2019, fifty-one patients underwent reconstruction of the carotid artery using an autologous bifurcated interposition graft (38 males, 75%; median age: 68.7 years; interquartile range [IQR]: 60.2-76.5). Thirty-eight patients were asymptomatic (74.5%). Indication for reconstruction was recurrent carotid stenosis unfavorable for endovascular treatment/redo patch plasty (n = 32, symptomatic: n = 7), carotid aneurysm (n = 11, symptomatic: n = 5), neck tumor with vascular involvement (n = 7), trauma (n = 1). Nonreversed valve depleted saphenous vein y-graft from the groin was used in 49 (94.2%) and reversed cubital vein bifurcation in 3 (5.8%) procedures. The median ICA cross-clamp time was 15 min (IQR: 13-20 min). In four procedures (7.7%), a shunt was inserted because of a significant decrease of cerebral perfusion. In one patient, additional intraoperative stent placement of a proximal common carotid artery (CCA) stenosis was performed. Six patients suffered from ischemic neurological deficits (11.5%), all but 1 recovered with no or moderate symptoms. After a median follow-up of 5.2 years (IQR: 1.1-8.7 years), 7 significant asymptomatic stenoses (13.5%) and 2 occlusions (3.8%, one symptomatic) of the ICA, two significant asymptomatic CCA stenoses (3.8%), five significant stenoses (9.6%) and 7 asymptomatic occlusions (13.5%) of the ECA were observed. This prompted 7 re-redo-interventions in 5 patients. Twenty-eight patients (54.9%) died after a median follow-up of 3.3 years (IQR: 0.5-5.6 years). Two of these patients died due to conditions related to the performed carotid artery reconstruction. CONCLUSIONS: Autologous bifurcated carotid artery interposition graft provides results comparable to other complex ICA revascularizations. Overall survival in this heterogeneous patient cohort is poor. Due to the high risk of stroke and poor long-term outcome, this procedure should be reserved for symptomatic patients with no other option for revascularization.
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Artéria Carótida Interna , Estenose das Carótidas , Masculino , Humanos , Idoso , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Artéria Carótida Interna/patologia , Constrição Patológica , Estudos Retrospectivos , Resultado do Tratamento , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Estenose das Carótidas/patologia , Procedimentos Cirúrgicos Vasculares , Artéria Carótida ExternaRESUMO
OBJECTIVES: The aim of this study was to compare aortic diameters from admission computed tomography angiography (CTA) scans to postoperative aortic diameters in patients with traumatic aortic injury (TAI) and evaluate the influence of substantial blood loss on aortic diameter. METHODS: The aortic databases of two tertiary university centers were retrospectively screened for patients with TAI between February 2002 and February 2019. Concomitant organ injuries, bone fractures, blood loss, and clinical outcomes were evaluated. Aortic diameters were measured in CTA upon admission and were compared with the CTA before discharge at three different aortic levels (mid-ascending, 5 cm distal to the end of the stent graft, and at the celiac trunk level). RESULTS: We identified 45 patients, aged 43 (first quartile; third quartile [26; 55]) years with a TAI treated by thoracic endovascular aortic repair. The most frequent cause of TAI was a car accident (n = 24). Concomitant injuries were seen in all but one patient. Bone and pelvic fractures were seen in 40 (89%) and 15 (33%) patients, respectively. Type III aortic injury was present in 25 patients (56%). Increase of aortic diameter after stabilization was +1.7 mm (-0.6 mm; 2.5 mm; p = 0.004) at the mid-ascending aorta, +2.1 mm (0.2 mm; 3.8 mm; p < 0.001) 5 cm distal to the stent graft, and +1.5 mm (0.5 mm; 3.2 mm; p < 0.001) at the celiac trunk level. CONCLUSION: In patients with TAI, the aortic diameter is significantly reduced as compared with the aortic diameter at discharge. The reduction of aortic diameter might be caused by hemorrhagic shock and should be kept in mind for appropriate stent-graft sizing.
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Implante de Prótese Vascular , Procedimentos Endovasculares , Lesões do Sistema Vascular , Aorta/cirurgia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Humanos , Estudos Retrospectivos , Stents , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/cirurgiaRESUMO
INTRODUCTION: The indication for surgical valve replacement in cases of infective endocarditis is well defined in current guidelines. However, some patients are not fit or willing to undergo major surgical procedures. Interestingly, to the best of our knowledge, there is scarce information in the literature on how to deal with such cases and what might be the outcome. CASE REPORT: We present two complicated cases of prosthetic infective endocarditis with definite indication for replacement of involved foreign material, who were treated successfully with long-term suppressive antibiotic therapy. CONCLUSION: These two cases demonstrate that individualized long-term antibiotic suppressive therapy might be effective in selected patients with complicated PVE unfit or unwilling to undergo high-risk cardiothoracic surgical interventions.
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Antibacterianos/uso terapêutico , Prótese Vascular/efeitos adversos , Endocardite Bacteriana/tratamento farmacológico , Próteses Valvulares Cardíacas/efeitos adversos , Infecções Relacionadas à Prótese/tratamento farmacológico , Idoso , Aorta/microbiologia , Prótese Vascular/microbiologia , Endocardite Bacteriana/microbiologia , Feminino , Próteses Valvulares Cardíacas/microbiologia , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/microbiologia , Artéria Subclávia/microbiologiaRESUMO
BACKGROUND: evidence-based medicine (EBM) approaches have reached broad acceptance, both in conservative and surgical disciplines. The aim of this study is to clarify the role of EBM in a rare condition of aortic regurgitation (AR) with surgical indication. METHODS: A purpose-built Internet-based questionnaire was sent to 607 cardiovascular surgeons in Germany, Austria, and Switzerland. A virtual 64-year-old patient's medical history was presented, including two ultrasound images and one computed tomography scan, showing a 58-mm aortic root aneurysm and a severe trileaflet regurgitant aortic valve. Participants had to choose their preferred therapeutic strategy from a list. Additionally, demographics including nationality, the center size, and the frequency of similar types of patients referred to their departments were collected. RESULTS: Of 607 questionnaires, 100 were returned (16%). One participant was excluded due to conflicting answers. Most surgeons (n = 84; 84%) chose a valve-sparing root replacement (VSRR). A Bentall procedure was preferred by 13 surgeons (13%). Two surgeons voted for aortic valve replacement combined with partial root resection. The decision-making process was not significantly influenced by center size, nationality, or frequency of patients. CONCLUSION: Applying the current guidelines to our virtual study patient, 84% of participants acted accordingly choosing VSRR. Remarkably, 14% of these surgeons see less than 10 and 43% see not more than 20 comparable patients per year. Since the guidelines reserve VSRR for competent centers, those numbers as well as the guidelines themselves should be further discussed.
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Aneurisma Aórtico/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese Vascular/tendências , Medicina Baseada em Evidências/tendências , Implante de Prótese de Valva Cardíaca/tendências , Padrões de Prática Médica/tendências , Cirurgiões/tendências , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/fisiopatologia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Aortografia/tendências , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada/tendências , Ecocardiografia Doppler em Cores/tendências , Europa (Continente) , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Carga de TrabalhoRESUMO
OBJECTIVES: The aim of the study was to investigate the potential prognostic role of preoperative measurement of erector spinae myosteatosis with Hounsfield Unit Average Calculation (HUAC) as a marker for sarcopenia and frailty in patients undergoing coronary bypass surgery (CABG). METHODS: Preoperative computer tomography (CT) derived measurements of 479 consecutive patients undergoing CABG between January 2017 and December 2019 were retrospectively performed. The erector spinae muscle at the level of the 12th vertebra was manually outlined bilaterally on the axial CT slices and Hounsfield Unit Average Calculation (HUAC) was performed. The lower quartile of muscle density values was defined as myosteatotic and thus sarcopenic. Sarcopenic (n = 121) versus non-sarcopenic patients (n = 358) were compared regarding postoperative morbidity, short-term and long-term mortality. Results were adjusted for age, Body Mass Index (BMI), atrial fibrillation and hypertension using inverse probability weighting (IPW). RESULTS: Sarcopenia was associated with higher 30-day mortality (4.1% vs 0.8% p = 0.012), mid-term mortality after 1 year (9.3% vs 3.1% p = 0.047) and 2 years (10.8% vs 4.2% p = 0.047). Long-term mortality (5 years) was 20.8% for sarcopenic and 13.0% for non-sarcopenic patients but was not found to be significantly different (p = 0.089). Sarcopenia was associated with higher rates of reintubation (7.5% vs 1.1% p < 0.001), sternal wound infections (7.5% vs 2.8% p = 0.039) and acute kidney injury requiring hemodialysis (2.5% vs 0.4% p = 0.021). CONCLUSIONS: In patients undergoing coronary bypass surgery, sarcopenia was associated with increased short-term mortality, mid-term mortality and morbidity. The measurement of erector spinae myosteatosis could be an easy and useful parameter in preoperative risk assessment.
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Background/Objectives: Infective endocarditis (IE) often requires surgical intervention, with postoperative acute kidney injury (AKI), posing a significant concern. This retrospective study aimed to investigate AKI incidence, its impact on short-term mortality, and identify modifiable factors in patients with IE scheduled for valve surgery. Methods: This single-center study enrolled 130 consecutive IE patients from 2013 to 2021 undergoing valve surgery. The creatinine levels were monitored pre- and postoperatively, and AKI was defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patient demographics, comorbidities, procedural details, and complications were recorded. Primary outcomes included AKI incidence; the relevance of creatinine levels for AKI detection; and the association of AKI with 30-, 60-, and 180-day mortality. Modifiable factors contributing to AKI were explored as secondary outcomes. Results: Postoperatively, 35.4% developed AKI. The highest creatinine elevation occurred on the second postoperative day. Best predictive value for AKI was a creatinine level of 1.35 mg/dL on the second day (AUC: 0.901; sensitivity: 0.89, specificity: 0.79). Elevated creatinine levels on the second day were robust predictors for short-term mortality at 30, 60, and 180 days postoperatively (AUC ranging from 0.708 to 0.789). CK-MB levels at 24 h postoperatively and minimum hemoglobin during surgery were identified as independent predictors for AKI in logistic regression. Conclusions: This study highlights the crucial role of creatinine levels in predicting short-term mortality in surgical IE patients. A specific threshold (1.35 mg/dL) provides a practical marker for risk stratification, offering insights for refining perioperative strategies and optimizing outcomes in this challenging patient population.
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OBJECTIVE: To evaluate the efficacy of tezosentan in reducing the incidence of right ventricular (RV) failure and associated mortality in patients with pre-existing pulmonary hypertension. The primary endpoint was the proportion of patients with RV failure during weaning from cardiopulmonary bypass (CPB), assessed 30 minutes after the end of CPB. DESIGN: Multicenter, double-blind, randomized, placebo-controlled trial. SETTING: Thirty-one cardiac surgical centers in 14 countries. PARTICIPANTS: Two hundred seventy-four patients with pulmonary hypertension aged ≥ 18 years scheduled to undergo cardiac surgery. INTERVENTION: Intravenous tezosentan (5 mg/h) during surgery and up to 24 hours afterwards (1 mg/h), or matched placebo. MEASUREMENTS AND MAIN RESULTS: One-hundred thirty-three patients received tezosentan and 141 placebo. RV failure occurred in 30 patients (10.9%), 37% of whom died. There was no difference in the incidence of RV failure between the two treatment groups (relative risk reduction: 0.07 [95% CI-0.83, 0.53; P = 0.8278]). CONCLUSION: A reduction in RV failure with tezosentan was not observed in this study.(Current Controlled Trials, identifier NCT00458276).
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Procedimentos Cirúrgicos Cardíacos/métodos , Hipertensão Pulmonar/tratamento farmacológico , Piridinas/uso terapêutico , Tetrazóis/uso terapêutico , Vasodilatadores/uso terapêutico , Disfunção Ventricular Direita/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar , Método Duplo-Cego , Determinação de Ponto Final , Feminino , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/epidemiologia , Humanos , Hipertensão Pulmonar/complicações , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Piridinas/administração & dosagem , Tetrazóis/administração & dosagem , Vasodilatadores/administração & dosagem , Disfunção Ventricular Direita/complicações , Adulto JovemRESUMO
BACKGROUND: Aortic valve replacement is one of the most common cardiac surgical procedures, especially in elderly patients. Whether or not there is a net life gain over a long period of time is a matter for debate. OBJECTIVE: To compare survival of patients with that of the age, sex, and follow-up year-matched normal population (relative survival). DESIGN: Single-centre, prospectively collected data. SETTING: Tertiary care centre, Vienna, Austria. PATIENTS: We enrolled 1848 patients undergoing elective aortic valve replacement between 1997 and the end of 2008. INTERVENTIONS: None. MAIN OUTCOME MEASUREMENT: Relative survival at the end of 2011 as determined by relative Cox regression analysis. RESULTS: Sixty-nine patients (3.7%) died within the first 30 days. Another 70 patients (3.8%) died within the first year and 429 (23.2%) died during the remaining follow-up period. The longest follow-up period was 14 years (median, 5.8; interquartile range, 3.2 to 8.9). Medical risk indicators for relative survival were diabetes mellitus [hazard ratio 1.69, 95% confidence interval, CI 1.37 to 2.07, P<0.001], pulmonary disease (hazard ratio 1.45, 95% CI 1.16 to 1.81, P=0.001), history of atrial fibrillation (hazard ratio 1.35, 95% CI 1.10 to 1.66, P=.005) and angiotensin-converting enzyme inhibitor medication (hazard ratio 1.21, 95% CI 1.02 to 1.44, P=0.031). Perioperative risk indicators were urgent surgery (hazard ratio 1.40, 95% CI 1.00 to 1.94, P=0.047), resternotomy at 48 h or less (hazard ratio 1.87, 95% CI 1.29 to 2.70, P=0.001), resternotomy at more than 48 h (hazard ratio 1.80, 95% CI 1.32 to 2.45, P<0.001), blood transfusion (hazard ratio 1.06, 95% CI 1.01 to 1.12, P=0.018) and renal replacement therapy (hazard ratio 2.02, 95% CI 1.41 to 2.90, P<0.001). Relative survival was highest in the oldest age quartile (76 to 94 years) and lowest in the youngest (19 to 58 years) (hazard ratio 0.27, 95% CI 0.21 to 0.36; P<0.001). CONCLUSION: Patients who survived the first year after aortic valve replacement had a similar chance of survival as the matched normal population. Relative survival benefit was higher in the oldest age quartile.
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Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/métodos , Adulto , Idoso , Feminino , Doenças das Valvas Cardíacas/mortalidade , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Risco , Resultado do Tratamento , Adulto JovemRESUMO
This paper presents a rare case of malignant melanoma metastasizing to the heart, highlighting the diagnostic journey, therapeutic considerations, and clinical implications. Enhanced awareness of atypical metastases aids early recognition and treatment strategies for improved patient care. Comprehensive understanding of cardiac involvement in melanoma contributes to better outcomes and clinical decision making. (Level of Difficulty: Beginner.).
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Introduction: Hypertrophies of the cardiac septum are caused either by aortic valve stenosis (AVS) or by congenital hypertrophic obstructive cardiomyopathy (HOCM). As they induce cardiac remodeling, these cardiac pathologies may promote an arrhythmogenic substrate with associated malignant ventricular arrhythmias and may lead to heart failure. While altered calcium (Ca2+) handling seems to be a key player in the pathogenesis, the role of mitochondrial calcium handling was not investigated in these patients to date. Methods: To investigate this issue, cardiac septal samples were collected from patients undergoing myectomy during cardiac surgery for excessive septal hypertrophy and/or aortic valve replacement, caused by AVS and HOCM. Septal specimens were matched with cardiac tissue obtained from post-mortem controls without cardiac diseases (Ctrl). Results and discussion: Patient characteristics and most of the echocardiographic parameters did not differ between AVS and HOCM. Most notably, the interventricular septum thickness, diastolic (IVSd), was the greatest in HOCM patients. Histological and molecular analyses showed a trend towards higher fibrotic burden in both pathologies, when compared to Ctrl. Most notably, the mitochondrial Ca2+ uniporter (MCU) complex associated proteins were altered in both pathologies of left ventricular hypertrophy (LVH). On the one hand, the expression pattern of the MCU complex subunits MCU and MICU1 were shown to be markedly increased, especially in AVS. On the other hand, PRMT-1, UCP-2, and UCP-3 declined with hypertrophy. These conditions were associated with an increase in the expression patterns of the Ca2+ uptaking ion channel SERCA2a in AVS (p = 0.0013), though not in HOCM, compared to healthy tissue. Our data obtained from human specimen from AVS or HOCM indicates major alterations in the expression of the mitochondrial calcium uniporter complex and associated proteins. Thus, in cardiac septal hypertrophies, besides modifications of cytosolic calcium handling, impaired mitochondrial uptake might be a key player in disease progression.
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OBJECTIVES: The aim of this study was to evaluate the impact of concomitant ascending aortic replacement on operative morbidity and mortality in patients undergoing aortic valve replacement (AVR). METHODS: We retrospectively analysed our institutional database for all patients undergoing elective isolated AVR and AVR with concomitant replacement of the ascending aorta between January 2009 and May 2020. Patients undergoing surgery for infective endocarditis or requiring hypothermic circulatory arrest were excluded. A 3:1 propensity matching was performed for 688 patients to compare isolated AVR (120 patients) with AVR + ascending aortic replacement (40 patients). RESULTS: There were significant differences in median cardiopulmonary bypass (CPB) time [92.5 (75-114) vs 118.5 (104-131) min; P < 0.001], median aortic cross-clamp time [65.0 (51.5-78.5) vs 84.5 (77-94) min; P < 0.001] and median intensive care unit stay [1 (1-3) vs 2 (1-6) days; P < 0.01]. There was no significant difference in the use of intraoperative and postoperative blood products, re-exploration for bleeding, postoperative atrial fibrillation, acute renal failure, incidence of stroke, perioperative myocardial infarction and 30-day mortality. CONCLUSIONS: Concomitant replacement of the ascending aorta significantly prolongs CPB and aortic clamp times but does not increase operative morbidity and mortality. Therefore, replacement of a dilated ascending aorta appears to be the most durable and safest treatment option in patients undergoing AVR with an aneurysmatic ascending aorta.
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Valva Aórtica , Implante de Prótese de Valva Cardíaca , Aorta/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Morbidade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: A lower hemisternotomy is an infrequently used approach in cardiac surgery. This single center report evaluates applicability and clinical outcomes of procedures performed through a lower hemisternotomy. METHODS: The institutional database was reviewed. From 2014 to 2019, 55 consecutive patients had undergone minimally invasive procedures through a lower hemisternotomy (median follow-up 34 months). Demographic as well as outcome data were retrieved from our prospectively maintained institutional database. RESULTS: Performed procedures included mitral and tricuspid repairs, aortic valve replacement as well as coronary artery bypass grafting. The median patient age was 72 years. Out of the 55 patients, 55% were male. Predominantly mitral valve procedures (11 isolated, 30 combined) had been performed. Mitral valve procedures (N.=41) consisted of 36 repairs and 5 replacements. Repair rate for degenerative mitral insufficiency was 97.6%. Median EuroScore II was 3.4% (2.1-6.0). Median cross-clamp time was 67 (44-99) min. Median procedural length was 169 (138-201) min. Reoperation rate for bleeding was 1.8%. Major vascular complications occurred in two patients. Freedom from valve related reoperation was 96.1% during follow-up. Thirty-day mortality and overall mortality during follow-up was 3.6% and 10.9%. CONCLUSIONS: In properly selected cases the lower hemisternotomy allows for a variety of cardiac procedures. It permits central aortic cannulation and a direct vision of intracardiac structures and therefore should be kept in mind as an alternative minimally invasive approach.
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Ponte de Artéria Coronária , Cardiopatias/cirurgia , Implante de Prótese de Valva Cardíaca , Esternotomia/métodos , Adulto , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Bases de Dados Factuais , Feminino , Cardiopatias/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Esternotomia/efeitos adversos , Esternotomia/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Despite recommendations for standardized preoperative waiting of at least 3, 5, and 7 days for ticagrelor, clopidogrel, and prasugrel, respectively, there is still substantial interinstitutional variation in preoperative discontinuation of dual antiplatelet therapy in patients needing coronary artery bypass grafting (CABG). METHODS: In 299 patients undergoing CABG with or without valve intervention less than 7 days after last P2Y12 receptor inhibition, this study evaluated calculated red blood cell loss and Bleeding Academic Research Consortium type 4 (BARC-4) bleeding. RESULTS: A total of 83% of patients underwent CABG less than 48 hours after last drug intake. Calculated blood loss was lower in patients taking clopidogrel as compared with prasugrel or ticagrelor (1063 mL [690 to 1394 mL] vs 1351 mL [876 to 1829 mL] vs 1330 mL [994 to 1691 mL]; P < .001). Overall, 135 (45%) patients sustained BARC-4 bleeding; the incidence differed among the groups (P = .015) and was significantly higher in prasugrel-treated patients, as compared with clopidogrel-treated patients. In multivariable linear regression analysis, European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), aspirin dose, cardiopulmonary bypass time, drug withdrawal time, and type of P2Y12 receptor inhibitor were significantly associated with red blood cell loss. Compared with 0 to 24 hours, a period of more than 48 hours of preoperative discontinuation substantially reduced calculated blood loss by 37% to 48% and BARC-4 bleeding by 58% to 71%, depending on the P2Y12 receptor inhibitor. CONCLUSIONS: Exposure to prasugrel and ticagrelor 24 hours or less before CABG increases both calculated blood loss and BARC-4 bleeding as compared with clopidogrel. Although discontinuation for longer than 48 hours substantially reduced calculated blood loss and BARC-4 bleeding across all P2Y12 receptor inhibitors, our single-center data further support strict adherence to the 2017 guidelines whenever justified by stable hemodynamics and nonjeopardized myocardium.
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Clopidogrel/administração & dosagem , Ponte de Artéria Coronária , Hemorragia/epidemiologia , Inibidores da Agregação Plaquetária/administração & dosagem , Cloridrato de Prasugrel/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Ticagrelor/administração & dosagem , Suspensão de Tratamento , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Estudos Prospectivos , Fatores de TempoRESUMO
This position statement is an update to the 2011 consensus statement of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGTHG) for transfemoral transcatheter aortic valve implantation.Due to a number of recently published studies, broadening of indications and recommendations of medical societies and our own national developments, the ÖKG and the ÖGHTG wish to combine the 2017 ESC/EACTS guidelines for the management of valvular heart disease with a national position paper and to focus on certain details for the application in Austria. Thus, this position statement serves as a supplement and further interpretation of the international guidelines.
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Estenose da Valva Aórtica , Cardiologia , Doenças das Valvas Cardíacas , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Estenose da Valva Aórtica/cirurgia , Áustria , HumanosRESUMO
This report describes a technique to create a biologic Bentall from a pericardial tube and a rapid deployment valve. This technique facilitates reimplantation of the coronary arteries because the proximal anastomosis is sewn before valve implantation and allows suturing of the coronary ostia from inside and outside, given that there is no interference with the implanted valve. Indications for this technique include complex redo cases and patients with contraindications to a conventional Bentall procedure. This technique has been used in 2 patients with good results.
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Valva Aórtica/cirurgia , Vasos Coronários/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Valva Mitral/cirurgia , Pericárdio/cirurgia , Idoso , Anastomose Cirúrgica , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reimplante , Técnicas de Sutura , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
PURPOSE: The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. DESCRIPTION: This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. EVALUATION: The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. CONCLUSIONS: The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.
Assuntos
Aorta Torácica/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca/métodos , Parada Cardíaca Induzida/métodos , Próteses Valvulares Cardíacas , Animais , Insuficiência da Valva Aórtica/diagnóstico , Cateterismo Cardíaco , Modelos Animais de Doenças , Ecocardiografia , Pressão , Desenho de Prótese , SuínosRESUMO
OBJECTIVES: The aim of the study was to compare the conventional frozen elephant trunk implantation technique with a modified implantation technique with an aortic anastomosis in zone 1 and extra-anatomic revascularization of the left subclavian artery during reperfusion. METHODS: Between May 2014 and March 2018, 40 patients (26 male; mean age 60.2 ± 11.2 years) underwent complete aortic arch replacement with the Thoraflex Hybrid prosthesis™ (Vascutek, Inchinnan, Scotland) at our institution. Seventeen patients underwent conventional arch replacement (group 1) and 23 patients the modified procedure (group 2). Indication for arch replacement included all types of acute and chronic diseases. RESULTS: Cardiopulmonary bypass time (213.1 ± 53.5 vs 243.8 ± 67.0 min, P = 0.13) and aortic cross-clamp time (114.4 ± 40.7 vs 117.3 ± 56.6 min, P = 0.86) did not differ significantly between group 1 and 2. There was a trend towards a shorter circulatory arrest time (50.72 ± 9.6 vs 44.7 ± 15.5 min; P = 0.20) in group 2. Perioperative mortality was 10% (5.9% vs 13%; P = 0.62). Stroke occurred in 10% (5.9% vs 13%; P = 0.62) of patients. Spinal cord injury occurred in 7.5% of patients (11.8% vs 4.3% P = 0.57). Due to the a proximal aortic anastomosis, there was a significantly shorter coverage of the descending aorta with the prosthesis ending at vertebral level Th7.5 (6.75-8) in group 1 versus Th6.0 (5.0-6.0) in group 2 (P-value = 0.004). CONCLUSIONS: Implantation of the frozen elephant trunk prosthesis in zone 1 allows for a more proximal aortic anastomosis that could make the procedure more feasible especially in patients with difficult anatomies or in an acute setting.
Assuntos
Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Idoso , Dissecção Aórtica/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Masculino , Pessoa de Meia-Idade , Stents , Resultado do TratamentoRESUMO
Endovascular treatment of thoracic aortic pathologies has recently progressed towards more proximal pathologies, including those of the aortic arch and ascending aorta where there is a higher risk for stent-graft migration during the deployment or the moulding procedure due to the beating and ejecting heart. Typical measures to prevent dislodgement of the balloon or the stent-graft during the procedure are rapid pacing or pharmacologically induced hypotension. We present a circular and fully non-occlusive stent-graft moulding balloon that does not require any reduction of cardiac output or hypotension during inflation, moulding and deflation of the balloon.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Procedimentos Endovasculares/instrumentação , Stents , Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Desenho de Equipamento , Humanos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: This study sought to compare patency rates and clinical outcomes of nitinol stents and primary vein bypass in long femoropopliteal lesions. BACKGROUND: An endovascular-first strategy for long femoropopliteal lesions is widely recommended without sufficient data comparing it with bypass surgery. Nitinol stents are widely used as the standard endovascular therapy. METHODS: A single-center randomized controlled trial was performed with the primary endpoints of technical success, primary and secondary patency. Secondary endpoints were limb salvage, survival, complications, and clinical improvement. RESULTS: A total of 110 limbs (55 per group) in 103 patients were treated. Baseline and lesion characteristics were similar, with a mean lesion length of 276 mm. Critical limb threatening ischemia was the indication for treatment in 49% of limbs in both groups. Technical success was achieved in 87% in the stent group. During a 2-year follow-up, patency rates, limb salvage, survival and complications showed no significant differences between both groups. At 24 months, primary and secondary patency rates for the stent group were 60% and 72% versus 56% and 73% in the bypass group, respectively. Clinical improvement was significantly better in the bypass group. CONCLUSIONS: There were no significant differences regarding patency rates, limb salvage, survival, or complications after 2 years. Technical success and clinical improvement in the bypass group were significantly better, but the promising results of the stent group suggest that an endovascular-first strategy for femoropopliteal lesions up to 30 cm may be reasonable. Mid- as well as long-term results need to be awaited.