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OBJECTIVE: Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes. RESULTS: From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival. CONCLUSIONS: Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.
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Aneurisma de la Aorta Torácica/cirugía , Procedimientos Quirúrgicos Vasculares , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/mortalidad , Bases de Datos Factuales , Femenino , Disparidades en el Estado de Salud , Disparidades en Atención de Salud , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
BACKGROUND: Little evidence shows whether a third arterial graft provides superior outcomes compared with the use of 2 arterial grafts in patients undergoing coronary artery bypass grafting. A meta-analysis of all the propensity score-matched observational studies comparing the long-term outcomes of coronary artery bypass grafting with the use of 2-arterial versus 3-arterial grafts was performed. METHODS: A literature search was conducted using MEDLINE, EMBASE, and Web of Science to identify relevant articles. Long-term mortality in the propensity score-matched populations was the primary end point. Secondary end points were in-hospital/30-day mortality for the propensity score-matched populations and long-term mortality for the unmatched populations. In the matched population, time-to-event outcome for long-term mortality was extracted as hazard ratios, along with their variance. Statistical pooling of survival (time-to-event) was performed according to a random effect model, computing risk estimates with 95% confidence intervals. RESULTS: Eight propensity score-matched studies reporting on 10 287 matched patients (2-arterial graft: 5346; 3-arterial graft: 4941) were selected for final comparison. The mean follow-up time ranged from 37.2 to 196.8 months. The use of 3 arterial grafts was not statistically associated with early mortality (hazard ratio, 0.93; 95% confidence interval, 0.71-1.22; P=0.62). The use of 3 arterial grafts was associated with statistically significantly lower hazard for late death (hazard ratio, 0.8; 95% confidence interval, 0.75-0.87; P<0.001), irrespective of sex and diabetic mellitus status. This result was qualitatively similar in the unmatched population (hazard ratio, 0.57; 95% confidence interval, 0.33-0.98; P=0.04). CONCLUSIONS: The use of a third arterial conduit in patients with coronary artery bypass grafting is not associated with higher operative risk and is associated with superior long-term survival, irrespective of sex and diabetic mellitus status.
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Enfermedad de la Arteria Coronaria/terapia , Prótesis Vascular , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/patología , Bases de Datos Factuales , Diabetes Mellitus Tipo 2/complicaciones , Humanos , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Factores Sexuales , Tasa de SupervivenciaRESUMEN
Graft failure occurs in a sizeable proportion of coronary artery bypass conduits. We herein review relevant current evidence to give an overview of the incidence, pathophysiology, and clinical consequences of this multifactorial phenomenon. Thrombosis, endothelial dysfunction, vasospasm, and oxidative stress are different mechanisms associated with graft failure. Intrinsic morphological and functional features of the bypass conduits play a role in determining failure. Similarly, characteristics of the target coronary vessel, such as the severity of stenosis, the diameter, the extent of atherosclerotic burden, and previous endovascular interventions, are important determinants of graft outcome and must be taken into consideration at the time of surgery. Technical factors, such as the method used to harvest the conduits, the vasodilatory protocol, the storage solution, and the anastomotic technique, also play a major role in determining graft success. Furthermore, systemic atherosclerotic risk factors, such as age, sex, diabetes mellitus, hypertension, and dyslipidemia, have been variably associated with graft failure. The failure of a coronary graft is not always correlated with adverse clinical events, which vary according to the type, location, and reason for failed graft. Intraoperative flow verification and secondary prevention using antiplatelet and lipid-lowering agents can help reducing the incidence of graft failure.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Vasos Coronarios , Oclusión de Injerto Vascular , Enfermedad de la Arteria Coronaria/metabolismo , Enfermedad de la Arteria Coronaria/patología , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/metabolismo , Vasos Coronarios/patología , Vasos Coronarios/fisiopatología , Vasos Coronarios/cirugía , Oclusión de Injerto Vascular/metabolismo , Oclusión de Injerto Vascular/patología , Oclusión de Injerto Vascular/fisiopatología , Humanos , Factores de RiesgoRESUMEN
OBJECTIVE: Despite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients. METHODS: Our institutional aortic database was queried to identify those ≥80 years old and those <80 years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes. RESULTS: From 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80 years old. Octogenarians were more likely to be female (P = .018), with chronic pulmonary disease (P = .012), severe peripheral vascular disease (P < .001), and hypertension (P = .025). Degenerative aneurysms were more common among octogenarians (P < .001), whereas chronic and acute dissections were more common among those younger than 80 years (P < .001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80 years, 5.7%; ≥80 years, 5.6%; P = .852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80 years, 6.7%; ≥ 80 years, 1.0%; P = .029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80 years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; P < .001), which led to significantly shorter cross-clamp times in this cohort (26.6 minutes vs 30.7 minutes; P < .004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; P < .025). Short- and long-term survival was significantly reduced in octogenarians. CONCLUSIONS: In select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome.
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Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Factores de Edad , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Tempo Operativo , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: We sought to investigate the impact of radial artery harvesting techniques on clinical outcomes using a meta-analytic approach limited to randomized controlled trials and propensity-matched studies for clinical outcomes, in which graft patency was analyzed. METHODS: A systematic literature review was conducted using PubMed and MEDLINE to identify publications containing comparisons between endoscopic radial artery harvesting (ERAH) and open harvesting (ORAH). Only randomized controlled trials and propensity-matched series were included. Data were extracted and analyzed with RevMan. The primary endpoint was wound complication rate, while secondary endpoints were patency rate, early mortality, and long-term cardiac mortality. RESULTS: Six studies comprising 743 patients were included in the meta-analysis. Of them 324 (43.6%) underwent ERAH and 419 (56.4%) ORAH. ERAH was associated with a lower incidence of wound complications (odds ratio: 0.33, confidence interval 0.14-0.77; p = 0.01). There were no differences in graft patency, and early and long-term cardiac mortality between the two techniques. CONCLUSION: ERAH reduces wound complications and does not affect graft patency, or short- and long-term mortality compared to ORAH.
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Endoscopía/métodos , Supervivencia de Injerto , Puntaje de Propensión , Arteria Radial/cirugía , Ensayos Clínicos Controlados Aleatorios como Asunto , Recolección de Tejidos y Órganos/métodos , Bases de Datos Bibliográficas , Endoscopía/efectos adversos , Endoscopía/mortalidad , Humanos , Pronóstico , Dehiscencia de la Herida Operatoria/prevención & control , Infección de la Herida Quirúrgica/prevención & control , Factores de Tiempo , Recolección de Tejidos y Órganos/efectos adversos , Recolección de Tejidos y Órganos/mortalidadRESUMEN
BACKGROUND: The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS: We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS: A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS: Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.
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Mamoplastia , Colgajo Perforante , Humanos , Abdomen/cirugía , Mama/cirugía , Arterias Epigástricas/cirugía , Mamoplastia/efectos adversos , Mamoplastia/métodos , Colgajo Perforante/efectos adversos , Colgajo Perforante/cirugía , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugíaRESUMEN
Purpose: Infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased costs. This study aimed to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on cost. Methods: This study used the PearlDiver national database, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020. The cohort included patients undergoing distal radius fracture fixation. The endpoint was postoperative infection within 180 days of fixation. Two-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. A propensity-matched cohort was created using patient age, gender, and open fracture. Logistic regression analyses defined independent risk factors for developing a postoperative infection among all patients and within the matched cohorts. A Mann-Whitney U test was used to compare costs of care with and without infection. Results: The database included 87,169 patients who underwent distal radius fracture fixation. Postoperative infections were identified in 781 patients (0.9%). There was a significant difference in rates of postoperative infection with percutaneous fixation (1.3%) versus open fixation (0.8%). Logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco to be independent risk factors for developing a postoperative infection. Logistic regression analysis of the propensity-matched cohorts identified tobacco use as a significant risk factor. The average cost of care for patients undergoing fracture fixation without an infection was $6,383, versus $23,355 for those with an infection, which was significantly different. Conclusions: Multiple risk factors for postoperative infection were identified. Cost is significantly increased after postoperative infection, by almost 4-fold. Attempts to correct or optimize modifiable risk factors may lead to substantial cost savings, and potentially decreased rates of infection. Type of study/level of evidence: Prognostic III.
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OBJECTIVES: Both the open and endovascular techniques are commonly used for harvesting the radial artery (ORAH and ERAH, respectively), and yet, very little is known about the effects of these 2 techniques on endothelial integrity and function of the radial artery (RA). The aim of this study was to assess the endothelial integrity and function of RA harvested using the 2 approaches. METHODS: Two independent surgical teams working in the same institution routinely use the RA for coronary artery bypass grafting exclusively employing either ORAH or ERAH. Thirty-nine consecutive patients were enrolled in this comparative study. Endothelial function after ORAH or ERAH was assessed by using the wire myograph system. The integrity of the RA endothelium was evaluated by immunohistochemical staining for erythroblast transformation specific-related gene. RESULTS: The vasodilation in response to acetylcholine was significantly higher in RA harvested with ORAH (P ≤ 0.001 versus ERAH). Endothelial integrity was not different between the 2 groups. CONCLUSIONS: ORAH is associated with a significantly higher endothelium-dependent vasodilation. Further investigation on the potential implications of these findings in terms of graft spasm and patency as well as clinical outcomes are needed.
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Puente de Arteria Coronaria , Endoscopía , Procedimientos Endovasculares , Arteria Radial/trasplante , Recolección de Tejidos y Órganos , Anciano , Endotelio Vascular/patología , Endotelio Vascular/fisiopatología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Arteria Radial/patología , Arteria Radial/fisiopatología , VasodilataciónRESUMEN
BACKGROUND: This meta-analysis of randomized controlled trials (RCTs) was aimed at comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary disease. METHODS: All RCTs randomizing patients to any type of PCI with stents vs. CABG for left main disease (LMD) were included. Primary outcome was a composite of follow-up death/myocardial infarction/stroke/repeat revascularization. Secondary outcomes were peri-procedural mortality and the individual components of the primary outcome. Incidence rate ratio (IRR) or odds ratio (OR) and 95% confidence intervals (CIs) were pooled using a generic inverse variance method with random effects model. Subgroup analyses were done based on: (I) type of PCI [bare metal stents (BMS) vs. drug-eluting stents (DES)] and; (II) mean SYNTAX score tertiles. Leave one-out analysis and meta-regression were performed. RESULTS: Six trials were included (4,700 patients; 2,349 PCI and 2,351 CABG). Follow-up ranged from 2.33 to 5 years. PCI was associated with higher risk of follow-up death/myocardial infarction/stroke/repeat revascularization (IRR =1.328, 95% CI, 1.114-1.582, P=0.002) and of repeated revascularization (IRR =1.754, 95% CI, 1.470-2.093, P<0.001). The risk of peri-procedural mortality (OR =0.866, 95% CI, 0.460-1.628, P=0.654), follow-up mortality (IRR =0.947, 95% CI, 0.711-1.262, P=0.712), myocardial infarction (IRR =1.342, 95% CI, 0.827-2.179, P=0.234) and stroke (IRR =0.800, 95% CI, 0.374-1.710, P=0.565) were similar between groups. No differences were found between DES and BMS subgroups. The risk of follow-up death/myocardial infarction/stroke/repeat revascularization with PCI was higher in all SYNTAX tertiles, with a progressive increase from the 1st to the 3rd tertile. At meta-regression, higher mean SYNTAX score was associated with higher risk for the primary outcome in the PCI group (beta =0.02, P=0.05), whereas no association was found with female gender, mean age, or diabetes. CONCLUSIONS: CABG remains the therapy of choice for the treatment of unprotected LMD, especially for patients with a high SYNTAX score.
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BACKGROUND: The optimal brain protection strategy for prolonged periods of circulatory arrest is still controversial. This study evaluated whether retrograde cerebral perfusion (RCP) provides adequate brain protection for prolonged periods of deep hypothermic circulatory arrest (DHCA). METHODS: From January 1997 to December 2014, 1,043 patients underwent aortic arch operations using RCP and DHCA at 18°C. The DHCA time for 993 patients was 49 minutes or less and the DHCA time for the remaining 50 patients was 50 minutes or more. Propensity matching between the two groups was performed, taking into account the main preoperative and surgical variables and all the preoperative and intraoperative neurologic risk factors. Logistic regression analysis was performed to identify independent predictors of operative death and postoperative cerebral complications. RESULTS: In the unmatched population, mortality in the 50 minutes or more vs the 49 minutes or less group was 8% vs 3.8% (p = 0.143), and the stroke rate was 2% vs 1.2% (p = 0.623). Propensity matching resulted in 48 pairs. Operative death and incidence of transient and permanent neurologic deficit were similar and not statistically significant in the matched groups for all comparisons. No difference in the incidence of other major postoperative complications was found between the two groups. Midterm survival was similar. Regression analysis showed DHCA duration was not independently associated with operative death or postoperative neurologic deficits. CONCLUSIONS: RCP is an effective adjunctive cerebral protection strategy for complex aortic arch aneurysm repair with prolonged DHCA and is not associated with increased death or neurologic complications.
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Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Circulación Cerebrovascular/fisiología , Paro Circulatorio Inducido por Hipotermia Profunda/métodos , Perfusión/métodos , Accidente Cerebrovascular/prevención & control , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/fisiopatología , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Persona de Mediana Edad , New York/epidemiología , Complicaciones Posoperatorias , Estudios Retrospectivos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The optimal technique for brain perfusion during circulatory arrest remains controversial. Concern exists that retrograde cerebral perfusion (RCP) via the superior vena cava (SVC) is unable to perfuse the brain. We evaluated whether RCP blood circulates through the brain parenchyma in humans during deep hypothermic circulatory arrest (DHCA). We hypothesized that a significant difference in the levels of S-100ß (a protein with very high neuro-sensitivity) between the blood infused in the SVC and the effluent blood returning in the left carotid artery (CA) during RCP, should be regarded as a sign of the circulation of RCP blood through the brain parenchyma. METHODS: We enrolled 10 non-consecutive patients undergoing elective arch-surgery using DHCA and RCP. Circulating S-100ß levels were measured at baseline and immediately before DHCA. During DHCA and RCP the difference in S-100ß between the SVC and the CA was evaluated after 10 minutes of arrest and immediately before resumption of the circulation. S-100ß levels were evaluated using enzyme-linked immunosorbent assay (ELISA). RESULTS: Mean DHCA duration was 22.4±7.9 minutes. Mean S-100ß level at baseline was 92.5±54.9 µg/L. After 10 minutes of DHCA the level of S-100ß in the CA was significantly higher than in the SVC (936.9±326.3 vs. 810.9±307.4 µg/L, P=0.0021). This difference was enhanced at the second DHCA sample (1113.8±334.2 vs. 920.5±340.0 µg/L, P=0.0002). There was a statistically significant correlation between the duration of DHCA and the percent difference in S-100ß level between the SVC and the CA (Pearson's correlation coefficient =0.902). CONCLUSIONS: RCP is able to perfuse the brain parenchyma in humans during DHCA.
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BACKGROUND: We sought to investigate the impact of incomplete revascularization (IR) on long-term survival after isolated coronary artery bypass grafting (CABG). The possible interaction between IR and off-pump surgery was also explored. METHODS: A total of 13,701 patients with multivessel disease undergoing CABG were included in the analysis. All patients received left internal thoracic artery (LITA) to the left anterior descending artery (LAD) territory. IR was defined as at least one diseased arterial territory (right coronary artery [RCA] and/or circumflex [CX] artery) incompletely revascularized. RESULTS: Overall, 3107 (22.7%) patients received IR. After propensity score matching, IR did not increase all-cause death in the overall group (HR 1.09; 95%CI 0.96-1.22; P=0.17). However, when both RCA and CX artery were incompletely revascularized, late survival was significantly lower (HR 2.15; 95%CI 1.57-2.93). IR was associated with a higher risk of death after off-pump (HR 1.26; 95%CI 1.05-1.49) regardless the extent of IR. After on-pump, IR significantly affected survival only when both RCA and CX artery only were incompletely revascularized (HR 2.32; 95%CI 1.27-4.22). CONCLUSIONS: The present analysis shows that in patients with LITA-LAD graft the impact of IR on survival is marginal when only one coronary territory is left ungrafted. When both the RCA and CX territory remain unrevascularized the survival rate is significantly reduced. IR after off-pump CABG is associated with significantly lower survival and affects long-term outcome even when only one coronary territory is not revascularized.
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Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Revascularización Miocárdica/mortalidad , Anciano , Puente de Arteria Coronaria/tendencias , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/tendencias , Estudios Prospectivos , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
In terms of in-hospital outcomes, controversy still remains whether off-pump coronary artery bypass grafting is superior to on-pump coronary artery bypass surgery. We investigated whether the volume of off-pump coronary artery bypass procedures by hospital and individual surgeon influences patient outcomes when compared with on-pump coronary artery bypass surgery. Discharge records from the Nationwide Inpatient Sample were retrospectively reviewed for in-hospital admissions from 2003 to 2011, including 999 hospitals in 44 states. A total of 2,094,094 patients undergoing on- and off-pump coronary artery bypass surgery were included. In patients requiring 2 or more grafts, off-pump coronary artery bypass compared with on-pump coronary artery bypass was associated with increased risk-adjusted mortality when performed in low-volume centers (<29 cases per year) (odds ratio [OR] 1.32, 95% confidence interval [CI] 1.06 to 1.57) or by low-volume surgeons (<19 cases per year) (OR 1.26, 95% CI 1.02 to 1.56). In high-volume off-pump coronary artery bypass centers (≥164 cases per year) and surgeons (≥48 cases per year), off-pump coronary artery bypass reduced mortality compared with on-pump coronary artery bypass in cases requiring a single graft (OR 0.66, 95% CI 0.49 to 0.89 and OR 0.33, 95% CI 0.22 to 0.47, respectively) or 2 or more grafts (OR 0.82, 95% CI 0.66 to 0.99 and OR 0.63, 95% CI 0.49 to 0.81, respectively). In conclusion, the outcome of off-pump coronary artery bypass grafting procedures is dependent on volume at both the institution and the individual surgeon level. Off-pump coronary artery bypass should not be performed at low-volume centers and by low-volume surgeons.
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Competencia Clínica/estadística & datos numéricos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Hospitales de Alto Volumen , Hospitales de Bajo Volumen , Indicadores de Calidad de la Atención de Salud , Anciano , Puente de Arteria Coronaria Off-Pump , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: The effect of high transfusion ratios of fresh frozen plasma (FFP): packed red blood cell (RBC) on mortality is still controversial. Observational evidence contradicts a recent randomized controlled trial regarding mortality benefit. This is an updated meta-analysis, including a non-trauma cohort. METHODS: Patients were grouped into high vs. low based on FFP:RBC ratio. Primary outcomes were 24-h and 30-day/in-hospital mortality. Secondary outcomes were acute respiratory distress syndrome and acute lung injury rates. Random model and leave-one-out-analyses were used. RESULTS: In 36 studies, lower ratio showed poorer 24-h and 30-day survival (p < 0.001). In trauma and non-trauma settings, a lower ratio was associated with worse 24-h and 30-day mortality (P < 0.001). A ratio of 1:1.5 provided the largest 24-h and 30-day survival benefit (p < 0.001). The ratio was not associated with ARDS or ALI. CONCLUSIONS: High FFP:RBC ratio confers survival benefits in trauma and non-trauma settings, with the highest survival benefit at 1:1.5.
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Transfusión Sanguínea/métodos , Estudios Observacionales como Asunto , Plasma , Complicaciones Posoperatorias/terapia , Ensayos Clínicos Controlados Aleatorios como Asunto , Choque Traumático/terapia , Transfusión de Eritrocitos/métodos , Salud Global , Mortalidad Hospitalaria/tendencias , Humanos , Complicaciones Posoperatorias/mortalidad , Pronóstico , Choque Traumático/mortalidad , Tasa de Supervivencia/tendenciasRESUMEN
BACKGROUND: With the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials. METHODS: All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. RESULTS: Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable. CONCLUSIONS: The introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/instrumentación , Stents , Teorema de Bayes , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Difusión de Innovaciones , Humanos , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Diseño de Prótesis , Ensayos Clínicos Controlados Aleatorios como Asunto , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
Although aortic hemiarch replacement without the use of deep hypothermic circulatory arrest may be feasible in experienced centers, manipulation of the aortic arch and great vessels is of concern. Additional research is necessary before widespread adoption of this technique.
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Perfusión , Complicaciones Posoperatorias , Aorta , Aorta Torácica , Circulación Cerebrovascular , Paro Circulatorio Inducido por Hipotermia Profunda , HumanosRESUMEN
OBJECTIVE: To evaluate the impact of preoperative pulmonary function on outcomes after open repair of descending thoracic (DTA) and thoracoabdominal aortic (TAAA) aneurysms. METHODS: The outcomes of patients undergoing open repair of DTA or TAAA were analyzed in relation to the results of preoperative pulmonary function tests. Receiver operating characteristic was adopted to assess the effect of forced expiratory volume in one second (FEV1) on the incidence of mortality. Logistic regression analysis and propensity score matching were used. RESULTS: Between 1997 and 2015, 726 patients underwent open DTA or TAAA repair. Pulmonary function tests were available in 711 (97.9%). Receiver operating characteristic analysis revealed the cutoff value of FEV1 to be 50%. Propensity score matching led to 149 pairs of patients with FEV1 below and above 50% with only limited residual imbalance. In the matched population operative mortality was 11.4% and 6.0% in patients with FEV1 ≤ 50% and FEV1 ≥ 51%, respectively (P = .10). The incidence of major adverse events was 33.1% in cases with FEV1 ≤ 50% and 19.5% in those with FEV1 ≥ 51% (P = .008). FEV1 ≤ 50% was associated with a 6.99× increase in the risk of major postoperative adverse events at logistic regression analysis. CONCLUSIONS: Preoperative FEV1 < 50% is strongly predictive of increased respiratory failure, tracheostomy, and operative mortality in patients undergoing open DTA/TAAA repair. For these very high-risk patients with either extensive TAAAs or anatomy unsuitable for endovascular repair, medical therapy may offer the best long-term survival.
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Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/métodos , Volumen Espiratorio Forzado/fisiología , Complicaciones Posoperatorias/epidemiología , Puntaje de Propensión , Anciano , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , New York/epidemiología , Periodo Preoperatorio , Curva ROC , Pruebas de Función Respiratoria , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Triple valve surgery (TVS) remains a challenging procedure with limited existing literature. We aim to evaluate the prevalence, in-hospital outcomes, and prognostic determinants of TVS in the current era. MATERIALS AND METHODS: We reviewed the Nationwide Inpatient Sample database from 2003 to 2012 and included all patients who underwent aortic valve replacement (AVR) combined with mitral valve replacement (MVR) or repair (MVRep) and tricuspid valve replacement (TVR) or repair (TVRep). Logistic regression analysis was used to identify independent predictors of in-hospital mortality and propensity score matching was adopted to compare groups receiving different operations. RESULTS: Overall, 5234 patients were included. In-hospital mortality was 13.9%. Major adverse events occurred in 42.9% of the cases (44.9%, 40.3%, 44.4% and 74.2% in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups respectively, p < 0.05 for all intergroup comparisons). In-hospital mortality in the AVR + MVR + TVR, AVR + MVR + TVRep, AVR + MVRep + TVRep and AVR + MVRep + TVR groups was 19.9%, 13.3%, 12.9% and 0% respectively (p < 0.05 for all intergroup comparisons). At regression analysis, age, reoperation, and urgent/emergent operation were independent predictors of in-hospital mortality. Patients submitted to tricuspid valve repair and mitral and tricuspid repair had a 62% and 63% mortality risk reduction (OR:0.380, CI:0.19-0.76 p = 0.006 and OR:0.37, CI:0.18-0.78 p = 0.009 respectively). In the propensity matched comparisons, in-hospital mortality was statistically similar (p = 0.08 for AVR + MVR + TVR vs. AVR + MVR + TVRep comparison and p = 0.06 for AVR + MVR + TVR vs. AVR + MVRep + TVRep comparison). CONCLUSIONS: TVS is associated with significant in-hospital mortality and morbidity. The use of valve repair strategies for the mitral and tricuspid valves can positively impact postoperative outcomes.
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Implantación de Prótesis de Válvulas Cardíacas , Adulto , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Bases de Datos Factuales , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Prevalencia , Pronóstico , Válvula Tricúspide/cirugíaRESUMEN
The history of echocardiography is sprinkled with many interesting episodes and anecdotes showing that devoting your life to the pursuit of one goal is praiseworthy, and that at the same time, a little luck goes a long way. Transthoracic echocardiography (TTE) has led to dramatic improvements in cardiovascular medicine, and is now the most widely used diagnostic cardiac test after electrocardiography (ECG). The present review pays tribute to the pioneering efforts of those who believed in this innovative technology despite mounted skepticism and briefly describes the evolution of TTE from its early days to the most recent developments.
RESUMEN
Early graft patency is a major determinant of morbidity and mortality following coronary artery bypass surgery. Long-term graft failure is caused by intimal hyperplasia and atherosclerosis, while early failure, especially in the first year, has been attributed, in part, to surgical error. The need for intraoperative graft evaluation is paramount to determine need for revision and ensure future functioning grafts. Transit time flowmetry (TTFM) is the most commonly used intraoperative modality, however, only about 20% of cardiac surgeons in North America use TTFM. When combined with high resolution epicardial ultrasonography, TTFM provides high diagnostic yield. Fluorescence imaging can provide excellent visualization of the coronary and graft vasculature; however, data on this subject is limited. We herein examine the literature and discuss the available techniques for graft assessment along with their limitations.