RESUMEN
BACKGROUND: Alternative cannulation sites such as the right/left axillary artery, the ascending aorta and aortic arch have been recently preferred to the femoral artery to improve neurologic outcome in patients undergoing surgery of the thoracic aorta. In 2004, we started to select the innominate artery as an arterial cannulation site for CPB and antegrade cerebral perfusion institution. Here we present our preliminary experience with 55 patients. METHODS: Between November 2004 and 2006, 55 patients (mean age 60+/-14 years) underwent surgery on the thoracic aorta using the innominate artery as a site for arterial cannulation. Indication for surgery was a degenerative aneurysm in 49 (89.1%), an acute type A dissection in 2 patients (3.6%), a post-dissection aneurysm in 3 (5.4%), a supravalvular aortic stenosis in 1 patient (1.8%). Operative procedure included total arch replacement (n=9), hemiarch replacement (n=6), ascending aorta replacement (n=21), Bentall procedure (n=18) and aortoplasty with patch (n=1). Mean CPB and cross clamp times were 131+/-60 and 95+/-29 min, respectively. Mean cerebral perfusion time was 54+/-26 min. RESULTS: The hospital mortality rate was 3.6%. There were no permanent neurologic dysfunction and one (1.8%) temporary neurological dysfunction. CONCLUSION: Our results with the cannulation of the innominate artery were encouraging. This provides the same advantages of the axillary artery cannulation with greater simplicity and avoiding extra surgical incisions which may be site for local complications. It may represent a valid option for CPB and antegrade cerebral perfusion institution in aortic procedures.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Tronco Braquiocefálico/cirugía , Cateterismo/métodos , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/mortalidad , Puente Cardiopulmonar/métodos , Circulación Cerebrovascular/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Perfusión/métodos , Complicaciones Posoperatorias , Resultado del TratamientoRESUMEN
BACKGROUND: Use of a minimally invasive approach for isolated aortic valve surgery is increasing. However, management of the root and/or ascending aorta through a mini-invasive incision is not so frequent. The aim of this study is to report our initial experience with surgery of the ascending aorta through a ministernotomy approach. METHODS: We retrospectively analyzed 102 patients treated for ascending aorta disease through a ministernotomy. Several types of surgeries were performed, including isolated or combined surgical procedures. Pre-operative and operative parameters and in-hospital clinical outcomes were retrospectively analyzed. RESULTS: Patient mean age was 63.9 ± 13.6 years (range 29-85). There were 33 (32.4%) female and 69 (67.6%) male patients. Preoperative logistic EuroSCORE I was 7.4% ± 2.1%. Mean cardiopulmonary bypass and aortic cross-clamp time were 123.7 ± 36.9 and 100.8 ± 27.5 min, respectively. In-hospital mortality was 0%. CONCLUSIONS: Our experience shows that surgery of the ascending aorta with or without combined procedures can be safely performed through an upper ministernotomy, without compromising surgical results. Although our series is not large, we believe that the experience gained on the isolated aortic valve through a ministernotomy can be safely reproduced in ascending aorta surgery as a routine practice.
Asunto(s)
Aorta/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular , Esternotomía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades de la Aorta/diagnóstico , Implantación de Prótesis Vascular/efectos adversos , Puente Cardiopulmonar , Constricción , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Esternotomía/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to evaluate early results and to determine predictive risk factors associated with an adverse outcome in elderly patients after acute type A aortic dissection repair using antegrade selective cerebral perfusion (ASCP). Adverse outcome was defined as the occurrence of death or permanent neurologic dysfunction. METHODS: From October 1995 to March 2002, 178 patients (group A < 75 years, n = 156, 87.6%; group B > 75 years, n = 22, 12.4%) underwent surgery for acute type A aortic dissection using ASCP and moderate hypothermia. An ascending aorta/hemiarch replacement was performed in 128/178 (71.9%) patients (group A 71.2%, group B 77.3%, p = NS), an ascending aorta and arch replacement in 50/178 (28.1%) patients (group A 28.8%, group B 22.7%, p = NS). Associated procedures were performed in 55/178 (20.9%) patients (group A 31.4%, group B 27.3%, p = NS), the arch vessels were reimplanted using the separated graft technique in 32/50 (64.0%) patients (group A 62.2%, group B 80.0%, p = NS). The mean ASCP time was 59 +/- 27 min. RESULTS: The overall adverse outcome rate was 20.8% (group A 21.2%, group B 18.2%, p = NS). The transient neurologic dysfunction rate was 9.5% (group A 9.5%, group B 5.6%, p = NS). A logistic regression analysis revealed cardiopulmonary bypass time (p = 0.045, odds ratio 1.03/min) to be the only independent predictor of adverse outcome in group A. CONCLUSIONS: During type A aortic dissection repair the implementation of ASCP resulted in an acceptable hospital mortality and neurologic outcome. If ASCP is used, the risk of hospital mortality and postoperative morbidity is similar in patients younger and older than 75 years. Duration of cardiopulmonary bypass still remains an important risk factor for hospital mortality and neurologic outcome in elderly patients.
Asunto(s)
Aneurisma de la Aorta Torácica/mortalidad , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/mortalidad , Disección Aórtica/cirugía , Hipotermia Inducida/métodos , Accidente Cerebrovascular/prevención & control , Enfermedad Aguda , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Anastomosis Quirúrgica , Disección Aórtica/diagnóstico , Aneurisma de la Aorta Torácica/diagnóstico , Implantación de Prótesis Vascular/métodos , Circulación Cerebrovascular/fisiología , Estudios de Cohortes , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Perfusión , Complicaciones Posoperatorias/prevención & control , Probabilidad , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Resultado del Tratamiento , Procedimientos Quirúrgicos VascularesRESUMEN
Here we present our simplified technique of cannulation of the brachiocephalic trunk for cardiopulmonary bypass and antegrade cerebral perfusion institution.
Asunto(s)
Aorta Torácica/cirugía , Tronco Braquiocefálico , Cateterismo Venoso Central/métodos , Puente Cardiopulmonar , Circulación Cerebrovascular , Humanos , Cuidados Intraoperatorios/métodos , Perfusión/métodosRESUMEN
Operations on the aortic arch remain a major challenge for the cardiac surgeon and neurologic injuries represent the most feared complication. During the last decades, different cerebral protection techniques, including deep hypothermic circulatory arrest, and retrograde and antegrade cerebral perfusion have been introduced into clinical practice to reduce the incidence of such complications. All three methods present advantages and disadvantages. In this review, the theoretical impact of the current methods of brain protection is reported and discussed.
Asunto(s)
Aorta Torácica/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Puente Cardiopulmonar , Circulación Cerebrovascular/fisiología , Humanos , Hipotermia Inducida , Perfusión , Complicaciones Posoperatorias/fisiopatología , Accidente Cerebrovascular/fisiopatologíaRESUMEN
BACKGROUND: Replacement of the aortic valve and ascending aorta with a composite graft is the most common surgical treatment for aortic root aneurysms with or without aortic regurgitation (AR). In the early 90's reconstructive procedures of the aortic root have been described with encouraging results. This paper presents our experience with this technique. METHODS: Between January 2001 and May 2003, 28 patients (25 males, 3 females, mean age 60 years) with aortic root aneurysm were treated with reimplantation of the aortic valve. Twenty-two patients had AR > 2+, 5 had Marfan syndrome, 5 had an aortic arch aneurysm, 4 had type A aortic dissection, 2 patients had associated coronary artery disease, and one had mitral valve insufficiency. The only contraindication was primitive disease of the aortic leaflets. RESULTS: There was one perioperative death (type A aortic dissection) and 1 patient was discharged with mild to moderate AR requiring aortic valve replacement. The cardiopulmonary bypass and aortic cross-clamping times were 230 and 184 min respectively. No neurological events were recorded. During follow-up (mean 16.7 months, range 3-32 months) 1 patient died and one had mild AR. Freedom from reoperation and from AR at 24 months was 94 and 89% respectively. At multivariate analyses we did not find any correlation between Marfan syndrome, type A aortic dissection, grade of preoperative AR, and recurrence of AR. CONCLUSIONS: In our experience, valve-sparing surgery was feasible with a low mortality and morbidity and with good early results. It should be applied to all patients requiring aortic root surgery for aortic root aneurysm, a diseased aortic valve being the only contraindication.
Asunto(s)
Aneurisma de la Aorta/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Reimplantación/métodos , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Tereftalatos Polietilenos/uso terapéutico , Técnicas de Sutura , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to compare the ability of three risk models to predict operative mortality after cardiac surgery. METHODS: Risk factors of 3111 patients (73% male, mean age 65.2 +/- 10.7 years) were derived from our institutional database at the Cardiac Surgery Department of the G.M. Lancisi Hospital, Ancona, Italy. The predicted mortality was derived from the Society of Thoracic Surgeons risk score (STS), the EuroSCORE (ES) and the Northern New England Cardiovascular Disease Study Group score (NE). RESULTS: The observed mortality in the myocardial revascularization population (1995 patients) was 2.2% (43 patients). The mean predicted mortality by STS, ES and NE was 1.9, 4.2 and 1.9%, respectively. The predictive ability of the models was measured by means of the ROC curve. Curves were respectively of 0.82, 0.77 and 0.78. CONCLUSIONS: All tested models proved e good accuracy level but ES showed a constant overestimation of mortality at all risk levels.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/mortalidad , Medición de Riesgo/métodos , Anciano , Comorbilidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Italia/epidemiología , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/mortalidad , Revascularización Miocárdica/estadística & datos numéricos , Curva ROC , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: To evaluate performance of the European System for Cardiac Operation Risk Evaluation (EuroSCORE II), to assess the influence of model updating and to derive a hierarchical tree for modelling the relationship between EuroSCORE II risk factors and hospital mortality after cardiac surgery in a large prospective contemporary cohort of consecutive adult patients. METHODS: Data on consecutive patients, who underwent on-pump cardiac surgery or off-pump coronary artery bypass graft intervention, were retrieved from Puglia Adult Cardiac Surgery Registry. Discrimination, calibration, re-estimation of EuroSCORE II coefficients and hierarchical tree analysis of risk factors were assessed. RESULTS: Out 6293 procedures, 6191 (98.4%) had complete data for EuroSCORE II assessment with a hospital mortality rate of 4.85% and EuroSCORE II of 4.40 ± 7.04%. The area under the receiver operator characteristic curve (0.830) showed good discriminative ability of EuroSCORE II in distinguishing patients who died and those who survived. Calibration of EuroSCORE II was preserved with lower predicted than observed risk in the highest EuroSCORE II deciles. At logistic regression analysis, the complete revision of the model had most of re-estimated regression coefficients not statistically different from those in the original EuroSCORE II model. When missing values were replaced with the mean EuroSCORE II value according to urgency and weight of intervention, the risk score confirmed discrimination and calibration obtained over the entire sample. A recursive tree-building algorithm of EuroSCORE II variables identified three large groups (55.1, 17.1 and 18.1% of procedures) with low-to-moderate risk (observed mortality of 1.5, 3.2 and 6.4%) and two groups (3.8 and 5.9% of procedures) at high risk (mortality of 14.6 and 32.2%). Patients with low-to-moderate risk had good agreement between observed events and predicted frequencies by EuroSCORE II, whereas those at greater risk showed an underestimation of expected mortality. CONCLUSIONS: This study demonstrates that EuroSCORE II is a good predictor of hospital mortality after cardiac surgery in an external validation cohort of contemporary patients from a multicentre prospective regional registry. The EuroSCORE II predicts hospital mortality with a slight underestimation in high-risk patients that should be further and better evaluated. The EuroSCORE II variables as a risk tree provides clinicians and surgeons a practical bedside tool for mortality risk stratification of patients at low, intermediate and high risk for hospital mortality after cardiac surgery.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/mortalidad , Anciano , Femenino , Indicadores de Salud , Mortalidad Hospitalaria , Humanos , Italia/epidemiología , Modelos Logísticos , Masculino , Persona de Mediana Edad , Modelos Estadísticos , Estudios Prospectivos , Sistema de Registros , Medición de Riesgo , Análisis de SupervivenciaRESUMEN
AIMS: To evaluate the feasibility of a cardiac surgery registry and to describe patients' characteristics, type of procedures performed, incidence of postoperative complications with short and middle-term mortality. METHODS: A database with clinical information and details on cardiac surgical operations was implemented by Puglia Health Regional Agency to collect data of each cardiac surgery procedure performed in the seven adult cardiac surgery centres of the region. Health regional agency personnel guaranteed data accuracy and quality control procedures. Mortality after the discharge was evaluated for residents in Puglia by linking clinical data to the Health Information System. RESULTS: From January 2011 to December 2012, 6429 operations were performed. All operations were included in the registry with very high completeness of collected data (95.3% per patient). The majority of the operations performed were coronary artery bypass graft alone (41.1%), valve surgery alone (26.2%), coronary artery bypass graft and valve surgery (11.4%), or valve with other surgery (11.8%). During a median follow-up of 12 months (interquartile range 6-18 months), 211 deaths were detected after the discharge. Overall, cumulative mortality from the operation was 8.2% at 6 months and 9.5% at 12 months. CONCLUSION: Implementation of a regional clinical registry of cardiac surgery is feasible with a great level of accuracy and the evaluation of mid-term mortality overcomes the limited value of hospital mortality. An accurate cardiac surgery registry elicits epidemiologic evaluations, comparisons between expected and observed mortality, incidence of postoperative complications and encourages a reliable public reporting.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Sistema de Registros , Distribución por Edad , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/estadística & datos numéricos , Estudios de Factibilidad , Femenino , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Incidencia , Italia/epidemiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiologíaAsunto(s)
Neoplasias Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Válvula Pulmonar , Anciano , Ecocardiografía Transesofágica , Femenino , Neoplasias Cardíacas/patología , Enfermedades de las Válvulas Cardíacas/patología , Humanos , Válvula Pulmonar/diagnóstico por imagenAsunto(s)
Síndrome Coronario Agudo/diagnóstico por imagen , Aneurisma de la Aorta/diagnóstico por imagen , Disección Aórtica/diagnóstico por imagen , Intervención Coronaria Percutánea , Síndrome Coronario Agudo/cirugía , Anciano , Disección Aórtica/cirugía , Aneurisma de la Aorta/cirugía , Manejo de la Enfermedad , Estudios de Seguimiento , Humanos , Masculino , Intervención Coronaria Percutánea/métodos , RadiografíaRESUMEN
We describe a patient with pulmonary embolism originating from right atrial thrombosis that developed at least 18 months after patent foramen ovale (PFO) device implantation. On surgical inspection, the PFO device was found to be correctly positioned, stable and well endothelialized. We then hypothesize that current smoker status, double antiplatelet regimen discontinuation and mild hyperhomocysteinaemia may have had a role in determining this severe, unexpected and late complication in this patient.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Foramen Oval Permeable/cirugía , Cardiopatías/etiología , Embolia Pulmonar/etiología , Trombosis/etiología , Adulto , Procedimientos Quirúrgicos Cardíacos/instrumentación , Remoción de Dispositivos , Ecocardiografía , Femenino , Foramen Oval Permeable/patología , Cardiopatías/complicaciones , Cardiopatías/patología , Cardiopatías/cirugía , Humanos , Hiperhomocisteinemia/complicaciones , Inhibidores de Agregación Plaquetaria/efectos adversos , Embolia Pulmonar/patología , Embolia Pulmonar/cirugía , Reoperación , Factores de Riesgo , Fumar/efectos adversos , Trombosis/complicaciones , Trombosis/patología , Trombosis/cirugíaRESUMEN
Total arterial myocardial revascularization (TAMR) is advisable because of the excellent long-term patency of arterial conduits. We present early and midterm outcomes of five different surgical configurations for TAMR. Between January 1998 and May 2004, 112 patients (aged 56.5 +/- 4.5 years, 20% female) with three-vessel disease underwent TAMR. The internal mammary arteries (IMAs) were harvested in a sketelonized fashion. The surgical techniques for TAMR consisted in Y or T composite grafts (n = 88, 78%) constructed between the in situ right IMA (RIMA) and the free left IMA (LIMA) graft (n = 58) or the radial artery (n = 30) (RA) in three different configurations. The other techniques consisted in T- and inverted T-graft (n = 24, 22%) constructed between the RA conduit and the free LIMA graft in two different configurations. The mean follow-up time was 40 +/- 23 months. Postoperative angiographic control was performed in 76/111 (70%) patients. Overall, 472 arterial anastomoses (average 4.2 per patient) were performed. One (0.9%) patient, undergoing the inverted T-graft technique, died on postoperative day 2. Another patient (0.9%), undergoing the lambda-graft technique using both IMAs and RA, suffered a new myocardial infarction probably due to RA conduit vasospasm. One week after surgery, after the transthoracic echocardiographic Doppler with adenosine provocative test, the coronary flow reserve (CFR) at the LIMA and RIMA main stems were 2 +/- 0.4 and 2.4 +/- 0.3, respectively. At 12-month follow-up, after adenosine provocative test, the CFRs at the LIMA and RIMA stems were significantly higher than the values at 1 week after surgery within the same group; (LIMA)CFR (1 week) 2.4 +/- 0.3 (12 months) vs 2 +/- 04 (1 week), P = 0.002; (RIMA)CFR 2.58 +/- 0.4 vs 2.4 +/- 0.3, P = 0.001. The CFR at the RIMA main stem was higher in all measurements within the same group than in the LIMA main stem, but not significantly. In one patient undergoing the lambda-graft technique using both IMAs, the RIMA was found to have a string sign. Postoperative angiography in 50 patients showed that the patency rate for the LIMA was 100%, for the RIMA 97.3%, and for the RA 96.7%. Angiography at 3-year follow-up in 76 patients documented excellent patency rates of the LIMA (97.4%), RIMA (95%), and RA (87%). Survival at 7 years was 92.5%, event-free survival 89.3%, and freedom from angina 94%. Total arterial myocardial revascularization using different surgical configurations is safe and effective. The use of composite arterial grafts provides excellent clinical and angiographic results, with a low rate of angina recurrence and late cardiac events. These configurations allow for complete arterial revascularization.
Asunto(s)
Enfermedad Coronaria/cirugía , Revascularización Miocárdica/métodos , Adulto , Anciano , Velocidad del Flujo Sanguíneo , Puente Cardiopulmonar , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico , Ecocardiografía Doppler , Femenino , Oclusión de Injerto Vascular , Humanos , Anastomosis Interna Mamario-Coronaria , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Arteria Radial/trasplante , Estadísticas no Paramétricas , Tasa de Supervivencia , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
A persistent left superior vena cava draining into the left atrium may produce a symptomatic right-to-left shunt. Although intra-atrial rerouting techniques, in patients with no connecting vein, have proved to be reliable and successful, in many cases the extracardiac repair is preferable. We report a case of a 5-month-old patient with a not connected left superior vena cava draining into the left atrium, associated with atrial septal defect and partial anomalous pulmonary venous connection. The correction has been achieved by rerouting the pulmonary venous return into the left atrium and by transposition of the left vena cava on the right appendage.