RESUMO
Left atrial intramural hematoma (LAIH) is an uncommon entity for which a timely diagnosis is critical for decision making. Cardiac surgical or catheter-based procedures are potential causing factors. Though cardiac computerized tomography and magnetic resonance are highly accurate diagnostic modalities, their role is limited by the lack of widespread availability. The present clinical case illustrates the diagnostic features of LAIH that can be obtained using echocardiography at the bedside in critically ill patients. We report a case of LAIH, that followed a catheter ablation procedure and was complicated by cardiac and cerebral ischemia. Cardiac surgical management was required.
Assuntos
Apêndice Atrial , Ablação por Cateter , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/cirurgia , Hematoma/diagnóstico por imagem , Hematoma/cirurgia , HumanosRESUMO
OBJECTIVE: Risk stratification models perform poorly regarding elderly patients. This study aims to evaluate the performance of the Italian Coronary Artery Bypass Graft Outcome Project (ItCABG) model and the logistic European System for Cardiac Operative Risk Evaluation (LogEuroSCORE) model by age group to build a model specifically for elderly patients. METHODS AND RESULTS: Data from the ItCABG and Mattone Outcome-BYPASS study (MO-BYPASS) have been used. ItCABG and LogEuroSCORE models were applied to the ItCABG population (n = 34,310) stratified by four age classes: < 60, 60-69, 70-79, > or = 80 years. Each model's ability to predict 30-day mortality was assessed for accuracy (Brier score and pseudo-R2), calibration (Hosmer-Lemeshow test, X(H-L)) and discrimination (area under the receiver operating characteristic curve, AUC) in age classes. To estimate the elderly risk function a logistic regression was performed on 2,255 octogenarian patients from ItCABG and MO-BYPASS. Elderly model's performance was tested. Model accuracy is fair in all age classes although the explained variance is poor. ItCABG and LogEuroSCORE models revealed good discrimination power in patients aged < (60, 60-69, and 70-79 years, but not in patients aged > or = 80 years (AUCs: 0.82, 0.77, 0.76, 0.64, and 0.78, 0.75, 0.74, 0.65, respectively). Calibration of both models is poor in patients 80 years (ItCABG: X(H-L) = 18.1, P = 0.05; LogEuroSCORE: X(H-L) = 129.7, P < 0.001). When a new model specific to octogenarian patients was built, discrimination power remained poor (AUC = 0.66), although calibration power improved (X(H-L) = 3.93, P = 0.86). CONCLUSIONS: ItCABG and LogEuroSCORE models were poor predictors of mortality in octogenarian patients. Elderly-specific risk factors must be assessed to improve risk stratification in patients aged 80 years and older.
Assuntos
Avaliação Geriátrica/estatística & dados numéricos , Modelos Estatísticos , Medição de Risco/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
The novel Permanent Life Support (PLS; Maquet, Jostra Medizintechnik AG, Hirrlingen, Germany) as peripheral veno-arterial extracorporeal membrane oxygenation (ECMO) support system has been investigated as treatment for patients with refractory cardiogenic shock (CS). Between January 2007 and July 2011, 73 consecutive adult patients were supported on peripheral PLS ECMO system at our institution (55 men; age 60.3 ± 11.6 years, range: 23-84 years). Indications for support were failure to wean from cardiopulmonary bypass in the setting of postcardiotomy (n = 50) and primary donor graft failure (n = 8), post-acute myocardial infarction CS (n = 12), and CS on chronic heart failure (n = 3). Mean support time was 10.9 ± 7.6 days (range: 2-34 days). Overall, 26 (35.6%) patients died on ECMO. Among survivors on ECMO, 44 (60.2%) patients were successfully weaned from support, and three (4.1%) were switched to a mid-long-term ventricular assist device. Thirty-three (45.2%) were successfully discharged. The following variables were significantly different if survivors and nonsurvivors on ECMO were compared: age (P = 0.04), female gender (P < 0.01), cardiopulmonary resuscitation before ECMO (P < 0.01), lactate level before ECMO (P = 0.01), number of platelets, fresh frozen plasma units, and packed red blood cells (PRBCs) transfused during ECMO support (P = 0.03, P = 0.02, and P < 0.01), blood lactate level (P = 0.01), and creatine kinase isoenzyme MB (CK-MB) relative index 72 h after ECMO initiation (P < 0.001), and multiple organ failure on ECMO (P < 0.01). Stepwise logistic regression identified blood lactate level and CK-MB relative index at 72 h after ECMO initiation, and number of PRBCs transfused on ECMO as significant predictors of mortality on ECMO (P = 0.011, odds ratio [OR] = 2.48; 95% confidence interval [CI] = 1.11-3.12; P = 0.012, OR = 2.81, 95% CI = 1.026-2.531; and P = 0.012, OR = 1.94, 95% CI = 1.02-5.21; respectively). Patients with an initial poor hemodynamic status could benefit by rapid peripheral installation of PLS ECMO. The blood lactate level, CK-MB relative index, and PRBCs transfused should be strictly monitored during ECMO support.
Assuntos
Oxigenação por Membrana Extracorpórea/instrumentação , Choque Cardiogênico/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Transfusão de Sangue , Creatina Quinase Forma MB/sangue , Feminino , Humanos , Ácido Láctico/sangue , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/sangue , Resultado do Tratamento , Adulto JovemAssuntos
Implante de Prótese de Valva Cardíaca/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Cardiomiopatia de Takotsubo/diagnóstico por imagem , Cardiomiopatia de Takotsubo/etiologia , Idoso , Feminino , Humanos , UltrassonografiaRESUMO
OBJECTIVE: Coronary revascularization methods are among the most common major medical procedures performed in industrialized countries. The short- and long-term comparative effectiveness of different techniques remains undetermined. METHODS AND RESULTS: The study population included all adult patients (94,864 subjects) admitted for acute myocardial infarction (AMI) in 2004 in Italy, as recorded in the National Hospital Discharge Records. Invasive reperfusion therapy (coronary artery bypass graft, percutaneous coronary intervention), and standard medical treatments were compared. End points were short-term (30-day) in-hospital mortality and any combination of new revascularizations, re-AMI, stroke, or death (MACCE) occurring within 6 and 12 months from initial treatment. Risk factors and comorbidities were used to define patients' health status. The Cox model was applied to evaluate risk-adjusted hazard ratios (HR) for different approaches. Medical treatment was used as the reference category. Propensity score matching was performed to evaluate selection bias in the allocation to CABG or percutaneous coronary intervention (PCI). Both short-term mortality and 6- and 12-month MACCE risk for invasive reperfusion therapy was significantly lower than the reference (HR: 0.50, P < 0.001; 0.54, P < 0.001; 0.64, P < 0.001, respectively). In the matched population, while short-term mortality was significantly lower for PCI (HR 0.36, P < 0.001), long-term MACCE risk was lower for CABG (6-month HR 2.93, P < 0.001; 12-month HR 3.01, P < 0.001). CONCLUSIONS: In spite of adjustments for patients' health status, medical treatment resulted in a higher mortality and increased MACCE risk. While PCI gave the best short-term results, after 1 year the risk of re-interventions or further events was significantly lower for patients undergoing CABG.
Assuntos
Infarto do Miocárdio/terapia , Revascularização Miocárdica , Idoso , Angioplastia Coronária com Balão , Comorbidade , Ponte de Artéria Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry. METHODS: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47⯱â¯16â¯years (range 15-86â¯years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival. RESULTS: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (nâ¯=â¯17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25â¯years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs. CONCLUSIONS: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25â¯years.
Assuntos
Endocardite/cirurgia , Doenças das Valvas Cardíacas/microbiologia , Doenças das Valvas Cardíacas/cirurgia , Valva Tricúspide/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Tempo , Insuficiência da Valva Tricúspide/complicações , Insuficiência da Valva Tricúspide/cirurgia , Adulto JovemRESUMO
In a 60-year-old woman with episodic exertional faintness, a large left ventricular (LV) myxoma attached by a pedicle to the apical interventricular septum and prolapsing through the LV outflow tract and the aortic valve causing a severe obstruction was found by echocardiography. Early surgical excision was successfully performed using the transaortic approach.
Assuntos
Neoplasias Cardíacas/complicações , Mixoma/complicações , Obstrução do Fluxo Ventricular Externo/etiologia , Feminino , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Septos Cardíacos , Ventrículos do Coração , Humanos , Pessoa de Meia-Idade , Mixoma/diagnóstico por imagem , Mixoma/cirurgia , Ultrassonografia , Obstrução do Fluxo Ventricular Externo/cirurgiaRESUMO
BACKGROUND: Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up. METHODS AND RESULTS: Twenty patients selected for the study (12 men and 8 women, mean age 60 +/- 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 +/- 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed. CONCLUSION: Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.
Assuntos
Dobutamina , Ecocardiografia/métodos , Aumento da Imagem/métodos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Prolapso da Valva Mitral/diagnóstico por imagem , Prolapso da Valva Mitral/cirurgia , Idoso , Teste de Esforço/métodos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Síndrome , Resultado do Tratamento , VasodilatadoresAssuntos
Cardiopatias Congênitas , Doenças das Valvas Cardíacas , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/cirurgia , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgiaRESUMO
BACKGROUND: Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period. METHOD: From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access. RESULTS: Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation. CONCLUSIONS: Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.
Assuntos
Miocardite/cirurgia , Complicações Pós-Operatórias/epidemiologia , Doença Aguda , Adulto , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Seguimentos , Humanos , Itália/epidemiologia , Masculino , Miocardite/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
Selection of elderly patients for heart failure surgery is based on careful evaluation of the risk/benefit ratio. The global risk profile and the single variable impact can be easily quantified by using validated scoring systems. Both age and left ventricular dysfunction are independent determinants of mortality; nevertheless they cannot be considered absolute contraindications for surgery. Risk of mortality is related to age in a linear fashion; consequently an age cut-off value for excluding patients from surgery cannot be defined. The presence of other risk factors and the resulting global risk profile have to be considered to identify suitable patients for surgery. Elderly patients undergoing mitral valve surgery need a particularly accurate assessment since mitral procedures are associated with an increased short- and medium-term mortality; hemodynamic instability, renal failure, advanced heart failure and concomitant coronary surgery might contraindicate surgery. A significant improvement in the functional status and quality of life justifies surgical treatment of elderly patients when the predicted risk is reasonable although benefits in terms of increased survival have not been clearly confirmed yet.
Assuntos
Insuficiência Cardíaca/cirurgia , Seleção de Pacientes , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/complicações , Humanos , Incidência , Masculino , Qualidade de Vida , Fatores de Risco , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/epidemiologiaRESUMO
AIM: Osteogenesis imperfecta (OI) is an inherited connective tissue disorder in which fragile bones readily cause fractures. Aortic root dilatation, aortic valve regurgitation and mitral valve prolapse are uncommon cardiovascular manifestations of OI. Cardiac surgery in these patients carries a high risk of complications due to increased tissue and capillary fragility. We describe an open heart surgery in a woman with isolated aortic valve regurgitation secondary to OI. MATERIAL OF STUDY: A 58-year-old woman was referred to our hospital for surgical correction of aortic valve regurgitation. She had a past history of recurrent long bone fractures, and OI was diagnosed in the childhood. A standard median sternotomy was performed; the sternum was found to be thin and brittle. The native aortic valve was replaced with a size 23 mm stented aortic bioprosthesis. The sternum was closed with stainless steel wires. RESULTS: The postoperative course was uneventful, and the patient was discharged home on the eighth postoperative day. We used thoracic band to avoid sternal diastasis. One year postoperatively, the echocardiogram showed a normal aortic bioprosthesis function without paravalvular leakage. The sternum was stable without dehiscence. DISCUSSION: The mortality rate in cardiac surgery patients with heritable generalized connective tissue disorders, such as osteogenesis imperfecta, is high. Although tissue friability had no impact on surgical outcome, it should be kept in mind when operating on patients with OI. CONCLUSIONS: We highlight the importance of a meticulous surgical technique, together with a strategy for management of anticipated perioperative complications to ensure a successful outcome. KEY WORDS: Aortic valve, Endocardirtis, Mitral valve, Replacement.
Assuntos
Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Osteogênese Imperfeita/complicações , Insuficiência da Valva Aórtica/diagnóstico , Bioprótese , Feminino , Humanos , Pessoa de Meia-Idade , Fatores de Risco , Resultado do TratamentoAssuntos
Migração de Corpo Estranho/complicações , Ventrículos do Coração/lesões , Marca-Passo Artificial/efeitos adversos , Parede Torácica/lesões , Idoso , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Humanos , Parede Torácica/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: Aortic dissection is an evolving process that may require one or several reoperations after its initial repair. We conducted a study to evaluate risk factors and define the incidence and locations of reoperations after surgical correction of acute type A aortic dissection (AAD). METHODS: Between 1998 and 2008, 250 consecutive patients (mean age 62.5±12.4 years) underwent surgery for AAD at our institution. Replacement of the ascending aorta was done in 173 cases, composite graft replacement in 61 cases, separate aortic valve and ascending aorta replacement in 2 cases, and arch replacement required by distal repair in 14 cases. Mean follow-up time was 4.7±5.6 years. RESULTS: Freedom from reoperation was 99%, 82%, and 79% at 1, 5, and 10 years, respectively. Twenty-five patients required 25 reoperations at a mean interval of 4.7 years after initial surgery for the correction of AAD. Reoperations included 21 procedures on the proximal aorta (ascending aorta, aortic root, or valve) and 4 procedures on the distal aorta (arch or descending aorta). Cox regression analysis identified the use of gelatin-resorcinol-formaldehyde (GRF) glue (p=0.0270), and nonreplacement of the aortic root at the time of initial AAD repair (p=0.0004), as a significant risk factor for proximal reoperation, and a patent false lumen (p=0.0107) as a significant risk factor for distal reoperation. CONCLUSIONS: A patent false lumen, the use of GRF glue, and aortic root preservation at initial operation influence the risk for surgical correction in patients undergoing surgery for AAD. These patients need long-term follow-up.
Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Ponte Cardiopulmonar/estatística & dados numéricos , Comorbidade , Intervalo Livre de Doença , Combinação de Medicamentos , Emergências , Feminino , Seguimentos , Formaldeído/uso terapêutico , Gelatina/uso terapêutico , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Reoperação/estatística & dados numéricos , Resorcinóis/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Adesivos Teciduais/uso terapêutico , Resultado do Tratamento , Adulto JovemRESUMO
A rare cause of valvular heart disease is the deposition of foreign material in the valvular tissues, including material accumulating as a result of inborn errors of metabolism of the essential amino acids. Alkaptonuria can result in accumulation of homogentisic acid. We report the case of a patient with alkaptonuria undergoing surgery for aortic valve replacement.
Assuntos
Alcaptonúria/complicações , Alcaptonúria/metabolismo , Estenose da Valva Aórtica/etiologia , Implante de Prótese de Valva Cardíaca , Ocronose/etiologia , Estenose da Valva Aórtica/metabolismo , Estenose da Valva Aórtica/cirurgia , Feminino , Ácido Homogentísico/metabolismo , Humanos , Pessoa de Meia-Idade , Ocronose/metabolismo , Ocronose/cirurgiaRESUMO
BACKGROUND: In early 2008, a new national prospective study on short-term outcomes of coronary artery bypass graft (CABG) procedures started in Italy. The aim was to describe short-term results in patients undergoing CABG and improve methodologies for comparative outcome evaluation. METHODS: Only 26 Italian cardiac surgery centers participated in this survey. For each patient undergoing a CABG procedure, all centers were requested to provide specific data (type of procedure, hemodynamic conditions, comorbidities, recent myocardial infarction and unstable angina, ventricular function, emergency conditions, vital status at 30 days). Representativeness was tested by comparing characteristics of the enrolled population with information derived from national hospital discharge records. A multiple logistic regression analysis was used to perform indirect standardization; the mortality rate of the whole population was used as a reference standard. Comparison with the CABG model built on 34 310 patients in 2002-2004 was performed as well. RESULTS: The analysis of 7436 isolated CABG procedures showed a 30-day mortality of approximately 2%. The study population seemed to be representative of the Italian population of CABG patients. Using the new estimate model, two cardiac surgery centers showed significantly better risk adjusted mortality rates than the national reference standard, and two others showed significantly worse rates. The application of the "CABG model" yielded similar results. CONCLUSIONS: Our study shows a high-quality level of Italian cardiac surgery centers and confirms the good applicability of the CABG model to the Italian CABG population. Comparison between results from the two models highlights the usefulness of regular outcome studies either for updating risk adjustment procedures and monitoring quality of care in Italian hospitals.
Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Idoso , Feminino , Hospitais , Humanos , Itália , Masculino , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
The Levitronix CentriMag (Levitronix LLC, Waltham, MA) ventricular assist device (VAD) is a magnetically levitated rotary pump designed for temporary extracorporeal support. Between February 2004 and May 2010, 42 consecutive adult patients were supported with Levitronix at our institution (32 men; age 62.3 ± 10.5 years, range: 31-76 years). Indications for support were (group A, n = 37) failure to wean from the cardiopulmonary bypass in the setting of postcardiotomy (n = 23), primary donor graft failure (n = 4), or right ventricular failure after axial left VAD (LVAD) placement (n = 10) and (group B, n = 5) refractory heart failure after acute myocardial infarction. The mean support time was 11.2 ± 6.8 days (range: 3-43 days) in group A and 8.6 ± 4.3 days (range: 5-11 days) in group B. In the postcardiotomy cohort (group A), 11 (47.8%) patients were weaned from support as all were supported graft failure patients. Eight patients of axial LVAD cohort were weaned from right VAD (RVAD). One patient was bridged to heart transplantation (Htx). Thirteen (35.1%) patients died on support in group A. In group B, one patient was bridged to Htx and four died on support. In overall population, bleeding requiring reoperation occurred in 15 (35.7%) cases and cerebral major events in four (9.5%). There were no device failures. Of the 23 (54.7%) patients who recovered and were discharged home, 20 (47.6%) are presently alive, and additionally, two patients of both groups who were bridged to Htx (overall n = 22, 52.3%). The Levitronix proved to be useful in patients previously considered nonsuitable for transplantation or long-term assist device. The device was technically easy to manage, and the results were encouraging.
Assuntos
Coração Auxiliar , Choque Cardiogênico/cirurgia , Disfunção Ventricular Direita/terapia , Adulto , Idoso , Ponte Cardiopulmonar , Estudos de Coortes , Desenho de Equipamento , Feminino , Insuficiência Cardíaca/cirurgia , Transplante de Coração/métodos , Ventrículos do Coração/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Disfunção Ventricular Direita/patologiaRESUMO
The aim of this study is to evaluate the effect of gender and age on outcome following coronary surgery in several hospitals enrolled in a national quality assessment program. Patients undergoing isolated coronary artery bypass graft (CABG) during 2003-2005 in Italy were included in the study (n=74,577). The outcome measure was 30-day in-hospital mortality. Comorbidities recorded during previous and current hospitalizations were used to define patients' health status and to build the adjustment model. The interaction term (gender*hospital) was introduced into the model to test the effect modification of gender; if present, gender specific models were analyzed to test the effect modification of age. A significant effect modification by gender was found in 39 hospitals; the adjusted odds ratios (AdjORs) showed significant increased risk for females (AdjORs ranging from 3.7 to 21.6). In three of these hospitals a significant increased risk was found for older age (AdjORs for elderly patients ranging from 8.1 to 14.6). Two hospitals showed a significant excess risk for patients ≥75 years (AdjORs=6.6 and 13.8). The technical aspects of surgery could account for the excess risk found in female patients; differences in the entire care process (intraoperative and postoperative management) could explain the variations in outcome among elderly patients.
Assuntos
Ponte de Artéria Coronária/mortalidade , Hospitais/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Fatores Etários , Idoso , Comorbidade , Bases de Dados como Assunto , Feminino , Mortalidade Hospitalar , Humanos , Itália/epidemiologia , Masculino , Razão de Chances , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The excellent results with left ventricular assist devices (LVADs) have revolutionized the treatment options for end-stage heart failure. The use of pulsatile devices is associated with significant comorbidity and limited durability. The axial-flow HeartMate II LVAD represents the new generation of devices. The clinical use of this pump resulted in superior outcomes. We review the HeartMate II technology, management, clinical usage and our experience. METHODS: Between 3/2002 and 12/2008, 18 transplantable adult patients were supported on long-term HeartMate II LVAD at our institution (13 men, age 52 +/- 8.4 years, range: 31-64 years). Primary indications were: ischemic cardiomyopathy (CMP) (n = 13), idiopathic CMP (n = 5). All patients were in New York Heart Association (NYHA) Class IV heart failure. None of patients had prior open-heart surgery. Implantation via cannulation of the left ventricular apex and the ascending aorta was always elective. RESULTS: Mean support time was 217 +/- 212.3 days (range: 1-665 days). Early (30-day) mortality was 27.7% (five patients) with multiple organ failure and sepsis as main causes of death. Bleeding requiring reoperation occurred in six (33.3%) cases. Cerebral hemorrhage occurred in one patient. There were two driveline infections and no device failure. Twelve (66.6%) patients were successfully discharged home. Overall nine patients (50%) were transplanted and two patients are actually waiting for a suitable organ (n = 2 patients discharged home and n = 1 patient in hospital). At latest, follow-up survival rate after heart transplantation is 66.6% (six patients). CONCLUSION: Long-term HeartMate II LVAD provides good mid-term, long-term results. This new technology requires delicate management. Functional status and quality of life greatly improve in patients who survive the perioperative period.