RESUMO
BACKGROUND: Our 8-year experience with ECMO support as a bridge to decision was reviewed. METHODS: A cohort of 124 consecutive patients received ECMO for refractory cardiogenic shock in our institution. Twenty-six of these were out of hospital cardiac arrests and were excluded from this analysis. The median age was 43 years, in the range of 11 to 73 years. RESULTS: The median duration of ECMO support was 4.5 days. Mortality while supported by ECMO was 50% with a median support time of 2 days. Weaning from ECMO was achieved for 49 patients with the following outcomes: cardiac recovery (60%), heart transplantation (26%), and VAD implantation (14%). Median duration of support before weaning was 8 days. Hospital survival was 83%, 61.5% and 71% for cardiac recovery, heart transplantation and VAD implantation, respectively. ECMO weaning was significantly improved in all patients who had normalized their renal function, and when duration of support>6 days (HR: 4.255 [1.255-14.493], p=0.02 and HR: 2.164 [1.152-4.082], p=0.02, respectively). A creatinine level>14 mg/l the day of weaning was a significant predictor of death (HR: 5.807 [1.089-30.953]; p=0.04). Median follow up was 2.4 years; one-year survival rate was 78%, 51% and 75% for cardiac recovery, heart transplantation and VAD implantation, respectively. CONCLUSION: With at least 6 days of support, ECMO allowed a better patient selection for myocardial recovery, VAD implantation or heart transplantation. Whether VAD implantation or heart transplant in those patients is a better indication remains to be evaluated.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Coração , Coração Auxiliar , Choque Cardiogênico/terapia , Adolescente , Adulto , Idoso , Criança , Tomada de Decisão Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica/fisiologia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/fisiopatologia , Adulto JovemRESUMO
BACKGROUND: Primary cardiac sarcomas are uncommon and rare, with an unequal distribution in the population. A dismal prognosis is usually admitted that is related to a high propensity to develop distant metastasis with survival rarely exceeding 2 years. We report a case of a patient with a primary cardiac rhabdomyosarcoma characterized by an exceptional long-term survival after surgical treatment by a total orthotopic heart transplantation. From this limited experience, we reviewed factors that may influence survival to optimize therapeutic strategy. METHODS: A 33-year-old man was found to have a 10-cm primary cardiac rhabdomyosarcoma located in the right atrium and extending to the atrioventricular groove; therefore, resection was not possible. Since no metastases were detected, the patient was scheduled for urgent cardiac transplantation, which was performed after adjuvant radiotherapy. RESULTS: Postoperative outcome was uneventful and the patient is still alive, with regular follow-up, at 102 months. CONCLUSIONS: In a case of primary rhabdomyosarcoma, heart transplantation, despite immunosuppressive therapy, can provide long-term survival and can be considered for selected patients after rigorous analysis of predictors of survival.
Assuntos
Neoplasias Cardíacas/cirurgia , Transplante de Coração , Rabdomiossarcoma/cirurgia , Adulto , Seguimentos , Átrios do Coração/patologia , Átrios do Coração/cirurgia , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/patologia , Humanos , Masculino , Rabdomiossarcoma/diagnóstico , Rabdomiossarcoma/patologia , Taxa de SobrevidaAssuntos
Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/microbiologia , Insuficiência da Valva Mitral/microbiologia , Doença Aguda , Adulto , Aggregatibacter actinomycetemcomitans/isolamento & purificação , Antibacterianos/uso terapêutico , Cardiobacterium/isolamento & purificação , Terapia Combinada , Eikenella corrodens/isolamento & purificação , Endocardite Bacteriana/complicações , Feminino , Haemophilus/isolamento & purificação , Humanos , Kingella kingae/isolamento & purificação , Valva Mitral/patologia , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/cirurgia , Adulto JovemRESUMO
BACKGROUND AND AIM OF THE STUDY: Valve ring abscesses in acute infective aortic endocarditis have a low, though not insignificant, prevalence. Surgical treatment with implantation of prosthetic valves may lead to major life-threatening complications, such as recurrent endocarditis and partial or complete prosthetic dislocation. Valvular homografts may offer a higher resistance to recurrent infection and have thus become recognized as an excellent and safe substitute for orthotopic left ventricular outflow reconstruction. METHODS: Between May 1991 and July 1996, 25 patients underwent surgical treatment for aortic endocarditis with annular destruction. Staphylococcus spp. were present in 32% of patients and Streptococcus spp. in 48%. Seven aortic valve replacements (AVR) and 18 aortic root replacements (ARR) were performed using cryopreserved valvular homografts. All grafts were implanted in the subannular position. RESULTS: The overall outcome was good in 23 patients, two died in the early postoperative period. Mean follow up was 38 +/- 18 months (range: 14 to 76 months). No recurrence of endocarditis was detected and no significant alterations of the implants were described. Transvalvular gradients were significantly lower in ARR patients than in AVR patients. CONCLUSIONS: Despite the severity of the tissue damage, cryopreserved homografts, when implanted in the subannular position, constitute a safe and reproducible surgical treatment of aortic endocarditis with annular involvement.
Assuntos
Valva Aórtica , Endocardite Bacteriana/cirurgia , Implante de Prótese de Valva Cardíaca , Doença Aguda , Adulto , Idoso , Criopreservação , Endocardite Bacteriana/diagnóstico por imagem , Feminino , Doenças das Valvas Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , UltrassonografiaRESUMO
We report the case of a 22-year-old woman in whom a focal aplasia of the pulmonary valve annulus associated with a multiple aneurysmal compensatory dysplasia was found. This patient had been followed since the age of seven years for a congenital asymmetric hypertrophic cardiomyopathy. Cardiac Doppler analysis showed significant pulmonary valvular insufficiency. The patient underwent heart transplant surgery because of total and refractory cardiac insufficiency. Pathological examination of the explanted heart (at the European Homograft Bank) enabled us to describe this valvular malformation. To date, this anomaly has not been described in the literature. Whether it is a malformation discovered fortuitously, or whether it is responsible in part for some of the signs associated with congenital hypertrophic cardiomyopathy is unclear. However, its role might be disclosed by a rigorous investigation of the patient's family.
Assuntos
Aneurisma Cardíaco/etiologia , Valva Pulmonar/anormalidades , Adulto , Cardiomiopatia Hipertrófica/congênito , Cardiomiopatia Hipertrófica/cirurgia , Feminino , Aneurisma Cardíaco/cirurgia , Transplante de Coração , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/congênito , Doenças das Valvas Cardíacas/cirurgia , HumanosRESUMO
BACKGROUND AND AIM OF THE STUDY: Cardiac papillary fibroelastoma (CPF) is a rare and histologically benign tumor, but may have a malignant propensity for life-threatening complications; thus, surgical removal is justified. Case histories were reviewed of four patients who underwent surgical management after diagnosis of CPF located on aortic (n = 2) or mitral (n = 2) valves. Our aim was to provide explanations for the clinical diversity of the lesions and, using histological and immunohistochemical methods, to hypothesize the genesis of these tumors. METHODS: Among four patients with a diagnosis of valvular CPF, two had previous and recent history of neurological embolic symptoms with small echographically located tumors attached to the ventricular side of aortic cusps. Two other patients (one with paroxysmal atrial fibrillation, one with no neurological or rhythmically related stroke) had CPFs located on the posterior or anterior mitral leaflets. RESULTS: Surgical excision was performed with a conservative valve-sparing approach. Histological and specific immunohistochemical (IHC) studies were conducted on all samples. The postoperative course was uneventful, and histological analysis confirmed the diagnosis of CPF with typical fronds characterized by three successive layers. In the first two patients there was correlation between neurological events and the presence of thrombus aggregated on the injured superficial endothelial layer. In the other patients, no endothelial damage or thrombus was found. IHC studies showed dysfunction of the superficial endothelium, a centrifugal mesenchymal cellular migration arising from the central layer to the superficial layer with differentiation steps, the presence of dendritic cells in the intermediate layer, and remnants of cytomegalovirus (CMV) in the intermediate layer. CONCLUSION: Despite their benign histological aspect, and independent of their size, CPFs justify surgical excision because of their high potential to systemic embolization. In most cases, valve sparing management is possible with no observed recurrence after complete excision. The presence of dendritic cells and CMV strongly suggests the possibility of a virus-induced tumor, therefore evoking the concept of a chronic form of viral endocarditis.
Assuntos
Fibroma , Neoplasias Cardíacas , Doenças das Valvas Cardíacas , Adulto , Idoso , Feminino , Fibroma/diagnóstico , Fibroma/patologia , Fibroma/cirurgia , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/patologia , Neoplasias Cardíacas/cirurgia , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/patologia , Doenças das Valvas Cardíacas/cirurgia , Humanos , Imuno-Histoquímica , Masculino , Pessoa de Meia-IdadeRESUMO
We report the case of a patient with five primary pneumococcal multilocular mycotic aneurysms located in the left femoral artery, the descending thoracic aorta and the right internal iliac artery. A successful treatment combining three different procedures was performed, including the use of two cryopreserved thoracic homografts. At a 54-month follow-up, the patient is alive and leads a normal life. Regular evaluation including computed tomographic scans of the thorax and abdomen showed no recurrence of infectious aneurysmal process. Moreover, this latter examination confirmed no dilatation nor significant calcifications of the thoracic arterial allograft, though chest roentgenogram showed discrete calcifications along the borders at the 50th month.
Assuntos
Aneurisma Infectado/cirurgia , Prótese Vascular , Infecções Pneumocócicas/cirurgia , Aneurisma Infectado/microbiologia , Aneurisma Infectado/terapia , Aneurisma da Aorta Torácica/microbiologia , Aneurisma da Aorta Torácica/cirurgia , Embolização Terapêutica , Artéria Femoral , Humanos , Artéria Ilíaca , Masculino , Pessoa de Meia-IdadeRESUMO
Petrous apicitis as a potentially fatal complication of suppurative otitis media presents in a variety of forms. Gradenigo's triad of abducens paralysis, deep facial pain due to trigeminal involvement and acute suppurative otitis media rarely occurs. The conflicting symptoms reported in the literature usually result in the delayed recognition of the condition with potentially disastrous consequences. The VIth nerve palsy is considered to be the least reliable sign as it is least often present. We present a case in which it was the sole presenting symptom.
Assuntos
Doenças do Nervo Abducente/etiologia , Neoplasias Palpebrais/complicações , Hemangioma/complicações , Osteíte/complicações , Otite Média Supurativa/complicações , Osso Petroso , Doenças do Nervo Abducente/diagnóstico , Criança , Neoplasias Palpebrais/diagnóstico , Feminino , Hemangioma/diagnóstico , Humanos , Imageamento por Ressonância Magnética/métodos , Otite Média Supurativa/diagnósticoRESUMO
From December 1986 to December 1994, 36 patients underwent surgical treatments for intractable ventricular tachyarrhythmias after myocardial infarction. Preoperative electrophysiological studies confirmed inducibility of sustained monomorphic ventricular tachycardia and its resistance to antiarrhythmic drugs in all patients, 2 different concepts were assessed: 1) 22 non-guided surgical procedures were performed. 17 patients underwent Encircling thermic exclusion by Nd-Yag laser beam (Group A) and 5 patients underwent extended cryoablations (n = 5) with endocardial resections. Mean preoperative value of left ventricular function in Groups A and B were 35.23% and 30.20% respectively. 10 coronary bypasses (Group A: n = 8; Group B: n = 2) and 1 mitral valve replacement (Group A) were also performed. Perioperative mortality was 5.5% in Group A. No perioperative deaths occurred in Group B. Ventricular tachycardias recurred spontaneously in 2 patients (Group A) and 7 remained inducible after evaluation by electrophysiological studies. 2) 14 patients underwent extended cryoablations guided by intraoperative cardiac mapping, including endocardial resections in all cases. Mean preoperative value of left ventricular function was 32.80%. Mitral valve replacements were achieved in 2 cases, 1 perioperative death occurred (7.14%). Clinical recurrence of ventricular tachycardias concerned 1 patient (7.69%) and 2 remained inducible after electrophysiological studies (15.38%). We conclude that the better results obtained with cardiac mapping and cryoablations may be due to available detection and destruction of deep septal arrhythmogenic substrates. Moreover, cryoablation creates a nonarrhythmogenic scar and can be performed in papillary muscles while preserving the structure of the tissue. No postoperative alteration of left ventricular function was therefore observed.
Assuntos
Criocirurgia , Terapia a Laser , Infarto do Miocárdio/complicações , Taquicardia Ventricular/cirurgia , Adulto , Idoso , Ablação por Cateter , Eletrodiagnóstico/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/cirurgia , Taquicardia Ventricular/etiologiaAssuntos
Antibacterianos/uso terapêutico , Daptomicina/uso terapêutico , Endocardite Bacteriana/tratamento farmacológico , Prótese de Quadril/efeitos adversos , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Valva Mitral/microbiologia , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Estafilocócicas/tratamento farmacológico , Idoso , Antibacterianos/efeitos adversos , Antibacterianos/farmacologia , Bacteriemia/tratamento farmacológico , Bacteriemia/microbiologia , Terapia Combinada , Daptomicina/farmacologia , Remoção de Dispositivo , Quimioterapia Combinada , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/cirurgia , Evolução Fatal , Feminino , Gentamicinas/administração & dosagem , Gentamicinas/uso terapêutico , Humanos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Valva Mitral/patologia , Valva Mitral/cirurgia , Complicações Pós-Operatórias/etiologia , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/cirurgia , Síndrome do Desconforto Respiratório/etiologia , Rifampina/administração & dosagem , Rifampina/uso terapêutico , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/cirurgia , Trombocitopenia/induzido quimicamente , Vancomicina/administração & dosagem , Vancomicina/efeitos adversos , Vancomicina/uso terapêuticoRESUMO
OBJECTIVE: The authors assessed the management of community-acquired pneumonia (CAP) and empirical antibiotic prescription in a primary care center. METHOD: A retrospective study was made on medical charts of patients admitted to the emergency department for CAP. RESULTS: Seventy-six patients were included. Their mean age was 65years for a sex ratio of 1.81. Fever (83%) and cough (72%) were the most common symptoms. Chest X-ray was abnormal in 86%. The median CRP value was 138mg/L (58-235). The median Fine's score was 85.5 (60-127). Blood cultures were sterile for 82.5% of samples. Pneumococcal and legionella antigenuria were performed for 70% of patients, only one was positive for legionella. Antibiotherapy was prescribed to 18 patients before hospitalization. Amoxicillin-clavulanic acid was the most frequently prescribed empirical treatment (48.5%), followed by ceftriaxone (15%). The therapeutic adequation index was calculated at a median of 1.7 by three investigators (0-3.7). Kendall's concordance coefficient for the three investigators was good at 0.86 (P<0.0001). Close to 39% of antibiotic prescription had a bad therapeutic adequation index more than three. DISCUSSION: Our clinical, radiological, and microbiological data was quite similar to reported data from teaching hospital series except for severity that seemed lower in primary care centers. The therapeutic adequation index is a useful tool to assess the adequacy of antibiotic prescription.
Assuntos
Antibacterianos/uso terapêutico , Infecções Comunitárias Adquiridas/tratamento farmacológico , Serviço Hospitalar de Emergência , Pneumonia Bacteriana/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Testes Diagnósticos de Rotina/estatística & dados numéricos , Gerenciamento Clínico , Uso de Medicamentos , Feminino , Fidelidade a Diretrizes , Humanos , Prescrição Inadequada/prevenção & controle , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/diagnóstico , Pneumonia Bacteriana/epidemiologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Adulto JovemRESUMO
Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.
Assuntos
Carcinoma de Células Renais/cirurgia , Ponte Cardiopulmonar/métodos , Neoplasias Cardíacas/cirurgia , Neoplasias Renais/cirurgia , Neoplasias Vasculares/cirurgia , Carcinoma de Células Renais/secundário , Procedimentos Cirúrgicos Cardiovasculares/métodos , Feminino , Átrios do Coração , Neoplasias Cardíacas/secundário , Humanos , Neoplasias Renais/patologia , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Nefrectomia , Trombectomia , Neoplasias Vasculares/secundário , Veia Cava InferiorRESUMO
This study was undertaken to develop a rodent (rat) model of cardiopulmonary bypass (CPB) that has been designed to mimic functionally the minimally invasive clinical setting. The circuit is similar to the clinical model in terms of its construction, configuration, material surface area to blood volume ratio, and priming volume to blood ratio. The overall priming volume was 10 mL. Thirty-six male Sprague-Dawley rats (422 +/- 32 g) were anaesthetized while maintaining spontaneous ventilation. Anticoagulation was achieved with heparin (500 IU/kg). Blood arterial pressure was monitored continuously. Normal central temperature was maintained throughout. Intermittent arterial blood gas levels also were monitored. All animals were cannulated in preparation for CPB; however, CPB, utilizing a double roller pump and a flow rate of 100 mL/kg/minute for 60 min, was initiated in only 18 animals, the remaining 18 animals acting as non-CPB controls (Sham). The animals were haemodynamically stable. After the operative procedure, the animals were allowed to recover from the anaesthesia and, after transfer to a recovery facility, were monitored for a period of 1 week. There were no differences between the groups in terms of blood gas analysis and blood pressure data; all animals survived the procedure and had an uneventful follow-up. Differences were found between the CPB animals and the Sham group in terms of TNFalpha used as a marker of inflammatory processes. This trend tends to support this model as an analogue for the clinical scenario for future studies of CPB-related inflammation. Overall, the CPB procedure was easy to perform and was associated with excellent survival. This recovery model is an effective tool to perform pathophysiological studies associated with minimally invasive CPB.
Assuntos
Ponte Cardiopulmonar/instrumentação , Ponte Cardiopulmonar/métodos , Modelos Animais , Animais , Gasometria , Pressão Sanguínea , Convalescença , Desenho de Equipamento , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Mortalidade , Período Pós-Operatório , Ratos , Ratos Sprague-Dawley , Fatores de Tempo , Fator de Necrose Tumoral alfa/metabolismoRESUMO
BACKGROUND: The first generation of pericardial valves had a high rate of premature deterioration. The aim of this study was to compare the outcome after aortic valve replacement with second generation pericardial prostheses (Pericarbon and Carpentier-Edwards). METHODS AND RESULTS: Between 1987 and 1994, 162 patients underwent aortic valve replacement with either a Pericarbon (n=81, 69+/-11 years) or a Carpentier-Edwards (n=81, 70+/-11 years) pericardial prosthesis. Mean follow-up was 4.4+/-2.7 years for Pericarbon and 4.8+/-2.4 years for Carpentier-Edwards valves (P=0. 27), giving a total follow-up of 745 patient-years. Thirty-day mortality and 5-year actuarial survival were, respectively, 6.2% and 63.2+/-5.7% in the Pericarbon group and 6.2% and 63.5+/-5.6% in the Carpentier-Edwards group. At 8 years, freedom from (and linearized rates per patient-year) thromboembolism, structural failure, and all valve-related events were, respectively, 91.8+/-3.6% (1.4%), 76. 9+/-8.7% (2.5%), and 58.4+/-9.3% (5.6%) in the Pericarbon group and 94.4+/-2.7% (1%), 100% (0%, P<0.01), and 88.8+/-3.7% (2%, P<0.05) in the Carpentier-Edwards group. There were 9 (11.1%) Pericarbon structural failures related predominantly to severe calcification and stenosis. The actual reoperation rate was 7.4% (1.6% per patient-year) in the Pericarbon group for fibrocalcific degeneration (n=3), periprosthetic leak (n=1), endocarditis (n=1), and aortic dissection (n=1). There was neither structural valve failure nor valve reoperation in the Carpentier-Edwards group. Echocardiographic review of 70 patients from 85 survivors (82.3%) found 4 additional Pericarbon valves with signs of early structural failure but no Carpentier-Edwards valve with such changes. CONCLUSIONS: Eight years after aortic valve replacement, Pericarbon pericardial prostheses compared unfavorably with Carpentier-Edwards pericardial prostheses, with a high incidence of structural valve failure and reoperation.