RESUMO
We encountered an informative case of infected aortic arch aneurysm. The proximal descending aorta, left common carotid artery, and left subclavian artery were severely involved in an abscess; thus, typical in situ reconstruction of the arch was considered impossible. Therefore, to secure more distal branches appropriate for anastomosis, a modified extra-anatomic arch repair was performed through additional incisions. The patient developed renal and respiratory failure and died of septicemia five and a half months after the operation. However, postoperative computed tomograms demonstrated that the abscess had disappeared.
RESUMO
UNLABELLED: Surgical site infections are a major cause of postoperative morbidity and mortality in cardiovascular surgery. Proper antibiotic prophylaxis can reduce the rate of such infections, but the concentration of antibiotic must be maintained at an adequate level throughout the operation. This study aimed to use renal function to determine the most appropriate timing for intraoperative repeated dosing of ampicillin-sulbactam, a commonly used prophylactic antibiotic, to maintain adequate concentrations throughout the course of surgery. The mean volume of distribution, elimination rate constant, elimination half-life, and total clearance of ampicillin were 13.2 l, 0.652 h⻹, 1.32 h, and 8.45 l/h, respectively. A statistically significant (P < 0.0001) correlation (r = 0.771) was observed between the total clearance of ampicillin and creatinine clearance of the patients. Plasma concentrations of ampicillin were simulated with the pharmacokinetic parameters obtained. We developed a nomogram for adjusting the dosing interval according to renal function and predicted ampicillin trough concentrations. We revealed the best dosage and dosing interval for cardiovascular surgery by analyzing the perioperative pharmacokinetics of ampicillin-sulbactam administered prophylactically. We suggest that the dosage and dosing interval for ampicillin-sulbactam should be adjusted to optimize treatment efficacy and safety, on the basis of the MIC90 of methicillin-sensitive Staphylococcus aureus (MSSA) in each institution. TRIAL REGISTRATION: UMIN000007356.
Assuntos
Antibacterianos/administração & dosagem , Antibacterianos/farmacocinética , Rim/efeitos dos fármacos , Idoso , Idoso de 80 Anos ou mais , Ampicilina/administração & dosagem , Ampicilina/sangue , Ampicilina/farmacocinética , Antibacterianos/sangue , Antibioticoprofilaxia/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Creatinina/urina , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Rim/fisiologia , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Sulbactam/administração & dosagem , Sulbactam/sangue , Sulbactam/farmacocinética , Infecção da Ferida Cirúrgica/prevenção & controleRESUMO
PURPOSE: The infusion of a cardioplegic solution is the standard method of myocardial protection during open heart surgery. However, this method interrupts the surgical procedure and it is difficult to ensure a bloodless surgical field. To address these problems, the effect of continuous retrograde gaseous oxygen persufflation (ROP) on myocardial protection was assessed in comparison to St. Thomas' solution (STS). METHODS: Eighteen adult mongrel dogs were divided into three groups of six. Group G received continuous ROP, Group C received STS every 30 min, and Group N received hypothermia alone during the 120 min hypothermic ischemia. The myocardial metabolism was assessed by measuring the coronary sinus lactate concentration, lactate extraction ratio (LER), coronary sinus lipid peroxidation (LPO) concentration, left ventricular myocardial adenosine triphosphate (ATP) concentration, and water content. Cardiac function was assessed by the percent recovery relative to the baseline. RESULTS: In Group G, the lactate, LPO, and water content were significantly lower (P = 0.0062, P = 0.03, and P = 0.0065, respectively), and ATP was significantly higher (P = 0.028) than in Group C. The LER was only positive in Group G. In addition, the cardiac functions in Groups G and C were not significantly different. CONCLUSIONS: Retrograde gaseous oxygen persufflation was not inferior to STS in regard to myocardial protection. This technique could therefore represent a potentially promising cardioplegic method.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Hipotermia Induzida/métodos , Soluções Isotônicas/administração & dosagem , Oxigênio/administração & dosagem , Trifosfato de Adenosina/metabolismo , Animais , Água Corporal/metabolismo , Cães , Lactatos/metabolismo , Peroxidação de Lipídeos , MiocárdioRESUMO
We report a surgical case of infected thoracic aortic aneurysm. Before arrival of the cryopreserved aortic allograft, the patient had hemoptysis resulting from aneurysm rupture. Therefore endovascular stent grafting was urgently performed three days prior to in situ allograft implantation. Palliative stent grafting prevented circulatory collapse and stabilized the patient until successful allograft implantation.
Assuntos
Aneurisma Infectado/cirurgia , Aorta/transplante , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Implante de Prótese Vascular/instrumentação , Prótese Vascular , Criopreservação , Stents , Idoso , Aneurisma Infectado/diagnóstico por imagem , Aneurisma Infectado/microbiologia , Angiografia Digital , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/microbiologia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/microbiologia , Aortografia/métodos , Remoção de Dispositivo , Hemoptise/microbiologia , Humanos , Masculino , Cuidados Paliativos , Desenho de Prótese , Reoperação , Salmonella/isolamento & purificação , Choque/microbiologia , Choque/prevenção & controle , Tomografia Computadorizada por Raios X , Transplante Homólogo , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to review characteristics of patients undergoing left ventricular reconstruction (LVR) with or without mitral annuloplasty (MAP) for postinfarction ventricular remodeling. PATIENTS AND METHODS: Forty-seven patients were divided into two groups: LVR (LVR group, n = 22) and LVR with MAP (LVRM group, n = 25). Echocardiographic parameters including left ventricular (LV) dimensions, LV end-diastolic and end-systolic volume indexes, and LV ejection fraction (LVEF) at immediate and midterm postoperative stages were evaluated. The perioperative contributing factors to all deaths and death from congestive heart failure (CHF) were analyzed in all 47 patients. RESULTS: Patients in the LVRM group had greater preoperative LV dimension and volume, and significantly lower LVEF, with notably frequent use of intra-aortic balloon pumping. All postoperative deaths occurred within 1 year from surgery. The LV end-diastolic volume > 110 ml/m2 and creatinine > 1.2 mg/dl were significant preoperative contributing factors to all deaths, and the latter was to CHF deaths. CONCLUSIONS: The coexistence of ischemic mitral regurgitation with LV dilatation required more aggressive surgical approaches for the patients with more impaired LV function. More intensive postoperative management is required for patients with enlarged hearts and renal dysfunctions.
Assuntos
Implante de Prótese de Valva Cardíaca , Ventrículos do Coração/cirurgia , Hipertrofia Ventricular Esquerda/cirurgia , Insuficiência da Valva Mitral/cirurgia , Infarto do Miocárdio/complicações , Função Ventricular Esquerda , Idoso , Ponte de Artéria Coronária , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/mortalidade , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Ventrículos do Coração/fisiopatologia , Humanos , Hipertrofia Ventricular Esquerda/etiologia , Hipertrofia Ventricular Esquerda/mortalidade , Hipertrofia Ventricular Esquerda/fisiopatologia , Nefropatias/complicações , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Infarto do Miocárdio/cirurgia , Desenho de Prótese , Análise de Regressão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Remodelação VentricularRESUMO
We report a case of recurrent malignant fibrous histiocytoma (MFH) in the left atrium, treated by removal of the tumor and the right half of the left atrium, which was reconstructed with two equine pericardial patches. Postoperative echocardiography showed patent right pulmonary veins and a properly shaped left atrium. The patient survived for 3 years after the operation with no cardiac symptoms.
Assuntos
Átrios do Coração/cirurgia , Neoplasias Cardíacas/cirurgia , Histiocitoma Fibroso Maligno/cirurgia , Pericárdio/transplante , Procedimentos de Cirurgia Plástica/métodos , Adolescente , Animais , Encefalocele , Evolução Fatal , Átrios do Coração/patologia , Neoplasias Cardíacas/diagnóstico , Histiocitoma Fibroso Maligno/diagnóstico , Cavalos , Humanos , Masculino , Metástase Neoplásica , Recidiva Local de Neoplasia , Transplante HeterólogoRESUMO
Prevention of paraplegia remains an important issue in repair of descending thoracic and thoracoabdominal aneurysms. Therefore, we investigated the protective effect of sivelestat sodium hydrate (ONO-5046) on ischemia-induced spinal cord damage in a rabbit model. Twenty New Zealand white rabbits were divided into two equal groups; ONO-5046 (1.6 mg/kg)+isotonic NaCl (30 ml) was administered selectively to the spinal cord via the lumbar arteries for the first 3 min during 30 min of infra-renal aorta clamping in the experimental group (group E), whereas NaCl was given alone in the control group (group C). Motor function of the lower limbs was assessed two days later by Tarlov criteria. The number of intact motor neurons in the anterior segment of the cord (L5 level) was counted after hematoxylin-eosin staining and the number of apoptotic motor neurons after TUNEL staining. Motor function of the lower limbs in group E was significantly better (P=0.003) than that in group C. The number of intact motor neurons was greater and of apoptotic motor neurons was less in group E than C. Selective infusion of sivelestat sodium hydrate directly into the spinal cord via the lumbar arteries significantly attenuated functional and morphological ischemia-induced spinal cord injury.
Assuntos
Glicina/análogos & derivados , Elastase de Leucócito/antagonistas & inibidores , Fármacos Neuroprotetores/farmacologia , Paraplegia/prevenção & controle , Inibidores de Serina Proteinase/farmacologia , Traumatismos da Medula Espinal/prevenção & controle , Isquemia do Cordão Espinal/tratamento farmacológico , Sulfonamidas/farmacologia , Animais , Apoptose/efeitos dos fármacos , Modelos Animais de Doenças , Glicina/administração & dosagem , Glicina/farmacologia , Infusões Intra-Arteriais , Atividade Motora/efeitos dos fármacos , Neurônios Motores/efeitos dos fármacos , Neurônios Motores/patologia , Fármacos Neuroprotetores/administração & dosagem , Paraplegia/etiologia , Paraplegia/patologia , Paraplegia/fisiopatologia , Coelhos , Inibidores de Serina Proteinase/administração & dosagem , Traumatismos da Medula Espinal/etiologia , Traumatismos da Medula Espinal/patologia , Traumatismos da Medula Espinal/fisiopatologia , Isquemia do Cordão Espinal/complicações , Isquemia do Cordão Espinal/patologia , Isquemia do Cordão Espinal/fisiopatologia , Sulfonamidas/administração & dosagemRESUMO
BACKGROUND: A Tei index is known to reflect overall cardiac performance including systolic and diastolic function in a variety of heart disease. We investigated the relationship between preoperative Tei index and postoperative left ventricular (LV) mass regression and survival after aortic valve replacement (AVR) for aortic valve stenosis (AS). METHODS: One hundred fifty-four patients with AS were classified into a group with abnormal (Abn) LV function (n=47, 0.45 < or = Tei index) and a group with normal (Nor) LV function (n=107, Tei index < 0.45). The pre- and postoperative echocardiographic variables including LV dimension, LV wall thickness, and LV mass regression as well as 6-year survival were compared between the two groups. RESULTS: There was a significant difference in both absolute and relative LV mass index (LVMI) regression (P=0.004 and 0.0007). Multiple linear regression analysis revealed that the preoperative LVMI, Tei index, and follow-up period were independent predictors of LVMI regression after AVR. Thirteen patients died (valve-related death in 5). Although the overall survival rate in the Nor-LV group (92.8%) was significantly better than that in the Abn-LV group (71.6%), there was no significant difference in survival free from valve-related death. CONCLUSIONS: Preoperative Tei index can be one of the significant predictors of LVMI regression and overall survival after AVR.
Assuntos
Estenose da Valva Aórtica/cirurgia , Ecocardiografia Doppler , Próteses Valvulares Cardíacas , Ventrículos do Coração/diagnóstico por imagem , Disfunção Ventricular/diagnóstico por imagem , Disfunção Ventricular/mortalidade , Idoso , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Bioprótese , Feminino , Humanos , Masculino , Análise de Regressão , Disfunção Ventricular/complicaçõesRESUMO
Uterine arteriovenous malformation (AVM) is a rare and potentially life-threatening disease. The present report describes a postmenopausal patient with uterine AVM manifesting recurrent, massive genital bleeding. Uterine artery embolization (UAE) was scheduled before hysterectomy, but UAE was unsuccessful due to the dilated, tortuous internal iliac arteries, and extremely rapid arterial blood flow. Hysterectomy appeared to carry a potential risk of massive blood loss due to multiple dilated vessels around the uterine corpus and cervix. Therefore, six arteries feeding the uterus were surgically ligated. At 10 months after the operation there have been no episodes of atypical genital bleeding.
Assuntos
Artérias/anormalidades , Malformações Arteriovenosas/patologia , Útero/irrigação sanguínea , Artérias/diagnóstico por imagem , Artérias/cirurgia , Malformações Arteriovenosas/diagnóstico por imagem , Malformações Arteriovenosas/cirurgia , Embolização Terapêutica/métodos , Feminino , Humanos , Ligadura/métodos , Pessoa de Meia-Idade , Ultrassonografia , Útero/diagnóstico por imagem , Útero/cirurgiaRESUMO
BACKGROUND: Procedures on the subvalvular apparatus are an etiology-based treatment for ischemic mitral regurgitation (IMR). METHODS AND RESULTS: Fifty-nine patients with IMR were divided into 3 groups: mitral annuloplasty (MAP) (M group, n=27), MAP+left ventricular reconstruction (LVR) (LV group, n=18), and MAP+LVR+subvalvular procedure (S group, n=14). Tenting height and area, angle between the annular line and the line connecting leaflet base to the bending- or tip-point of either the anterior or posterior leaflet, and leaflet mobility were measured echocardiographically preoperatively and at immediate- and mid-term postoperative follow-up. The angles at the bending-point of the anterior leaflet in mid-systole remained greater than those at its tip-point in the M and LV groups, but became significantly smaller postoperatively only in the S group (p<0.05). Postoperative leaflet mobility at the bending-point in the S group became significantly greater than in the other groups (p<0.01). The grade of MR, after significant reduction by the procedure, increased again in the M and LV groups, but remained almost unchanged in the S group. CONCLUSION: Subvalvular procedures improved the configuration and mobility of the anterior leaflet, and can be expected to reduce the recurrence of IMR.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Isquemia Miocárdica/cirurgia , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/patologia , Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/patologia , Insuficiência da Valva Mitral/fisiopatologia , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/patologia , Isquemia Miocárdica/fisiopatologia , RecidivaRESUMO
We report a rare case of simultaneous repair for Cor triatriatum (CT), partially unroofed coronary sinus (CS) with persistent left superior vena cava (PLSVC), moderately severe tricuspid regurgitation, and atrial flutter 35 years after radical operation for tetralogy of Fallot (TOF). A 40-year-old woman underwent patch closure of atrial septal defect as to drain blood from left SVC to right atrium (RA), excision of diaphragm in left atrium (LA), tricuspid annuloplasty, and cryoablation. Postoperative course was uneventful with successful anatomical correction.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Coração Triatriado/cirurgia , Seio Coronário/cirurgia , Tetralogia de Fallot/cirurgia , Veia Cava Superior/cirurgia , Adulto , Coração Triatriado/patologia , Seio Coronário/patologia , Criocirurgia , Feminino , Humanos , Tetralogia de Fallot/patologia , Fatores de Tempo , Resultado do Tratamento , Veia Cava Superior/patologiaRESUMO
We report a case of intervalvular fibrosa pseudoaneurysm, causing massive shunt flow from the left ventricle below the left coronary cusp to the left atrium above the anterior mitral annulus, which was clearly demonstrated on preoperative three-dimensional transesophageal echocardiography. Superior extension of the right-sided left atriotomy toward the pseudoaneurysm, combined with transection of aorta and main pulmonary artery, provided its sufficient exposure. Its opening to the left ventricle was closed with a patch, leaving no residual shunt flow.
Assuntos
Falso Aneurisma/fisiopatologia , Valva Aórtica/fisiopatologia , Endocardite/fisiopatologia , Aneurisma Cardíaco/fisiopatologia , Hemodinâmica , Valva Mitral/fisiopatologia , Idoso , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/cirurgia , Aorta/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Bioprótese , Procedimentos Cirúrgicos Cardíacos , Circulação Coronária , Ecocardiografia Transesofagiana , Endocardite/diagnóstico por imagem , Endocardite/cirurgia , Feminino , Aneurisma Cardíaco/diagnóstico por imagem , Aneurisma Cardíaco/cirurgia , Átrios do Coração/fisiopatologia , Implante de Prótese de Valva Cardíaca/instrumentação , Ventrículos do Coração/fisiopatologia , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Pericárdio/transplante , Artéria Pulmonar/cirurgia , Transplante Autólogo , Resultado do TratamentoRESUMO
BACKGROUND AND AIM OF THE STUDY: The recurrence of ischemic mitral regurgitation (IMR) after mitral annuloplasty is a major determinant of patient survival. The study aim was to investigate, retrospectively, the characteristics of patients with postoperative recurrence of IMR. METHODS: Twenty patients who had no regurgitation immediately after mitral annuloplasty, were allocated to either recurrence (n = 8) or non-recurrence (n = 12) groups. Recurrence was defined as any interval upgrade of regurgitation. The patients' preoperative profiles and parameters of preoperative, immediate postoperative and intermediate postoperative echocardiography were compared. RESULTS: Patients with recurrence were more frequently dyspneic and had a significantly higher cardiothoracic ratio (p = 0.041) on radiologic examination. The preoperative left ventricular end-diastolic and end-systolic dimensions (p = 0.018 and 0.021), and left ventricular end-diastolic and end-systolic volumes (p = 0.038 and 0.041), and left ventricular wall motion score (p = 0.0002) were significantly greater in the recurrence group. These differences in left ventricular volume persisted at the immediate and intermediate postoperative stages. Reverse remodeling occurred at a ca. 50% lower rate in the recurrence group, and was associated with significantly smaller preoperative left ventricular dimension and volume. At intermediate follow up, the left ventricular ejection fraction was improved and significantly greater in the non-recurrence group (p = 0.024), but remained unchanged in the recurrence group. CONCLUSION: Advanced left ventricular remodeling and dilatation before surgery predispose to a recurrence of mitral regurgitation and a lesser incidence of reverse remodeling. Mitral annuloplasty alone may have a limited role in preventing the recurrence of regurgitation in the case of advanced IMR, without functional recovery.
Assuntos
Ventrículos do Coração/fisiopatologia , Insuficiência da Valva Mitral/fisiopatologia , Isquemia Miocárdica/fisiopatologia , Cuidados Pré-Operatórios , Remodelação Ventricular/fisiologia , Idoso , Volume Cardíaco/fisiologia , Ecocardiografia , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/métodos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/cirurgia , Contração Miocárdica/fisiologia , Isquemia Miocárdica/complicações , Isquemia Miocárdica/cirurgia , Prognóstico , Recidiva , Estudos Retrospectivos , Volume Sistólico/fisiologiaRESUMO
BACKGROUND: The impact of aortic valve replacement (AVR) with prosthesis-patient mismatch (PPM) on intermediate-term outcome and left ventricular mass (LVM) regression in patients with aortic stenosis (AS) was investigated. METHODS: One hundred fifty patients with AS (87 pure stenosis and 63 combined stenosis and regurgitation) were classified into a PPM group (n = 34, indexed effective orifice area (EOAI) >0.65 cm(2)/m(2) and < or =0.85 cm(2)/m(2); moderate PPM) and a non-PPM group (n = 116, EOAI > 0.85). Mean age, mean and peak aortic pressure gradient (PG) were not different between the groups (PPM, 99.7 +/- 37.2 and 54.9 +/- 23.2 mmHg; non-PPM, 95.9 +/- 29.2 and 54.4 +/- 16.0 mmHg). The absolute and relative regression in indexed left ventricular mass (LVMI) was estimated by preoperative and postoperative echocardiography (n = 98). RESULTS: Twelve patients died (valve-related death in 7) during 5 years of follow-up. Comparing the PPM and non-PPM groups, overall survival (78.7% vs. 87.8%) and survival free from valve-related death (96.8% vs. 92.1%) were not significantly different. New York Heart Association (NYHA) functional class improved in all patients and there were no patients in class III or IV. The postoperative mean PG was 14.6 +/- 6.1 mmHg in the PPM group and 9.4 +/- 3.8 mmHg in the non-PPM group (p = 0.0005), with an inverse correlation (r = -0.48, p < 0.0001) between EOAI and the postoperative mean PG. However, there was no significant difference in the absolute and relative LVMI regression between the two groups. Multiple linear regression analysis was performed and higher preoperative LVMI and mean aortic PG were independent predictors of greater LVMI regression after AVR. CONCLUSIONS: Moderate PPM does not appear to alter LVMI regression, NYHA class, or intermediate-term outcome in AS patients undergoing AVR with mechanical prostheses. In multivariate analysis, preoperative LVMI and mean aortic PG were important independent predictors of LVMI regression.
Assuntos
Valva Aórtica/patologia , Próteses Valvulares Cardíacas , Ventrículos do Coração/patologia , Hipertrofia Ventricular Esquerda/prevenção & controle , Resultado do Tratamento , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Progressão da Doença , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/mortalidade , Masculino , Estudos Prospectivos , Valores de Referência , Volume Sistólico , Fatores de Tempo , UltrassonografiaRESUMO
We report the case of a 54-year-old woman who, 32 years previously, had undergone replacement of the ascending aorta by the inclusion method with a Starr-Edwards ball valve prosthesis and recently underwent aortic root re-reconstruction by the Bentall method. Routine chest radiography revealed dilatation of the mediastinum, and computed tomography revealed an aneurysm of the ascending aorta. At reoperation, although the cloth covering the cage of the Starr-Edwards ball valve prosthesis appeared worn and some pannus formation was seen, the Starr-Edwards ball valve was functioning normally. The aortic root was replaced with a composite graft that consisted of a 23-mm St. Jude bileaflet prosthesis and a 24-mm Hemashield gold graft. The patient was discharged from the hospital in good condition 25 days after surgery.
Assuntos
Valva Aórtica , Remoção de Dispositivo/métodos , Próteses Valvulares Cardíacas , Procedimentos Cirúrgicos Cardíacos/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Falha de Prótese , ReoperaçãoRESUMO
Surgical correction of the subvalvular apparatus to reduce tethering, along with mitral annuloplasty, has recently been highlighted in the treatment of functional mitral regurgitation. However, because of anatomical differences in the subvalvular apparatus between cases of progressive cardiomyopathy, a uniform procedure to reduce tethering has not been established. We report a case-specific reconstructive method consisting of procedures mainly on papillary muscles for a rare case of dilated-phase hypertrophic cardiomyopathy with moderately severe mitral regurgitation.
Assuntos
Cardiomiopatia Dilatada/complicações , Insuficiência da Valva Mitral/cirurgia , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Humanos , MasculinoRESUMO
BACKGROUND: The aim of this study was to investigate the mid-term changes of left ventricular (LV) geometry and function after Dor, septal anterior ventricular exclusion (SAVE), and Overlapping ventricular remodeling procedures. METHODS: Forty-three patients who underwent LV reconstruction for end-stage ischemic heart disease, were divided into three groups, undergoing Dor (n=15), SAVE (n=12), and Overlapping procedures (n=16). Coronary artery bypass grafting and mitral annuloplasty were performed concomitantly when indicated. Left ventricular diastolic and systolic dimensions (LVDd and LVDs), LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI), LV ejection fraction (LVEF), deceleration time (DcT), sphericity index (SI), and grade of mitral regurgitation were measured on preoperative and postoperative (immediately and at intermediate-term) echocardiography. RESULTS: In the Dor group, the LVEDVI and LVESVI were significantly reduced immediately after the operation, and increased again at intermediate follow-up. The SI was significantly increased immediately after the operation and increased thereafter in a linear fashion. In the SAVE group, the DcT was significantly reduced immediately after the operation and was not improved in the later stage. In the Overlapping group, the LVEDVI and LVESVI were significantly reduced, and remained as such at intermediate follow-up. The SI was not increased and remained almost unchanged after the operation. CONCLUSION: Progression in LV sphericity after the Dor procedure and persistent reduction of the DcT after the SAVE procedure seem to be procedure-related problems. The Overlapping procedure provided significant LV volume reduction, maintaining the most elliptical LV shape with acceptable early and late mortality.
Assuntos
Insuficiência Cardíaca/cirurgia , Função Ventricular Esquerda , Idoso , Ponte de Artéria Coronária , Seguimentos , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/patologia , Ventrículos do Coração/cirurgia , Humanos , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/cirurgia , Infarto do Miocárdio/complicações , Análise de Sobrevida , Resultado do Tratamento , Remodelação VentricularRESUMO
Prevention of catastrophic thromboembolic complications during surgery in patients with heparin-induced thrombocytopenia (HIT) remains a challenging problem during cardiac surgery. We infused an increasing dose of epoprostenol sodium, which is one of three anti-HIT regimens available in Japan, ahead of administration of heparin and performed a mitral valve operation for a patient with type II HIT. The absence of thromboembolic events and platelet consumption during cardiopulmonary bypass, together with considerable reduction of platelet adhesion to the fibers of the membrane oxygenator, support the efficacy and safety of our strategy.
Assuntos
Anticoagulantes/efeitos adversos , Procedimentos Cirúrgicos Cardíacos , Epoprostenol/uso terapêutico , Heparina/efeitos adversos , Cuidados Intraoperatórios , Inibidores da Agregação Plaquetária/uso terapêutico , Trombocitopenia/tratamento farmacológico , Idoso , Flutter Atrial/etiologia , Flutter Atrial/cirurgia , Epoprostenol/administração & dosagem , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/cirurgia , Humanos , Infusões Intravenosas , Masculino , Estenose da Valva Mitral/complicações , Estenose da Valva Mitral/cirurgia , Inibidores da Agregação Plaquetária/administração & dosagem , Trombocitopenia/induzido quimicamente , Insuficiência da Valva Tricúspide/complicações , Insuficiência da Valva Tricúspide/cirurgiaRESUMO
OBJECTIVE: There are few data available on the effect of ultrasonic skeletonization with the harmonic scalpel on internal thoracic artery (ITA) and gastroepiploic artery (GEA) vessel function. METHODS: Rings of segments of the skeletonized ITA, pedicled ITA, skeletonized GEA, and pedicled GEA were studied. Arterial segments were treated with high KCl and norepinephrine (NE) to obtain smooth muscle contractions. Endothelium-dependent and independent vasorelaxant potencies in 10(-6)mol/l NE-pre-constricted arteries were assessed by acetylcholine (ACh), and isosorbide dinitrate (ISDN) and diltiazem, respectively. RESULTS: There were no differences in contractile potencies induced by high KCl and NE between the rings cut from skeletonized and pedicled grafts. The rings from skeletonized and pedicled vessels also showed equal sensitivity to ISDN and diltiazem. However, the rings from pedicled grafts showed greater relaxation responses to ACh than rings from skeletonized grafts. CONCLUSION: Ultrasonic complete skeletonization with the harmonic scalpel may retain smooth muscle function of skeletonized grafts, whereas endothelial function of ultrasonic skeletonized grafts may be significantly compromised.
Assuntos
Ponte de Artéria Coronária , Doença das Coronárias/cirurgia , Artéria Gastroepiploica/diagnóstico por imagem , Artéria Torácica Interna/diagnóstico por imagem , Coleta de Tecidos e Órgãos/métodos , Acetilcolina , Análise de Variância , Diltiazem , Endotélio Vascular/diagnóstico por imagem , Endotélio Vascular/fisiopatologia , Artéria Gastroepiploica/fisiopatologia , Humanos , Dinitrato de Isossorbida , Artéria Torácica Interna/fisiopatologia , Músculo Liso Vascular/diagnóstico por imagem , Músculo Liso Vascular/fisiopatologia , Coleta de Tecidos e Órgãos/instrumentação , Transplantes , Ultrassonografia , Grau de Desobstrução Vascular , VasodilatadoresRESUMO
BACKGROUND: Surgical annuloplasty can potentially hoist the posterior annulus anteriorly, exaggerate posterior leaflet (PML) tethering, and lead to recurrent ischemic/functional mitral regurgitation (MR). Characteristics of leaflet configurations in late postoperative MR were investigated. METHODS AND RESULTS: In 30 patients with surgical annuloplasty for ischemic MR and 20 controls, the anterior leaflet (AML) and PML tethering angles relative to the line connecting annuli, posterior and apical displacement of the coaptation and the MR grade were measured by echocardiography before, early after, and late after surgery. Early after surgery, grade of MR and AML tethering generally decreased (P<0.01), whereas PML tethering significantly worsened (P<0.01). Nine of the 30 patients showed recurrent/persistent MR late after surgery. Compared with patients without late MR, those with the MR showed similar reduction in the annular area, significant re-increase in posterior displacement of the coaptation, and progressive worsening in PML tethering (P<0.05) late after surgery in comparison to the early phase. Both preoperative MR and late postoperative MR were significantly correlated with all tethering variables in univariate analysis. Although apical displacement of the coaptation was the primary determinant of preoperative MR (r2=0.60, P<0.0001), increased PML tethering was the primary determinant of late MR (r2=0.75, P<0.0001). CONCLUSIONS: Whereas both leaflets tethering is related to preoperative ischemic MR, both leaflets tethering but with predominant contribution from augmented and progressive PML tethering is related to recurrent/persistent ischemic/functional MR late after surgical annuloplasty.