RESUMEN
BACKGROUND: We studied the incidence of primary graft dysfunction (PGD), its impact on in-hospital and follow-up outcomes and searched for independent risk factors. METHODS: During an 18-year period, 508 individuals underwent heart transplantation at our institution. Patients were diagnosed with none, mild, moderate or severe PGD according to ISHLT criteria. RESULTS: Thirty-eight patients (7.5%) met the ISHLT criteria for mild PGD, 92 (18.1%) for moderate PGD and 23 (4.5%) for severe PGD. Patients were classified into none/mild PGD (77.4%) and moderate/severe PGD (22.6%) groups. In-hospital mortality was 12.4% (7.8% for none/mild PGD and 28.7% for moderate/severe PGD; p < .001). Survival at 1, 5, and 15 years was 85.5 ± 1.9% versus 67.2 ± 4.5%, 80 ± 2.2% versus 63.5 ± 4.7%, and 60.4 ± 3.6% versus 45.9 ± 8.4%, respectively (p < .001). Excluding the events occurring during the first month of follow-up, survival was comparable between the two groups (93.1 ± 1.4% vs. 94.7 ± 2.6 at 1 year and 65.6 ± 3.8% vs. 70.4 ± 10.4% at 15 years, respectively; p = .88). Upon multivariate logistic regression analysis preoperative mechanical circulatory support (odds ratio [OR] = 5.86) and preoperative intra-aortic balloon pump (IABP) (OR = 9.58) were independently associated with moderate/severe PGD. CONCLUSIONS: Our results confirm that PGD is associated with poor in-hospital outcome. The poor outcome does not extend beyond the first month of follow-up, with comparable survival between patients with none/mild PGD and moderate/severe PGD in the short and long-term. Mechanical circulatory support and preoperative IABP were found to be independent risk factors for moderate/severe PGD.
Asunto(s)
Trasplante de Corazón , Corazón Auxiliar , Disfunción Primaria del Injerto , Trasplante de Corazón/efectos adversos , Trasplante de Corazón/métodos , Corazón Auxiliar/efectos adversos , Humanos , Disfunción Primaria del Injerto/epidemiología , Disfunción Primaria del Injerto/etiología , Estudios Retrospectivos , Factores de RiesgoRESUMEN
OBJECTIVE: To shed light on contemporary results of open total aortic arch surgery, we undertook a systematic review to identify all reports on this procedure published in the last 10 years. METHODS: Extensive electronic literature search was undertaken to identify all published articles from 2004 to 2014 that provided results on total aortic arch replacement. According to inclusion and exclusion criteria, 21 relevant studies were selected and meta-analyzed to assess outcomes. RESULTS: The pooled estimate for operative mortality was 5.3%. Permanent and transient neurologic deficit occurred postoperatively at a pooled rate of 3.4% and 5.2%, respectively. Pooled rate of irreversible spinal cord injury was 0.6%, whereas renal failure occurred at a pooled rate of 4.1%. Prolonged intubation occurred at pooled rate of 15.4%. Among elective patients, pooled rate of mortality and permanent neurologic deficit was 2.9% and 2.2%, respectively, with a significant difference compared with urgent/emergency surgery cases. CONCLUSIONS: The main findings from this meta-analysis indicate that total aortic arch replacement can be performed with satisfactory mortality and morbidity. The pooled rates of mortality and permanent neurologic deficit among elective cases were surprisingly low, and these data have an even greater prominence when they are compared with outcomes of hybrid arch series. Under urgent/emergency surgery, early mortality and neurologic complications showed an about threefold higher rate. Moderate hypothermic circulatory arrest and early rewarming seem to provide proper renal protection, with an intermediate risk of prolonged intubation.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular , Anciano , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Urgencias Médicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
We report a young diabetic patient who was found to have an unusable radial artery (RA) for coronary bypass grafting because of severe and diffuse atherosclerosis. Techniques to diagnose RA conduits, which are not usable for coronary surgery, are reviewed.
Asunto(s)
Aterosclerosis/diagnóstico , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Oclusión de Injerto Vascular/prevención & control , Arteria Radial , Recolección de Tejidos y Órganos/métodos , Aterosclerosis/patología , Enfermedad de la Arteria Coronaria/complicaciones , Diabetes Mellitus Tipo 1/complicaciones , Humanos , Masculino , Arterias Mamarias/trasplante , Persona de Mediana Edad , Periodo Preoperatorio , Arteria Radial/patología , Índice de Severidad de la Enfermedad , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: To determine whether the hybrid approach to acute type A aortic dissection results in improved outcomes in terms of mortality, neurologic complications, need for distal aortic reintervention, and false lumen thrombosis compared with the conventional approach. METHODS: Data from comparative studies of hybrid versus conventional treatment of acute type A aortic dissection were combined through meta-analysis. Pooled odd ratios were calculated using random effects models. RESULTS: Seven comparative studies including 967 patients were identified; of these, 503 underwent conventional proximal aortic repair and 429 extensive distal aortic repair including a stented elephant trunk technique. Between the two groups there was no significant difference in operative mortality (p = 0.96), permanent neurologic deficit (p = 0.95), and late mortality (p = 0.59). Distal aortic repair showed a higher rate of false lumen thrombosis of the thoracic aorta (odd ratio 11.16; p < 0.001) and a reduced risk of distal reintervention (odd ratio 0.37; p = 0.01). In sub-group analysis, frozen elephant trunk procedure showed a lower rate of distal aortic reintervention and a higher rate of false lumen thrombosis than antegrade/retrograde stent deployment techniques (p = 0.008 and <0.001, respectively). CONCLUSIONS: Distal aortic repair may reduce the risk of distal reintervention and increase the rate of false lumen thrombosis without significant increase in operative mortality and permanent neurologic deficit; however, no benefit with respect to late mortality was found. The frozen elephant trunk may reduce the risk of distal aortic reintervention and may increase the false lumen thrombosis of the thoracic aorta in comparison with antegrade/retrograde stent deployment procedures.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/mortalidad , Aneurisma de la Aorta/mortalidad , Bases de Datos Bibliográficas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del Tratamiento , Procedimientos Quirúrgicos Vasculares/mortalidadRESUMEN
Conversion to a full sternotomy may complicate up to 1.8% of the sternal-sparing coronary artery surgery. Left internal mammary artery injury and anastomotic problems are the common causes. The purpose of this article is to retrospectively review the outcomes of six patients that required conversion to sternotomy during minimally invasive direct coronary artery bypass and also to point out technical aspects in order to avoid such a complication.
Asunto(s)
Puente de Arteria Coronaria/métodos , Complicaciones Intraoperatorias/prevención & control , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Esternotomía/métodos , Anciano , Anastomosis Quirúrgica/efectos adversos , Femenino , Humanos , Masculino , Arterias Mamarias/lesiones , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
An otherwise healthy 47-year-old man presented to the emergency department in cardiogenic shock after suffering a massive myocardial infarction due to left main occlusion. He was initially supported by extracorporeal membrane oxygenation and subsequently was converted to paracorporeal support with a Levitronix left ventricular assist device. He experienced multiple postoperative complications including renal failure, respiratory failure, retroperitoneal hematoma requiring suspension of anticoagulation, and fungal bloodstream infection precluding transition to an implantable device. He was reconditioned and successfully underwent orthotopic heart transplant 183 days after presentation. A discussion of the relevant issues is included.
Asunto(s)
Ventrículos Cardíacos/cirugía , Corazón Auxiliar , Infarto del Miocardio/cirugía , Choque Cardiogénico/cirugía , Candida/aislamiento & purificación , Candidiasis/complicaciones , Candidiasis/diagnóstico , Oxigenación por Membrana Extracorpórea , Trasplante de Corazón , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/complicaciones , Complicaciones Posoperatorias/microbiología , Complicaciones Posoperatorias/cirugía , Choque Cardiogénico/complicacionesRESUMEN
Conversion to surgical aortic valve replacement (AVR) has been described as a complication following transcatheter aortic valve implantation. This complication occurs in up to 8% of cases and, to the best of our knowledge, preoperative data and surgical outcomes of such patients have not been properly evaluated. Mild paraprosthetic regurgitation is commonly observed after transcatheter aortic valve implantation and usually leads to a benign clinical course. Unequal distribution of valve calcifications is described as a potential mechanism. We report a case of a perioperative paraprosthetic regurgitation that underwent successful urgent surgical AVR and review the incidence and results of paraprosthetic leaks following transcatheter implantation.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Complicaciones Posoperatorias/cirugía , Anciano , Insuficiencia de la Válvula Aórtica/etiología , Procedimientos Endovasculares , Humanos , Masculino , Reoperación , ToracotomíaRESUMEN
An easily reproducible surgical technique to switch from percutaneous minimally invasive biventricular mechanical support to cardiopulmonary bypass during heart transplantation is illustrated. After cannulation of the distal ascending aorta with a standard arterial cannula, the ProtekDuo® cannula and the ProtekSolo® Transseptal cannula were partially retracted to reach the superior and inferior vena cava, respectively, and connected to the pump circuit for the venous drainage. With this cardiopulmonary bypass configuration, orthotopic heart transplantation was routinely performed and, at the end of the procedure, the 2 cannulas were uneventfully removed.
Asunto(s)
Puente Cardiopulmonar , Trasplante de Corazón , Cánula , Cateterismo , Humanos , Vena Cava InferiorRESUMEN
OBJECTIVES: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and midterm results. However, extending the age criterion in patient selection remains a debate. This study reviews the results of reimplantation valve-sparing aortic replacement in patients greater than 60 years of age. METHODS: During a 51-month period, 63 patients with aortic root aneurysms underwent reimplantation valve-sparing aortic root replacement. The Gelweave Valsalva prosthesis (TERUMO CardioVascular Systems Corp., Ann Arbor, MI, USA) was used in all but one case. The patients were predominantly male, and the mean age was 67 years (range, 61-83 years). Four patients had congenital bicuspid aortic valves, and cusp repair was required in one patient. The mean follow-up was 25 months (range, 1-51 months). RESULTS: There were one hospital and two late deaths. Overall survival at 51 months was 84 +/- 9.9%. During follow-up, one patient developed severe aortic incompetence (AI) requiring an aortic valve replacement (AVR). Freedom from reoperation at 51 months was 92.8 +/- 6.8%. Moderate AI was present at latest echocardiogram in one patient. Freedom from moderate or severe AI at 51 months was 90 +/- 9.4%. There was no episode of endocarditis on follow-up. Univariate analysis demonstrated that no preoperative or intraoperative factor was a predictor for late reimplantation failure. CONCLUSIONS: Reimplantation valve-sparing aortic root replacement in patients greater than 60 years old can be performed with satisfactory perioperative and midterm results. Long-term results are needed to define the durability of this technique and its role in this subset of patients.
Asunto(s)
Aorta/cirugía , Válvula Aórtica , Aneurisma Coronario/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Factores de Edad , Anciano , Anciano de 80 o más Años , Aorta/patología , Aneurisma Coronario/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pennsylvania , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Acute aortic syndrome includes three main pathological conditions: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU). These are life-threatening conditions, therefore early diagnosis and interventional/surgical treatment are fundamental for the survival of affected individuals. While anatomical findings of classical AD provided by imaging techniques are known to all cardiologists, imaging findings of IMH and PAU are less known, as are their prognostic implications and consequences on management and treatment strategies. This review aims to describe and discuss findings and role of imaging techniques in patients with IMH and PAU.
Asunto(s)
Enfermedades de la Aorta/diagnóstico por imagen , Disección Aórtica/diagnóstico por imagen , Hematoma/diagnóstico por imagen , Úlcera/diagnóstico por imagen , Enfermedad Aguda , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Ecocardiografía Transesofágica , Hematoma/cirugía , Humanos , Imagen por Resonancia Magnética , Síndrome , Tomografía Computarizada por Rayos X , Úlcera/cirugíaRESUMEN
Type A acute aortic dissection (TA-AAD) is a catastrophic condition for which emergency surgery is the mainstay of therapy. Surgical treatment of TA-AAD is centered on excision of the proximal intimal tear, replacement of the ascending aorta and re-establishment of a dominant flow in the distal true lumen. In patients who survive surgery, a dissected distal and/or proximal aorta remains, posing a risk of subsequent aneurysmal degeneration, rupture and malperfusion, and secondary extensive interventions are often required. However, knowledge regarding the risk factors of progression of residual aortic dissection is limited, and no well-defined recommendations for clinical and imaging follow-up have been generated thus far. The aim of this paper is to review and discuss on the current evidence and controversies on the long-term management of patients operated on for TA-AAD.
Asunto(s)
Aorta/cirugía , Disección Aórtica/cirugía , Complicaciones Posoperatorias/cirugía , Túnica Íntima/lesiones , Enfermedad Aguda , Disección Aórtica/clasificación , Disección Aórtica/diagnóstico por imagen , Aneurisma Falso/diagnóstico por imagen , Aorta/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Válvula Aórtica , Implantación de Prótesis Vascular , Progresión de la Enfermedad , Tratamiento de Urgencia , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Complicaciones Posoperatorias/diagnóstico por imagen , Pronóstico , Reimplantación , Factores de Riesgo , Rotura/cirugíaRESUMEN
Although the indications for surgical management of severe functional tricuspid regurgitation (TR) are now generally accepted, controversy persists concerning the role of intervention for moderate TR. However, there is a trend for intervention in this setting, particularly in patients with annular dilation. Echocardiographic imaging is the gold standard to identify functional TR and distinguish it from a primitive or degenerative form. Currently, surgery remains the best approach for the interventional treatment of TR. Ring annuloplasty seems to provide better results than suture annuloplasty (De Vega technique) and rigid rings appear to be more reliable in the long term, in comparison with flexible bands. Tricuspid valve repair is more beneficial compared with replacement, except in highly selected cases of long-standing TR with multifactorial mechanism.
Asunto(s)
Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/cirugía , Ecocardiografía/normas , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Imagen por Resonancia Magnética , Resultado del Tratamiento , Válvula Tricúspide/anatomía & histología , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/fisiopatología , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/fisiopatologíaRESUMEN
Coverage of the left subclavian artery in thoracic endovascular aortic repair is still a controversial procedure. We report a case of 30-year-old patient with a chronic rupture of the aortic isthmus and short proximal lending zone (10 mm) treated by thoracic endovascular aortic repair using a balloon catheter inflated at the origin of the left subclavian artery (and protruding in the aortic arch) to both preserve the arterial branch patency and fully exploit the proximal neck.
Asunto(s)
Aneurisma Falso/cirugía , Angioplastia de Balón , Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Arteria Subclavia/fisiopatología , Grado de Desobstrucción Vascular , Adulto , Aneurisma Falso/complicaciones , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/fisiopatología , Angioplastia de Balón/instrumentación , Aneurisma de la Aorta Torácica/complicaciones , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/etiología , Rotura de la Aorta/fisiopatología , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/instrumentación , Angiografía por Tomografía Computarizada , Femenino , Humanos , Diseño de Prótesis , Stents , Arteria Subclavia/diagnóstico por imagen , Resultado del TratamientoRESUMEN
: We present a false aneurysm of ventricular left apex after mitral valve in valve prosthesis transapical implantation.
Asunto(s)
Aneurisma Falso/etiología , Aneurisma Cardíaco/etiología , Lesiones Cardíacas/etiología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Enfermedad Iatrogénica , Válvula Mitral/cirugía , Anciano de 80 o más Años , Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/terapia , Femenino , Aneurisma Cardíaco/diagnóstico por imagen , Aneurisma Cardíaco/terapia , Lesiones Cardíacas/diagnóstico por imagen , Lesiones Cardíacas/terapia , Humanos , Imagen por Resonancia CinemagnéticaRESUMEN
BACKGROUND: We assessed whether additional cusp repair during valve-sparing aortic root replacement affects the echocardiographic mid-term results; a subgroup analysis among patients with bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) was performed. METHODS: Between June 2002 and May 2015, 157 consecutive patients underwent valve-sparing aortic root replacement with the David technique. Thirty patients (19%) had BAV. In 19 patients (12%), cusp motion or anatomic abnormalities contributed in determining aortic regurgitation requiring an additional cusp repair. Mean follow-up was 7 ± 3.4 years. RESULTS: The cumulative 1-, 5-, and 12-year survival rates were 98%, 94%, and 90%, respectively. Fourteen patients (9%) required aortic valve replacement during follow-up. In 2 patients the underlying cause was bacterial endocarditis. Freedom from aortic valve reoperation was 96% at 1 year, 92% at 5 years, and 89% at 12 years. Reoperation rate was significantly higher (p < 0.001) in patients who received leaflet repair compared with patients who did not, with a freedom from reoperation at 8 years of 58% versus 94%. Among patients with BAV, those who did not require cusp repair had a freedom from reoperation at 8 years of 94%, with a significant difference compared with patients who received cusp repair (p = 0.04). Cusp repair did not affect reoperation risk in patients with tricuspid aortic valve. CONCLUSIONS: Adjunctive cusp repair seems to affect the mid-term reoperation risk in patients with BAV and not in patients with tricuspid aortic valve. We recommend caution in using this technique in case of asymmetric BAV requiring cusp repair.
Asunto(s)
Aorta/cirugía , Aneurisma de la Aorta/cirugía , Válvula Aórtica/anomalías , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Enfermedades de las Válvulas Cardíacas/cirugía , Reoperación , Adulto , Insuficiencia de la Válvula Aórtica/cirugía , Enfermedad de la Válvula Aórtica Bicúspide , Calcinosis/epidemiología , Calcinosis/etiología , Calcinosis/cirugía , Endocarditis Bacteriana/etiología , Endocarditis Bacteriana/cirugía , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/epidemiología , Enfermedades de las Válvulas Cardíacas/etiología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Tratamientos Conservadores del Órgano , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , RiesgoRESUMEN
AIM: Minimally invasive coronary artery bypass (MIDCAB) allows revascularization of the left anterior descending coronary (LAD) artery through a less traumatic surgical approach. However, the procedure is technically challenging and concern still exists, mainly based on graft patency. The purpose of this study is to critically evaluate short and long-term benefits of this surgical treatment. METHODS: Between June 1997 and July 2012, 306 patients underwent MIDCAB on LAD. The mean age was 62â±â10 years (range, 32-87 years) and 264 patients (86.3%) were men. Mean ejection fraction was 54%. Eighty-nine procedures (29.1%) were performed using a hybrid approach by means of MIDCAB and postoperative (60 patients, 67.4%) or preoperative (29 patients, 32.6%) percutaneous interventions on non-LAD vessels. A EuroScore more than 6 was found in 43 (14%) patients. The average follow-up time was 9.5â±â3.2 years and was 89% complete. RESULTS: Six patients (1.9%) required intraoperative conversion to sternotomy, whereas cardiopulmonary bypass institution after the sternotomy was necessary in one. Postoperative acute myocardial infarction occurring nine patients (2.9%), low output syndrome in four (1.3%). Postoperative mortality was 1.6% (nâ=â5), and perioperative stroke rate 0.6% (nâ=â2). Five and 10-year survival were 94.1 and 86.9%, respectively. Freedom from death due to cardiac events and major cardiac and cerebral events at 10 years was, respectively, 97.1 and 92.1%. CONCLUSIONS: The results confirm the favorable short and long-term results of the MIDCAB procedure. MIDCAB, in experienced centers, can represent an alternative treatment option for LAD disease.
Asunto(s)
Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/terapia , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/etiología , Humanos , Estimación de Kaplan-Meier , Masculino , Arterias Mamarias/cirugía , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos/efectos adversos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Intervención Coronaria Percutánea , Accidente Cerebrovascular/etiología , Resultado del TratamientoRESUMEN
AIMS: Aortic valve-sparing operations are nowadays considered safe and reliable procedures in terms of mid-term and long-term results. Although surgical techniques regarding the modality of grafts' implantation have been properly addressed, the modality of cusp repair, when needed, is still open to debate. We sought to review the literature to try to shed light on when the cusp repair is required and how it should be performed. METHODS: We searched the PubMed database using the keywords aortic valve-sparing operation, aortic valve-sparing reimplantation, valve-sparing aortic root replacement, aortic valve repair, and aortic cusp repair. Only studies that included and described in detail the technique of cusp repairs in adjunct to aortic valve-sparing operation were considered. RESULTS: Bicuspid aortic valve more often requires correction when compared with tricuspid valve. The range of the techniques varies from the 'simple' free margin plication to the more complex triangular resection with patch repair. Results in the literature seem to be encouraging, showing that, in most of the cases, cusp repair does not affect valve competence in the mid-term and long-term. CONCLUSION: Correction of the cusp is a delicate balance between undercorrection that could lead to residual prolapse and overcorrection that could lead to cusp restriction. Although complex repair of the aortic valve in addition to root replacement provided satisfactory results, it should be reserved for experienced centers with a large volume of patients.
Asunto(s)
Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Válvula Aórtica/anomalías , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/patología , Insuficiencia de la Válvula Aórtica/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía Transesofágica , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/patología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Complicaciones Posoperatorias/epidemiología , Recurrencia , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Composite valve graft replacement is currently the treatment of choice for a wide variety of lesions of the aortic root and the ascending aorta. In this study we report our experience with aortic root replacement using a composite graft. METHODS: Between October 1978 and May 2001, 274 patients (79.6% male and 20.4% female) with a mean age of 53.5 years underwent composite graft replacement of the aortic root. One hundred sixty-one patients (70.8%) had annuloaortic ectasia and 46 (16.8%) aortic dissection. The classic Bentall technique was used in 94 patients (34.3%), the "button technique" in 172 patients (62.8%), and the Cabrol technique in 8 patients (2.9%). RESULTS: The early mortality rate was 6.9% (19 of 274 patients). Cardiopulmonary bypass time longer than 180 minutes and associated coronary artery bypass grafting were found to be independent risk factors of early mortality. The actuarial survival rate was 77.7% at 5 years and 63% at 10 years. The independent risk factors for late mortality were coronary artery disease, chronic renal failure, and postoperative dialysis. The actuarial freedom from reoperation on the remaining aorta was higher among patients without Marfan syndrome (94.6% versus 79.6% at 10 years, p = 0.008). CONCLUSIONS: Composite valve graft replacement can be performed with low hospital mortality and morbidity. The button technique offers some advantages and should be used whenever possible. In case of acute aortic dissection root replacement is usually not necessary. Marfan patients should be treated with early root replacement before dissection occurs.
Asunto(s)
Aorta Torácica/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/mortalidad , Implantación de Prótesis Vascular/métodos , Prótesis Vascular , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/mortalidad , Bioprótesis , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias , Probabilidad , Modelos de Riesgos Proporcionales , Diseño de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
Left ventricular assist device (LVAD) support is an established therapy for patients with end-stage heart failure as a bridge to transplant; its usage as an alternative for those patients not eligible for transplant is not an established therapy yet. A 68-year-old male had a Thoratec-Heartmate LVAD implanted as destination therapy. After an uneventful (apart from early fever) recovery in the intensive care unit, the patient developed an intractable high temperature, and generalized sepsis and died 21 days following implant. The white cell blood count never exceeded the guard limits, and the patient succumbed with severe LVAD valve malfunction. At post-mortem examination friable material consisting of fungal hyphae was found on the inflow and outflow valves. According to published clinical trials, infection accounts for more than 40% of mortality in LVAD supported patients. Fungal LVAD endocarditis is a particularly deadly disease. Successful management requires a high level of suspicion and timely institution of antifungal therapy to control the infection. This has led some authors to recommend empiric antifungal therapy in LVAD recipients with culture-negative sepsis unresponsive to broad-spectrum antibiotics.
Asunto(s)
Aspergilosis/diagnóstico , Desfibriladores Implantables , Insuficiencia Cardíaca/cirugía , Corazón Auxiliar , Infecciones Relacionadas con Prótesis/microbiología , Anciano , Profilaxis Antibiótica , Aspergilosis/tratamiento farmacológico , Resultado Fatal , Humanos , Masculino , Infecciones Relacionadas con Prótesis/tratamiento farmacológicoRESUMEN
BACKGROUND: The Synergy system, a miniature partial circulatory support device, is implanted by an off-pump, minimally invasive surgical approach. The system has been optimized to improve performance in an EU clinical trial for chronic ambulatory heart failure. This therefore offers the possibility of treating elderly chronic heart failure patients who might not usually be considered for long-term circulatory support. METHODS: From June 2007 to December 2012, 63 patients were implanted with the Synergy system (12 patients ≥70 years) using four different releases of the device. Briefly, the system draws blood through the inflow cannula from the left atrium into the micro-pump (placed in a right subclavicular pocket) and pumps it through an outflow graft to the right subclavian artery. In this paper, we present an intermediate analysis of the clinical trial as performed on April 30, 2013, leading to the placing of the CE mark. RESULTS: Mean duration of support is ongoing at 230 days (range 23-1387). Follow-up showed improved hemodynamic response, with additional improvements in 6-min walk distance (299 ± 144 to 420 ± 119 m) and Minnesota Living with Heart Failure Questionnaire (69.5 ± 20.4 to 49.2 ± 24.3). Older patients had longer mean durations of support (337 vs 188 days). On average, elderly and younger patients showed similar improvements in hemodynamics and 6-min walk distance (107 ± 120 vs 130 ± 121 m). Major adverse cardiac events included bleeding (n=4) with one bleeding related to renal failure resulting in death. CONCLUSIONS: Clinical use of the Synergy device was associated with a significant functional improvement. Very low adverse event rates were reported with the latest device release. Older patients had smaller body sizes and worse renal function than younger patients. Both groups experienced similar hemodynamic benefits and functional improvements. The risk of bleeding and renal dysfunction appears to be increased in the elderly, though still within acceptable ranges compared to other full support devices. Minimally invasive long-term circulatory support devices, like Synergy, offer a new treatment option that might be available even for the elderly chronic heart failure population.