RESUMEN
PURPOSE: To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery. DATA SOURCES: A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home. CONCLUSIONS: Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services. IMPLICATIONS FOR PRACTICE: Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/rehabilitación , Evaluación de Necesidades , Cuidados Posoperatorios , Atención Progresiva al Paciente , Anciano , Comorbilidad , Femenino , Humanos , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Retrospectivos , Texas/epidemiologíaRESUMEN
BACKGROUND: Direct mechanical ventricular actuation (DMVA) is a non-blood contacting method of biventricular support. DMVA employs a vacuum attached, pneumatically regulated, flexible membrane to transfer both systolic and diastolic forces to the ventricular myocardium. The purpose of this study was to determine if DMVA effectively restores pump performance when applied to the severely failing heart. METHODS: Bovines (n = 10) underwent thoracotomy and were instrumented for continuous hemodynamic monitoring. Cardiac failure was induced by beta1-blockade to achieve a cardiac index of < 1.5 l/min/m2 for 1 hour. Heart rate was maintained at 100 bpm by atrioventricular sequential pacing. Synchronous DMVA support was then applied for 3 hours. RESULTS: Eight animals achieved significant reductions in cardiac index and mean arterial pressures (35%* and 43%* control, respectively; *p < 0.05). DMVA restored cardiac index to baseline and significantly increased arterial pressures (p < 0.05; DMVA versus cardiac failure). Pulmonary flow and mean pulmonary artery pressures were similar to baseline during DMVA (p = NS). Pathologic exam did not demonstrate evidence of significant device trauma. CONCLUSIONS: DMVA support can effectively restore pump performance of the acutely failing heart. Synchronization may be inherent to the stimulus of cardiac compression. These data further substantiate DMVA's potential as an adjunct to the field of circulatory support.
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Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Animales , Bovinos , Electrocardiografía , Endocardio/patología , Diseño de Equipo , Análisis de Falla de Equipo , Insuficiencia Cardíaca/patología , Insuficiencia Cardíaca/fisiopatología , Ventrículos Cardíacos/fisiopatología , Hemodinámica/fisiología , Miocardio/patologíaRESUMEN
BACKGROUND: Surgical treatment of traumatic pulmonary injuries requires knowledge of multiple approaches and operative interventions. We present a 15year experience in treatment of traumatic pulmonary injuries. We hypothesize that increased extent of lung resection correlates with higher mortality. METHODS: Surgical registry data of a level 1 trauma center was retrospectively reviewed from 1984 to 1999 for traumatic lung injuries requiring operative intervention. Epidemiologic, operative, and hospital mortality data were obtained. RESULTS: Operative intervention for traumatic pulmonary injuries was required in 397 patients, of whom 352 (89%) were men. Penetrating trauma was seen in 371 (93%) patients. Location of the injuries was noted in the left side of the chest in 197 (50%), right side of the chest in 171 (43%), and bilateral in 29 (7%). Operative interventions included pneumonorraphy (58%), wedge resection or lobectomy in (21%), tractotomy (11%), pneumonectomy (8%), and evacuation of hematoma (2%). Overall mortality was 27%. If concomitant laparotomy was required, mortality increased to 33%. The mortality rate in the pneumonectomy group was 69.7%. CONCLUSIONS: The majority of lung injuries occurred in males due to penetrating trauma. Surgical treatment options ranged from simple oversewing of bleeding injury to rapid pneumonectomy. Mortality increased as the complexity of the operative intervention increased. Rapid intraoperative assessment and appropriate control of the injury is critical to the successful management of traumatic lung injury.
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Lesión Pulmonar , Procedimientos Quirúrgicos Torácicos/métodos , Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Hematoma/cirugía , Humanos , Masculino , Persona de Mediana Edad , Neumonectomía , Estudios Retrospectivos , Tasa de Supervivencia , Heridas no Penetrantes/mortalidad , Heridas no Penetrantes/cirugía , Heridas Penetrantes/mortalidad , Heridas Penetrantes/cirugíaRESUMEN
Thrombotic thrombocytopenic purpura (TTP) is an uncommon syndrome characterized by reversible, systemic aggregation of platelets in the microcirculation and disseminated microvascular thrombosis. Surgery may precipitate TTP and has been associated with relapse in some patients. However, relapse of this life-threatening disorder is unpredictable. We report a patient with an antecedent history of TTP who experienced a relapse after elective cardiac surgery. In this case, decreased von Willebrand factor (vWF)-cleaving metalloproteinase activity and an inhibitor of this endogenous enzyme were demonstrated preoperatively. These findings suggest that decreased vWF-cleaving metalloproteinase activity and/or the presence of its inhibitor may predict an increased risk for surgical-associated relapse of TTP.
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Puente de Arteria Coronaria/efectos adversos , Púrpura Trombocitopénica Trombótica/sangre , Púrpura Trombocitopénica Trombótica/etiología , Factor de von Willebrand/metabolismo , Adulto , Humanos , Masculino , Metaloendopeptidasas/sangre , Agregación Plaquetaria , Púrpura Trombocitopénica Trombótica/terapia , Recurrencia , Factores de RiesgoRESUMEN
BACKGROUND: Empyema thoracis (ET) is associated with substantial morbidity and mortality. The optimal means for draining the pleural space remains controversial but there may be increasing bias for less invasive strategies. This study compared outcome after a nonsurgical versus a surgical approach to ET. METHODS: Patients with ET over a 10-year period (n = 93) were reviewed and stratified into nonsurgical (thoracentesis and/or closed tube thoracostomy) and surgical (thoracotomy, decortication, and/or open window thoracostomy) groups based on pleural drainage techniques. Hospital course was analyzed except when altered by death (n = 12), noncompliance (n = 3), or severe comorbidities (n = 3). RESULTS: Seventy-five patients were stratified into nonsurgical (n = 32) and surgical (n = 43) groups. Demographics, comorbidities, signs and symptoms, and causative organisms were similar between groups. Mortality did not significantly differ in nonsurgical (16%) versus surgical (10%) groups (P = 0.7). Although delay in diagnosis and number of therapeutic interventions were nearly identical, the time to definitive therapy was longer in the surgical versus the nonsurgical group (18 +/- 3.8 versus 8.5 +/- 3.8 days, P = 0.023). The time to discharge after definitive therapy (20.0 +/- 3.5 versus 35.6 +/- 14.0 days, P < 0.001), and overall hospital stay (40.6 +/- 5.3 versus 47.4 +/- 15 days, P = 0.01) was significantly decreased in the surgical versus nonsurgical treatment groups, respectively. CONCLUSION: The treatment of ET is complex. Failure to adequately evacuate the pleural space and/or persistent signs of infection should prompt surgical intervention. Surgical therapy is preferred for advanced stages of ET. Delaying definitive surgical treatment is largely responsible for prolonging hospital course.
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Empiema Pleural/mortalidad , Empiema Pleural/cirugía , Evaluación de Resultado en la Atención de Salud , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: We evaluated contemporary outcomes of open thoracic aortic surgery at a Veterans Affairs (VA) medical center affiliated with a major academic aortic program and examined the predictive value of 2 established cardiac risk models. METHODS: We retrospectively reviewed all open thoracic aortic operations performed between April 1998 and April 2008 (n = 100). Both the EuroSCORE and the VA Continuous Improvement in Cardiac Surgery Program (CICSP) scores were evaluated. RESULTS: Procedures included ascending aortic repair (n = 74, 15 with arch repair), descending thoracic repair (n = 11, 1 with arch repair), and thoracoabdominal aortic repair (n = 15). Emergency surgery was necessary in 15 cases, and 19 procedures were reoperations. The patients' logistic EuroSCORE and the CICSP scores were similar (18.7% and 18.2%, respectively), but both scores significantly exceeded the observed operative mortality rate (8.0%, P = .008). CONCLUSIONS: Good outcomes can be achieved when thoracic aortic surgery is performed at an experienced VA center. The cardiac risk models we examined overpredicted operative mortality.
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Aorta Torácica/cirugía , Enfermedades de la Aorta/mortalidad , Enfermedades de la Aorta/cirugía , Modelos Estadísticos , Complicaciones Posoperatorias/mortalidad , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Estados Unidos , Procedimientos Quirúrgicos Vasculares/métodos , VeteranosRESUMEN
BACKGROUND: We examined outcomes of patients with ischemic cardiomyopathy (ICMP), defined by left ventricular ejection fraction (LVEF) <35%, compared with patients with better-preserved LVEF, undergoing coronary bypass graft surgery (CABG). In addition, we examined the relative impact of a reduced LVEF in comparison with other comorbidities on long-term mortality in these patients. METHODS AND RESULTS: We evaluated 1381 patients (114 with ICMP, 1267 with better-preserved LVEF) who underwent isolated CABG at a tertiary Veterans Administration (VA) hospital between 1990 and 2000 using data from the VA Continuous Improvement in Cardiac Surgery Program and other VA databases. The 5-year survival was 74.0% in patients with ICMP and 84.4% in the group with better-preserved LVEF ( p = .005). LVEF <35% remained a significant predictor of long-term mortality in multivariable models (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.02-2.35). However, the presence of comorbidities, especially renal insufficiency, peripheral vascular disease, and cerebrovascular disease, had a similar or greater impact on long-term mortality. Renal insufficiency (serum creatinine >1.5 mg/dL) was associated with the highest risk of long-term mortality (HR 2.02, 95% CI 1.46-2.80). The use of a left internal thoracic artery graft reduced the risk of long-term mortality (HR 0.72, 95% CI 0.54-0.98). CONCLUSION: Even though severely depressed LVEF is associated with an increased risk of long-term mortality, the presence of comorbid factors, especially renal dysfunction and noncardiac vascular disease, increase the risk of long-term mortality by a similar or even larger magnitude. These comorbid factors should be given important consideration when evaluating the risks and benefits of CABG.
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Cardiomiopatías/mortalidad , Puente de Arteria Coronaria , Isquemia Miocárdica/mortalidad , Disfunción Ventricular Izquierda/mortalidad , Factores de Edad , Cardiomiopatías/terapia , Trastornos Cerebrovasculares/mortalidad , Estudios de Cohortes , Diuréticos/uso terapéutico , Femenino , Hospitales de Veteranos , Humanos , Masculino , Arterias Mamarias/trasplante , Persona de Mediana Edad , Isquemia Miocárdica/terapia , Enfermedades Vasculares Periféricas/mortalidad , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Insuficiencia Renal/mortalidad , Estudios Retrospectivos , Volumen Sistólico/fisiología , Análisis de Supervivencia , Texas/epidemiología , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/terapiaRESUMEN
Cardiorrhaphy is a relatively common procedure performed in a trauma center. However, there is a subgroup of patients with more complicated cardiac injuries such as coronary artery injuries, septal defects, and valvular injuries. Cardiac valvular injuries are often diagnosed subacutely when a new murmur is heard. Transesophageal echocardiography has been increasingly performed to diagnosis these injuries and may be helpful intraoperatively. Cardiac catheterization may be indicated in selected patients. Techniques to address these injuries may involve repair or prosthetic replacement. A high index of suspicion is needed to diagnose these relatively rare injuries.
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Lesiones Cardíacas/diagnóstico por imagen , Lesiones Cardíacas/terapia , Cateterismo Cardíaco , Ecocardiografía Transesofágica , HumanosRESUMEN
PURPOSE OF REVIEW: The purpose of this review is to evaluate the current indications and results of treatment of combined coronary and carotid disease. Synchronous carotid stenosis in patients with coronary artery disease poses a management challenge in patients with advanced atherosclerosis. RECENT FINDINGS: Recent case series continue to demonstrate concomitant coronary and carotid disease with significant carotid stenosis greater than 70% in approximately 8% of patients evaluated for coronary artery bypass grafting. Surgical management options include staged operations addressing the carotid stenosis first, reverse staged operations addressing the coronary disease first, and combined synchronous operations addressing both territories during the same anesthetic. Recent reports demonstrate safety and acceptable risks with each operative approach. Lower trends in stroke rates were noted following staged procedures when compared with combined procedures. However, several metaanalyses showed no significant difference in rates of combined morbidity and mortality for all three strategies. Total morbidity and mortality risks for combined disease tended to be higher than for isolated coronary artery bypass grafting or carotid endarterectomy procedures performed for disease in a single vascular territory. SUMMARY: Despite a large volume of data present in the literature, the treatment indications and surgical options remain controversial. We currently advocate treatment of symptomatic territory first in favor of staged procedures and reserve combined procedures for patients with critical stenosis or symptoms in both territories.
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Enfermedades de las Arterias Carótidas/complicaciones , Enfermedades de las Arterias Carótidas/terapia , Arteria Carótida Común/patología , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/terapia , Enfermedades de las Arterias Carótidas/epidemiología , Arteria Carótida Común/cirugía , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/epidemiología , Endarterectomía Carotidea , Humanos , Incidencia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiologíaRESUMEN
The authors analyzed the early outcomes in two groups of patients undergoing coronary artery bypass grafting (CABG) with single versus bilateral internal thoracic arteries (ITA) in their institution. One thousand sixty-nine patients underwent CABG with single or bilateral ITAs from 1990 to 2000. Of these patients, 911 (85.2%) had single ITA and 158 had bilateral ITA (14.8%). The incidence of tobacco abuse was 40.3% in the single ITA group and 56.7% in the double ITA group (P = 0.0001). The incidence of perioperative myocardial infarction, renal failure, reoperation for bleeding, stroke, or operative mortality did not differ in the two groups. There was a 4.4% incidence of mediastinitis in the bilateral ITA group versus 2.2% in the single ITA group (P = 0.0602). Early outcomes after bilateral ITA grafting for CABG are similar to single ITA grafting. Careful judgment should be exercised in selecting patients for bilateral ITA grafting, particularly if the patient smokes.