RESUMO
BACKGROUND: In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI, few data exist on the magnitude of platelet activation, aggregation and dosing of glycoprotein (GP) IIb/IIIa receptor inhibitors. METHODS: Sixty STEMI patients were randomised to abciximab, to high-dose tirofiban or to no additional GP IIb/IIIa inhibitor treatment. Platelet activation (P-selectin expression) was measured using flow cytometry and the level of inhibition of platelet aggregation was assessed using the Plateletworks assay. Additionally, the PFA-100 with the collagen/adenosine-diphosphate cartridge (CADP) was used to compare the levels of platelet inhibition. All measurements were performed at baseline (T(0)), immediately after (T(1)), 30 minutes (T(2)), 60 minutes (T(3)) and 120 minutes (T(4)) after primary PCI. RESULTS: The level of platelet activation in both GP IIb/IIIa receptor inhibitor treated groups was significantly lower compared with the control group at all time points after primary PCI (p=0.04). Also the administration of the currently recommended dose of abciximab resulted in significantly lower levels of inhibition of aggregation compared with high-dose tirofiban (p<0.0001). In addition, the CADP closure times were significantly prolonged in both GP IIb/IIIa inhibitor treated groups compared with the control group at time points T(1) (p=0.006) and T(4) (p<0.0001). CONCLUSION: The administration of high-dose tirofiban resulted in a significantly higher inhibition of platelet aggregation compared with the currently recommended dose of abciximab. Large clinical trials are needed to assess whether this laboratory superiority of high-dose tirofiban translates into higher clinical efficacy. (Neth Heart J 2007;15:375-81.).
RESUMO
BACKGROUND: Coronary angioplasty frequently creates a thrombogenic surface, with subsequent mural thrombosis that may lead to acute complications and possibly stimulates the development of restenosis. Whether coumarins can prevent these complications is unclear. The objective of this open, randomized trial was to assess the clinical effect of coumarins started before coronary angioplasty and continued for 6 months. METHODS AND RESULTS: Before coronary angioplasty, 530 patients were randomly assigned to aspirin plus coumarins and 528 patients to aspirin alone. At the start of the angioplasty, the mean international normalized ratio was 2.7+/-1.1; during follow-up, it was 3.0+/-1.1. At 30 days, the composite end point of death, myocardial infarction, target-lesion revascularization, and stroke was observed in 18 patients (3.4%) treated with aspirin plus coumarin compared with 34 patients (6.4%) treated with aspirin alone (relative risk, 0.53; 95% CI, 0.30 to 0.92). At 1 year, these figures were 14.3% and 20.3%, respectively (relative risk, 0.71; 95% CI, 0.54 to 0.93). The incidence of major bleeding and false aneurysm during hospitalization was 3.2% and 1.0%, respectively (relative risk, 3.39; 95% CI, 1.26 to 9.11). The benefit of coumarins was observed in both stented and nonstented patients. CONCLUSIONS: Coumarins in addition to aspirin started before PTCA and continued for 6 months was more effective than aspirin alone in the prevention of acute and late complications after coronary angioplasty. This benefit was accompanied by a small but significant increase in bleeding complications.
Assuntos
Angioplastia Coronária com Balão , Anticoagulantes/administração & dosagem , Aspirina/administração & dosagem , Doença das Coronárias/terapia , Cumarínicos/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
OBJECTIVES: We sought to evaluate the short- and long-term results of balloon angioplasty for stenoses in the proximal left anterior descending coronary artery. BACKGROUND: Both the supposedly high rate of acute complications and relatively poor long-term results of balloon angioplasty for stenoses in the proximal left anterior descending coronary artery have led to a search for alternative interventional techniques. METHODS: We analyzed the success rates and long-term follow-up results in 351 consecutive patients who underwent balloon angioplasty for stenosis of the left anterior descending coronary artery proximal to its first side branch. The power of the study was >80% in detecting a difference of 9% in the proportion of patients who survived at 10 years, assuming an 80% survival rate in the control group. RESULTS: There were 60 ostial and 291 nonostial stenoses. Follow-up lasted a median of 85 months (range 0 to 137) and was 100% complete. The angiographic success rate was 90.9%. The clinical success rate was 86.3%. Nine patients (2.6%) died, 17 (4.8%) needed emergency coronary artery bypass graft surgery, and 10 (2.8%) developed a myocardial infarction. Several patients had subsequent complications. The success and complication rates were not significantly different for patients with ostial and nonostial stenoses. Ten years after balloon angioplasty, freedom from mortality was 80%, freedom from cardiac death was 87%, freedom from myocardial infarction was 84%, freedom from vessel-related reinterventions was 66%, and freedom from angina pectoris was 33%. There were more reinterventions for ostial stenoses, with a 1-year relative risk of ostial versus nonostial stenoses for related reinterventions of 1.7 (95% confidence interval 1 to 2.8, p = 0.049). CONCLUSIONS: More than 10 years ago, balloon angioplasty for stenoses in the proximal left anterior descending coronary artery, either ostial or nonostial, had a high success rate. Although the long-term results are satisfactory, ostial stenoses are associated with a higher early clinical restenosis rate requiring more reinterventions.
Assuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Angioplastia Coronária com Balão/estatística & dados numéricos , Estudos de Casos e Controles , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/epidemiologia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Recidiva , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The aim of this study was to evaluate the safety and efficacy of a biodegradable collagen plug that has been developed to reduce the arterial compression time required to achieve hemostasis at the arterial puncture site after diagnostic and interventional coronary procedures. BACKGROUND: After diagnostic and interventional coronary catheterization procedures, local arterial compression is required to achieve hemostasis and complications may ensue, especially in patients on full anticoagulation. METHODS: Between March 1991 and July 1991, 252 patients admitted for routine coronary angiography or angioplasty to four large hospitals received such a hemostatic device immediately after the procedure. Hemostasis was achieved with collagen in 87% of patients after a mean compression time of 4.8 min. Time to hemostasis was independent of the heparin load. A total of 54 hematomas (21%) was reported; all but 2 resolved without additional treatment. Two patients had a severe hematoma, requiring blood transfusion, and two patients required surgery to repair a pseudoaneurysm. During a follow-up period of 4 weeks no severe late complications were reported. CONCLUSIONS: We conclude that the collagen plug appears to be a safe device to achieve hemostasis at the arterial puncture site, independent of anticoagulation.
Assuntos
Angioplastia Coronária com Balão , Cateterismo Cardíaco , Colágeno , Técnicas Hemostáticas , Punções , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Artéria Femoral , Hematoma/epidemiologia , Hematoma/etiologia , Técnicas Hemostáticas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Punções/efeitos adversos , Sistema de Registros , Resultado do TratamentoRESUMO
OBJECTIVES: This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents. BACKGROUND: Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis. METHODS: A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty. RESULTS: Laser angioplasty success (< or =50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by < or =30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non-Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%. CONCLUSIONS: Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.
Assuntos
Angioplastia a Laser , Doença das Coronárias/terapia , Oclusão de Enxerto Vascular/terapia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão , Angiografia Coronária , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Resultado do TratamentoRESUMO
To investigate the effectiveness and safety of low-dose sotalol (a class III antiarrhythmic beta-blocking agent) in the prevention of supraventricular tachyarrhythmias (SVTs) and to identify predictors for the occurrence of these arrhythmias shortly after coronary artery bypass grafting, 300 consecutive patients were randomized in a double-blind, placebo-controlled fashion. Patients with severely depressed left ventricular function or other contraindications for beta blockers were excluded. Beginning at 4 hours and up to the sixth day after surgery, 150 patients received 40 mg of sotalol every 6 hours. SVT was observed in 24 (16%) of 150 low-dose sotalol-and in 49 (33%) of 150 placebo-treated patients [p less than 0.005]. In patients receiving sotalol, atrial fibrillation was the only noted tachyarrhythmia, whereas in the placebo group, 42 (28%) patients had atrial fibrillation, 3 (2%) atrial flutter, 1 (0.7%) atrial tachycardia and 3 (2%) sinus tachycardia. Drug-related adverse effects necessitating discontinuation of the drug were noted in only 2 (1%) sotalol-treated patients and 4 (3%) placebo-treated patients (p = not significant). For both groups, univariate analysis indicated that older age, 1- or 2-vessel coronary artery disease, long bypass (greater than or equal to 150 minutes) and aorta cross-clamp time (greater than or equal to 120 minutes) were predictive variables for the occurrence of SVTs. Multivariate analysis showed that male sex (odds ratio 2.3), 1- or 2-vessel coronary artery disease (odds ratio 2.0) and older age (odds ratio 1.1) were independent risk factors for increased occurrence of postoperative SVT.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Sotalol/uso terapêutico , Taquicardia Supraventricular/prevenção & controle , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Sotalol/efeitos adversos , Taquicardia Supraventricular/etiologiaRESUMO
A hemodynamic significant left subclavian artery stenosis or occlusion proximal to the origin of the left internal mammary artery (LIMA) can result in an impaired or reversed flow through the LIMA and the coronary artery to which it has been anastomosed. In this study, we report on our immediate and long-term follow-up results in 31 consecutive patients who underwent percutaneous transluminal coronary angioplasty of the left subclavian artery shortly before or after coronary artery bypass grafting with use of the LIMA.
Assuntos
Angioplastia com Balão , Arteriosclerose/terapia , Doença das Coronárias/cirurgia , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Artéria Subclávia , Síndrome do Roubo Subclávio/terapia , Angiografia , Arteriosclerose/diagnóstico por imagem , Humanos , Artéria Subclávia/diagnóstico por imagem , Síndrome do Roubo Subclávio/diagnóstico por imagem , Síndrome do Roubo Subclávio/etiologia , Síndrome do Roubo Subclávio/prevenção & controleRESUMO
A prospective study comparing the long-term results of balloon angioplasty in patients over 75 years of age with those in a younger patient group is not available. A total of 192 consecutive patients aged > or = 75 years (group I) who underwent a balloon angioplasty were matched with 192 control patients aged 40 to 65 years (group II). The groups were matched for gender, angina pectoris class, left ventricular function, 1-, 2-, and 3-vessel coronary artery disease, and previous myocardial infarction. The mean follow-up was 40.4 months (range 0 to 110). Actuarial analysis (freedom from events) after 5 years yielded the following results for group I versus group II: free from death remained 77.1% versus 97.9% (p = 0.0001), from cardiac death 92.4% versus 97.9% (p = 0.049), and from angina pectoris 54.6% versus 75.1% (p = 0.03). The differences were not significant for those remaining free from myocardial infarction, repeat balloon angioplasty, or coronary artery bypass grafting. When elderly patients with complete revascularization (n = 127) were compared with a matched control group of 127 patients aged 40 to 65 years who underwent complete revascularization, there was only a significant difference in noncardiac death rates. We conclude that patients > 75 years of age have a significant higher cardiac and noncardiac death rate and a higher incidence of angina pectoris after successful balloon angioplasty. However, the incidence of reintervention and myocardial infarction is lower in the elderly. If complete revascularization is achieved in the elderly, then freedom from cardiac death and recurrence of angina pectoris would be comparable to that in younger patients.
Assuntos
Envelhecimento , Angioplastia Coronária com Balão , Análise Atuarial , Adulto , Idoso , Idoso de 80 Anos ou mais , Angina Pectoris/terapia , Estudos de Casos e Controles , Ponte de Artéria Coronária , Doença das Coronárias/patologia , Doença das Coronárias/cirurgia , Doença das Coronárias/terapia , Morte Súbita Cardíaca/etiologia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/patologia , Infarto do Miocárdio/terapia , Estudos Prospectivos , Taxa de Sobrevida , Função Ventricular EsquerdaRESUMO
Supraventricular tachyarrhythmias are reported in up to 40% of patients early after coronary artery bypass graft operations. In a randomized study, we compared the efficacy and safety of the class III antiarrhythmic beta-blocking drug sotalol versus propranolol at low and high doses in the prevention of supraventricular tachyarrhythmias in 429 consecutive patients after coronary artery bypass graft operations. Patients with severely depressed left ventricular function and other contraindications for beta-blockers were excluded. From the fourth hour up to the sixth day after coronary artery bypass, 74 patients received low-dose sotalol (40 mg every 8 hours), 66 patients low-dose propranolol (10 mg every 6 hours), 133 patients high-dose sotalol (80 mg every 8 hours), and 156 patients high-dose propranolol (20 mg every 6 hours). Baseline characteristics were comparable in all groups. Supraventricular tachyarrhythmia was observed in 10 of 72 (13.9%) who received low-dose sotalol, 12 of 64 (18.8%) who received low-dose propranolol, 13 of 119 (10.9%) who received high-dose sotalol, and 19 of 139 (13.7%) who received high-dose propranolol (not significant). Drug-related adverse effects necessitating discontinuation of the drug occurred in four receiving low doses (2.9%) and in 31 receiving high doses (10.7%) (p less than 0.02). In conclusion, no medication was found to be superior, although supraventricular tachyarrhythmias tended to be less prevalent in patients treated with sotalol than in those treated with propranolol. Moreover, significantly fewer adverse effects were noted in both low-dose groups. Therefore, low-dose beta-blocking treatment, especially low-dose sotalol, seems preferable.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Propranolol/administração & dosagem , Sotalol/administração & dosagem , Taquicardia Supraventricular/prevenção & controle , Administração Oral , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Propranolol/efeitos adversos , Propranolol/uso terapêutico , Estudos Prospectivos , Sotalol/efeitos adversos , Sotalol/uso terapêutico , Taquicardia Supraventricular/etiologia , Fatores de TempoRESUMO
Between December 1984 and December 1988, coronary artery bypass operations, involving the use of 119 sequential internal mammary artery grafts with three or more anastomoses per conduit, were performed in 116 patients. Patients included 14 women and 102 men, with a mean age of 60 years. They received a total of 629 anastomoses; 373 anastomoses were used in multiple sequential arterial bypass grafts; 116 sequential left and three right internal mammary artery jump grafts were performed. There were 27 patients with bilateral internal mammary artery grafts, but only 17 had completely arterial revascularizations. Perioperative infarction occurred in 3.4% of the patients; 1.7% of infarctions were related to sequential internal mammary artery grafts. There were no hospital deaths. Control angiography was performed within a month of the operation in 72 patients (with 371 anastomoses, of which 229 were in sequential arterial bypass grafts). The overall patency rate was 94.6%, and for the internal mammary artery sequential graft with three or more anastomoses it was 96.1%. The mean follow-up period was 13 months; 110 patients were in New York Heart Association class I; there was one non-cardiac-related death, and three patients (2.6%) had a late myocardial infarction. One was related to the area revascularized by the sequential internal mammary artery graft. Multiple sequential internal mammary artery bypass grafts in coronary artery disease are feasible, with a high short-term patency and a low perioperative morbidity and mortality.
Assuntos
Doença das Coronárias/cirurgia , Anastomose de Artéria Torácica Interna-Coronária , Angiografia Coronária , Doença das Coronárias/mortalidade , Estudos de Viabilidade , Feminino , Seguimentos , Humanos , Anastomose de Artéria Torácica Interna-Coronária/métodos , Anastomose de Artéria Torácica Interna-Coronária/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Fatores de Tempo , Grau de Desobstrução VascularRESUMO
In 83 patients with previous coronary artery bypass grafting, 92 percutaneous transluminal coronary angioplasty attempts were done, 33 in a venous bypass graft (success rate 97%) and 59 in a native coronary artery (success rate 86.4%). There were no procedural-related deaths and two myocardial infarctions. Forty-six percent of the patients with successful angioplasty after previous bypass grafting remain symptom free after 5 years versus 79% of the patients without previous bypass grafting (p less than 0.001). Long-term success rates for native vessel angioplasty as compared with bypass graft angioplasty are similar. Patients with a short interval between the recurrence of angina after bypass grafting and the angioplasty attempt have a better chance of long-term success. Repeat angiography indicates that a restenosis occurs after angioplasty of a venous graft in 31% and in the native system in 28.6% and that signs of progression of coronary artery disease elsewhere are present in 30%. Of the 83 patients, 11 had reoperation eventually. We conclude that percutaneous transluminal coronary angioplasty after coronary bypass grafting gives less satisfactory results than a primary procedure, that angioplasty provides symptomatic relief in a smaller number of patients than in those with primary angioplasty, but that symptomatic relief is often sufficient to further postpone or prevent bypass grafting and can be achieved with low mortality and low complication rates.
Assuntos
Angina Pectoris/terapia , Angioplastia com Balão , Ponte de Artéria Coronária , Análise Atuarial , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária , Seguimentos , Humanos , Pessoa de Meia-Idade , Fatores de TempoRESUMO
The late follow-up of 230 patients who underwent synchronous operation for extensive, obstructive extracranial and coronary artery disease from 1974 to 1989 was analyzed. Mean age at operation was 62.5 years; 161 patients (70%) were in New York Heart Association class III or IV, 185 (80%) had triple-vessel disease, and 67 (29%) had left main stem lesions of 50% or more. Previous myocardial infarctions were present in 132 patients (57%). Only 78 had normal left ventricular function. Included were 16 patients undergoing coronary reoperations, 17 patients with additional cardiac procedures, and 3 with synchronous pulmonary procedures. Symptomatic extracranial vascular disease or stabilized neurological deficits were present in 108 patients. Bilateral hemodynamically significant carotid disease was present in 91 patients and arch vessel lesions in 37. The hospital mortality in 8 patients (3.5%) was due to cardiac (n = 4), neurological (n = 1), or multiorgan failure (n = 3). Operative morbidity was mainly neurological (n = 20, 8.7%): 7 reversible deficits and 7 major strokes occurred, 2 reversible and 5 major strokes were related to the operated side(s), and 4 postoperative myocardial infarctions occurred. Actuarial survival at 5 years was 74% (+/- 3.3), at 10 years 54% (+/- 4.9), and at 15 years, 35% (+/- 6.6). This was mainly determined by late cardiac death (41/66). Late morbidity was mainly attributable to cardiac causes rather than neurological causes. At 5 and 10 years, respectively, 72% and 44% of the patients were free of major cardiac and neurological events or death. Synchronous revascularization can be performed relatively safely. The long-term outcome is determined by the extent and severity of the cardiovascular disease.
Assuntos
Artérias Carótidas/cirurgia , Doenças das Artérias Carótidas/cirurgia , Ponte de Artéria Coronária , Doença das Coronárias/cirurgia , Endarterectomia , Adulto , Idoso , Arteriopatias Oclusivas/cirurgia , Procedimentos Cirúrgicos Cardíacos , Doenças das Artérias Carótidas/complicações , Transtornos Cerebrovasculares/etiologia , Doença das Coronárias/complicações , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias , Fatores de RiscoRESUMO
A case of complete rupture of the left common carotid artery at the aortic arch and avulsion of a cusp of the aortic valve due to blunt trauma is presented. The ruptured carotid artery was reimplanted into the left subclavian artery, and the avulsed aortic valve cusp was successfully repaired by direct suturing.
Assuntos
Valva Aórtica/lesões , Lesões das Artérias Carótidas , Ferimentos não Penetrantes/complicações , Adulto , Valva Aórtica/cirurgia , Artérias Carótidas/cirurgia , Humanos , Masculino , Ruptura , Ferimentos não Penetrantes/cirurgiaRESUMO
Concomitant severe coronary artery disease and lung malignancies are uncommon. Combining conventional coronary surgery with cardiopulmonary bypass with lung resection is still a controversial issue. Conversely, combining off-pump coronary surgery with right lung resections through a midline sternotomy can be an attractive approach. Off-pump coronary surgery avoids the risks of cardiopulmonary bypass, reduces systemic inflammatory response and does not affect the immune system. We report a series of three patients successfully operated using this approach.
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Ponte de Artéria Coronária/métodos , Doença das Coronárias/complicações , Doença das Coronárias/cirurgia , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Adenocarcinoma/complicações , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Carcinoma de Células Escamosas/complicações , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Terapia Combinada , Seguimentos , Humanos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Esterno/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction. METHODS: From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 +/- 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 +/- 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 +/- 11.8 days. RESULTS: There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 +/- 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%). CONCLUSIONS: Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.
Assuntos
Valva Aórtica/cirurgia , Endocardite/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Abscesso/diagnóstico , Abscesso/etiologia , Abscesso/mortalidade , Abscesso/cirurgia , Análise Atuarial , Idoso , Valva Aórtica/transplante , Ponte Cardiopulmonar/mortalidade , Desbridamento/métodos , Ecocardiografia , Endocardite/diagnóstico , Endocardite/etiologia , Endocardite/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/transplante , Recidiva , Taxa de Sobrevida , Transplante HomólogoRESUMO
BACKGROUND: Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic regurgitation (AR), and for pulmonary allograft valve stenosis are identified. METHODS: From February 1991 through April 1998, 80 adults (mean age 34.4 years) underwent pulmonary autograft aortic root replacement. Primary diagnosis was AR in 43 (53.7%) patients, aortic stenosis in 13 (16.3%) and mixed disease in 24 (30%) patients. A root reinforcement ring was used in 32 (40%) patients. RESULTS: There was no hospital mortality. Estimated patient survival is 100% at 7 years. A total of 3 patients underwent reoperation: 2 on the autograft for severe AR, 1 for pulmonary allograft stenosis. Freedom from reoperation on the autograft is 96.7 +/- 2.4% at 7 years. Multivariate analysis indicated bicuspid aortic valve disease as an incremental risk factor for AR at discharge (p = 0.036, odds 3.5). Univariate analysis identified operation for pure AR as risk factor for AR during follow-up (p = 0.041). Mild AR or more increased from 2.5% at discharge to 11.3% during follow-up (p = 0.008). Progression of AR was limited by the use of a reinforcement root ring (p = 0.031). Freedom from mild AR or more in patients with and without a reinforcement root ring was 100% and 72.9 +/- 9.3% respectively, at 5 years (p = 0.119). Pulmonary allograft stenosis occurred in 15 (22.5%) patients. Multivariate analysis revealed that large sized pulmonary allografts were less prone to stenosis (p = 0.048, odds 0.13). CONCLUSIONS: Pulmonary autograft root replacement can be performed with few complications. During follow-up, a significant increase in mild AR or more is observed. The use of a reinforcement root ring is effective in preventing progression of AR.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Valva Pulmonar/transplante , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Fatores de Risco , Transplante Autólogo , Resultado do TratamentoRESUMO
BACKGROUND: An evaluation of early and long-term results of aortic root replacement with cryopreserved aortic allografts and echocardiographic follow-up of allograft valve function was performed. METHODS: From September 1989 through May 1998, 132 patients aged 17 to 77 years (mean, 50.8 +/- 14.8 years) underwent freestanding aortic root replacement with a cryopreserved aortic allograft. Eighty-six (65.1%) patients had New York Heart Association class III or IV functional status before operation, and 27 (20.5%) patients underwent emergency operation. Fifty-nine (44.7%) patients had undergone previous cardiac operations. The cause of aortic disease was acute endocarditis in 63 (47.7%) patients, healed endocarditis in 15 (11.3%), degenerative in 20 (15.2%), congenital in 20 (15.2%), failed prosthesis in 10 (7.6%) and rheumatic in 4 (3.0%). Follow-up was complete, with a mean of 42 months. RESULTS: There were 12 hospital deaths (9.1%; 70% confidence limits [CL], 6.6% and 11.6%); 9 of them were operated on for active endocarditis (p = 0.062). Multivariate analysis determined age older than 65 years (p = 0.012) and emergency operation (p = 0.009) as independent risk factors for hospital mortality. During follow-up, 6 (5.0%; 70% CL, 3.0% and 7.0%) patients died. Cumulative survival rate for the entire group was 81.8% +/- 5.4% at 8 years. Freedom from reoperation for structural valve failure was 100%, freedom from reoperation for any cause was 96.3% +/- 1.8% at 8 years. Freedom from endocarditis at 8 years was 97.9% +/- 1.4%. Follow-up of allograft valve function showed no or trivial aortic regurgitation in 97% of patients and absence of stenosis of the allograft in 100%. CONCLUSIONS: Aortic root replacement with cryopreserved aortic allografts can be performed with acceptable hospital mortality and long-term results. The durability of cryopreserved aortic allografts is good, and reoperation for structural valve failure is absent at 8 years.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/transplante , Criopreservação , Adolescente , Adulto , Idoso , Estenose da Valva Aórtica/cirurgia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Estudos Retrospectivos , Transplante Homólogo , Resultado do TratamentoRESUMO
OBJECTIVE: To assess short and long term efficacy of coronary stent implantation for unprotected left main coronary artery stenosis. DESIGN: Retrospective follow up study. SETTING: Tertiary referral centre for interventional cardiology and cardiac surgery. PATIENTS: Eighteen consecutive patients (12 men; age 70.8 years) between May 1993 and July 1996. Ten patients presented with stable angina and underwent the procedure electively, eight patients presented either with unstable angina or myocardial infarction and underwent the procedure in emergency. INTERVENTION: Johnson and Johnson Palmaz-Schatz stents were used in 16 patients, and a Microstent and a Gianturco-Roubin in one patient each. An intra-aortic balloon pump was prophylactively used for two patients in the elective group. In the acute group, six required an intra-aortic balloon pump. MAIN OUTCOME MEASURES: Procedural success rate and major adverse cardiac events. RESULTS: Successful stent implantation was achieved in all patients. In the elective group, no major adverse cardiac event occurred during the procedure, but one patient had to undergo repeated angioplasty before discharge. All patients of the elective group were discharged alive and there has been one non-cardiac death during a follow up of (mean (SD)) 10 (4) months. In the emergency group, one patient died during the procedure, one patient developed a non Q-wave myocardial infarction, one patient underwent emergency coronary bypass surgery, while another patient died suddenly before hospital discharge. Six patients of the emergency group were discharged alive and there has been one non-cardiac death during a follow up of 7 (4) months. CONCLUSIONS: Elective stent implantation for unprotected left main coronary artery stenosis is safe and effective in selected stable patients. Urgent stent implantation, however, cannot be considered as a definitive procedure in emergency situation.