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OBJECTIVES: In our center, an unusual rate of patients had abnormalities of hemostasis in immediate postoperative period of cardiac surgery. Our objectives were to identify the cause of these sudden hemostasis abnormalities and to evaluate the performances of point of care coagulation testing. METHODS: In this prospective and descriptive study, we included 33 consecutive patients undergoing elective cardiac surgery for 1 month. Heparin-induced anticoagulation and calculation of the protamine dose were tested by the Hemostasis Management System Plus device (Medtronic, Minneapolis, MN, USA). Fifteen minutes after the end of the protamine infusion, activated clotting time (ACT), activated partial thromboplastin time and anti Xa activity were measured. In case of unusual clinical bleeding, a Quantra analysis (Stago, HemoSonics LLC, Charlottesville, VA) was added. RESULTS: Residual antiXa activity >0.2 IU/mL after neutralization was present in 44% of patients. Our investigation concluded incomplete heparin reversal. There was no association between cellular reinfusate and the presence of heparin. The unusual rate of hemostasis abnormalities was explained by a less efficient protamine reversal of heparin. ACT and Clot Time Ratio (CTR, Quantra system) correlated with AntiXa with Spearman's coefficients of 0.85 (p < .0001) and 0.95 (p = .0012), respectively. About ACT, a threshold of 150 seconds had a sensitivity of 85% [58-97] and a specificity of 85% [58-97%] for detection of AntiXa>0.2. For CTR, a threshold of 1.4 had a sensitivity of 67% [30-94] and a specificity of 100% [18-100]. CONCLUSION: The use of point of care coagulation testing is effective in detecting incomplete reversal of heparin.
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Procedimentos Cirúrgicos Cardíacos , Heparina , Humanos , Heparina/efeitos adversos , Heparina/uso terapêutico , Masculino , Feminino , Procedimentos Cirúrgicos Cardíacos/métodos , Idoso , Estudos Prospectivos , Pessoa de Meia-Idade , Protaminas/uso terapêutico , Anticoagulantes/uso terapêutico , Anticoagulantes/farmacologia , Testes de Coagulação Sanguínea/métodosRESUMO
BACKGROUND: Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. METHODS: Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. RESULTS: Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5â¯months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7â¯years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (nâ¯=â¯113' 45.4%), Enterobacteriaceae (nâ¯=â¯61; 24.6%), Pseudomonas aeruginosa (nâ¯=â¯34; 13.7%), coagulase-negative staphylococci (nâ¯=â¯13; 5.2%), and Candida species (nâ¯=â¯13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; Pâ¯=â¯.031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; Pâ¯=â¯.031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. CONCLUSIONS: Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.
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Infecções Relacionadas a Cateter/etiologia , Coração Auxiliar/efeitos adversos , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/mortalidade , Desfibriladores Implantáveis/estatística & dados numéricos , Remoção de Dispositivo/estatística & dados numéricos , Feminino , França/epidemiologia , Ventrículos do Coração , Coração Auxiliar/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Estudos Retrospectivos , Fatores de RiscoRESUMO
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Authors. This abstract has been published due to a miscommunication in the ANZSCTS ASM conference supplement. It needs to be retracted as we the authors wish to submit a full length paper with updated material.
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BACKGROUND/AIMS: Long-term mechanical assist devices are now commonly used in the treatment of severe heart failure to unload the failing ventricle, maintain sufficient end-organ perfusion and improve functional capacity. Depending on the assisted ventricles, 3 categories of long-term assist devices are available: left ventricular assist device (LVAD), biventricular assist device and total artificial heart. Improvements in technology, especially the advent of smaller, durable continuous flow pumps, have led to the use of LVADs in a much broader population of patients in the last 10 years. Both the number of patients living with LVADs and the life expectancy of these patients are increasing. Regarding this growing number of patients with LVAD, intensivists need to understand the physiology of the devices, their functioning, potential complications and their management. METHODS: We performed a narrative review of relevant medical literature regarding the physiology of patients with LVAD and management of common complications relevant to the critical care physicians. RESULTS: The most frequent complications occurring in the LVAD patients after the post-operative period are bleeding, driveline infections, thrombosis, device malfunction, right ventricular failure and arrhythmias. Bleeding is the most frequent adverse event in LVAD due to a combination of anticoagulation and acquired von Willebrand disease secondary to shear stress produced within the pump. Their management includes antiplatelet therapy arrest, reduction of the anticoagulation regimen and specific therapy if feasible. Infection is the second most common cause of death after cardiac failure in LVAD patients. All infections must be aggressively treated to avoid seeding the device. Device thrombosis can develop even when patients are adequately anticoagulated and taking antiplatelet therapy because the LVAD is responsible for a chronic hypercoagulable state. CONCLUSION: Management of these unique patients in the ICU is best accomplished with a multidisciplinary team that includes specialists in advanced heart failure, LVAD nurse coordinators and intensivists.
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Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Coração Auxiliar , Expectativa de Vida , Animais , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/terapia , Cuidados Críticos/métodos , Falha de Equipamento , Insuficiência Cardíaca/epidemiologia , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/terapia , Humanos , Trombose/epidemiologia , Trombose/etiologia , Trombose/terapia , Fatores de TempoAssuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Tentativa de Suicídio/estatística & dados numéricos , Idoso , Depressão/etiologia , Feminino , França/epidemiologia , Insuficiência Cardíaca/psicologia , Coração Auxiliar/psicologia , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Risco , Tristeza , Tentativa de Suicídio/psicologiaRESUMO
OBJECTIVES: To evaluate the precise dimensions of the normal aortic root, especially the true aortic annulus, during the cardiac cycle using an innovative reconstruction method based on multiphase cardiac computed tomography and to assess the feasibility and the reproducibility of this method for aortic root analysis. METHODS: Between January 2019 and June 2021, 30 optimal consecutive ECG-gated multiphase cardiac computed tomography of patients with normal tricuspid aortic valve were analysed using an in-house software. Aortic annulus border was pinpointed on 9 reconstructed planes and the 3D coordinates of the 18 consecutive points were interpolated into a 3D curve using a cubic spline. Three additional planes were generated at the level of the left ventricular outflow tract, the level of the Valsalva sinus and the level of the sinotubular junction. This procedure was repeated for all the 10 temporal phases of the RR interval. RESULTS: The aortic annulus mean 3D and 2D areas were 7.67 ± 1.51 and 5.16 ± 1.40 cm2, respectively. The mean 2D diameter was 2.51 ± 0.23 cm. The mean global area expansion was 11.8 ± 3.5% and the mean perimeter expansion of 7.1 ± 2.6%. During the cardiac cycle, the left ventricle outflow tract expands, reaching its maximum surface at the end of diastole, followed by the aortic annulus, the Valsalva sinuses and the sinotubular junction. The aorta changes from a clover-shaped cone during diastole to more cylindrical shape during systole. Compared to the 3D measurements, the analysis of the virtual basal ring significantly underestimates the annulus area, perimeter, and mean diameter. CONCLUSIONS: 4D morphometric analysis enables to have a precise and reproducible evaluation of the aortic annulus. The aortic annulus and root are deformable structures that undergo a unique expansion sequence during the cardiac cycle which should be considered for procedural planning.
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Estenose da Valva Aórtica , Seio Aórtico , Humanos , Valva Aórtica , Tomografia Computadorizada Quadridimensional , Reprodutibilidade dos Testes , Aorta , Seio Aórtico/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgiaRESUMO
BACKGROUND: Legionnaires disease (LD) is a rare, life-threatening opportunistic bacterial infection that poses a significant risk to patients with impaired cell-mediated immunity such as solid organ transplant recipients. However, the epidemiologic features, clinical presentation, and outcomes of LD in this population are poorly described. RESEARCH QUESTION: What are the clinical manifestations, radiologic presentation, risk factors for severity, treatment, and outcome of LD in solid organ transplant recipients? STUDY DESIGN AND METHODS: In this 10-year multicenter retrospective cohort study in France, where LD notification is mandatory, patients were identified by hospital discharge databases. Diagnosis of LD relied on positive culture findings from any respiratory sample, positive urinary antigen test (UAT) results, positive specific serologic findings, or a combination thereof. Severe LD was defined as admission to the ICU. RESULTS: One hundred one patients from 51 transplantation centers were eligible; 64 patients (63.4%) were kidney transplant recipients. Median time between transplantation and LD was 5.6 years (interquartile range, 1.5-12 years). UAT results were positive in 92% of patients (89/97). Among 31 patients with positive culture findings in respiratory samples, Legionella pneumophila serogroup 1 was identified in 90%. Chest CT imaging showed alveolar consolidation in 98% of patients (54 of 57), ground-glass opacity in 63% of patients (36 of 57), macronodules in 21% of patients (12 of 57), and cavitation in 8.8% of patients (5 of 57). Fifty-seven patients (56%) were hospitalized in the ICU. In multivariate analysis, severe LD was associated with negative UAT findings at presentation (P = .047), lymphopenia (P = .014), respiratory symptoms (P = .010), and pleural effusion (P = .039). The 30-day and 12-month mortality rates were 8% (8 of 101) and 20% (19 of 97), respectively. In multivariate analysis, diabetes mellitus was the only factor associated with 12-month mortality (hazard ratio, 3.2; 95% OR, 1.19-8.64; P = .022). INTERPRETATION: LD is a late and severe complication occurring in solid organ transplant recipients that may present as pulmonary nodules on which diabetes impacts its long-term prognosis.
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Legionella pneumophila , Doença dos Legionários , Transplante de Órgãos , Humanos , Doença dos Legionários/diagnóstico , Doença dos Legionários/epidemiologia , Doença dos Legionários/microbiologia , Estudos Retrospectivos , Fatores de Risco , Transplante de Órgãos/efeitos adversosRESUMO
Objectives: Secondary functional tricuspid regurgitation (FTR) management remains controversial mainly due to the lack of knowledge in its pathogenesis and the difficulties to measure the actual dimensions of tricuspid annulus (TA) with current imaging methods. Using a novel method based on multiphase cardiac computed tomography (CT) scan acquisition to accurately analyze the right atrioventricular junction size, we sought to explore modifications of TA morphometry and dynamics in secondary FTR. Methods: Echocardiographic and cardiac CT studies were obtained from 21 patients with severe mitral regurgitation (MR group) and 21 patients with dilated cardiomyopathy (DCMP group). Using an in-house software, a 3-dimensiontal (3D) semiautomated delineation of the TA perimeter was assessed. Modifications of diameters, 2-dimensional/3D areas and perimeters were analyzed through time. These 2 groups of patients were compared with 30 healthy subjects, considering the presence of a significant (≥2+) versus nonsignificant (<2+) FTR in each group. Results: Maximum TA 3D areas were 7.0 ± 1.2 cm2/m2 in healthy subjects at mid-to-late diastole and were smaller than in the MR group (9.8 ± 2.1 cm2/m2, P < .001) and the DCMP group (9.2 ± 3.0 cm2/m2, P < .001). In the MR group, patients with FTR <2+ had also larger TA areas and diameters than healthy patients (P < .01 for all 3D/2-dimensional parameters). TA shape was more circular only in the DCMP group with FTR ≥2+ compared with other patients (P < .05 for eccentricity). In multivariate analysis, both RA area (P < .001) and RV volume (P = .002) were independently related to TA dilatation. Conclusions: Based on multiphase CT image analyses, TA dilatation was directly related to RV and RA enlargement. Patients with severe mitral myxomatous disease and nondysfunctional tricuspid valve had yet dilated TA, which questioned the current cut-off recommendation for concomitant tricuspid annuloplasty in this specific population.
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PURPOSE: To improve knowledge of the tricuspid valve and right atrioventricular junction (RAVJ) coupling, four-dimensional (4D) imaging is mandatory (3D + time). Based on multiphase cardiac-volume computed tomography (CT) and innovative 4D analysis, we proposed to assess dynamical features of tricuspid annulus (TA) in relation to the right ventricle (RV) and right atrial (RA) functions. METHODS: Cardiac-volume CT data sets through time were obtained in 30 healthy patients (Male 57%, mean age 57 ± 11 years). Using an in-house software, 3D semi-automated delineation of 18 points around TA perimeter were defined through 10 cardiac phases within RR interval and used to calculate TA features such as 3D/2D areas, perimeters, 360°-diameters and vertical deformation. RV and RA inner contours were also delineated. Bi-dimensional parameters were compared with multiplanar reconstruction (MPR) measurements. RESULTS: TA was elliptical in horizontal projection with a maximal eccentricity index (EcImax) of 0.58 ± 0.12; and saddle-shaped in vertical projection with a horn nearby the antero-septal commissure. This feature remained throughout the cardiac cycle, but TA was more planar and less circular in late diastole (TA-height: 4.53 ± 1.06 mm, EcImax = 0.61 ± 0.14) when TA 3D area and perimeter reached a maximum of 7.05 ± 1.23 and 7.48 ± 0.93cm/m2, respectively. Correlations between minimal and maximal TA 3D areas and TA Projected 2D areas were excellent (r = 0.993 and r = 0.995, p < 0.001). TA 2D area measurements by MPR overestimated the projected values by 22 to 24%. Correlation between RV concentric strain and TA maximal diameter shortening was r = 0.452 (p = 0.01). CONCLUSIONS: Cardiac-volume CT improves physiological knowledge of the relationships between the RAVJ components in healthy subjects.
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Ecocardiografia Tridimensional , Insuficiência da Valva Tricúspide , Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Ecocardiografia Tridimensional/métodos , Voluntários Saudáveis , Tomografia Computadorizada Quadridimensional , Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/cirurgiaRESUMO
OBJECTIVES: Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS: The multicentric CAVIAAR (Conservation Aortique Valvulaire dans les Insuffisances Aortiques et les Anévrismes de la Racine aortique) prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analysed with propensity score-weighted Cox model analysis. Secondary outcomes included major adverse valve-related events and components of primary outcome. RESULTS: The mean age was 56.1 years, and valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome [Hazard Ratio (HR) 0.66 (0.39; 1.12)] but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for the occurrence of multiple events in a single patient, the REPAIR group had half the occurrence of major adverse valve-related events (HR 0.51 [0.31; 0.86]). CONCLUSIONS: Although the primary outcome did not significantly differ between the REPAIR and REPLACE groups, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.
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Aneurisma Aórtico , Insuficiência da Valva Aórtica , Anuloplastia da Valva Cardíaca , Implante de Prótese de Valva Cardíaca , Humanos , Pessoa de Meia-Idade , Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca/efeitos adversos , Aneurisma Aórtico/cirurgia , Estudos Prospectivos , Qualidade de Vida , Resultado do Tratamento , Reoperação/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Estudos RetrospectivosRESUMO
OBJECTIVES: Right ventricular failure after left ventricular assist device (LVAD) insertion is associated with significant mortality and morbidity. Mechanical support options include right ventricular assist devices, venoarterial extracorporeal membrane oxygenation (ECMO) and venopulmonary artery ECMO, the latter often involving central cannulation. We sought to evaluate the feasibility and early outcomes of a truly percutaneous venopulmonary artery (pVPA) ECMO strategy, with the potential advantage of bedside removal once weaned. METHODS: Data from a single tertiary centre were reviewed retrospectively from January 2014 to January 2019. During this time, 54 patients underwent LVAD insertion, with 19 requiring mechanical support for right ventricular failure. Among them, 10 patients received pVPA ECMO. Implantation of the pVPA ECMO was performed under transoesophageal echocardiography and fluoroscopy guidance, with an inflow cannula placed in the right atrium via the right femoral vein and an outflow cannula placed in the left pulmonary artery (PA) via the right internal jugular vein. RESULTS: Cannula insertion was 100% successful with no need for repositioning. Eight patients (80%) were able to be successfully weaned (at the bedside); 6 were discharged from the hospital and there were no cases of early sepsis, mediastinitis or thromboembolism. At follow-up, 5 patients had received transplants (50%), with 1 on LVAD support as destination therapy (10%). Survival was 60 ± 15% and 50 ± 16% at 6 and 12 months, respectively. CONCLUSIONS: pVPA ECMO is 100% technically feasible and is an efficient method for temporary right ventricular support after LVAD insertion with the advantage of simple bedside removal and avoidance of a PA graft remnant in the chest cavity.
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Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Coração Auxiliar , Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Humanos , Artéria Pulmonar/diagnóstico por imagem , Estudos RetrospectivosRESUMO
PURPOSE: To report a case of retrograde acute Stanford type A aortic dissection treated without hypothermic circulatory arrest. CASE REPORT: A 55-year-old man presented with a retrograde acute type A aortic dissection with an entry tear 30 mm below the left subclavian artery. A concurrent emergent endovascular and surgical treatment was performed, excluding the entry tear with retrograde delivery of a stent-graft and replacing the ascending aorta with a Dacron tube without circulatory arrest. CONCLUSION: Avoiding hypothermic circulatory arrest was the main advantage of this hybrid therapeutic choice. This combined technique may be of interest in acute retrograde type A dissections that present complications such as impending rupture or visceral malperfusion. A close collaboration between endovascular specialists and cardiac surgeons is essential for such a hybrid strategy.
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Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Dissecção Aórtica/diagnóstico por imagem , Aneurisma Aórtico/diagnóstico por imagem , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Polietilenotereftalatos , Desenho de Prótese , Stents , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVES: Our goal was to provide a picture of left ventricular assist device (LVAD) activity in France between 2007 and 2016 based on the multicentric ASSIST-ICD registry. METHODS: We retrospectively collected 136 variables including in-hospital data, follow-up survival rates and adverse events from 671 LVAD recipients at 20 out of 24 LVAD implant centres in France. The average follow-up time was 1.2 years (standard deviation: 1.4); the total follow-up time was 807.5 patient-years. RESULTS: The included devices were the HeartMate II®, HeartWare LVAS® or Jarvik 2000®. The overall likelihood of being alive while on LVAD support or having a transplant (primary end point) at 1, 2, 3 and 5 years postimplantation was 65.2%, 59.7%, 55.9% and 47.7%, respectively, given a cumulative incidence of 29.2% of receiving a transplant at year 5. At implantation, 21.5% of patients were on extracorporeal life support. The overall rate of cardiogenic shock at implantation was 53%. The major complications were driveline infection (26.1%), pump pocket or cannula infection (12.6%), LVAD thrombosis (12.2%), ischaemic (12.8%) or haemorrhagic stroke (5.4%; all strokes 18.2%), non-cerebral haemorrhage (9.1%) and LVAD exchange (5.2%). The primary end point (survival) was stratified by age at surgery and by the type of device used, with inference from baseline profiles. The primary end point combined with an absence of complications (secondary end point) was also stratified by device type. CONCLUSIONS: The ASSIST-ICD registry provides a real-life picture of LVAD use in 20 of the 24 implant centres in France. Despite older average age and a higher proportion of patients chosen for destination therapy, survival rates improved compared to those in previous national registry results. This LVAD registry contrasts with other international registries because patients with implants have more severe disease, and the national policy for graft attribution is distinct. We recommend referring patients for LVAD earlier and suggest a discussion of the optimal timing of a transplant for bridged patients (more dismal results after the second year of support?).
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Insuficiência Cardíaca , Coração Auxiliar , França/epidemiologia , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Humanos , Sistema de Registros , Estudos Retrospectivos , Resultado do TratamentoRESUMO
The impact of uncommon etiology cardiomyopathies on Left-ventricular assist device (LVAD)-recipient outcomes is not very well known. This study aimed to characterize patients with uncommon cardiomyopathy etiologies and examine the outcomes between uncommon and ischemic/idiopathic dilated cardiomyopathy. This observational study was conducted in 19 centers between 2006 and 2016. Baseline characteristics and outcomes of patients with uncommon etiology were compared to patients with idiopathic dilated/ischemic cardiomyopathies. Among 652 LVAD-recipients included, a total of 590 (90.5%) patients were classified as ischemic/idiopathic and 62 (9.5%) patients were classified in the "uncommon etiologies" group. Main uncommon etiologies were: hypertrophic (nâ¯=â¯12(19%)); cancer therapeutics-related cardiac dysfunction (CTRCD) (nâ¯=â¯12(19%)); myocarditis (nâ¯=â¯11(18%)); valvulopathy (nâ¯=â¯9(15%)) and others (nâ¯=â¯18(29%)). Patients with uncommon etiologies were significantly younger with more female and presented less co-morbidities. Additionally, patients with uncommon cardiomyopathies were less implanted as destination therapy compared with ischemic/idiopathic group (29% vs 38.8%). During a follow-up period of 9.1 months, both groups experienced similar survival. However, subgroup of hypertrophic/valvular cardiomyopathies and CTRCD had significantly higher mortality compared to the ischemic/idiopathic or myocarditis/others cardiomyopathies. Conversely, patients with myocarditis/others etiologies experienced a better survival. Indeed, the 12-months survival in the myocarditis/others; ischemic/idiopathic and hypertrophic/CTRCD/valvulopathy group were 77%; 65%, and 46% respectively. In conclusion, LVAD-recipients with hypertrophic cardiomyopathy, valvular heart disease and CTRCD experienced the higher mortality rate.
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Cardiomiopatia Dilatada/cirurgia , Cardiomiopatia Hipertrófica/cirurgia , Coração Auxiliar , Isquemia Miocárdica/cirurgia , Adulto , Idoso , Cardiomiopatia Dilatada/etiologia , Cardiomiopatia Hipertrófica/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/etiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Cardiac transplantation is an ever more frequent requirment for patients presenting with end-stage right systemic ventricular failure late after atrial switch operations. But as the time on the donor waiting list lengthens, the clinical conditions of these patients can easily and abruptly deteriorate, sometimes requiring systemic ventricular assistance. We document the first case of right systemic ventricular assistance with a De Bakey VAD axial pump in a patient presenting with systemic ventricular failure 23 years after procedure. He rapidly recovered total autonomy and was thus able to participate in a rehabilitation program to optimize his condition for heart transplantation.
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Insuficiência Cardíaca/terapia , Coração Auxiliar , Transposição dos Grandes Vasos/cirurgia , Procedimentos Cirúrgicos Cardíacos , Desenho de Equipamento , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Fatores de Tempo , Tomografia Computadorizada por Raios X , Ultrassonografia , Adulto JovemRESUMO
BACKGROUND: Aortopathy is common in patients with bicuspid aortic valve (BAV). AIM: To evaluate the fate of unreplaced Valsalva sinuses in patients with BAV, 10 years after aortic valve replacement (AVR) with or without replacement of the ascending aorta (RAA). METHODS: We retrospectively reviewed all surgical patients with BAV who were operated on between January 2005 and December 2007. Patients who underwent AVR with or without RAA were included. Surgical data were entered prospectively. Ten-year clinical and echocardiographic follow-up data as well as survival data were collected by contacting the patients and their personal cardiologists, and by consulting the French national mortality registry. Overall, 25% of the patients had computed tomography angiographic assessment of the aortic root at follow-up. RESULTS: A total of 133 patients with BAV were operated on within the selected period. Thirty-two patients did not meet the inclusion criteria, and had primary Valsalva sinus surgery. Twenty-four patients underwent AVR with RAA and 77 patients had isolated AVR; all of these 101 patients were included in the study. The median follow-up was 9 years (up to 12 years). During follow-up, eight patients (7.9%) underwent late reoperation; two of them (2.0%) required root surgery. Ten-year freedom from reoperation was 86.2±4.7%. Ten-year freedom from dilatation of the Valsalva sinuses (>45mm) was 86.6±5.2%. Ten-year cumulative survival was 83.5±4%. CONCLUSIONS: Ascending aorta and Valsalva sinuses seem to have different fates after AVR in BAV disease. When the Valsalva sinuses are not dilated at the initial surgery, the risk of secondary dilatation at 10 years is low. Preservation of the sinuses is therefore justified in patients with BAV with a non-dilated root. In BAV with isolated aortic insufficiency, a more aggressive approach may be justified, especially in young patients.
Assuntos
Valva Aórtica/anormalidades , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Seio Aórtico , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Aortografia/métodos , Doença da Válvula Aórtica Bicúspide , Angiografia por Tomografia Computadorizada , Dilatação Patológica , Feminino , Seguimentos , Doenças das Valvas Cardíacas/diagnóstico por imagem , Doenças das Valvas Cardíacas/fisiopatologia , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Reoperação , Estudos Retrospectivos , Fatores de Risco , Seio Aórtico/diagnóstico por imagem , Seio Aórtico/fisiopatologia , Seio Aórtico/cirurgia , Fatores de Tempo , Remodelação VascularRESUMO
BACKGROUND: Ventricular arrhythmias (VAs) can occur after continuous flow left ventricular assist device (LVAD) implantation as a single arrhythmic event or as electrical storm (ES) with multiple repetitive VA episodes. OBJECTIVE: We aimed at analyzing the incidence, predictors, and clinical impact of ES in LVAD recipients. METHODS: Patients analyzed were those included in the multicenter ASSIST-ICD observational study. ES was consensually defined as occurrence of ≥3 separate episodes of sustained VAs within a 24-hour interval. RESULTS: Of 652 patients with an LVAD, 61 (9%) presented ES during a median follow-up period of 9.1 (interquartile range [IQR] 2.5-22.1) months. The first ES occurred after 17 (IQR 4.0-56.2) days post LVAD implantation, most of them during the first month after the device implantation (63%). The incidence then tended to decrease during the initial years of follow-up and increased again after the third year post LVAD implantation. History of VAs before LVAD implantation and heart failure duration > 84 months were independent predictors of ES. The occurrence of ES was associated with an increased early mortality since 20 patients (33%) died within the first 2 weeks of ES. Twenty-two patients (36.1%) presented at least 1 recurrence of ES, occurring 43.0 (IQR 8.0-69.0) days after the initial ES. Patients experiencing ES had a significantly lower 1-year survival rate than did those free from ES (log-rank, P = .039). CONCLUSION: There is a significant incidence of ES in patients with an LVAD. The short-term mortality after ES is high, and one-third of patients will die within 15 days. Whether radiofrequency ablation of arrhythmias improves outcomes would require further studies.
Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Taquicardia Ventricular/etiologia , Fibrilação Ventricular/etiologia , Fibrilação Ventricular/mortalidade , Adulto , Fatores Etários , Idoso , Estudos de Coortes , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/mortalidade , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Taxa de Sobrevida , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Fibrilação Ventricular/fisiopatologiaRESUMO
OBJECTIVES: Surgical mortality and long-term outcomes are important considerations when determining strategies for multiple reoperations on the aortic valve (AV). With the rise of percutaneous valve-in-valve, we sought to evaluate the current outcomes of conventional surgery for AV reoperation, focusing first on the effect of the number of previous AV interventions with a subsequent analysis of the risk factors for adverse outcomes. METHODS: From January 2007 to December 2016, 316 consecutive patients underwent an open redo operation (replacement) on their AV at a single centre. It was the first AV reintervention in 263 patients (Group 1), second in 42 patients (Group 2) and third or more in 11 patients (Group 3). RESULTS: There were 230 men and 86 women, with a median age of 58 (Q1-Q3: 46-70) years. Structural valve deterioration (SVD) of the bioprosthesis (n = 136, 44%), endocarditis (n = 57, 18%) and prosthetic valve dehiscence (n = 41, 13%) were the most common reasons for reintervention. Overall, in-hospital mortality was 7.3%: 7.2% in Group 1, 4.76% in Group 2 and 18.2% in Group 3 (P = 0.233) and ranged from 3.7% for SVD to 14.0% when endocarditis was the reason for reintervention. Higher preoperative New York Heart Association (NYHA) class (III/IV) [odds ratio (OR) 15.9, P = 0.011], injury during re-entry (OR 16.9, P = 0.015), endocarditis (OR 3.7, P = 0.038) and concomitant mitral valve replacement (OR 5.6, P = 0.006) were independent risk factors for in-hospital mortality. Survival at 8 years was 79.0 ± 3.0% for the entire cohort and 88.4 ± 3.2% for re-replacement after SVD. CONCLUSIONS: Multiple AV reoperations carry an acceptable risk of early postoperative mortality, particularly for isolated valve replacements of SVD.