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Minimalist approaches have evolved for TAVR over the last years with impact on in-hospital stay and patient safety. As part of this concept, transradial secondary arterial access is capable of reducing vascular and bleeding complications. Yet, steering of the marker pigtail catheter in the descending aorta might by fluoroscopic imaging sometimes be challenging. In our manuscript, we present a very simple "piggyback" technique, simplifying management of transradial secondary access in transfemoral TAVR.
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Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Estudios Retrospectivos , Resultado del Tratamiento , Arteria Femoral/diagnóstico por imagen , Factores de Riesgo , Válvula Aórtica/cirugíaRESUMEN
Transfemoral aortic valve replacement (TAVR) has become a standard therapeutic option for patients with symptomatic severe aortic stenosis. Special anatomies can pose distinct challenges for vascular access and later closure of the access site, for example, in preoperated patients. Here, we elucidate a case of transfemoral TAVR with vascular access by direct puncture of an aorto-bifemoral bypass graft and illustrate the feasibility of vascular closure by an anchored collagen-plug vascular closure device (Teleflex MANTA® ).
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Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Técnicas Hemostáticas , Humanos , Punciones , Resultado del TratamientoRESUMEN
We present a T-shaped transseptal approach for mitral valve surgery that makes adequate exposure possible under challenging anatomic and surgical circumstances, hence eliminating the need for forceful retraction on potentially fragile tissues. Particularly suited for patients with complex mitral pathology, it also facilitates juxta-annular transseptal right atrial anchoring, especially in cases of endocarditic anterior mitral annular destruction.
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Implantación de Prótesis de Válvulas Cardíacas , Anuloplastia de la Válvula Mitral , Válvula Mitral/cirugía , Puente Cardiopulmonar , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Anuloplastia de la Válvula Mitral/efectos adversos , Anuloplastia de la Válvula Mitral/instrumentación , Esternotomía , Técnicas de Sutura , Resultado del TratamientoRESUMEN
AIMS: The antiplatelet treatment strategy providing optimal balance between thrombotic and bleeding risks in patients undergoing coronary artery bypass grafting (CABG) is unclear. We prospectively compared the efficacy of ticagrelor and aspirin after CABG. METHODS AND RESULTS: We randomly assigned in double-blind fashion patients scheduled for CABG to either ticagrelor 90 mg twice daily or 100 mg aspirin (1:1) once daily. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), repeat revascularization, and stroke 12 months after CABG. The main safety endpoint was based on the Bleeding Academic Research Consortium classification, defined as BARC ≥4 for periprocedural and hospital stay-related bleedings and BARC ≥3 for post-discharge bleedings. The study was prematurely halted after recruitment of 1859 out of 3850 planned patients. Twelve months after CABG, the primary endpoint occurred in 86 out of 931 patients (9.7%) in the ticagrelor group and in 73 out of 928 patients (8.2%) in the aspirin group [hazard ratio 1.19; 95% confidence interval (CI) 0.87-1.62; P = 0.28]. All-cause mortality (ticagrelor 2.5% vs. aspirin 2.6%, hazard ratio 0.96, CI 0.53-1.72; P = 0.89), cardiovascular death (ticagrelor 1.2% vs. aspirin 1.4%, hazard ratio 0.85, CI 0.38-1.89; P = 0.68), MI (ticagrelor 2.1% vs. aspirin 3.4%, hazard ratio 0.63, CI 0.36-1.12, P = 0.12), and stroke (ticagrelor 3.1% vs. 2.6%, hazard ratio 1.21, CI 0.70-2.08; P = 0.49), showed no significant difference between the ticagrelor and aspirin group. The main safety endpoint was also not significantly different (ticagrelor 3.7% vs. aspirin 3.2%, hazard ratio 1.17, CI 0.71-1.92; P = 0.53). CONCLUSION: In this prematurely terminated and thus underpowered randomized trial of ticagrelor vs. aspirin in patients after CABG no significant differences in major cardiovascular events or major bleeding could be demonstrated. CLINICALTRIALS.GOV IDENTIFIER: NCT01755520.
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Aspirina/uso terapéutico , Puente de Arteria Coronaria/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Ticagrelor/uso terapéutico , Anciano , Método Doble Ciego , Terminación Anticipada de los Ensayos Clínicos , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/prevención & control , Hemorragia Posoperatoria/inducido químicamente , Hemorragia Posoperatoria/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND: For patients with coronary artery disease undergoing coronary bypass surgery, acetylsalicylic acid (ASA) currently represents the gold standard of antiplatelet treatment. However, adverse cardiovascular event rates in the first year after coronary artery bypass grafting (CABG) still exceed 10%. Graft failure, which is predominantly mediated by platelet aggregation, has been identified as a major contributing factor in this context. Therefore, intensified platelet inhibition is likely to be beneficial. Ticagrelor, an oral, reversibly binding and direct-acting P2Y12 receptor antagonist, provides a rapid, competent, and consistent platelet inhibition and has shown beneficial results compared with clopidogrel in the subset of patients undergoing bypass surgery in a large previous trial. HYPOTHESIS: Ticagrelor is superior to ASA for the prevention of major cardiovascular events within 1 year after CABG. STUDY DESIGN: The TiCAB trial (NCT01755520) is a multicenter, phase III, double-blind, double-dummy, randomized trial comparing ticagrelor with ASA for the prevention of major cardiovascular events within 12 months after CABG. Patients undergoing CABG will be randomized in a 1:1 fashion to either ticagrelor 90 mg twice daily or ASA 100 mg once daily. The study medication will be started within 24 hours after surgery and maintained for 12 months. The primary end point is the composite of cardiovascular death, myocardial infarction, stroke, and repeat revascularization at 12 months after CABG. The sample size is based on an expected event rate of 13% of the primary end point within the first 12 months after randomization in the control group, a 2-sided α level of .0492 (to preserve the overall significance level of .05 after planned interim analysis), a power of 0.80%, 2-sided testing, and an expected relative risk of 0.775 in the active group compared with the control group and a dropout rate of 2%. According to power calculations based on a superiority design for ticagrelor, it is estimated that 3,850 patients should be enrolled. SUMMARY: There is clinical equipoise on the issue of optimal platelet inhibition after CABG. The TiCAB trial will provide a pivotal comparison of the efficacy and safety of ticagrelor compared with ASA after CABG.
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Adenosina/análogos & derivados , Aspirina/uso terapéutico , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Adenosina/uso terapéutico , Anciano , Enfermedades Cardiovasculares/mortalidad , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Revascularización Miocárdica/estadística & datos numéricos , Accidente Cerebrovascular/epidemiología , Ticagrelor , Resultado del TratamientoRESUMEN
INTRODUCTION: Haemostasis is a critical part of surgery. Haemostatic agent selection is based upon a number of factors including surgeon's experience and choice. This post-marketing survey determined surgeons' intraoperative use and perception of Hemopatch® (Baxter Healthcare Corporation, Deerfield, IL), a resorbable collagen-based sealing haemostat. METHODS AND PARTICIPANTS: A one-arm questionnaire was distributed to European general, cardiac, pulmonary, and urologic surgeons who used Hemopatch® to achieve haemostasis in situations where bleeding control by pressure, ligature, or conventional procedures had been ineffective or was impractical. Responses were summarized for patient characteristics, surgical procedures/techniques, and surgeons' assessment of Hemopatch® regarding their overall satisfaction and utilization characteristics of Hemopatch®. RESULTS: Of 1028 responses received from seven European countries, the majority were from Germany (47.3%) or Italy (36%). Most cases were in males (60.7%), 50-75 years of age (61.8%), performed by an open approach (82.5%), with 52.7% general-, 16.2% cardiac-, 7.5% lung, 19.5% urologic-type procedures and 3.7% other/unknown. Successful haemostasis after two minutes of approximation occurred in 93.3% of patients (86.8%-96.9% across surgical subtypes), with similar rates by approach (93.1% open; 94.1% minimally-invasive), and patient's use of anticoagulant and/or antiplatelet agents (87.9% - 93.1%). Over 92% of surgeon's rated Hemopatch® as "excellent" or "good" in assessments of overall satisfaction, haemostasis efficacy, ease of preparation, ease of handling, flexibility/pliability, and tissue adherence. These characteristics were rated as excellent or good by 81% or more of surgeons in analyses by surgical subspecialty and surgical approach of open or minimally invasive. CONCLUSIONS: Hemopatch® provides effective haemostasis across a variety of surgical procedures, both in open- and minimally-invasive, as well as in patients receiving anticoagulant and/or antiplatelet agents. Surgeon's generally rated their overall satisfaction with Hemopatch®, its haemostatic efficacy, and other characteristics as "much better" or "better" than their previously used haemostat.
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Actitud del Personal de Salud , Pérdida de Sangre Quirúrgica/prevención & control , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Hemostáticos/administración & dosificación , Cuidados Intraoperatorios/estadística & datos numéricos , Cirujanos/estadística & datos numéricos , Adulto , Anciano , Vendajes , Embolización Terapéutica/instrumentación , Embolización Terapéutica/métodos , Embolización Terapéutica/estadística & datos numéricos , Europa (Continente)/epidemiología , Femenino , Encuestas de Atención de la Salud , Humanos , Cuidados Intraoperatorios/instrumentación , Cuidados Intraoperatorios/métodos , Masculino , Persona de Mediana Edad , Pautas de la Práctica en Medicina/estadística & datos numéricos , Prevalencia , Resultado del Tratamiento , Revisión de Utilización de Recursos , Adulto JovenAsunto(s)
Enterobacter cloacae/aislamiento & purificación , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Ácido Hipocloroso/uso terapéutico , Marcapaso Artificial/efectos adversos , Infecciones Relacionadas con Prótesis/terapia , Hipoclorito de Sodio/uso terapéutico , Anciano , Humanos , Masculino , Complicaciones Posoperatorias , Infecciones Relacionadas con Prótesis/diagnóstico , Infecciones Relacionadas con Prótesis/microbiología , Resultado del TratamientoRESUMEN
Topical hemostatic agents that can seal tissues and assist in the coagulation cascade of patients undergoing surgery have been readily available for several decades. Using either synthetic or animal/plant-derived materials, these agents represent a powerful tool to reduce postoperative bleeding complications in cases where mechanical or energy-driven hemostasis is not possible or insufficient. Recently, a novel sealing hemostatic patch, HEMOPATCH (Baxter International, Deerfield, IL), was developed. The device is a thin and flexible patch consisting of a specifically-formulated porous collagen matrix, coated on one side with a thin protein-binding layer. This gives the patch a dual mechanism of action, in which the two components interact to achieve hemostasis by sealing off the bleeding surface and initiating the body's own clotting mechanisms. Here we present a series of case reports that outline the quick, effective hemostatic sealing of HEMOPATCH in a variety of clinical applications, including solid organ, gastrointestinal, biliopancreatic, endocrine, cardiovascular, and urologic surgeries. Essentially a feasibility study, these reports demonstrate how HEMOPATCH can be applied to seal almost any bleeding surface encountered during a range of procedures. Our results show that the device is eminently capable in both via laparotomy and laparoscopic approaches, and in patients with impaired coagulation or highly variable anatomies. In conclusion, our cases document the ease-of-use, application, and immediate hemostatic effect of the patch across a broad range of surgical settings and paves the way for future randomized clinical trials with more extensive follow-up.
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OBJECTIVES: There are disparities in the adherence to guideline-recommended therapies after coronary artery bypass graft (CABG). We therefore sought to evaluate the effect of guideline-adherent medical secondary prevention on 1-year outcome after CABG. METHODS: Data were taken from the randomized 'Ticagrelor in CABG' trial. From April 2013 until April 2017, patients who underwent CABG were included. For the present analysis, we compared patients who were treated with optimal medical secondary prevention with those where 1 or more of the recommended medications were missing. RESULTS: Follow-up data at 12 months were available in 1807 patients. About half (54%) of them were treated with optimal secondary prevention. All-cause mortality [0.5% vs 3.5%, hazard ratio (HR) 0.14 (0.05-0.37), P < 0.01], cardiovascular mortality [0.1% vs 1.7%, HR 0.06 (0.01-0.46), P = 0.007] and major adverse events [6.5% vs 11.5%, HR 0.54 (0.39-0.74), P < 0.01] were significantly lower in the group with optimal secondary prevention. The multivariable model for the primary end point based on binary concordance to guideline recommended therapy identified 3 independent factors: adherence to guideline recommended therapy [HR 0.55 (0.39-0.78), P < 0.001]; normal renal function [HR 0.99 (0.98-0.99), P = 0.040]; and off-pump surgery [HR 2.06 (1.02-4.18), P = 0.045]. CONCLUSIONS: Only every second patient receives optimal secondary prevention after CABG. Guideline adherent secondary prevention therapy is associated with lower mid-term mortality and less adverse cardiovascular events after 12 months.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Pronóstico , Prevención Secundaria , Ticagrelor , Resultado del TratamientoRESUMEN
OBJECTIVE: The use of homografts for aortic valve replacement (AVR) is an alternative to mechanical or biological valve prostheses, especially in younger patients. This retrospective comparative study evaluated our single-center long-term results, with a focus on the different origins of the homografts. METHODS: Since 1992, 366 adult patients have undergone AVR with homografts at our center. We compared 320 homografts of aortic origin and 46 homografts of pulmonary origin. The grafts were implanted via either a subcoronary technique or the root replacement technique. We performed a multivariate analysis to identify independent factors that influence survival. Freedom from reintervention and survival rates were calculated as cumulative events according to the Kaplan-Meier method, and differences were tested with the log-rank test. RESULTS: Overall mortality within 1 year was 6.5% (21/320) in the aortic graft group and 17.4% (8/46) in the pulmonary graft group. In the pulmonary graft group, 4 patients died from valve-related complications, 1 patient died after additional heterotopic heart transplantation, and 1 patient who entered with a primary higher risk died from a prosthesis infection. Two patients died from non-valve-related causes. During the long-term follow-up, the 15-year survival rate was 79.9% for patients in the aortic graft group and 68.7% for patients in the pulmonary graft group (P = .049). The rate of freedom from reoperation was 77.7% in the aortic graft group and 57.4% in the pulmonary graft group (P < .001). The reasons for homograft explantation were graft infections (aortic graft group, 5.0%; pulmonary graft group, 6.5%) and degeneration (aortic graft group, 7.5%; pulmonary graft group, 32.6%). CONCLUSION: Our study demonstrated superior rates of survival and freedom from reintervention after AVR with aortic homografts. Implantation with a pulmonary graft was associated with a higher risk of redo surgery, owing to earlier degenerative alterations.
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Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/fisiopatología , Niño , Ecocardiografía , Electrocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Estudios Retrospectivos , Volumen Sistólico , Factores de Tiempo , Trasplante Homólogo , Resultado del Tratamiento , Función Ventricular Izquierda , Adulto JovenRESUMEN
BACKGROUND: Remote extracorporeal life support (ECLS) implantation and mobile ECLS are increasingly applied to enable the treatment of patients with refractory heart failure at specialized care centers. Giant left atrium (GLA) is a rare cause but may lead to acute and devastating heart failure. CASE REPORT: Acute heart failure that gave rise to a prolonged period of out-of-hospital cardiopulmonary resuscitation in a patient who underwent remote ECLS implantation was found to have resulted from a GLA of impressive dimensions. There having no reasonable option for immediate surgical therapy, the patient was successfully bridged to recovery with a view to subsequent heart transplantation. CONCLUSIONS: The threshold to rapid institution of ECLS should be low in patients with acute refractory heart failure, including those with uncommon pathologies. Remote ECLS implantation and interhospital transfer on mobile ECLS increase the chances of survival in cases requiring treatment by specialized care centers.
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BACKGROUND: Obtaining hemostasis during cardiovascular procedures can be a challenge, particularly around areas with a complex geometry or that are difficult to access. While several topical hemostats are currently on the market, most have caveats that limit their use in certain clinical scenarios such as pulsatile arterial bleeding. The aim of this study was to assess the effectiveness and safety of Veriset™ hemostatic patch in treating cardiovascular bleeding. METHODS: Patients (N=90) scheduled for cardiac or vascular surgery at 12 European institutions were randomized 1:1 to treatment with either Veriset™ hemostatic patch (investigational device) or TachoSil® (control). After application of the hemostat, according to manufacturer instructions for use, time to hemostasis was monitored. Follow-up occurred up to 90 days post-surgery. RESULTS: Median time to hemostasis was 1.5 min with Veriset™ hemostatic patch, compared to 3.0 min with TachoSil® (p<0.0001). Serious adverse events within 30 days post-surgery were experienced by 12/44 (27.3%) patients treated with Veriset™ hemostatic patch and 10/45 (22.2%) in the TachoSil® group (p=0.6295). None of these adverse events were device-related, and no reoperations for bleeding were required within 5 days post-surgery in either treatment group. CONCLUSION: This study reinforces the difference in minimum recommended application time between Veriset™ hemostatic patch and TachoSil® (30 s versus 3 min respectively). When compared directly at 3 min, Veriset™ displayed no significant difference, showing similar hemostasis and safety profiles on the cardiovascular bleeding sites included in this study.
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BACKGROUND: The study was performed to analyze the results of open-heart surgery and bleeding complications after administration of novel oral anticoagulants (NOAC). METHODS: We investigated 81 consecutive patients (median age 74 years, interquartile range [IQR]: 68 to 78) who underwent open-heart operations at our institution between July 2014 and June 2016. All patients presented for surgery while on NOAC therapy: 37 received rivaroxaban (45.7%), 35 apixaban (43.2%), and 9 dabigatran (11.1%). The calculated risk using the European System for Cardiac Operative Risk Evaluation II was 3.5% (IQR: 2.0% to 8.1%). RESULTS: Surgery was performed at a median 4 days (IQR: 3 to 6) after NOAC withdrawal. Reduced renal function was predictive for length of intensive care unit stay and administration of red blood cells (p < 0.0001 and p = 0.0291, respectively). The NOAC withdrawal interval significantly influenced postoperative drainage volume (p = 0.0056). Five patients needed rethoracotomy because of relevant bleeding (6.2%), 4 after apixaban (11.4%) and 1 after rivaroxaban therapy (2.7%). Apixaban showed a borderline influence on prolonged intensive care unit stay (p = 0.0736). Prolonged cardiopulmonary bypass time was predictive for thrombocyte administration (p = 0.0249). Intensive care unit stay was 2 days after NOAC withdrawal of 10 days, compared with 4.2 days without termination. Thirty-day mortality was 3.7%. CONCLUSIONS: A lengthy NOAC withdrawal period, particularly for patients with reduced renal function, is essential for safe open-heart surgery. We conclude that despite official recommendations, patients should whenever possible not be considered for elective cardiac surgery within 10 days of terminating NOAC treatment.
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Anticoagulantes/uso terapéutico , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Dabigatrán/uso terapéutico , Cardiopatías/cirugía , Hemorragia Posoperatoria/epidemiología , Pirazoles/uso terapéutico , Piridonas/uso terapéutico , Rivaroxabán/uso terapéutico , Anciano , Transfusión Sanguínea , Cuidados Críticos , Femenino , Cardiopatías/complicaciones , Cardiopatías/patología , Humanos , Tiempo de Internación , Masculino , Estudios Retrospectivos , Medición de RiesgoRESUMEN
BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in younger patients is conventionally performed using a mechanical prosthesis (MP), although homograft (HG) implantation is an accepted alternative. This study compares, retrospectively, the follow up of these two dissimilar prostheses. METHODS: Since 1990, a total of 147 Sorin Bicarbon MPs and 285 HGs have been implanted at the authors' institution, and compared statistically for survival, reoperation rate and valve-dependent complications. Only patients aged <70 years were included in the study. RESULTS: The demographic parameters of both patient groups differed with regards to gender, age at the time of implantation, and duration of follow up. Survival was superior in the HG group (log-rank, p = 0.01). Sixteen of 42 late deaths in the MP group were valve-related due to cerebral infarction (n = 7), ventricular arrhythmias (n = 3), or ventricular failure (n = 6). Six of 24 deaths after HG implantation were valve-related (all prosthesis infections). The choice of valve type and patient age were independent risk factors in the multivariate analysis. Freedom from reoperation was superior after MP implantation (log rank, p = 0.007); in six MP patients the indications for redo surgery were prosthesis infection (n = 2) and paravalvular leak (n = 4). In 20 HG patients, redo surgery was required due to prosthesis infection (n = 12), stenotic degeneration (n = 2), regurgitation > grade II (n = 4), or paravalvular leak (n = 2). Age at the time of implantation and valve type were independent risk factors. Thromboembolic complications were mainly seen in MP patients (log rank, p <0.001): there were five ischemic infarctions and 11 transient ischemic attacks (TIAs) compared to three TIAs among HG patients. Cerebral bleeding was found in only 18 cases after MP implantation, and in no cases after HG implantation. In the multivariate analysis, the type of prosthesis was an independent risk factor. CONCLUSION: As expected, these data confirm a longer time period without need for reoperation after MP implantation, but demonstrate a significantly higher survival and fewer complications after AVR with HG.
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Válvula Aórtica/trasplante , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas , Adulto , Anciano , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Tasa de Supervivencia , Trasplante Homólogo , Resultado del TratamientoRESUMEN
Topical hemostatic agents are used in conjunction with conventional procedures to reduce blood loss. They are often used in cardiothoracic surgery, which is particularly prone to bleeding risks. Variation in their use exists because detailed policy and practice guidelines reflecting the current medical evidence have not been developed to promote best surgical practice in this setting. To address this need, the Society for the Advancement of Blood Management convened an International Hemostatic Expert Panel. This article reviews the available literature and sets out evidence-based recommendations for the use of topical hemostatic agents in cardiothoracic surgery.
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Pérdida de Sangre Quirúrgica/prevención & control , Procedimientos Quirúrgicos Cardíacos , Técnicas Hemostáticas , Hemostáticos/administración & dosificación , Administración Tópica , HumanosRESUMEN
BACKGROUND: This study analyzed the results of atrial fibrillation (AF) ablation concomitant to open heart operations using continuous monitoring. METHODS: We investigated 70 consecutive patients (mean age, 72.1 ± 6 years; European System for Cardiac Operative Risk Evaluation II: 9.7% ± 8.2%) who underwent AF ablation concomitant to cardiac operations in our institution between February 2012 and February 2013. For precise rhythm analysis we implanted Reveal XT devices (Medtronic Inc, Minneapolis, MN) in all patients at the end of operations. Twenty-two patients had paroxysmal (31.4%), 20 persistent (28.6%) and 28 longstanding-persistent AF (40%). AF duration time was at a median 18 months. Cardiac rhythm data were obtained by telemonitoring at 1-month intervals, and the AF burden was calculated at 3, 6, and 9 months and at 1 year postoperatively (ablation procedure success was defined as a burden of ≤ 0.5%). Further, a neurologic follow-up was performed at 1 year postoperatively. RESULTS: Overall survival was 95.7% at 30 days and 84.3% at 1 year. At 1 year, 66.7% of patients were in stable sinus rhythm, and AF burden was significantly reduced even in nonresponders: 88.2% of patients were off antiarrhythmic drugs, and oral anticoagulation had been stopped in 92.1%. No late neurologic events had occurred. Sinus rhythm at discharge and paroxysmal type of AF were predictive for later sinus rhythm (p = 0.04 and p = 0.048, respectively). CONCLUSIONS: Considering the long AF duration and the high proportion of longstanding-persistent AF, the overall success of ablation procedures was satisfactory. Even though oral anticoagulation was stopped in most patients, no neurologic events were detected.
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Anticoagulantes/administración & dosificación , Fibrilación Atrial/mortalidad , Fibrilación Atrial/cirugía , Ablación por Catéter/métodos , Electrocardiografía , Administración Oral , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Ablación por Catéter/mortalidad , Estudios de Cohortes , Terapia Combinada , Femenino , Estudios de Seguimiento , Alemania , Mortalidad Hospitalaria/tendencias , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Seguridad del Paciente/estadística & datos numéricos , Cuidados Posoperatorios/métodos , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background Early graft occlusion due to thromboembolic events is a well-known complication after coronary artery bypass grafting (CABG). Fibrinogen, the coagulation factor I, is a glycoprotein that is transformed by thrombin into fibrin. It plays a major role in thrombus formation and is highly elevated after CABG. Our aim was to determine if postoperative lowering of fibrinogen levels by H.E.L.P. (heparin-mediated extracorporeal low-density lipoprotein [LDL] fibrinogen precipitation) aphaeresis could reduce the rate of early graft occlusion in patients with hypercholesterolemia undergoing CABG. Methods Between December 2004 and September 2009, 36 male patients with hypercholesterolemia (mean LDL cholesterol 128 ± 12 mg/dL), mean age 58 ± 9 years, underwent CABG. Mean preoperative fibrinogen level was 387 ± 17 mg/dL. H.E.L.P. aphaeresis was postoperatively performed when fibrinogen levels exceeded 350 mg/dL on day 1 and 250 mg/dL every consecutive day up to day 8. Pre- and postaphaeresis blood samples were obtained and plasma fibrinogen level reduction was calculated. Early graft occlusion was evaluated by means of coronary angiography or multislice computed tomography before discharge. Results A total of 128 distal anastomoses were performed in 36 patients (mean 3.6/patient). Postoperatively, 191 H.E.L.P. aphaeresis sessions were performed (mean 5.3/patient). Fibrinogen levels were lowered from 391 ± 10 mg/dL (preaphaeresis) to 171 ± 5 mg/dL (postaphaeresis; p < 0.001). Coronary angiography (multislice computed tomography in 7 patients) revealed graft patency in 125 of 128 grafts (98% patency) with three occluded venous grafts to target vessels of 1.5 mm. H.E.L.P. aphaeresis-related complications were limited to hypotensive episodes in two patients and bacteremia in one patient. Conclusions H.E.L.P. apheresis offers an easy, save, and efficient method to decrease fibrinogen postoperatively in patients having CABG. Showing excellent graft patency rates in comparison to the literature, this method is a promising tool to reduce early graft occlusion after CABG.
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Intramyocardial dissecting hemorrhage is a very rare and potentially lethal complication of myocardial infarction. The diagnosis is typically made by echocardiography, by cardiac magnetic resonance imaging, at operation, or during postmortem examination. Medical treatment is most often associated with high mortality, and surgical treatment is required. We report a 53-year old man admitted to the urology department with a large left-sided kidney infarction. A subacute myocardial infarction by electrocardiogram, elevated troponin T level, and typical clinical signs of an acute coronary syndrome 5 days and 2 weeks before admission were also evident. Intramyocardial dissecting hemorrhage with an adjacent thrombotic formation was suspected by echocardiography and cardiac computed tomography and confirmed by magnetic resonance imaging. The patient underwent successful surgical correction and was discharged in good clinical condition.
Asunto(s)
Cardiopatías/etiología , Cardiopatías/cirugía , Hemorragia/etiología , Hemorragia/cirugía , Infarto del Miocardio/complicaciones , Procedimientos Quirúrgicos Cardíacos/métodos , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement using homografts is an accepted alternative to the use of other replacement devices, and has been established at the authors' institution for more than 10 years. METHODS: Since 1992, a total of 389 homografts was implanted, and 332 patients (mean age 54 years, 72% males) were followed up. The initial patients (n = 75) had subcoronary implantation, all subsequent patients had root replacement. Both aortic grafts (AG) and pulmonary grafts (PG) were used. Follow up was conducted with regard to the factors 'graft origin', 'implantation technique' and 'gender', and included clinical examination, ECG and transthoracic echocardiography on an annual basis. RESULTS: Overall 30-day mortality was 5.4% (AG patients 3.9%, PG patients 13.5%; p = 0.09). Among late deaths (n = 22), six were valve-related (all prosthetic infection). Four minor thrombembolic events were recorded due to amaurosis fugax and transient ischemic attacks (TIA). Freedom from reoperation was 86.5%. Indication for graft replacement was greater after subcoronary implantation than after root implantation (p = 0.04). Reoperation was necessary in 24 patients due to restenosis (n = 4), regurgitation grade >II (n = 5), paravalvular leak (n = 2) and prosthetic infection (n = 13). At the latest echocardiographic follow up, mean peak pressure gradient was 15.60 +/- 11.76 mmHg, homograft regurgitation grade was 0.82 +/- 0.66, left ventricular end-diastolic diameter (EDD) was 49.1 +/- 7.54 mm, and mean aortic root diameter was 30.54 +/- 5.48 mm. When comparing parameters at a mean of five years postoperatively, the pressure gradient increased from 10.26 to 15.02 mmHg, regurgitation grade increased from 0.53 to 0.81, and EDD decreased from 52.3 to 50.4 mm. Other variables showed no significant differences. CONCLUSION: The present results confirmed good midterm-results for aortic valve replacement with homografts. These prostheses are vulnerable to infection, and root replacement was superior to the subcoronary implantation technique.
Asunto(s)
Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Adolescente , Adulto , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/cirugía , Estudios de Cohortes , Ecocardiografía , Femenino , Estudios de Seguimiento , Alemania/epidemiología , Enfermedades de las Válvulas Cardíacas/mortalidad , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Reoperación , Índice de Severidad de la Enfermedad , Volumen Sistólico/fisiología , Análisis de Supervivencia , Trasplante Homólogo , Resultado del TratamientoRESUMEN
BACKGROUND: Success of surgical therapy for atrial fibrillation (AF) mainly depends on creating a complete set of transmural atrial lesions. The established Cox procedures may be simplified by dropping lesions, but not without the risk of impaired results. We aimed to create a complete set of lesions using bipolar irrigated radiofrequency including ablation of the posterior-inferior left atrium (LA) and coronary sinus. Feasibility and safety were investigated. METHODS: Six patients (mean age 63 +/- 14 years) with continuous AF (duration 15 +/- 8 months) underwent elective heart surgery for isolated mitral valve procedures (n = 4), in combination with myocardial revascularization (n = 1) or isolated bypass surgery (n = 1). Ablation of AF was performed using bipolar irrigated radiofrequency to create a modified Cox minimaze pattern. RESULTS: No major intraoperative or postoperative complication occurred. Two patients left the operating room in sinus rhythm and 4 in junctional rhythm with atrioventricular pacing. AF ablation required 20 +/- 5 minutes. CONCLUSIONS: Bipolar irrigated radiofrequency ablation including ablation of the posterior-inferior LA and coronary sinus is feasible and can be performed safety. Long-term studies in large patient cohorts are necessary to show efficiency of this method.