Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 6 de 6
Filtrar
1.
J Thorac Cardiovasc Surg ; 122(5): 919-28, 2001 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-11689797

RESUMEN

BACKGROUND: Increased left ventricular mass index has been shown to be associated with higher mortality in epidemiologic studies. However, the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement is unknown. METHODS: We studied 473 consecutive patients undergoing elective aortic valve replacement to assess the influence of left ventricular mass index on outcomes in patients having this procedure. Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index (considered increased if >134 g/m(2) in male patients and >110 g/m(2) in female patients). RESULTS: Left ventricular mass index was increased in 24% of patients undergoing aortic valve replacement. Postprocedural complications (respiratory failure, renal insufficiency, congestive heart failure, and atrial and ventricular arrhythmias), length of stay in the intensive care unit, and in-hospital mortality were increased in patients with increased left ventricular mass index. Multivariable analysis identified prior valve surgery (odds ratio, 4.3; 95% confidence interval, 1.2-15.7; P =.030), left ventricular ejection fraction (odds ratio, 1.07; 95% confidence interval, 1.01-1.14; P =.020), history of hypertension (odds ratio, 8.2; 95% confidence interval, 2.2-30.4; P =.002), history of liver disease (odds ratio, 50.4; 95% confidence interval, 4.2-609.0; P =.002), and increased left ventricular mass index (odds ratio, 38; 95% confidence interval, 9.3-154.1; P <.001) as independent predictors of in-hospital mortality. Furthermore, low output syndrome was identified as the most common mode of death (36%) after aortic valve replacement in patients with increased left ventricular mass index. CONCLUSIONS: Increased left ventricular mass index is associated with increased adverse in-hospital clinical outcomes in patients undergoing aortic valve replacement. Although this finding warrants special modification in perioperative management, further studies are needed to address whether outcomes in asymptomatic patients with aortic valve disease could be improved by earlier aortic valve replacement before a significant increase in left ventricular mass index.


Asunto(s)
Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Hipertrofia Ventricular Izquierda/complicaciones , Complicaciones Posoperatorias/epidemiología , Gasto Cardíaco Bajo/epidemiología , Comorbilidad , Ecocardiografía , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Hipertrofia Ventricular Izquierda/epidemiología , Tiempo de Internación/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Resultado del Tratamiento
2.
Am J Cardiol ; 87(7): 881-5, 2001 Apr 01.
Artículo en Inglés | MEDLINE | ID: mdl-11274944

RESUMEN

Atrial fibrillation (AF) after cardiac surgery is thought to increase length of stay (LOS). A clinical pathway focused on the management of postoperative AF, including prophylaxis with beta blockers, was implemented to assess the effect of AF on LOS after cardiac surgery. Data were obtained on consecutive cardiac surgery patients in preoperative normal sinus rhythm, no prior history of AF, and no chronic antiarrhythmic therapy from January to May 1995 (control) and November 1996 to June 1997 (pathway). Statistical analysis was performed to assess the effect of postoperative AF on the LOS, clinical outcomes, and cost after cardiac surgery. Despite the clinical pathway, the LOS (7 days for both periods; p = 0.12) and incidence of AF (28.9% vs 28.4%; p = 0.92) remained unchanged. Unadjusted direct costs were 15% higher in the pathway period (p <0.001). Increased rates of beta-blocker therapy had a marginal effect on the incidence of postoperative AF, except in the group who only underwent primary coronary artery bypass graft surgery (31.2% vs 25.3%; p = 0.31). Multivariate analysis revealed that AF contributed only 1 to 1.5 days to the LOS. Thus, this investigation represents the most recent analysis of the effects of postoperative AF on LOS, clinical outcomes, and cost after cardiac surgery. Unlike prior studies, the impact of postoperative AF is less prominent in the current era of cardiac surgical care regardless of the presence of a clinical pathway addressing AF.


Asunto(s)
Fibrilación Atrial/prevención & control , Procedimientos Quirúrgicos Cardíacos , Vías Clínicas , Tiempo de Internación , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/prevención & control , Antagonistas Adrenérgicos beta/uso terapéutico , Adulto , Fibrilación Atrial/economía , Fibrilación Atrial/epidemiología , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Missouri , Complicaciones Posoperatorias/economía , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos
3.
Am J Cardiol ; 85(4): 478-83, 2000 Feb 15.
Artículo en Inglés | MEDLINE | ID: mdl-10728954

RESUMEN

This study was undertaken to determine the prognostic significance of hypotension induced during preoperative dobutamine stress echocardiography (DSE) before vascular and noncardiac thoracic surgery. Wall motion abnormality during DSE predicts perioperative risk. Although hypotension during DSE has not been shown to correlate with the presence or severity of coronary artery disease, its significance in perioperative risk assessment is unknown. We retrospectively studied 300 patients who had DSE within 6 months of noncardiac surgery. Perioperative events including death, myocardial infarction, ischemia, and arrhythmias were recorded. Odds ratios with 95% confidence intervals were used to examine the association between clinical and echocardiographic variables and perioperative events. A hypotensive response during DSE was seen in 85 patients (28%). Forty-eight patients (16%) had 54 perioperative complications including 4 cardiac-related deaths, 10 myocardial infarctions, 12 myocardial ischemic events, and 28 arrhythmias. Hypotension during DSE was predictive of the combined end point of perioperative cardiac mortality, myocardial infarction, and ischemia (odds ratio 4.04, 95% confidence interval 1.72 to 9.51). In a multivariate logistic regression model, hypotension during DSE remained a significant predictor (odds ratio 4.10, p<0.01). DSE-related hypotension was predictive of perioperative cardiac events and therefore may have a role in risk stratification before vascular or noncardiac thoracic surgery.


Asunto(s)
Cardiotónicos , Enfermedad Coronaria/diagnóstico , Dobutamina , Ecocardiografía , Hipotensión/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea , Cardiotónicos/administración & dosificación , Enfermedad Coronaria/fisiopatología , Dobutamina/administración & dosificación , Prueba de Esfuerzo , Femenino , Humanos , Hipotensión/etiología , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Pronóstico , Estudios Retrospectivos , Disfunción Ventricular Izquierda/fisiopatología
4.
JAMA ; 283(7): 897-903, 2000 Feb 16.
Artículo en Inglés | MEDLINE | ID: mdl-10685714

RESUMEN

CONTEXT: Acute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting. OBJECTIVE: To assess the presentation, management, and outcomes of acute aortic dissection. DESIGN: Case series with patients enrolled between January 1996 and December 1998. Data were collected at presentation and by physician review of hospital records. SETTING: The International Registry of Acute Aortic Dissection, consisting of 12 international referral centers. PARTICIPANTS: A total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom had type A dissection. MAIN OUTCOME MEASURES: Presenting history, physical findings, management, and mortality, as assessed by history and physician review of hospital records. RESULTS: While sudden onset of severe sharp pain was the single most common presenting complaint, the clinical presentation was diverse. Classic physical findings such as aortic regurgitation and pulse deficit were noted in only 31.6% and 15.1% of patients, respectively, and initial chest radiograph and electrocardiogram were frequently not helpful (no abnormalities were noted in 12.4% and 31.3% of patients, respectively). Computed tomography was the initial imaging modality used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients with type A dissection managed surgically was 26%; among those not receiving surgery (typically because of advanced age and comorbidity), mortality was 58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in 20% of patients with type B dissection; mortality in this group was 31.4%. CONCLUSIONS: Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection.


Asunto(s)
Aneurisma de la Aorta , Disección Aórtica , Sistema de Registros , Adulto , Anciano , Disección Aórtica/diagnóstico , Disección Aórtica/epidemiología , Disección Aórtica/terapia , Aneurisma de la Aorta/diagnóstico , Aneurisma de la Aorta/epidemiología , Aneurisma de la Aorta/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Modelos Estadísticos
5.
Am J Cardiol ; 81(6): 702-7, 1998 Mar 15.
Artículo en Inglés | MEDLINE | ID: mdl-9527078

RESUMEN

Increased awareness of the risks of blood-borne infections has recently led to profound changes in the practice of transfusion medicine. These changes include, among others, the development of guidelines by the American College of Physicians (ACP) for transfusion. Although the incidence and predictors of vascular complications of percutaneous interventions have been well defined, there are currently no data on frequency, risk factors, and appropriateness of blood transfusions. We performed a retrospective analysis of 628 consecutive percutaneous coronary revascularization procedures. Predictors of blood transfusion were identified using multivariate logistic regression analysis. Appropriateness of transfusions was determined using modified ACP guidelines. Transfusions were administered after 8.9% of interventions (56 of 628). Multivariate analysis identified age >70 years, female gender, procedure duration, coronary stenting, acute myocardial infarction, postprocedural use of heparin and intra-aortic balloon pump placement as independent predictors of blood transfusions (all p <0.05). According to the ACP guidelines, 36 of 56 patients (64%) received transfusions inappropriately. Transfusion reactions (fever) occurred in 10% of patients who received tranfusions appropriately and in 5% of patients who received tranfusions inappropriately. The estimated additional costs per procedure related to transfusions were $551 and $419, respectively. In conclusion, unnecessary transfusions were performed frequently after percutaneous coronary interventions. Application of available guidelines could reduce the number of unnecessary transfusions, thus avoiding exposure of patients to additional risks and reducing procedural costs.


Asunto(s)
Transfusión Sanguínea/normas , Revascularización Miocárdica , Anciano , Algoritmos , Angioplastia Coronaria con Balón , Aterectomía Coronaria , Pérdida de Sangre Quirúrgica , Factores de Confusión Epidemiológicos , Femenino , Humanos , Contrapulsador Intraaórtico , Modelos Logísticos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/efectos adversos , Revascularización Miocárdica/métodos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Stents , Ultrasonografía Intervencional
6.
Ann Thorac Surg ; 64(6): 1669-75; discussion 1675-7, 1997 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-9436553

RESUMEN

BACKGROUND: An acute type A aortic dissection is considered a surgical emergency. Review of the risk factors for a type A dissection showed that preoperative malperfusion was associated with a 22% (2/9) intraoperative mortality and an 89% (8/9) hospital mortality. Intraoperative deaths were secondary to pulmonary failure resulting from capillary leak; the remaining patients died of multiorgan failure resulting from reperfusion injury. METHODS: The surgical delay approach was adopted for malperfused patients, and treatment in these patients included percutaneous reperfusion, with aortic fenestration and branch stenting where appropriate. Twenty patients had a type A dissection and malperfusion shown by pulsed-wave Doppler echocardiography, transesophageal echocardiography, or spiral computed tomographic scanning. Malperfusion was documented by angiography. After reperfusion, all patients' conditions were stabilized in the intensive care unit; intravenous beta-blockers were administered to decrease the maximum rate of increase of left ventricular pressure. Once patients completely recovered from the consequences of malperfusion, surgical repair was performed. Statistical comparison of the non-delay and delay groups was performed using Fisher's exact test and Student's t test. Multiple logistic regression analysis was used to establish independent predictors for mortality. RESULTS: The mean delay to repair was 20 days (2 to 67 days). Four (31%) patients were discharged home and readmitted for operation. Three patients (15%) died preoperatively, 1 of retrograde dissection and rupture and 2 of reperfusion injury. Seventeen underwent surgical repair, with two deaths (12%); 15 (75%) were discharged, with an average follow-up of 16.8 months (p < 0.003). Delay was the only independent predictor of outcome. CONCLUSIONS: Patients with an acute type A dissection and malperfusion should undergo percutaneous reperfusion, and surgical repair should be delayed until the reperfusion injury resolves.


Asunto(s)
Aneurisma de la Aorta/complicaciones , Aneurisma de la Aorta/cirugía , Disección Aórtica/complicaciones , Disección Aórtica/cirugía , Isquemia/etiología , Adulto , Anciano , Ecocardiografía Transesofágica , Urgencias Médicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo
SELECCIÓN DE REFERENCIAS
DETALLE DE LA BÚSQUEDA