RESUMO
The German Registry for Acute Aortic Dissection Type A (GERAADA) as an international registry for acute aortic dissection type A (AADA) offers a unique opportunity to answer questions regarding acute dissections that cannot be answered by single institution's database alone. GERAADA was started in 2006 by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) and has collected more than 3,300 AADA patients' data from 56 centers in Germany, Austria, and Switzerland up to now. In the second generated validated dataset comprising the years from 2006 to 2010, 2,137 patients were surgically treated for AADA with an overall 30-day mortality of 16.9%, and a new postoperative neurologic dysfunction of 9.5%. Risk factors for neurologic dysfunction were malperfusion syndromes, dissections of the supra-aortic vessels, and longer operating time. Neuroprotective drugs had no influence on stroke rates. Hypothermic circulatory arrest and antegrade selective cerebral perfusion (ACP) led to similar results if arrest times were less than 30 minutes while ACP for longer arrest periods is advisable. Septuagenarians had an early mortality rate (15.8%) similar to the whole cohort's, but the mortality rate in octogenarians (34.9%) was much higher. GERAADA with its validated 2,137 patient files (2006-2010) is the largest database on AADA worldwide and continues to collect data. Structured follow-up of more than 5 years will be available in the future.
Assuntos
Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular , Procedimentos Endovasculares , Doença Aguda , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/mortalidade , Áustria , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Fatores de Risco , Suíça , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The working group "Aortic Surgery and Interventional Vascular Surgery" of the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) set up the German registry for acute aortic dissection type A (GERAADA) in July 2006. This web-based database was developed to record data of patients who had undergone surgery for aortic dissection type A (AADA). The aim of GERAADA is to learn from analyzing the data of AADA patients how to improve the perioperative management and surgical treatment of patients with AADA and to identify possible parameters affecting patient risk and outcome. PATIENTS AND METHODS: Between July 2006 and June 2009 (2010), 1558 (2137) patients with AADA were enrolled in the multi-center, prospective GERAADA database by 50 cardiac surgery centers in German-speaking countries in Europe. Data on patients' preoperative and intraoperative status, postoperative complications, midterm results and circumstances of death were recorded. Data were analyzed to identify risk factors influencing the outcome of these patients. The Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI) in Mainz performed the statistical analyses. RESULTS: Analyses from GERAADA reveal a thirty-day mortality of 17% in 2137 AADA patients. Only short interventions in aortic arch surgery are safe during hypothermic circulatory arrest even without selective cerebral perfusion. If circulatory arrest times of over 30 min. are anticipated, antegrade cerebral perfusion is strongly recommended during the entire arch intervention using cardiopulmonary bypass. Surgical strategy in terms of isolated ascending aortic replacement versus ascending aortic replacement combined with aortic arch repair had no statistical relevant influence on 30-day mortality. AADA surgical results in elderly patients are more encouraging than those treated without surgery. Surgery is even feasible in octogenarians with a 35% mortality rate. CONCLUSION: The aim of this registry is to optimize AADA patients' medical care, thereby reducing their morbidity and mortality. AADA treatment should always involve open surgery. Initial analyses from GERAADA provide clinically relevant insights concerning patients with AADA, and may enable therapeutic recommendations for improving perioperative and surgical management. Our latest study detected significant influencing risk factors for the outcome of AADA patients and may contribute to a consensus in setting guidelines for standard medical treatment. PERSPECTIVE: A European Registry of Aortic Diseases ("EuRADa") is being established this year under the leadership of the "Vascular Domain" of the European Association for Cardio-Thoracic Surgery (EACTS). This database will collect parameters on all aortic diseases, dissection types A and B, aneurysms, perforating ulcer (PAU), intramural wall hematoma (IMH), traumatic aortic ruptures, and all potential treatment strategies (medical treatment, open surgical and endovascular).
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Sistema de Registros , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico , Dissecção Aórtica/mortalidade , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/mortalidade , Valva Aórtica/cirurgia , Implante de Prótese Vascular , Causas de Morte , Feminino , Alemanha , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Reoperação , Stents , Síndrome , Tomografia Computadorizada por Raios XRESUMO
Patients suffering from end-stage renal disease are an inhomogeneous high-risk group with a substantial perioperative mortality and morbidity when undergoing cardiac surgical procedures[1-3]. Myocardial ischemia, reperfusion injury and myocardial edema are a few of the deleterious consequences of the traditional use of cardioplegic arrest when performing valve surgery,irrespective of the type of cardioplegia used [4-7]. Novel operative techniques are required to reduce these induced perioperative risks. Clinical studies in the past have demonstrated the efficacy of beating heart valve surgery in the high-risk patient using retrograde, antegrade or combined coronary perfusion with warm oxygenated blood [8, 9]. We chose to combine the superior hemodynamic profile of stentless xenografts with the concept of performing valve replacement on the empty beating heart with continuous antegrade application of oxygenated blood in 2 chronic hemodialysis patients.
Assuntos
Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Falência Renal Crônica/complicações , Idoso , Feminino , Doenças das Valvas Cardíacas/complicações , Máquina Coração-Pulmão , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Diálise Renal , Transplante Heterólogo , Resultado do TratamentoRESUMO
OBJECTIVE: Surface-modifying additives (SMA) have been suggested for improving cardiopulmonary bypass (CPB) circuit biocompatibility, potentially minimizing inflammatory complications and bleeding associated with CPB. The purpose of this prospective, randomized clinical study was to compare a novel copolymer surface-modified CPB circuit (SMARXT; COBE Cardiovascular) against the unmodified circuit. METHODS: We randomized 122 patients with isolated coronary artery disease subjected to first-time surgery on CPB into either the SMA (n = 62) or the control group (n = 60). Exclusion criteria included renal insufficiency, liver disease, coagulopathy, anticoagulation therapy < 6 days preop, carotid artery stenosis > 70 %, and a history of stroke. We collected perioperative clinical data including drainage blood loss, transfusion requirements, duration of mechanical ventilation, and ICU stay. Platelet function was determined pre- and post-CPB. RESULTS: SMA patients received 3.2 +/- 0.9 (SD) grafts during 48 +/- 16 min of aortic cross clamp and 91 +/- 30 min CPB (Control: 3.0 +/- 0.9 grafts; p = 0.33, 46 +/- 14 min AXC; p = 0.36, and 84 +/- 23 min CPB; p = 0.14). In the SMA group, 23 patients (37 %) received red blood-cell transfusions, 9 patients (15 %) fresh frozen plasma, and 3 patients (5 %) received platelets (control: n = 27 [46 %], p = 0.44; n = 10 [17 %], p = 0.91; and n=4 [7 %], p = 0.71, respectively). Platelet count on CPB fell to the same level in both groups. In SMA patients, platelet function decreased from 94.2 +/- 24.9 % pre-CPB to 79.5 +/- 32.8 % post-CPB (p = 0.043) (control: from 87.7 +/- 25.6 % to 69.4 +/- 34.7 %; p = 0.001). Postoperative drainage blood loss, mechanical ventilation duration, and ICU stay were similar in both groups (p > 0.3). One patient of the control group was excluded due to surgical bleeding, and one SMA patient died. CONCLUSIONS: Our results show that the surface-modified CPB circuit decreased neither blood loss nor transfusions despite slightly better platelet function preservation compared to the unmodified circuit. This type of CPB circuit surface modification does not appear to improve clinical outcome in low-risk coronary artery surgery patients.