RESUMO
INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Humanos , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Volume Sistólico , Função Ventricular Esquerda , Resultado do Tratamento , Prognóstico , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Expectativa de Vida , Índice de Gravidade de Doença , Estudos RetrospectivosRESUMO
OBJECTIVES: Long-term real-world outcomes are critical for informing decisions about biological (Bio) or mechanical (Mech) prostheses for aortic valve replacement, particularly in patients aged between 50 and 65 years. The objective was to compare long-term survival and major adverse cardiac and cardiovascular events (ie, stroke, reoperation, and major bleeding) within this population. METHODS: This was a multicenter observational study including all patients aged between 50 and 65 years who underwent an aortic valve replacement because of severe isolated aortic stenosis between the years 2000 and 2018. A total of 5215 patients from 27 Spanish hospitals were registered with a follow-up of 15 years. Multivariable analyses, including a 2:1 propensity score matching (1822 Mech and 911 Bio) and competing risks analyses were applied. RESULTS: Bio prostheses were implanted in 19% of patients (n = 992). No significant differences were observed between matched groups in long-term survival (hazard ratio [HR], 1.14; 95% confidence interval [CI], 0.88-1.47; P = .33). Stroke rates were higher for Mech prostheses, but not significant (HR, 0.72; 95% CI, 0.50-1.03; P = .07). Finally, higher rates of major bleeding were found in the Mech group (HR, 0.65; 95% CI, 0.49-0.87; P = .004), whereas reoperation was more frequent among the Bio group (HR, 3.04; 95% CI, 1.80-5.14; P < .001). Bio prostheses increased from 13% in the period from 2000 to 2008 to 24% in 2009 to 2018. CONCLUSIONS: Long-term survival was comparable among groups in patients between 50 and 65 years of age. Mech prostheses were associated with a higher risk of major bleeding, whereas Bio prostheses entailed higher reoperation rates. Bio prostheses seem a reasonable choice for patients between 50 and 65 years in Spain.
Assuntos
Bioprótese , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Acidente Vascular Cerebral , Humanos , Pessoa de Meia-Idade , Idoso , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Resultado do Tratamento , Bioprótese/efeitos adversos , Próteses Valvulares Cardíacas/efeitos adversos , Acidente Vascular Cerebral/etiologia , Hemorragia/etiologia , Reoperação/efeitos adversos , Estudos RetrospectivosRESUMO
OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.
Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Expectativa de Vida , Masculino , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
Abstract Introduction: Postoperative acute kidney injury contributes to longer hospital stays and increased costs related to cardiac surgery in the elderly. We analyse the influence of the patient's age on risk factors for acute kidney injury after cardiac valve surgery. Methods: We evaluated the prevalence and risk factors for acute kidney injury in 939 consecutive patients undergoing valve surgery, between 2013 and 2018. Results: The prevalence of acute kidney injury was 19.5%. Hypertension (P=0.017); RR (95% CI): 1.74 (1.10-3.48), age ≥70 years (P=0.006); RR (95% CI): 1.79 (1.17-2.72), preoperative haematocrit <33% (P=0.009); RR (95% CI): 2.04 (1.19-3.48), glomerular filtration rate <60 ml/min/1.73 m2 (P<0.0001); RR (95%) CI: 2.36 (1.54-3.62) and cardiac catheterization <8 days before surgery (P=0.021); RR (95% CI): 2.15 (1.12-4.11) were identified as independent risk factors. In patients older than 70 years, with no kidney disease diagnosed preoperatively, glomerular filtration rate <70 ml/min/1.73 m2, male gender, cardiopulmonary bypass time, preoperative haematocrit <36% and preoperative therapy with angiotensin-converting enzyme inhibitors were risk factors for acute kidney injury after valve surgery. Conclusions: In elderly patients, postoperative acute kidney injury develops with higher values of preoperative glomerular filtration rate than those observed in a younger population. Preoperative correction of anaemia, discontinuation of angiotensin-converting enzyme inhibitors and surgical techniques reducing cardiopulmonary bypass time would be considered to reduce the prevalence of renal failure.
Assuntos
Humanos , Masculino , Feminino , Idoso , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Filtração Glomerular , Valvas CardíacasRESUMO
INTRODUCTION: Postoperative acute kidney injury contributes to longer hospital stays and increased costs related to cardiac surgery in the elderly. We analyse the influence of the patient's age on risk factors for acute kidney injury after cardiac valve surgery. METHODS: We evaluated the prevalence and risk factors for acute kidney injury in 939 consecutive patients undergoing valve surgery, between 2013 and 2018. RESULTS: The prevalence of acute kidney injury was 19.5%. Hypertension (P=0.017); RR (95% CI): 1.74 (1.10-3.48), age ≥70 years (P=0.006); RR (95% CI): 1.79 (1.17-2.72), preoperative haematocrit <33% (P=0.009); RR (95% CI): 2.04 (1.19-3.48), glomerular filtration rate <60 ml/min/1.73 m2 (P<0.0001); RR (95%) CI: 2.36 (1.54-3.62) and cardiac catheterization <8 days before surgery (P=0.021); RR (95% CI): 2.15 (1.12-4.11) were identified as independent risk factors. In patients older than 70 years, with no kidney disease diagnosed preoperatively, glomerular filtration rate <70 ml/min/1.73 m2, male gender, cardiopulmonary bypass time, preoperative haematocrit <36% and preoperative therapy with angiotensin-converting enzyme inhibitors were risk factors for acute kidney injury after valve surgery. CONCLUSION: In elderly patients, postoperative acute kidney injury develops with higher values of preoperative glomerular filtration rate than those observed in a younger population. Preoperative correction of anaemia, discontinuation of angiotensin-converting enzyme inhibitors and surgical techniques reducing cardiopulmonary bypass time would be considered to reduce the prevalence of renal failure.
Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Taxa de Filtração Glomerular , Valvas Cardíacas , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Gray platelet syndrome (GPS) is a rare (<1/1 000 000) and inherited platelet function disorder characterized by macrothrombocytopenia, α-granule deficiency, and hemorrhages. Bleeding intensity does not correlate with platelet count nor with functional test results. We hereby describe the perioperative bleeding prevention and management of a patient with GPS requiring multiple redo cardiac surgeries.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Transfusão de Eritrócitos/métodos , Síndrome da Plaqueta Cinza/cirurgia , Hemorragia/prevenção & controle , Assistência Perioperatória , Transfusão de Plaquetas/métodos , Adulto , Humanos , Masculino , Plasma , Doenças Raras , Reoperação , Resultado do TratamentoRESUMO
In non-rheumatic atrial fibrillation (AF), left atrial appendage (LAA) is thought to be the source of embolism in 90% of the strokes. Thus, as recent clinical trials have shown the non-inferiority of percutaneous LAA closure (LAAc) in comparison to medical treatment, and despite a IIb recommendation in the latest guidelines for concomitant surgical LAAc, we sought to investigate the beneficial effect of LAAc in the surgical population. A meta-analysis model was performed comparing studies including any cardiac surgery with or without concomitant surgical LAAc reporting stoke/embolic events and/or mortality, from inception to January 2019. Twenty-two studies (280 585 patients) were included in the model. Stroke/embolic events both in the perioperative period [relative risk (RR) 0.66, 95% confidence interval (CI) 0.53-0.82; P = 0.0001] and during follow-up of >2 years (RR 0.67, 95% CI 0.51-0.89; P < 0.005) were significantly reduced in patients who underwent surgical LAAc (RR 0.71, 95% CI 0.58-0.87; P = 0.001). Regarding the rate of preoperative AF, LAAc showed protective effect against stroke/embolic events in studies with >70% preoperative AF (RR 0.64, 95% CI 0.53-0.77; P < 0.00001) but no benefit in the studies with <30% of preoperative AF (RR 0.77, 95% CI 0.46-1.28; P = 0.31). Postoperative mortality was also significantly lower in surgical patients with LAAc at the mid- and long-term follow-up. (RR 0.72, 95% CI 0.67-0.78; P < 0.00001; I2 = 0%). Based on these findings, concomitant surgical LAAc is associated with lower rates of embolic events and stroke in the postoperative period in patients with preoperative AF and also improves postoperative mortality in the mid- and long-term follow-up.
Assuntos
Apêndice Atrial , Fibrilação Atrial , Procedimentos Cirúrgicos Cardíacos , Embolia , Acidente Vascular Cerebral , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Humanos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do TratamentoAssuntos
Aneurisma Aórtico/complicações , Implante de Prótese de Valva Cardíaca/efeitos adversos , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Pericárdio/transplante , Falha de Prótese , Seio Aórtico , Adulto , Animais , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/fisiopatologia , Aneurisma Aórtico/cirurgia , Bovinos , Síndrome da Plaqueta Cinza/complicações , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Xenoenxertos , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/fisiopatologia , Anuloplastia da Valva Mitral/instrumentação , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , Reoperação , Seio Aórtico/diagnóstico por imagem , Seio Aórtico/fisiopatologia , Seio Aórtico/cirurgia , Resultado do TratamentoAssuntos
Neoplasias Cardíacas/complicações , Insuficiência da Valva Mitral/etiologia , Mixoma/complicações , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Diagnóstico Diferencial , Ecocardiografia Transesofagiana , Feminino , Átrios do Coração , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/cirurgia , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/cirurgia , Mixoma/diagnóstico , Mixoma/cirurgia , Período Pré-Operatório , Índice de Gravidade de Doença , Tomografia Computadorizada por Raios XAssuntos
Humanos , Masculino , Adulto , Ventrículos do Coração/cirurgia , Ventrículos do Coração/lesões , Artéria Torácica Interna/cirurgia , Artéria Torácica Interna/lesões , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ventrículos do Coração/diagnóstico por imagem , Artéria Torácica Interna/diagnóstico por imagemAssuntos
Aneurisma Coronário/complicações , Ponte de Artéria Coronária/métodos , Trombose Coronária/etiologia , Vasos Coronários/diagnóstico por imagem , Tomografia Computadorizada Multidetectores/métodos , Aneurisma Coronário/diagnóstico , Aneurisma Coronário/cirurgia , Trombose Coronária/diagnóstico , Trombose Coronária/cirurgia , Vasos Coronários/cirurgia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: To assess the efficacy and safety of intramyocardial autologous bone marrow mononuclear stem cells (BMMNC) grafting combined with coronary artery bypass grafting (CABG) on ventricular remodeling and global and regional wall motion after acute transmural myocardial infarction (AMI). METHODS: Randomized controlled trial including 20 patients with non-revascularized transmural AMI, left ventricular ejection fraction (LVEF) lower than 50% and surgical indication for CABG. The stem cell group was treated with BMMNC grafting by direct intramyocardial injection between the 10th and 15th days after AMI (subacute phase) combined with CABG under cardiopulmonary bypass; the control group was only treated with CABG. Magnetic resonance imaging with gadolinium and stress echocardiography were performed presurgery and 9 months postsurgery. RESULTS: Seventeen patients completed the follow-up. The baseline characteristics of both groups were homogeneous. No significant differences were found in the increase in LVEF (control: 6.99±4.60, cells: 7.47±6.61, P=0.876) or in the decrease in global (control: 0.28±0.39, cells: 0.22±0.28, P=0.759) or regional (control: 0.52±0.38, cells: 0.74±0.60, P=0.415) wall motion indices between the control and stem cell groups of AMI patients. No differences were found in the recovered non-viable segments (control: 1.29±1.11, cells: 2.50±1.41, P=0.091) or in the decrease in end-diastolic (control: 14.05±19.72, cells: 18.40±29.89, P=0.725) or end-systolic (control: 15.42±13.93, cells: 23.06±25.03, P=0.442) volumes. No complications from stem cell grafting were observed. CONCLUSIONS: The results from our study reported herein suggest that intramyocardial BMMNC administration during CABG in patients with AMI causes no medium- to long-term improvement in ventricular remodeling.
Assuntos
Transplante de Medula Óssea , Infarto do Miocárdio/cirurgia , Miocárdio/patologia , Regeneração , Transplante de Células-Tronco , Função Ventricular Esquerda , Remodelação Ventricular , Idoso , Transplante de Medula Óssea/efeitos adversos , Ponte de Artéria Coronária , Método Duplo-Cego , Ecocardiografia sob Estresse , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Contração Miocárdica , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/patologia , Infarto do Miocárdio/fisiopatologia , Estudos Prospectivos , Recuperação de Função Fisiológica , Espanha , Transplante de Células-Tronco/efeitos adversos , Fatores de Tempo , Transplante Autólogo , Resultado do TratamentoAssuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Embolia/cirurgia , Endocardite Bacteriana/diagnóstico por imagem , Staphylococcus aureus/isolamento & purificação , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/cirurgia , Bacteriemia/complicações , Bacteriemia/diagnóstico , Ecocardiografia/métodos , Embolia/diagnóstico por imagem , Embolia/etiologia , Endocardite Bacteriana/complicações , Endocardite Bacteriana/cirurgia , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Músculos Papilares/microbiologia , Músculos Papilares/patologia , Doenças Raras , Medição de Risco , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/etiologiaAssuntos
Dissecação/métodos , Átrios do Coração , Neoplasias Cardíacas , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral , Mixoma , Adulto , Progressão da Doença , Ecocardiografia/métodos , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/patologia , Átrios do Coração/fisiopatologia , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/patologia , Neoplasias Cardíacas/cirurgia , Humanos , Achados Incidentais , Masculino , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/fisiopatologia , Insuficiência da Valva Mitral/cirurgia , Mixoma/complicações , Mixoma/patologia , Mixoma/cirurgia , Resultado do TratamentoAssuntos
Equinococose/complicações , Insuficiência Cardíaca/etiologia , Cisto Mediastínico/complicações , Pericárdio/parasitologia , Idoso , Procedimentos Cirúrgicos Cardíacos/métodos , Equinococose/diagnóstico , Equinococose/cirurgia , Ecocardiografia , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/cirurgia , Humanos , Cisto Mediastínico/parasitologia , Cisto Mediastínico/cirurgia , Pericárdio/diagnóstico por imagem , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: To evaluate the efficacy of perioperative atorvastatin administration for prophylaxis of postoperative atrial fibrillation (POAF) after heart valve surgery. METHODS: Our study included 90 patients with heart valve disease who were scheduled to undergo elective cardiac surgery. Cases with previous AF or preoperative beta-blocker therapy were excluded. Patients were randomized into the atorvastatin group, which included 47 patients who received 40 mg/day of atorvastatin 7 days before and after the surgery and the control group, which included 43 patients. Primary endpoint was the occurrence of POAF. Secondary endpoints included modifications in the preoperative and postoperative levels of the markers of inflammation (C-reactive protein [CRP]), myocardial injury (ultrasensitive troponin T and creatinine phosphokinase MB [CPK-MB]), and cardiac dysfunction (pro-brain natriuretic peptide [proBNP]) related to POAF and changes in the echocardiographic parameters, such as atrial electromechanical interval, A wave, E/A ratio, and Doppler imaging systolic velocity wave amplitude, related to POAF. RESULTS: No relationship between atorvastatin administration and reduction in the incidence of POAF was observed (42.6% in the atorvastatin vs. 30.2% in the control group) (p=0.226). No difference in the levels of CPK-MB, ultrasensitive troponin T, CRP, or proBNP and in the analyzed echocardiographic parameter was detected between both groups. CONCLUSIONS: Atorvastatin in the described dose, was not adequate for the prophylaxis of POAF after heart valve surgery. It was ineffective in controlling the inflammatory phenomena, myocardial injury, and echocardiographic predictors of POAF.