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1.
JACC Adv ; 3(5): 100916, 2024 May.
Artigo em Inglês | MEDLINE | ID: mdl-38939630

RESUMO

Background: Vasoplegia after cardiac surgery is associated with adverse outcomes. However, the clinical effects of vasoplegia and the significance of its duration after continuous-flow left ventricular assist device (CF-LVAD) implantation are less known. Objectives: This study aimed to identify predictors of and outcomes from transient vs prolonged vasoplegia after CF-LVAD implantation. Methods: The study was a retrospective review of consecutive patients who underwent CF-LVAD implantation between January 1, 2005, and December 31, 2017. Vasoplegia was defined as the presence of all of the following: mean arterial pressure ≤65 mm Hg, vasopressor (epinephrine, norepinephrine, vasopressin, or dopamine) use for >6 hours within the first 24 hours postoperatively, cardiac index ≥2.2 L/min/m2 and systemic vascular resistance <800 dyne/s/cm5, and vasodilatory shock not attributable to other causes. Prolonged vasoplegia was defined as that lasting 12 to 24 hours; transient vasoplegia was that lasting 6 to <12 hours. Patient characteristics, outcomes, and risk factors were analyzed. Results: Of the 600 patients who underwent CF-LVAD implantation during the study period, 182 (30.3%) developed vasoplegia. Mean patient age was similar between the vasoplegia and no-vasoplegia groups. Prolonged vasoplegia (n = 78; 13.0%), compared with transient vasoplegia (n = 104; 17.3%), was associated with greater 30-day mortality (16.7% vs 5.8%; P = 0.02). Risk factors for prolonged vasoplegia included preoperative dialysis and elevated body mass index. Conclusions: Compared with vasoplegia overall, prolonged vasoplegia was associated with worse survival after CF-LVAD implantation. Treatment to avoid or minimize progression to prolonged vasoplegia may be warranted.

2.
Curr Cardiol Rep ; 26(3): 83-90, 2024 03.
Artigo em Inglês | MEDLINE | ID: mdl-38294626

RESUMO

PURPOSE OF REVIEW: In this review, we aim to outline the criteria regarding the evaluation of patients with chronic renal disease (CKD) awaiting heart transplantation and discuss the outcomes of combined heart/kidney transplantation. Herein, we also review pathophysiology and risk factors that predispose to chronic kidney disease (CKD) and acute kidney injury (AKI) in patients with HF and after OHT. RECENT FINDINGS: In patients with end-stage systolic heart failure (HF) and an estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2, orthotopic heart transplantation (OHT) alone is a relative contraindication, with a consensus that these patients are better served with heart-kidney transplant (HKT). However, there is significant variation between institutions regarding timing and indication for heart/kidney transplantation, with little data available to predict post-transplant outcomes. A Scientific Statement from American Heart Association was published detailing the indications, evaluation, and outcomes for Heart-Kidney Transplantation, and noted a steady rise in the incidence of heart/kidney dual organ transplants. Recently, the Organ Procurement and Transplantation Network (OPTN) Multi-Organ Transplantation Committee implemented a safety net policy for heart transplant recipients who do need meet criteria for simultaneous heart-kidney transplant in 2023 but with a likely need for sequential kidney transplantation. Optimization of organ distribution and patient outcomes after cardiac transplantation requires appropriate recipient selection. This review also outlines the criteria regarding the evaluation of patients with CKD awaiting heart transplantation and outcomes of combined HKT.


Assuntos
Insuficiência Cardíaca , Transplante de Coração , Transplante de Rim , Insuficiência Renal Crônica , Insuficiência Renal , Humanos , Estudos Retrospectivos , Rim , Insuficiência Renal/complicações , Insuficiência Renal/cirurgia , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/cirurgia
3.
Tex Heart Inst J ; 50(4)2023 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-37624675

RESUMO

BACKGROUND: Postoperative respiratory failure is a major complication that affects up to 10% of patients who undergo cardiac surgery and has a high in-hospital mortality rate. Few studies have investigated whether patients who require tracheostomy for postoperative respiratory failure after continuous-flow left ventricular assist device (CF-LVAD) implantation have worse survival outcomes than patients who do not. OBJECTIVE: To identify risk factors for respiratory failure necessitating tracheostomy in CF-LVAD recipients and to compare survival outcomes between those who did and did not require tracheostomy. METHODS: Consecutive patients who underwent primary CF-LVAD placement at a single institution between August 1, 2002, and December 31, 2019, were retrospectively reviewed. Propensity score matching accounted for baseline differences between the tracheostomy and nontracheostomy groups. Multivariate logistic regression was used to identify tracheostomy risk factors and 90-day survival; Kaplan-Meier analysis was used to assess midterm survival. RESULTS: During the study period, 664 patients received a CF-LVAD; 106 (16.0%) underwent tracheostomy for respiratory failure. Propensity score matching produced 103 matched tracheostomy-nontracheostomy pairs. Patients who underwent tracheostomy were older (mean [SD] age, 57.9 [12.3] vs 54.6 [13.9] years; P = .02) and more likely to need preoperative mechanical circulatory support (61.3% vs 47.8%; P = .01) and preoperative intubation (27.4% vs 8.8%; P < .001); serum creatinine was higher in the tracheostomy group (mean [SD], 1.7 [1.0] vs 1.4 [0.6] mg/dL; P < .001), correlating with tracheostomy need (odds ratio, 1.76; 95% CI, 1.21-2.56; P = .003). Both before and after propensity matching, 30-day, 60-day, 90-day, and 1-year survival were worse in patients who underwent tracheostomy. Median follow-up was 0.8 years (range, 0.0-11.2 years). Three-year Kaplan-Meier survival was significantly worse for the tracheostomy group before (22.0% vs 61.0%; P < .001) and after (22.4% vs 48.3%; P < .001) matching. CONCLUSION: Given the substantially increased probability of death in patients who develop respiratory failure and need tracheostomy, those at high risk for respiratory failure should be carefully considered for CF-LVAD implantation. Comprehensive management to decrease respiratory failure before and after surgery is critical.


Assuntos
Coração Auxiliar , Procedimentos Cirúrgicos Torácicos , Humanos , Pessoa de Meia-Idade , Traqueostomia/efeitos adversos , Estudos Retrospectivos , Mortalidade Hospitalar
4.
Curr Cardiol Rep ; 25(8): 851-861, 2023 08.
Artigo em Inglês | MEDLINE | ID: mdl-37436647

RESUMO

PURPOSE OF REVIEW: Heart failure (HF) is a growing public health concern that impairs the quality of life and is associated with significant mortality. As the prevalence of heart failure increases, multidisciplinary care is essential to provide comprehensive care to individuals. RECENT FINDINGS: The challenges of implementing an effective multidisciplinary care team can be daunting. Effective multidisciplinary care begins at the initial diagnosis of heart failure. The transition of care from the inpatient to the outpatient setting is critically important. The use of home visits, case management, and multidisciplinary clinics has been shown to decrease mortality and heart failure hospitalizations, and major society guidelines endorse multidisciplinary care for heart failure patients. Expanding heart failure care beyond cardiology entails incorporating primary care, advanced practice providers, and other disciplines. Patient education and self-management are fundamental to multidisciplinary care, as is a holistic approach to effectively address comorbid conditions. Ongoing challenges include navigating social disparities within heart failure care and limiting the economic burden of the disease.


Assuntos
Reabilitação Cardíaca , Insuficiência Cardíaca , Equipe de Assistência ao Paciente , Autocuidado , Insuficiência Cardíaca/terapia , Humanos , Cardiologia , Qualidade de Vida , Telemedicina , Cuidados Paliativos
6.
Ann Surg Oncol ; 30(4): 2331-2338, 2023 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-36581726

RESUMO

BACKGROUND: Cancer centers are regionalizing care to expand patient access, but the effects on patient volume are unknown. This study aimed to compare patient volumes before and after the establishment of head and neck regional care centers (HNRCCs). METHODS: This study analyzed 35,394 unique new patient visits at MD Anderson Cancer Center (MDACC) before and after the creation of HNRCCs. Univariate regression estimated the rate of increase in new patient appointments. Geospatial analysis evaluated patient origin and distribution. RESULTS: The mean new patients per year in 2006-2011 versus 2012-2017 was 2735 ± 156 patients versus 3155 ± 207 patients, including 464 ± 78 patients at HNRCCs, reflecting a 38.4 % increase in overall patient volumes. The rate of increase in new patient appointments did not differ significantly before and after HNRCCs (121.9 vs 95.8 patients/year; P = 0.519). The patients from counties near HNRCCs, showed a 210.8 % increase in appointments overall, 33.8 % of which were at an HNRCC. At the main campus exclusively, the shift in regional patients to HNRCCs coincided with a lower rate of increase in patients from the MDACC service area (33.7 vs. 11.0 patients/year; P = 0.035), but the trend was toward a greater increase in out-of-state patients (25.7 vs. 40.3 patients/year; P = 0.299). CONCLUSIONS: The creation of HNRCCs coincided with stable increases in new patient volume, and a sizeable minority of patients sought care at regional centers. Regional patients shifted to the HNRCCs, and out-of-state patient volume increased at the main campus, optimizing access for both local and out-of-state patients.


Assuntos
Institutos de Câncer , Neoplasias de Cabeça e Pescoço , Humanos , Institutos de Câncer/organização & administração , Neoplasias de Cabeça e Pescoço/terapia , Acessibilidade aos Serviços de Saúde
7.
Cureus ; 14(9): e28926, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36225490

RESUMO

Angiokeratomas are benign vascular lesions that can occur anywhere in the body. Fordyce angiokeratomas, also known as genital angiokeratomas, often develop on the vulva in women and the scrotum in males. A subtype of genital angiokeratoma in males is called penile angiokeratoma (PEAKER). In females, clitoral angiokeratoma (CLANKER) is the embryologic equivalent. As a result of the underlying pathophysiology, these lesions are often bilateral. Unilateral Fordyce angiokeratoma instances are infrequent, and unilateral PEAKER cases have never been previously documented. We describe a case of Fordyce's unilateral angiokeratoma with unilateral PEAKER. To the best of our knowledge, such a variation in presentation of this rare disease has not been previously reported.

8.
Artif Organs ; 46(9): 1923-1931, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35524483

RESUMO

BACKGROUND: Hyponatremia is associated with adverse outcomes in heart failure and after cardiac surgery. We hypothesized that hyponatremia is associated with poorer short-term and longer term survival in patients after continuous-flow left ventricular assist device (CF-LVAD) placement. METHODS: We reviewed a single-center database of patients who received a CF-LVAD during 2012-2017. Sodium (Na) values obtained within 14 days before CF-LVAD insertion were averaged; patients (n = 332) were divided into hyponatremia (mean Na <135 mEq/L; n = 160; 48.2%) and normonatremia groups (mean Na 135-145 mEq/L; n = 172; 51.8%). Patients requiring preoperative dialysis or pump exchange were excluded. We compared outcomes between preoperative hyponatremia and normonatremia groups. RESULTS: The two groups' baseline characteristics were similar, although hyponatremia patients more often had preoperative mechanical circulatory support (44.4% vs. 31.4%, p = 0.002). Although hyponatremic and normonatremic patients did not differ in 30-day mortality (7.5% vs. 6.5%, p = 0.7), preoperative hyponatremia was associated with greater 5-year mortality (61% vs. 44%, p = 0.03). On binary logistic regression analysis, the strongest independent predictors of late mortality were hyponatremia (odds ratio [OR] 1.88, 95% CI [1.07-3.31], p = 0.02), older age (OR 1.03, 95% CI [1.01-1.05], p = 0.01), and elevated mean right atrial pressure/pulmonary capillary wedge pressure ratio (OR 4.69, 95% CI [1.76-12.47], p = 0.002). CONCLUSIONS: Hyponatremia was not associated with greater early mortality but was associated with poorer late survival. The optimal timing of LVAD implantation in relation to hyponatremia, and whether correcting hyponatremia perioperatively improves long-term survival, should be investigated.


Assuntos
Insuficiência Cardíaca , Implante de Prótese de Valva Cardíaca , Coração Auxiliar , Hiponatremia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Hiponatremia/epidemiologia , Análise de Sobrevida , Resultado do Tratamento
9.
Interact Cardiovasc Thorac Surg ; 34(3): 470-477, 2022 02 21.
Artigo em Inglês | MEDLINE | ID: mdl-34966937

RESUMO

OBJECTIVES: Dialysis is considered a contraindication to continuous-flow left ventricular assist device (CF-LVAD) implantation. We evaluated clinical outcomes and survival in carefully selected, low-risk patients with renal failure who required dialysis before CF-LVAD implantation. METHODS: We extracted medical record data of patients who underwent CF-LVAD placement at our centre between 1 January 2006 and 31 August 2017, with 2 clinical scenarios: those who required long-term (>14 days) dialysis and those who required short-term (≤14 days) dialysis immediately before implantation. Demographic, clinical and intraoperative characteristics and survival outcomes were assessed. RESULTS: Of 621 patients who underwent CF-LVAD implantation during the study period, 31 underwent dialysis beforehand. Of these, 17 required long-term dialysis (13 haemodialysis, 4 peritoneal dialysis), and 14 underwent short-term haemodialysis. Compared with the long-term dialysis patients, the short-term dialysis patients were more likely to be Interagency Registry for Mechanically Assisted Circulatory Support profile 1-2 (92.9% vs 70.6%; P < 0.001), to have needed preoperative mechanical circulatory support (78.6% vs 70.6%; P < 0.01) and to have higher in-hospital mortality (85.7% vs 29.4%; P = 0.01). Patients stable on long-term dialysis had acceptable overall survival and markedly better 6-month and 1-year survival than those with short-term dialysis before implantation (64.7% vs 14.3% and 58.8% vs 7.1%, respectively; P < 0.001). CONCLUSIONS: Carefully selected patients who are stable on long-term dialysis have acceptable survival rates after CF-LVAD implantation. Patients with acute renal failure had much poorer outcomes than those with chronic end-stage renal disease.


Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Humanos , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
10.
Middle East J Dig Dis ; 13(2): 160-162, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34712455

RESUMO

Hepatic involvement has been reported in 20-30% of patients with systemic sarcoidosis. However, isolated liver involvement is rare. We report a case of cirrhosis with portal hypertension, diagnosed as hepatic sarcoidosis based on high angiotensin-converting enzyme level and presence of multiple non-caseating granulomas in liver histopathology. She improved clinically after treatment with steroid and ursodeoxycholic acid.

11.
World Neurosurg ; 149: e612-e621, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33548528

RESUMO

BACKGROUND: Traditional laminectomy for excision of spinal tumors involves extensive dissection of the midline spinous ligaments, greater blood loss, and risk of delayed segmental instability. The minimally invasive technique of spinal tumor resection using tubular retractors can achieve safe and complete tumor resection while preserving the structural and functional integrity. The authors present their experience of minimally invasive spinal surgery for spinal tumors in this case series. METHODS: The authors retrospectively reviewed 41 consecutive spinal tumor cases operated by the MISS-Key Hole technique using the tubular retractor system at Sree Utharadom Thirunal Hospital, Kerala, India between January 2015 and January 2020. Preoperative clinical findings, surgical technique, operative statistics, complications, and patient outcomes were analyzed in detail. RESULTS: We could successfully achieve gross total resection in 39 cases (95.12%) and subtotal resection in 2 cases. There were 4 cervical, 1 craniovertebral junction, 20 thoracic, 14 lumbar, and 2 sacral lesions, of which 4 were extradural, 1 extradural foraminal, 33 intradural, and 3 dumbbell lesions. The Modified McCormick Scale at 12 weeks had improved by 1-2 scales in all but 2 patients. There was no cerebrospinal fluid leak, pseudomeningocele, or infection in our series. CONCLUSIONS: This series demonstrates the feasibility, safety and effectiveness of the keyhole approach for excision of intradural and extradural spinal tumors extending up to 2 levels. Careful case selection, good preoperative planning, meticulous microsurgical resection, and watertight dural closure are crucial for successful outcome. Early mobilization, less blood loss, and avoidance of delayed instability are the advantages of minimally invasive spinal surgery when compared with open surgery.


Assuntos
Neoplasias Epidurais/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias da Medula Espinal/cirurgia , Neoplasias da Coluna Vertebral/cirurgia , Resultado do Tratamento , Adulto , Neoplasias do Sistema Nervoso Central/cirurgia , Humanos , Região Lombossacral/cirurgia , Masculino , Microcirurgia/métodos , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Neurocirúrgicos/métodos
12.
J Artif Organs ; 24(2): 207-216, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33598826

RESUMO

Renal replacement therapy (RRT) after continuous flow left ventricular assist device (CF-LVAD) implantation significantly affects patients' quality of life and survival. To identify preoperative prognostic markers in patients requiring RRT after CF-LVAD implantation, we retrospectively reviewed data from patients who underwent implantation of a CF-LVAD at our institution during 2012-2017. Patients who required preoperative RRT were excluded. Preoperative and operative characteristics, as well as survival and adverse events, were compared between 74 (22.2%) patients requiring any duration of postoperative RRT and 259 (77.8%) not requiring RRT. Patients requiring RRT experienced more postoperative complications than patients who did not, including respiratory failure necessitating tracheostomy (35.7% vs 2.5%, p < 0.001), reoperation for bleeding (34.3% vs 11.7%, p < 0.001), and right heart failure necessitating perioperative mechanical circulatory support (32.4% vs 6.9%, p < 0.001). Patients requiring postoperative RRT also had poorer survival at 30 days (74.7% vs 98.8%), 6 months (48.2% vs 95.1%), and 12 months (45.3% vs 90.2%) (p < 0.001). Significant predictors of RRT after CF-LVAD implantation included urine proteinuria (odds ratio [OR] 3.6, 95% confidence interval [CI] [1.7-7.6], p = 0.001), estimated glomerular filtration rate < 45 mL/min/1.73 m2 (OR 3.4, 95% CI [1.5-17.8], p = 0.004), and mean right atrial pressure to pulmonary capillary wedge pressure ratio ≥ 0.54 (OR 2.6, 95% CI [1.3-5.], p = 0.01). Of the 74 RRT patients, 11 (14.9%) recovered renal function before discharge, 36 (48.6%) still required RRT after discharge, and 27 (36.5%) died before discharge. We conclude that preoperative renal and right ventricular dysfunction significantly predict postoperative renal failure and mortality after CF-LVAD implantation.


Assuntos
Coração Auxiliar , Insuficiência Renal/diagnóstico , Insuficiência Renal/cirurgia , Terapia de Substituição Renal , Disfunção Ventricular Esquerda/cirurgia , Adulto , Desenho de Equipamento , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/prevenção & controle , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Qualidade de Vida , Insuficiência Renal/complicações , Insuficiência Renal/epidemiologia , Terapia de Substituição Renal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/epidemiologia
13.
Int. j. cardiovasc. sci. (Impr.) ; 34(1): 81-88, Jan.-Feb. 2021. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1154539

RESUMO

Abstract Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome, which accounts for about 50% of patients with heart failure (HF). The morbidity and mortality associated with HFpEF is similar to HFrEF. Clinical trials to date have failed to show a benefit of medical therapy for HFpEF, which may due to lack of uniform phenotypes and heterogeneous population. In addition, medical therapy proven for HFrEF may not address the pathophysiologic basis for HFpEF. Left atrial remodeling and dysfunction is central to HFpEF and accounts for secondary pulmonary hypertension and pulmonary vascular congestion that frequently occurs with exertion. Interatrial shunts represent a novel treatment modality for HFpEF. These shunts allow for left atrial decongestion and a reduction in pulmonary venous hypertension during exercise leading to improvements in hemodynamics, functional status and quality of life. Trials to date have demonstrated safety and short-term efficacy of these devices for HFpEF. The long-term benefits are currently being evaluated in ongoing trials. If effective, the use of interatrial shunts may be a new therapeutic paradigm for the treatment of HFpEF.


Assuntos
Insuficiência Cardíaca Diastólica/cirurgia , Substituição da Valva Aórtica Transcateter , Equipamentos e Provisões , Insuficiência Cardíaca Diastólica/diagnóstico , Insuficiência Cardíaca Diastólica/fisiopatologia , Insuficiência Cardíaca Diastólica/mortalidade , Remodelamento Atrial
14.
bioRxiv ; 2020 Nov 05.
Artigo em Inglês | MEDLINE | ID: mdl-33173875

RESUMO

Epidemiological studies of the COVID-19 pandemic have revealed evidence of cardiac involvement and documented that myocardial injury and myocarditis are predictors of poor outcomes. Nonetheless, little is understood regarding SARS-CoV-2 tropism within the heart and whether cardiac complications result directly from myocardial infection. Here, we develop a human engineered heart tissue model and demonstrate that SARS-CoV-2 selectively infects cardiomyocytes. Viral infection is dependent on expression of angiotensin-I converting enzyme 2 (ACE2) and endosomal cysteine proteases, suggesting an endosomal mechanism of cell entry. After infection with SARS-CoV-2, engineered tissues display typical features of myocarditis, including cardiomyocyte cell death, impaired cardiac contractility, and innate immune cell activation. Consistent with these findings, autopsy tissue obtained from individuals with COVID-19 myocarditis demonstrated cardiomyocyte infection, cell death, and macrophage-predominate immune cell infiltrate. These findings establish human cardiomyocyte tropism for SARS-CoV-2 and provide an experimental platform for interrogating and mitigating cardiac complications of COVID-19.

15.
Circulation ; 142(1): e7-e22, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32476490

RESUMO

Transthyretin amyloid cardiomyopathy (ATTR-CM) results in a restrictive cardiomyopathy caused by extracellular deposition of transthyretin, normally involved in the transportation of the hormone thyroxine and retinol-binding protein, in the myocardium. Enthusiasm about ATTR-CM has grown as a result of 3 simultaneous areas of advancement: Imaging techniques allow accurate noninvasive diagnosis of ATTR-CM without the need for confirmatory endomyocardial biopsies; observational studies indicate that the diagnosis of ATTR-CM may be underrecognized in a significant proportion of patients with heart failure; and on the basis of elucidation of the mechanisms of amyloid formation, therapies are now approved for treatment of ATTR-CM. Because therapy for ATTR-CM may be most effective when administered before significant cardiac dysfunction, early identification of affected individuals with readily available noninvasive tests is essential. This scientific statement is intended to guide clinical practice and to facilitate management conformity by covering current diagnostic and treatment strategies, as well as unmet needs and areas of active investigation in ATTR-CM.


Assuntos
Amiloidose/diagnóstico , Amiloidose/terapia , Cardiomiopatias/diagnóstico , Cardiomiopatias/terapia , Algoritmos , Alelos , Amiloidose/etiologia , Amiloidose/metabolismo , Animais , Biomarcadores , Cardiomiopatias/etiologia , Cardiomiopatias/metabolismo , Tomada de Decisão Clínica , Gerenciamento Clínico , Suscetibilidade a Doenças , Inativação Gênica , Predisposição Genética para Doença , Genótipo , Testes de Função Cardíaca , Humanos , Imageamento por Ressonância Magnética , Técnicas de Diagnóstico Molecular , Pré-Albumina/genética , Pré-Albumina/metabolismo
16.
J Clin Exp Hepatol ; 10(3): 236-244, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32405180

RESUMO

INTRODUCTION: Ischemia reperfusion injury (IRI) is an important complication of liver transplant (LT). The donor risk index, which does not incorporate steatosis, includes several variables known to impact on allograft survival. The purpose of this study was to report on donor liver allograft steatosis and its association with severity of IRI. AIM: The aim of this study was to determine the effect of type and grade of donor liver steatosis on the occurrence and severity of IRI in LT recipients. METHODS: This was an observational study conducted at a single center over a period of 37 months from July 2013 to August 2016. Liver biopsy was performed twice, initially at the time of procurement before graft perfusion for steatosis assessment. Steatosis was classified as microsteatosis (MiS) or macrosteatosis (MaS) with mild, moderate, or severe grade. Second biopsy for IRI assessment was taken before skin closure in death donor LT (DDLT) and at the time of transaminitis in postoperative period (<72 hrs) in living donor LT (LDLT). IRI was graded as per neutrophil infiltrate, apoptosis, and hepatocyte cell dropout. Prevalence of IRI and association steatosis was studied along with other factors. RESULTS: Among 53 subjects, 35 were DDLTs and 18 were LDLTs. All live donor grafts were restricted to <15% MaS and the deceased liver grafts had different type and degree of steatosis. In DDLTs, the association between occurrence of IRI and MaS was not statistically significant (P = 0.201). In DDLTs, the mild steatosis was not significantly associated with IRI. Death donor and ischemic time were significantly associated with IRI. Child's stage and MELD scores, gender, and age were not associated with risk of IRI. Severity of IRI is significantly associated with 3-month mortality (P = 0.001). CONCLUSION: In patients with mild steatosis, IRI does not correlate with steatosis. However, more patients with moderate and severe steatosis are needed to define the relationship of the two in this group of patients.

17.
Gen Thorac Cardiovasc Surg ; 68(11): 1278-1284, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32338333

RESUMO

OBJECTIVE: Warfarin is standard anticoagulation therapy for patients with a continuous-flow left ventricular assist device (CF-LVAD). However, warfarin requires regular monitoring and dosage adjustments and fails for many patients, causing thromboembolic and bleeding events. Factor Xa inhibitors have been shown to be noninferior to warfarin in preventing strokes and are associated with less intracranial hemorrhage in patients with atrial fibrillation. We evaluated treatment safety and effectiveness in CF-LVAD patients who switched from warfarin to a factor Xa inhibitor (apixaban or rivaroxaban) after warfarin failure. METHODS: This was a retrospective, single-center study of patients treated between 2008 and 2018. We assessed the occurrence of stroke, non-central nervous system (CNS) embolism, pump thrombosis, and major gastrointestinal bleeding and intracranial hemorrhage during therapy. RESULTS: We identified seven patients: five were male, the average body mass index was 30 kg/m2, and average age was 56 years. Preimplantation comorbidities included hypertension (all patients) and diabetes mellitus, ischemic cardiomyopathy, atrial fibrillation, and previous myocardial infarction (four patients each). Overall, patients received warfarin for 3968 days and apixaban/rivaroxaban for 1459 days. The warfarin group was within the therapeutic INR range (2.0-3.0) 30% of the time. Complication rates did not differ between warfarin and apixaban/rivaroxaban: strokes, 0.20 vs none, non-CNS embolism, 0.54 vs none; pump thrombosis, 0.27 vs none; major gastrointestinal bleeding, 0.20 vs 0.50; intracranial hemorrhage, 0.13 vs none. CONCLUSIONS: Factor Xa inhibitors may be viable treatment options for CF-LVAD patients for whom warfarin therapy has failed. Large prospective studies are necessary to confirm these results.


Assuntos
Inibidores do Fator Xa/administração & dosagem , Insuficiência Cardíaca/terapia , Coração Auxiliar , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Rivaroxabana/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/prevenção & controle , Resultado do Tratamento , Varfarina/administração & dosagem
18.
Asian J Neurosurg ; 15(1): 132-135, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32181187

RESUMO

Complex Chiari malformation (CCM) is a spectrum of congenital bony and soft tissue abnormalities, which includes Chiari 1.5 malformation, medullary kinking, retroflexed odontoid, abnormal clival-cervical angle (CXA), occipitalization of the atlas, basilar invagination, syringomyelia, and scoliosis. CCM usually manifests in the pediatric age group and is a challenging entity to treat. It requires detailed evaluation of craniometric indices to decide the appropriate surgical management. Patients with maximum perpendicular distance of dens to the line from the basion to the inferoposterior part of the C2 body (pBC2 line) of more than 9 mm and CXA <125° require a posterior fixation and will benefit from a single-stage posterior fusion and foramen magnum decompression (FMD). We report a rare case of CCM manifesting in a 32-year-old male with brainstem compression and bulbar symptoms. We could realign the craniovertebral junction with only a C1-C2 fixation by a modified distraction, compression, extension, and reduction technique and also relieve the neural compression by FMD and tonsillar resection in a single surgery with a good outcome. The authors find it to be an effective alternative to avoid the occipital fixation.

19.
ASAIO J ; 66(5): 539-546, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31335367

RESUMO

In this study, we sought to determine the accuracy of several critical care risk scores for predicting survival of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profile 1 patients after continuous-flow left ventricular assist device (CF-LVAD) placement. We retrospectively analyzed the records of 605 patients who underwent CF-LVAD implantation between 2003 and 2016. We calculated the preoperative HeartMate II Risk Score (HMRS) and preoperative Right Ventricular Failure Risk Score (RVFRS) and the following risk scores for postoperative days 1-5: HMRS, RVFRS, Model for End-stage Liver Disease (MELD), MELD-eXcluding International Normalized Ratio, Post Cardiac Surgery (POCAS) risk score, Sequential Organ Failure Assessment (SOFA) risk score, and Acute Physiology and Chronic Health Evaluation III. The preoperative scores and the postoperative day 1, 5-day mean, and 5-day maximum scores were entered into a receiver operating characteristic curve analysis to examine accuracy for predicting 30-day, 90-day, and 1-year survival. The mean POCAS score was the best predictor of 30-day and 90-day survival (area under the curve [AUC] = 0.869 and 0.816). The postoperative mean RVFRS was the best predictor of 1-year survival (AUC = 0.7908). The postoperative maximum and mean RVFRS and HMRS were more accurate than the preoperative scores. Both of these risk score measurements of acuity in the postoperative intensive care unit setting help predict early mortality after LVAD implantation.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Índice de Gravidade de Doença , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos
20.
ASAIO J ; 66(1): 64-68, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30507849

RESUMO

Implantable continuous-flow left ventricular assist devices (CF-LVADs) are used for long-term LV support in bridging patients to heart transplantation or as destination therapy. With prolonged support times, some patients will have repeat complications necessitating multiple device exchanges. To elucidate the safety and efficacy of repeat device exchange, we retrospectively reviewed data from 25 patients who underwent two or more CF-LVAD implantations between July 2005 and August 2017. Indications for exchange were thrombus/hemolysis (n = 8, 32%), electromechanical device malfunction (n = 14, 56%), and infection (n = 3, 12%). The implanted devices were the HeartMate II (n = 13, 52%), the HeartWare HVAD (n = 11, 44%), and the Jarvik 2000 (n = 1, 4%). Average hospital length of stay was 44 days (range 4-221 days), and 17 patients (68%) survived to discharge. Average duration of support after the most recent LVAD implantation was 802 days (range 1-3,229 days). Overall survival was 72% at 1 year and 60% at 2 years. Postoperative complications included respiratory failure in five patients (20%), device infection in five (20%), bleeding requiring reoperation in four (16%), neurologic dysfunction in four (16%), and acute renal failure in two (8%). Overall, our data suggest that repeat LVAD exchange is a feasible option for patients with recurrent device-related complications.


Assuntos
Coração Auxiliar , Reoperação/mortalidade , Adolescente , Adulto , Idoso , Feminino , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Reoperação/efeitos adversos , Reoperação/métodos , Estudos Retrospectivos , Adulto Jovem
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