RESUMO
Secondary aortoesophageal fistula (AEF) is defined as a communication between the aorta and the esophagus, occurring after aortic disease treatment or esophageal procedures, associating very high mortality rates with treatment and being fatal without it. Several treatment strategies have been described in the literature, combining open surgery or endovascular aortic repair with surgical or endoscopic management of the esophageal lesion. We present the case of a 53-year-old patient with a history of open aortic surgery for a giant descending thoracic aortic pseudoaneurysm complicated with secondary AEF, successfully managed using emergency transiliac TEVAR (thoracic endovascular aortic repair), extensive antibiotic therapy associated with nutritional replenishment, and rehabilitation therapy. Novel endovascular and endoscopic devices have been developed, offering less invasive treatment strategies with improved outcomes, especially for high risk surgical patients. This case highlights the importance of a multidisciplinary approach to personalized medicine to manage such complex situations.
RESUMO
Pre-procedure mitral regurgitation (MR) is a frequent coexistent finding in patients undergoing transcatheter aortic valve replacement (TAVR), and most of them (up to 55%) experience a significant improvement in MR after the procedure. Although seldom described, mitral valve perforation after TAVR is a potentially serious complication that physicians should be aware of, as moderate or severe MR in TAVR recipients is associated with a high early mortality rate. We herein describe the case of a 65-year-old man presenting with worsening heart failure symptoms 5 months after TAVR due to an intraprocedural anterior mitral leaflet perforation and discuss the diagnostic process and therapeutic course of the case. Furthermore, we draw attention to the essential role of echocardiography in the management of TAVR procedures, taking into account its ability in detecting early complications, and emphasize the value of CT as a main determinant to predict long-term MR improvement after TAVR and to assess the potential candidates for double valve repair with percutaneous techniques.
Assuntos
Estenose da Valva Aórtica , Insuficiência da Valva Mitral , Idoso , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Humanos , Masculino , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/cirurgia , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
INTRODUCTION: We present a case of open surgical repair of an aortic arch pseudoaneurysm (AAP) without the use of hypothermic circulatory arrest in a patient with low ejection fraction and associated coronary artery disease (CAD) and discuss some issues regarding the management of this case. PRESENTATION OF THE CASE: A 69-year-old male with multiple pathologies and history of angina pectoris was transferred to our center from a local hospital with an initial diagnosis of non-ST-segment elevation myocardial infarction. Coronary angiography revealed stenotic lesions affecting all three coronary arteries. Multislice 3D contrast-enhanced computed tomography (CT-scan) revealed a 36 × 27 mm AAP. Endovascular stent-grafting was deemed to be unsuitable due to hostile landing zone. Therefore, the heart team decided for simultaneou treatment of the AAP and percutaneous therapy of CAD. The AAP was excised, and repair was performed with a Dacron patch on beating heart. After the surgical procedure, PCI with drug-eluting stents (DES) was performed on the right coronary artery (RCA) and the left circumflex artery (LCx) in the operating room. The patient's postprocedural course was uneventful and after thirteen days, he was discharged in good shape. 3D CT-scan performed after three month showed no residual AAP. DISCUSSION: We established this approach as being the most suitable for our case based on favorable circumstances such as: stable CAD, beating heart procedure with low impact on myocardial ischemia, the impossibility of successful placement of an endovascular stent-graft, the presence of a pseudoaneurysm neck with minimum calcification. CONCLUSION: We consider the best approach for individual cases is tailoring the treatment plan and the procedure to the patient's specific anatomy and pathology.
RESUMO
Association of elective debranching and endovascular thoracic aortic repair (TEVAR) with aberrant left vertebral artery (AVA) revascularization and supra-aortic left carotid-subclavian bypass in post-traumatic pseudoaneurysm of the distal aortic arch are extremely rare procedures that can minimize unnecessary neurologic complications. The patient was a 42-year-old man, stable, with a post-traumatic transection of the aortic isthmus, with origin of the AVA between the left common carotid artery (LCCA) and left subclavian artery (LSA). Preoperative planning and proper sizing of the stent-grafts were evaluated by means of computed tomography angiography (CT scan) images. The patient underwent a hybrid procedure that included TEVAR with landing zone 2, covering the origin of both the AVA and LSA and concomitant supra-aortic reimplantation of the AVA in the LCCA and left carotid-subclavian bypass combined with both ligation of the AVA and LSA proximally. Postoperative arteriography images confirmed the exclusion of the aneurysm and the patency of all arch vessels, including the AVA. No endoleak was reported.
Assuntos
Aorta/lesões , Aorta/cirurgia , Procedimentos Endovasculares/métodos , Artéria Vertebral/anormalidades , Acidentes de Trânsito , Adulto , Aorta/diagnóstico por imagem , Artérias Carótidas/cirurgia , Angiografia por Tomografia Computadorizada , Humanos , Imageamento Tridimensional , Masculino , Stents , Artéria Subclávia/cirurgia , Artéria Vertebral/diagnóstico por imagem , Artéria Vertebral/cirurgiaRESUMO
OBJECTIVES: The study sought to determine the incidence, predictors, characteristics, and outcomes of repeat revascularization during 5-year follow-up of the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) trial. BACKGROUND: Limited in-depth long-term data on repeat revascularization are available from randomized trials comparing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). METHODS: Incidence and timing of repeat revascularization and its relation to the long-term composite safety endpoint of death, stroke, and myocardial infarction were analyzed in the SYNTAX trial (n = 1,800) using Kaplan-Meier analysis. RESULTS: At 5 years, repeat revascularization occurred more often after initial PCI than after initial CABG (25.9% vs. 13.7%, respectively; p < 0.001), and more often consisted of multiple repeat revascularizations (9.0% vs. 2.8%, respectively; p = 0.022). Significantly more repeat PCI procedures were performed on de novo lesions in patients after initial PCI than initial CABG (33.3% vs. 13.4%, respectively; p < 0.001). At 5-year follow-up, patients who underwent repeat revascularization versus patients not undergoing repeat revascularization had significantly higher rates of the composite safety endpoint of death, stroke, and myocardial infarction after initial PCI (33.8% vs. 16.6%, respectively; p < 0.001), and a trend was found after initial CABG (22.4% vs. 15.8%, respectively; p = 0.07). After multivariate adjustment, repeat revascularization was an independent predictor of the composite safety endpoint after both initial PCI (hazard ratio [HR]: 2.2; 95% confidence interval [CI]: 1.6 to 3.0; p < 0.001) and initial CABG (HR: 1.8; 95% CI: 1.2 to 2.9; p = 0.011). CONCLUSIONS: Repeat revascularization rates are significantly higher after initial PCI than after initial CABG for complex coronary disease. Repeat revascularization is an independent predictor of death, stroke, and myocardial infarction for myocardial revascularization.
Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea , Idoso , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Sistema de Registros , Retratamento , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: There are no data available on specific causes of death from randomized trials that have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI). OBJECTIVES: The purpose of this study was to investigate specific causes of death, and its predictors, after revascularization for complex coronary disease in patients. METHODS: An independent Clinical Events Committee consisting of expert physicians who were blinded to the study treatment subclassified causes of death as cardiovascular (cardiac and vascular), noncardiovascular, or undetermined according to the trial protocol. Cardiac deaths were classified as sudden cardiac, related to myocardial infarction (MI), and other cardiac deaths. RESULTS: In the randomized cohort, there were 97 deaths after CABG and 123 deaths after PCI during a 5-year follow-up. After CABG, 49.4% of deaths were cardiovascular, with the greatest cause being heart failure, arrhythmia, or other causes (24.6%), whereas after PCI, the majority of deaths were cardiovascular (67.5%) and as a result of MI (29.3%). The cumulative incidence rates of all-cause death were not significantly different between CABG and PCI (11.4% vs. 13.9%, respectively; p = 0.10), whereas there were significant differences in terms of cardiovascular (5.8% vs. 9.6%, respectively; p = 0.008) and cardiac death (5.3% vs. 9.0%, respectively; p = 0.003), which were caused primarily by a reduction in MI-related death with CABG compared with PCI (0.4% vs. 4.1%, respectively; p <0.0001). Treatment with PCI versus CABG was an independent predictor of cardiac death (hazard ratio: 1.55; 95% confidence interval: 1.09 to 2.33; p = 0.045). The difference in MI-related death was seen largely in patients with diabetes, 3-vessel disease, or high SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) trial scores. CONCLUSIONS: During a 5-year follow-up, CABG in comparison with PCI was associated with a significantly reduced rate of MI-related death, which was the leading cause of death after PCI. Treatments following PCI should target reducing post-revascularization spontaneous MI. Furthermore, secondary preventive medication remains essential in reducing events post-revascularization. (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).
Assuntos
Ponte de Artéria Coronária , Doença das Coronárias/mortalidade , Doença das Coronárias/terapia , Stents Farmacológicos , Intervenção Coronária Percutânea , Idoso , Causas de Morte , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Despite various evidence supporting the advantages of multiple arterial grafting, inconsistencies in use of the procedure have resulted in high variability in the acceptance and practice of arterial grafting. The purpose of this study was to assess the effects of an arterial versus venous second grafts on outcomes at 5-year follow-up in the coronary artery bypass grafting population from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial. METHODS: Patients (n = 1419) with an arterial graft to the left anterior descending artery and ≥1 other graft were included and divided according to the second graft's type: 2nd-graft-arterial group (n = 456) and 2nd-graft-venous group (n = 963). Five-year outcomes were compared between subgroups. Event rates were estimated with Kaplan-Meier analyses. Propensity-score matching was used, to control for selection bias due to nonrandom group assignment in a 1:1 manner, resulting in 432 pairs with balanced baseline characteristics. RESULTS: In unmatched groups, the 2nd-graft-arterial group had significantly lower rates of death (8.9% vs 13.1%; P = .02), and composite safety endpoint of death/stroke/myocardial infarction (13.3% vs 18.7%; P = .02), compared with the 2nd-graft-venous group. The rate of major adverse cardiac or cerebrovascular events was similar between groups (22.9% vs 25.5%; P = .30), because it includes the rate of repeat revascularization (12.6% in the 2nd-graft-arterial group vs 9.6% in the 2nd-graft-venous group; P = .10). After propensity-score matching, no statistically significant differences were found between groups. CONCLUSIONS: This study reveals comparable 5-year outcomes with arterial and venous conduits as second grafts after an arterial graft anastomosed to the left anterior descending artery. This study demonstrates the multi-institutional variation in patient selection and operator technique with regard to arterial revascularization, although extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes. CLINICAL TRIAL NUMBER: NCT00114972.
Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Idoso , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Europa (Continente) , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Seleção de Pacientes , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Padrões de Prática Médica , Pontuação de Propensão , Desenho de Prótese , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVES: To investigate the until now undefined extent of differences in baseline characteristics, practice patterns and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG) for complex coronary artery disease in the USA versus Europe. METHODS: The impact of geographic enrollment on clinical outcomes was explored using the as-treated population of 1510 patients with de novo left main and/or three-vessel disease who underwent CABG in either the SYNTAX randomized trial or registries, and who were followed up for 5 years. RESULTS: There were 259 (17%) patients enrolled in the USA. Patients in the USA had more comorbidities. Off-pump procedures were more frequent in the USA (32 vs 13% in Europe; P < 0.001), and crystalloid cardioplegia was used less often (17 vs 38% in Europe; P < 0.001). In the USA, more grafts per patient were used (3.1 ± 0.8 vs 2.7 ± 0.7 in Europe; P < 0.001), with less complete arterial grafting (5 vs 18% in Europe; P < 0.001) but more complete revascularization (80 vs 66% in Europe; P < 0.001). At 5-year follow-up, patients treated in the USA versus Europe had comparable rates of major adverse cardiac and cerebrovascular events (MACCEs: 28.7 vs 24.3%, respectively; P = 0.11) and the composite safety endpoint of death, stroke and myocardial infarction (MI; 15.3 vs 17.5%, respectively; P = 0.43), but a significantly higher rate of repeat revascularization (15.0 vs 9.8%, respectively; P = 0.011) driven by repeat percutaneous coronary intervention (14.6 vs 9.2%; P = 0.005) and not repeat CABG (0.4 vs 0.8%; P = 0.48). Rates of graft occlusion were significantly higher in the USA versus Europe (8.7 vs 3.2%; P < 0.001). In multivariate analysis, enrollment in the USA was a non-significant predictor of MACCE [hazard ratio (HR) = 1.31, 95% confidence interval (95% CI) 1.00-1.73; P = 0.053], but independently predicted repeat revascularization (HR = 1.66, 95% CI 1.12-2.46; P = 0.011) and graft occlusion (HR = 2.65, 95% CI 1.52-4.62; P = 0.001). It was also a non-significant predictor of reduced rates of MI (HR = 0.38, 95% CI 0.14-1.06; P = 0.064). Differences between the USA and Europe were most pronounced among patients who underwent off-pump CABG. CONCLUSIONS: Repeat revascularization rates following CABG in the USA versus Europe were increased at 5 years, particularly in off-pump patients. There was no significant difference in the rate of death, stroke and MI.