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1.
J Card Surg ; 36(8): 2651-2657, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33960521

RESUMO

OBJECTIVES: Peripartum cardiomyopathy (PPCM) is a form of systolic heart failure occurring toward the end of pregnancy or in the period after delivery. Lack of myocardial recovery or therapy-refractory cardiogenic shock are rare complications and left ventricular assist device (LVAD) systems might be used as a life-saving option. The aim of this study was to investigate outcomes of PPCM patients supported with LVAD, registered in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). METHODS: All patients registered in EUROMACS with a primary diagnosis of PPCM were included in this study. Demographic, preoperative, intraoperative, postoperative, and follow-up data were collected and patients analysed concerning their outcome after initiation of LVAD therapy. RESULTS: Between May 2011 and September 2018, 16 patients with PPCM and consecutive LVAD implantation were enrolled into EUROMACS. The median age of the patient population was 31 (26;41) years with a mean left ventricular ejection fraction (LV-EF) of 15% ± 6%. In-hospital mortality after LVAD implantation was 6% (n = 1). One-year mortality accounted for 13% (n = 2). Six patients (40%) were transplanted with a median support time of 769 (193;1529) days. Weaning of LVAD support due to ventricular recovery was feasible in 3 (20%) patients. CONCLUSION: In patients with severe PPCM, LVAD therapy is associated with considerably low in-hospital mortality, potentially allowing bridging to heart transplantation, or left ventricular recovery. Therefore, durable mechanical support should be considered as a treatment option in this, by nature, young and often otherwise healthy patient population.


Assuntos
Cardiomiopatias , Insuficiência Cardíaca , Coração Auxiliar , Adulto , Cardiomiopatias/complicações , Cardiomiopatias/terapia , Feminino , Humanos , Período Periparto , Gravidez , Estudos Retrospectivos , Volume Sistólico , Resultado do Tratamento , Função Ventricular Esquerda
2.
BMC Cardiovasc Disord ; 20(1): 47, 2020 02 03.
Artigo em Inglês | MEDLINE | ID: mdl-32013875

RESUMO

BACKGROUND: Cardiac surgery for prosthetic valve endocarditis (PVE) is associated with substantial mortality. We aimed to analyze 30-day and 1-year outcome in patients undergoing surgery for PVE and sought to identify preoperative risk factors for mortality with special regard to perivalvular infection. METHODS: We retrospectively analyzed data of 418 patients undergoing valve surgery for infective endocarditis between January 2009 and July 2018. After 1:1 propensity matching 158 patients (79 PVE/79 NVE) were analyzed with regard to postoperative 30-day and 1-year outcomes. Univariate and multivariable analyses were performed to identify potential risk factors for mortality. RESULTS: 315 patients (75.4%) underwent surgery for NVE and 103 (24.6%) for PVE. After propensity matching groups were comparable with regard to preoperative characteristics, clinical presentation and microbiological findings, except a higher incidence of perivalvular infection in patients with PVE (51.9%) compared to NVE (26.6%) (p = 0.001), longer cardiopulmonary bypass (166 [76-130] vs. 97 [71-125] min; p < 0.001) and crossclamp time (95 [71-125] vs. 68 [55-85] min; p < 0.001). Matched patients with PVE showed a 4-fold increased 30-day mortality (20.3%) in comparison with NVE patients (5.1%) (p = 0.004) and 2-fold increased 1-year mortality (PVE 29.1% vs. NVE 13.9%; p = 0.020). Multivariable analysis revealed perivalvular abscess, sepsis, preoperative AKI and PVE as independent risk factors for mortality. Patients with perivalvular abscess had a significantly higher 30-day mortality (17.7%) compared to patients without perivalvular abscess (8.0%) (p = 0.003) and a higher rate of perioperative complications (need for postoperative pacemaker implantation, postoperative cerebrovascular events, postoperative AKI). However, perivalvular abscess did not influence 1-year mortality (20.9% vs. 22.3%; p = 0.806), or long-term complications such as readmission rate or relapse of IE. CONCLUSIONS: Patients undergoing surgery for PVE had a significantly higher 30-day and 1-year mortality compared to NVE. After propensity-matching 30-day mortality was still 4-fold increased in PVE compared to NVE. Patients with perivalvular abscess showed a significantly higher 30-day mortality and perioperative complications, whereas perivalvular abscess seems to have no relevant impact on 1-year mortality, the rate of readmission or relapse of IE.


Assuntos
Abscesso/cirurgia , Endocardite Bacteriana/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas/efeitos adversos , Infecções Relacionadas à Prótese/cirurgia , Abscesso/diagnóstico , Abscesso/microbiologia , Abscesso/mortalidade , Idoso , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/microbiologia , Endocardite Bacteriana/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/microbiologia , Infecções Relacionadas à Prótese/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
3.
J Card Surg ; 35(1): 83-88, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31692108

RESUMO

OBJECTIVES: Right ventricular (RV) failure is associated with poor outcome and increased mortality in cardiac surgery. Aim of our study was to analyze the outcome of veno arterial extracorporeal membrane oxygenation (va ECMO) therapy in patients with isolated RV failure in postcardiotomy cardiogenic shock (PCS) and to evaluate risk factors associated with 30-day-mortality. METHODS: Between August 2006 until August 2016, 64 consecutive patients with va ECMO therapy due to fulminant RV failure in PCS were identified and included in this retrospective observation. Further, outcome data and a comparison of va ECMO survivors and nonsurvivors was conducted. RESULTS: The mean age of the patient cohort was 63 ± 14 years. Patients were treated with va ECMO for 79 ± 61 hours. Twenty-eight patients (44%) were successfully weaned off ECMO support. Overall 30-day-mortality was 88% (56/64). Hemoglobin concentration before ECMO implantation, maximum rise of muscle-brain type creatine kinase during ECMO therapy, as well as lactic acid concentration 24 hours after initiation of va ECMO therapy were predictive for 30-day mortality. CONCLUSION: ECMO therapy in RV failure due to PCS is shown to be associated with an excessive mortality. Regarding our data, va ECMO might only be an appropriate short-term mechanical assist device separating patients form cardiopulmonary bypass with an acceptable weaning rate. Particularly, in case of failed hemodynamic recovery of the right heart on va ECMO, direct RV bypass systems might function as a bailout option. Additionally, cardiac enzymes and lactic acid might provide valuable information in meeting therapy-related decisions.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca/terapia , Complicações Pós-Operatórias/terapia , Choque Cardiogênico/terapia , Idoso , Feminino , Ventrículos do Coração , Humanos , Masculino , Pessoa de Meia-Idade
5.
Ann Cardiothorac Surg ; 8(6): 645-653, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31832354

RESUMO

BACKGROUND: There has been an increasing incidence of right-sided infective endocarditis (RSIE) due to the global rise of intravenous drug use (IVDU) and an increasing number of implantable cardiac electronic devices and central venous catheters. Our aim was to investigate differences in the clinical presentation, microbiological findings and prognosis of patients undergoing surgery for RSIE compared to left-sided infective endocarditis (LSIE). METHODS: Relevant clinical data of all 432 consecutive patients undergoing valve surgery for infective endocarditis (IE) at our institution between January 2009 and December 2018 were retrospectively analyzed. Acquired data included patients' demographic and preoperative comorbidities, manifestation of IE according to the recently modified Duke Criteria, perioperative data and relevant clinical outcomes. RESULTS: A total of 403 patients (93.3%) underwent surgery for LSIE and twenty-nine patients (6.7%) for RSIE. Eleven patients with RSIE (37.9%) showed a concomitant left-sided infection. Compared to LSIE, RSIE patients were significantly younger [47.5 (40.4-69.3) vs. 65.1 (53.7-74.6); P=0.008] and presented with less comorbidities such as hypertension (41.4% vs. 65.3%; P=0.010) and coronary artery disease (6.9% vs. 29.0%; P=0.010). Rates of IVDU (34.5% vs. 4.5%; P<0.001), human immunodeficiency virus (HIV) (10.3% vs. 1.7%; P=0.023) and hepatitis C virus (HCV) infection (24.1% vs. 5.2%; P=0.001) were greater in RSIE. The proportion of Staphylococcus aureus IE was significantly higher in RSIE compared to LSIE (37.9% vs. 21.1%; P=0.035). 30-day mortality was 6.9% after surgery for RSIE compared to 14.6% after operation for LSIE (P=0.372). CONCLUSIONS: Patients undergoing surgery for RSIE compared to LSIE presented with a higher rate of pulmonary septic emboli, more Staphylococcus aureus infections and larger vegetations. Larger multicenter prospective trials are needed to provide more reliable data on the clinical profile of these patients, in order to determine optimal surgical management.

6.
Ther Adv Cardiovasc Dis ; 12(12): 327-340, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30295137

RESUMO

BACKGROUND:: Stanford A acute aortic dissection (AAD) is a life-threatening emergency associated with major morbidity and mortality. The aim of this study was to compare outcomes of three different surgical approaches in patients with Stanford A AAD. METHODS:: From January 2006 to March 2015 a total of 240 consecutive patients with diagnosed Stanford A AAD underwent elective, isolated surgical aortic repair in our centre. Patients were divided into three groups according to the extent of surgical repair: isolated replacement of the ascending aorta, hemiarch replacement and total arch replacement. Patients were followed up for up to 9 years. After univariate analysis multinomial logistic regression was performed for subgroup analysis. Baseline characteristics and endpoints as well as long-term survival were analysed. RESULTS:: There were no statistically significant differences among the three groups in terms of demographics and preoperative baseline and clinical characteristics. Incidence of in-hospital stroke ( p = 0.034), need for reopening due to bleeding ( p = 0.031) and in-hospital mortality ( p = 0.017) increased significantly with the extent of the surgical approach. There was no statistical difference in terms of long-term survival ( p = 0.166) among the three groups. Applying multinomial logistic regression for subgroup analysis significantly higher odds for stroke ( p = 0.023), reopening for bleeding ( p = 0.010) and in-hospital mortality ( p = 0.009) for the arch surgery group in comparison to the ascending aorta surgery group as well as significantly higher odds for stroke ( p = 0.029) for the total arch surgery group in comparison to the hemiarch surgery group were identified. CONCLUSIONS:: With Stanford A AAD the incidence of perioperative complications increased significantly with the extent of the surgical approach. Subgroup analysis and long-term follow up in patients undergoing isolated ascending or hemiarch surgery showed a lower incidence of cerebrovascular events compared with surgery for total arch replacement.


Assuntos
Aorta Torácica/cirurgia , Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/métodos , Doença Aguda , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aorta Torácica/diagnóstico por imagem , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/mortalidade , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/mortalidade , Feminino , Alemanha/epidemiologia , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
7.
Ann Thorac Surg ; 106(6): 1749-1750, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30240760
8.
Ther Adv Cardiovasc Dis ; 12(11): 289-298, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30227769

RESUMO

BACKGROUND: The aim of the present study was to determine whether raised preoperative serum creatinine affected the long-term outcome in patients undergoing surgical aortic repair for Stanford A acute aortic dissection (AAD). METHODS: A total of 240 patients diagnosed with Stanford A AAD underwent surgical repair from January 2006 to April 2015. A propensity score matching was applied, resulting in 73 pairs consisting of one group with normal and one group with preoperative elevated creatinine levels. The cohorts were well balanced for baseline and preoperative clinical characteristics. Both groups were compared regarding their early postoperative variables, as well as estimated survival with up to 9-year follow up. Also, the impact of acute postoperative kidney injury and its severity on long-term survival was analyzed. RESULTS: The proportion of patients suffering Stanford A AAD with raised creatinine levels was 31.3% ( n = 75). After propensity matching, there were no statistically significant differences regarding demographics, comorbidities, preoperative baseline and clinical characteristics. Postoperatively matched patients with elevated creatinine had longer intensive care unit ( p < 0.001) and total hospital stay ( p = 0.002), prolonged intubation times ( p = 0.014), higher need for hemofiltration ( p < 0.001), higher incidence of temporary neurological disorders ( p = 0.16), infection ( p = 0.005), and trend toward higher incidence of sepsis ( p = 0.097). However, there were no significant differences regarding 30-day mortality (20.5% versus 20.5%, p = 1.000) and long-term overall survival. Further, neither the incidence nor the different stages of acute kidney injury according to the Acute Kidney Injury Network showed any statistically significant differences in terms of long-term survival for both groups [log rank p = 0.636, Breslow (generalized Wilcoxon) p = 0.470, Tarone-Ware p = 0.558]. CONCLUSIONS: Patients with elevated creatinine levels undergoing surgical repair for Stanford A AAD demonstrate higher rate of early postoperative complications. However, 30-day mortality and long-term survival in this patient cohort is not significantly impaired.


Assuntos
Injúria Renal Aguda/etiologia , Aneurisma Aórtico/cirurgia , Dissecção Aórtica/cirurgia , Creatinina/sangue , Nefropatias/sangue , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Doença Aguda , Injúria Renal Aguda/sangue , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/mortalidade , Idoso , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/mortalidade , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/mortalidade , Biomarcadores/sangue , Feminino , Humanos , Estimativa de Kaplan-Meier , Nefropatias/complicações , Nefropatias/diagnóstico , Nefropatias/mortalidade , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima , Procedimentos Cirúrgicos Vasculares/mortalidade
9.
Interact Cardiovasc Thorac Surg ; 27(2): 215-221, 2018 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-29538706

RESUMO

OBJECTIVES: Rapid-deployment aortic valve replacement (RD-AVR) potentially reduces procedure times providing excellent haemodynamic results compared to standard tissue aortic valve replacement. However, concerns have been raised regarding higher rates of postoperative pacemaker (PPM) requirement compared to standard aortic valve replacement. In this study, we sought to determine the PPM rate and its potential risk factors in RD-AVR patients. METHODS: Between 2011 and 2017, 193 patients underwent RD-AVR. The main outcome investigated was PPM. Other outcome parameters included hospital mortality, major morbidity, length of stay and discharge condition. Predictors of PPM were determined using multivariable regression models. RESULTS: Isolated RD-AVR was performed in 72 (37%) patients and 121 (63%) patients underwent combined RD-AVR [coronary artery bypass grafting (n = 110), mitral repair (n = 6) and others (n = 5)]. Aortic cross-clamp and cardiopulmonary bypass times were 57.1 ± 25.1 min and 90.0 ± 40.1 min in the overall RD-AVR population and 39.4 ± 13.5 min and 67.6 ± 24.5 min, respectively, in isolated RD-AVR procedures. PPM occurred in 20 (10.4%) patients. Multivariable analysis revealed bypass grafting of the circumflex artery [odds ratio = 2.8] and preoperative right branch bundle block (odds ratio = 11.7) as independent predictors for PPM. CONCLUSIONS: RD-AVR is a safe and simple procedure resulting in favourable short aortic cross-clamp and cardiopulmonary bypass times and considerable low gradients in postoperative echocardiography. PPM following isolated RD-AVR remains in the range of standard aortic valve replacement. However, patients undergoing concomitant coronary artery bypass grafting, particularly of the circumflex artery, face a 3-fold increased risk for PPM implantation enhanced if right branch bundle block is present. Follow-up examination is necessary to determine whether these patients remain pacer dependent during long-term follow-up.


Assuntos
Estenose da Valva Aórtica/cirurgia , Arritmias Cardíacas/terapia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Marca-Passo Artificial , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/etiologia , Bioprótese , Ponte de Artéria Coronária , Ecocardiografia , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Hemodinâmica , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
10.
Ann Thorac Surg ; 105(1): 24-30, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29132703

RESUMO

BACKGROUND: The aim of this study was to evaluate the effects of rapid deployment aortic valve replacement (RDAVR) on surgical outcome and hemodynamics compared with standard aortic valve replacement (AVR). METHODS: One hundred sixty-three RDAVR patients (isolated, n = 67; combined with coronary artery bypass graft surgery [CABG], n = 96) were compared with a propensity matched control group (n = 163). Primary endpoints included association between valve type and procedure times, prosthesis size, transvalvular gradient, and indexed effective orifice area. Secondary endpoints were postoperative mortality and morbidity. RESULTS: Aortic cross-clamp and cardiopulmonary bypass times in the RDAVR group were 55 ± 23 and 88 ± 38 minutes, respectively, compared with 77 ± 22 and 105 ± 38 minutes in the control group (p < 0.001). In the subgroup of patients undergoing isolated RDAVR (n = 67 of 163), the aortic cross-clamp and cardiopulmonary bypass times were 38 ± 13 and 66 ± 22 minutes, respectively, compared with 55 ± 14 and 81 ± 18 minutes in the control group (n = 67 of 163; p < 0.001). The RDAVR patients received larger prostheses (23.3 ± 1.8 mm) compared with standard AVR (22.8 ± 1.5 mm; p = 0.002). Mean transvalvular gradients and indexed effective orifice areas were 9 ± 5 mm Hg and 1.11 ± 0.11, respectively, in the RDVAR group compared with 13 ± 5 mm Hg and 0.95 ± 0.08 in the control group (p < 0.001). Hospital mortality was similar in both groups (1.8%, n = 3 of 163; p = 1.000). Postoperative pacemaker rates were 3.5% (n = 3 of 67) for isolated RDAVR versus 3.0% (n = 2 of 67; p = 0.649) for isolated AVR and 12.5% (n = 12 of 96) for RDAVR/CABG versus 4.2% (n = 4 of 96; p = 0.032) for AVR/CABG. CONCLUSIONS: RDAVR facilitates reduced aortic cross-clamp and cardiopulmonary bypass times compared with standard AVR, particularly in patients undergoing concomitant procedures, allowing the use of larger prostheses and resulting in lower transvalvular gradients and higher indexed effective orifice area compared with standard AVR. Therefore, RDAVR may help to overcome patient-prosthesis mismatch in some patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Duração da Cirurgia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Ponte de Artéria Coronária , Feminino , Próteses Valvulares Cardíacas , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento
11.
J Cardiothorac Surg ; 12(1): 68, 2017 Aug 09.
Artigo em Inglês | MEDLINE | ID: mdl-28793899

RESUMO

BACKGROUND: The frequency of circulating endothelial cells (CEC) in patients' peripheral blood can be assessed as a direct marker of endothelial damage. However, conventional enumeration methods are extremely challenging. We developed a novel, automated approach to determine CEC frequencies and tested this method on two groups of patients undergoing conventional (CAVR) versus trans-catheter aortic valve implantation (TAVI). METHODS: CEC frequencies were assessed by a flow cytometric approach, including automated pre-enrichment of CD34 positive blood cell subpopulation and isotype controls. The efficacy and reproducibility of the CEC enumeration method was validated by spiking blood samples of healthy control donors with defined numbers of endothelial cells. RESULTS: CEC frequencies were significantly higher in the TAVI group before (9.8 ± 4.1 vs. 5.5 ± 2.2, p = 0.019) and 1 h after surgery (13.4 ± 5.1 vs. 8.2 ± 4.1, p = 0.030) corresponding to higher Euroscore, STS score in higher risk patients from the TAVI group. Five days after surgery, CEC frequencies became significantly higher in the more invasive CAVR group (39.0 ± 13.0 vs. 14.3 ± 4.4, p < 0.001) compared to minimally invasive TAVI approach. CONCLUSIONS: The new flow cytometric approach might be a robust and reliable method for CEC enumeration. Initial results show that CEC frequency is a valid clinical marker for the assessment of pre-operative risk, invasiveness of surgical procedure and clinical outcome. Further studies are necessary to validate the practical clinical usefulness and the potential superiority compared to conventional markers.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Células Endoteliais/patologia , Endotélio Vascular/patologia , Citometria de Fluxo/métodos , Complicações Pós-Operatórias/diagnóstico , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico , Biomarcadores , Contagem de Células/métodos , Feminino , Humanos , Masculino , Prognóstico , Reprodutibilidade dos Testes
12.
Interact Cardiovasc Thorac Surg ; 24(5): 702-707, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28453793

RESUMO

OBJECTIVES: Previous research suggests that female gender is associated with increased mortality rates after surgery for Stanford A acute aortic dissection (AAD). However, women with AAD usually present with different clinical symptoms that may bias outcomes. Moreover, there is a lack of long-term results regarding overall mortality and freedom from major cerebrovascular events. We analysed the impact of gender on long-term outcomes after surgery for Stanford A AAD by comparing genders with similar risk profiles using propensity score matching. METHODS: A total of 240 patients operated for Stanford A AAD were included in this study. To control for selection bias and other confounders, propensity score matching was applied to gender groups. RESULTS: After propensity score matching, the gender groups were well balanced in terms of risk profiles. There were no statistically significant differences regarding duration of cardiopulmonary bypass ( P = 0.165) and duration of aortic cross-clamp time ( P = 0.111). Female patients received less fresh frozen plasma ( P = 0.021), had shorter stays in the intensive care unit ( P = 0.031), lower incidence of temporary neurological dysfunction ( P < 0.001) and lower incidence of dialysis ( P = 0.008). There were no significant differences regarding intraoperative mortality ( P = 1.000), 30-day mortality ( P = 0.271), long-term overall cumulative survival ( P = 0.954) and long-term freedom from cerebrovascular events ( P = 0.235) with up to a 9-year follow-up. CONCLUSIONS: Considering patients with similar risk profiles, female gender per se is not associated with worse long-term survival and freedom from stroke after surgical aortic repair. Moreover, female patients might even benefit from a smoother early postoperative course and lower incidence of early postoperative complications.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais , Taxa de Sobrevida/tendências , Fatores de Tempo
13.
Ann Thorac Surg ; 102(3): 787-794, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27173067

RESUMO

BACKGROUND: The choice of an optimal cannulation site for aortic repair in patients with Stanford A acute aortic dissection remains controversial. The aim of this study was to compare the early results and long-term outcomes of axillar and direct aortic cannulation. METHODS: A total of 235 consecutive patients who underwent surgical aortic repair with the use of axillar or direct aortic cannulation from January 2006 to April 2015 were analyzed. The primary end points were long-term overall cumulative survival and freedom from major cerebrovascular events with up to 10 years of follow-up. The secondary end points were early postoperative clinical characteristics and rates of adverse events. To control for confounders, a 1:3 propensity score matching was performed. RESULTS: After matching, there were no statistically significant differences between the two groups regarding baseline characteristics. Both groups were associated with comparable outcomes; among other things, the length of stay in the intensive care unit (ICU) (p = 0.220), mechanical ventilation (p = 0.177), total hospital stay (p = 0.243), and hospital rates of adverse events. There were no statistically significant differences (p = 0.625) in terms of freedom from major cerebrovascular events. However, both early (p = 0.009) and late (p = 0.016) overall survival were significantly poorer for patients undergoing aortic cannulation. CONCLUSIONS: The outcomes were comparable regarding early hospital outcomes and rates of adverse events. Whereas postoperative freedom from major cerebrovascular events was similar, survival over long-term follow-up was significantly poorer when direct aortic cannulation was used. More investigations are needed to enable an understanding of the underlying factors for potentially higher late mortality when direct aortic cannulation is used during a surgical procedure for acute Stanford A dissection.


Assuntos
Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Cateterismo/métodos , Idoso , Artéria Axilar , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
J Cardiothorac Surg ; 10: 180, 2015 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-26637200

RESUMO

BACKGROUND: The aim of this study was to determine whether intermittent warm blood cardioplegia (IWC) is associated with comparable myocardial protection compared to cold blood cardioplegia (ICC) in patients undergoing elective vs. emergent CABG procedures. METHODS: Out of 2292 consecutive patients who underwent isolated on-pump CABG surgery using cardioplegic arrest either with ICC or IWC between January 2008 and December 2010, 247 consecutive emergent patients were identified and consecutively matched 1:2 with elective patients based on gender, age (<50 years, 50-70 years, >70 years) and ejection fraction (<40 %, 40-50 %, >50 %). Perioperative outcomes and long-term mortality were compared between ICC and IWC strategies and predictors for 30-day mortality and perioperative myocardial injury were identified in both elective and emergent subgroups of patients. RESULTS: Preoperative demographics and baseline characteristics, logistic Euroscore, CPB-time, number of distal anastomoses and LIMA-use were comparable. Aortic cross clamp time was significantly longer in the IWC-group regardless of the urgency of the procedure (p = 0.05 and p = 0.015 for emergent and elective settings). There were no significant differences regarding ICU-stay, ventilation time, total blood loss and need for dialysis. The overall 30-day, 1-, 3- and 6-year survival of the entire patient cohort was 93.7, 91.8, 90.4 and 89.1 %, respectively, with significantly better outcomes when operated electively (p < 0.001) but no differences between ICC and IWC both in elective (p = 0.857) and emergent (p = 0.741) subgroups. Multivariate analysis did not identify the type of cardioplegia as a predictor for 30-day mortality and for perioperative myocardial injury. However, independent factors predictive of 30-day mortality were: EF < 40 % (OR 3.66; 95 % CI: 1.79-7.52; p < 0.001), atrial fibrillation (OR 3.33; 95 % CI: 1.49-7.47; p < 0.003), peripheral artery disease (OR 2.51; 95 % CI: 1.13-5.55; p < 0.023) and COPD (OR 0.26; 95 % CI: 1.05-6.21; p < 0.038); predictors for perioperative myocardial infarction were EF < 40 % (OR 2.04; 95 % CI: 1.32-3.15; p < 0.001), preoperative IABP support (OR 3.68; 95 % CI: 1.34-10.13; p < 0.012), and hemofiltration (OR 3.61; 95 % CI: 2.22-5.87; p < 0.001). CONCLUSION: Although the aortic cross clamp time was prolonged in the IWC group our results confirm effective myocardial protection under IWC, regardless of the urgency of the procedure. We suggest that intermittent warm cardioplegia in emergent CABG setting is a low-cost alternative and safe. It is associated with similar long-term outcomes both in elective and emergent settings compared to intermittent cold cardioplegia.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Procedimentos Cirúrgicos Eletivos/métodos , Parada Cardíaca Induzida/métodos , Idoso , Doença da Artéria Coronariana/mortalidade , Feminino , Seguimentos , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Taxa de Sobrevida/tendências , Fatores de Tempo
15.
Thorac Cardiovasc Surg ; 63(6): 504-7, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25756242

RESUMO

In aortic valve replacement, severe calcification of the sinotubular junction is a limitation in the application of the rapid deployment Edwards Intuity valve system. This is illustrated by a case presentation in which discrepancies of shape and diameter between sizer and valve mounted on the deployment system resulted in discarding the prosthesis and performing a biocomposite root replacement instead. Modification of the valve sizer will allow for safer sizing because the sizing process will mimic the implantation process more accurately.


Assuntos
Estenose da Valva Aórtica/cirurgia , Calcinose/cirurgia , Cardiomiopatias/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Idoso , Valva Aórtica , Estenose da Valva Aórtica/etiologia , Calcinose/diagnóstico , Calcinose/etiologia , Cardiomiopatias/diagnóstico , Cardiomiopatias/etiologia , Ecocardiografia , Desenho de Equipamento , Feminino , Humanos , Desenho de Prótese , Radiografia Torácica
16.
Eur J Cardiothorac Surg ; 47(3): 397-406; discussion 406, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25100715

RESUMO

Percutaneous coronary intervention (PCI) and minimally invasive direct coronary artery bypass (MIDCAB) grafting are both established therapeutic options for single-vessel disease of the left anterior descending artery (LAD). The present systematic review with meta-analysis aims to determine the current strength of evidence for or against PCI and MIDCAB for revascularization of the LAD. Therefore, we performed a meta-analysis of randomized, controlled trials (RCTs) and observational trials (OTs) that reported clinical outcome after isolated LAD revascularization. Analysed postoperative outcomes included major adverse cardiac and cerebrovascular events (MACCEs), all-cause mortality, myocardial infarction and stroke. Pooled treatment effects [odds ratio (OR) or weighted mean difference (WMD), 95% confidence intervals (95% CI)] were assessed using a fixed- or random-effects model. A total of 2885 patients from 12 studies (6 RCTs, 6 OTs) were identified after a literature search of major databases using a predefined list of keywords. PCI of the LAD was performed in 60.7% (n = 1751) and MIDCAB in 39.3% of patients (n = 1126). Pooled-effect estimates revealed an increased incidence for MACCEs after PCI (OR 1.98; 95% CI 1.45-2.69; P < 0.0001) 6 months after the procedure. Especially, PCI was particularly associated with an increased odds for target vessel revascularization (OR 2.11; 95% CI 1.00-4.47; P = 0.0295). No differences with regard to stroke, myocardial infarction and all-cause mortality were observed between both revascularization strategies. Patients after PCI had a shorter length of hospital stay (WMD -3.37 days; 95% CI (-)4.92 to (-)1.81; P < 0.0001). In conclusion, the present systematic review underscores the superiority of MIDCAB over PCI for treatment of single-vessel disease of the LAD.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/métodos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/estatística & dados numéricos
17.
J Cardiothorac Surg ; 9: 83, 2014 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-24886207

RESUMO

OBJECTIVE: The aim of this prospective observational study was to evaluate the efficiency of a new escalating treatment strategy with vernakalant, flecainide and electrical cardioversion (EC) in patients with new onset atrial fibrillation (AF) after cardiac surgery. MATERIAL AND METHODS: 24 patients with new onset AF after aortic valve surgery, coronary artery bypass surgery or combined procedures were evaluated in this study. Additional including criteria were age between 18 and 80, duration of AF less than four days, body weight less than 100 kg and no previous treatment with class I or III antiarrhythmic drugs. Exclusion criteria were poor left ventricular ejection fraction (LVEF < 40%) and history of myocardial infarction within 30 days. The patients were divided into converters and non-converters according to their response to combination treatment with vernakalant and flecainide, and the groups were compared. RESULTS: The mean age of the population was 69.6 ± 6.3 years and 26.1% of patients were female. There were no statistically significant differences between the two groups in terms of height, weight, gender distribution, comorbidities, preoperative medication, left ventricular function and left atrium diameter. Interventricular septum (IVS) in the non-converted group was significantly thicker compared to the converted group: 14.0 ± 1.00 vs. 10.40 ± 2.59 mm (p = 0.036). While 14 patients (60.9%) were successfully converted into stable sinus rhythm by pharmacological treatment with vernakalant and flecainide, 9 patients (39.1%, non-converted group) remained in AF. However, seven of them could be converted after additional EC. CONCLUSION: The combination of vernakalant and flecainide improves the conversion rate into a stable sinus rhythm in postcardiotomy patients with new onset AF compared to single drug therapy. Furthermore it might be an excellent precondition for successful EC in patients who are not converted after using both antiarrhtythmic drugs. Furthermore, left ventricular hypertrophy might be a potential negative predictor of successful pharmacological cardioversion.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardioversão Elétrica/métodos , Guias de Prática Clínica como Assunto , Volume Sistólico/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/etiologia , Fibrilação Atrial/fisiopatologia , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
18.
Interact Cardiovasc Thorac Surg ; 17(2): 319-26; discussion 326-7, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23667066

RESUMO

OBJECTIVES: In this study, we sought to analyse the incidence of major non-cardiac complications and their impact on survival following cardiac surgery procedures in a contemporary patient cohort. We further determined independent predictors of perioperative mortality and created a logistic regression model for prediction of outcome after the occurrence of these complications. METHODS: Prospectively collected data of 5318 consecutive adult patients (mean age 68.9±11.0 years; 29.3% [n=1559] female) undergoing cardiac surgery from January 2009 to May 2012 were retrospectively analysed. Outcome measures were six major non-cardiac complications including respiratory failure, dialysis-dependent renal failure, deep sternal wound infection (DSWI), cerebrovascular accident (CVA), gastrointestinal complications (GIC) and sepsis and their impact on perioperative mortality and hospital length of stay using multivariate regression models. The discriminatory power was evaluated by calculating the area under the receiver operating characteristic curves (C statistic). RESULTS: A total of 1321 complications were observed in 846 (15.9%) patients: respiratory failure (n=432; 8.1%), dialysis-dependent renal failure (n=295; 5.5%), GIC (n=154; 2.9%), CVA (n=151; 2.8%), DSWI (n=146; 2.7%) and sepsis (n=143; 2.7%). Perioperative mortality was 17.0% in patients with at least one major non-cardiac complication and correlated with the number of complications (single, 9.7%; n=53/549; double, 24.0%; n=44/183; ≥3, 41.2%; n=47/114, P<0.001). Six preoperative and four postoperative independent predictors of operative mortality were identified (age (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3-2.4), peripheral vascular disease (OR 2.6; 95% CI 1.6-4.2), pulmonary hypertension (OR 2.7; 95% CI 1.5-4.9), atrial fibrillation (OR 1.5; 95% CI 1.0-2.3), emergency (OR 5.0; 95% CI 3.4-7.2), other procedures than CABG (OR 1.5; 95% CI 1.0-2.1), postoperative dialysis (OR 4.0; 95% CI 2.6-6.1), sepsis (OR 3.4; 95% CI 2.0-5.6), respiratory failure (OR 3.2; 95% CI 2.2-4.9), GIC (OR 3.2; 95% CI 1.9-5.3)) and included in the logistic model, which accurately predicted outcome (C statistic, 0.892; 95% CI 0.868-0.916). Length of hospital stay was significantly increased according to the number of complications (single: median 15 (IQR 10-24) days, double: 16 (IQR 8-28) days, ≥3: 20 (IQR 13-39) days, P<0.001). CONCLUSIONS: With a worsening in the risk profile of patients undergoing cardiac surgery, an increasing number of patients develop major complications leading to increased length of stay and mortality, which is correlated to the number and severity of these complications. Our predictive model based on preoperative and postoperative variables allowed us to determine with accuracy the perioperative mortality in critically ill patients after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Idoso , Área Sob a Curva , Procedimentos Cirúrgicos Cardíacos/mortalidade , Distribuição de Qui-Quadrado , Análise Discriminante , Feminino , Alemanha/epidemiologia , Mortalidade Hospitalar , Humanos , Incidência , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Prognóstico , Curva ROC , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
19.
J Cardiothorac Surg ; 8: 75, 2013 Apr 11.
Artigo em Inglês | MEDLINE | ID: mdl-23577663

RESUMO

BACKGROUND: Coronary-artery-bypass-grafting (CABG) with conventional extracorporeal circulation (CECC) is associated with adverse effects such as systemic inflammatory response leading to a decrease in systemic vascular resistance and hemodynamic instability. Modern "less invasive" procedures have been established recently which potentially avoid negative side effects of CECC. The aim of this study was to compare perioperative outcome following coronary revascularization using either a minimized extracorporeal circuit (Mini-HLM) or off-pump technique (OPCAB). METHODS: In this prospective ethics-approved trial, 120 patients referred for CABG were randomly assigned either to off-pump coronary artery bypass (OPCAB) or to a Mini-HLM procedure. Patient demographics, preoperative characteristics and extensive postoperative outcome were analyzed for both groups. Hemodynamic data were measured at seven time points perioperatively. RESULTS: Operation-time was longer in the Mini-HLM group (178,3 ± 32,9 min) compared to OPCAB (133,2 ± 32,7 min, p < 0,001) with higher graft numbers in Mini-HLM group (3,11 ± 0,7 vs. 1,78 ± 0,7, p < 0.001). There were no significant differences in perioperative hemodynamic criteria, catecholaminergic support, hospital (p = 0,534) and intensive care unit stay (p = 0,880), ventilation time (p = 0,113), blood loss (p = 0,570), transfusion requirements, postoperative atrial fibrillation rate (p = 0,706) and neurocognitive disturbance (p = 0,297). No deaths and no myocardial infarctions were observed. CONCLUSIONS: Coronary revascularisation with Mini-HLM represents a suitable and "less invasive" procedure which achieves all benefits of OPCAB but may allow for less demanding revascularisation than OPCAB in special patients with complex coronary anatomy and can therefore be used both on a routine basis and in all "conversion" cases of OPCAB.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Circulação Extracorpórea/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária sem Circulação Extracorpórea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento
20.
J Surg Res ; 182(2): e43-9, 2013 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-23228324

RESUMO

BACKGROUND: Performing cardiac surgery is associated with stress for surgeons. We investigated stress levels of experienced surgeons and trainees during coronary artery bypass graft teaching procedures. METHODS: We assessed heart rate (HR) and sympathovagal balance (SVB) of experienced surgeons (attendings; n = 7) and residents enrolled in a training program (residents; n = 3) using a one-lead electrocardiogram during a total of 109 elective isolated coronary artery bypass graft procedures. We measured HR and SVB for baseline values at rest and at prespecified phases during the procedure in the role as primary surgeons (n = 10) and assistants (n = 9). RESULTS: All participants were healthy men with a mean age of 41.4 ± 4.3 y. For patients operated on during this study, demographic and intraoperative data were homogeneous. Compared with rest, mean HR and SVB for the whole procedure were higher for surgeons and assistants, with significant differences for HR values (surgeons, 83.7 ± 8.8 beats/min [bpm]; assistants, 85.4 ± 12.7 bpm, P < 0.05 versus 62.3 ± 5.1 bpm). Courses of HR and SVB were comparable for attending and resident groups but values were higher throughout for attendings compared with residents in their role as surgeons during the total procedure, and as assistants during cardiopulmonary bypass. Mean HR and SVB values of attendings assisting the procedure were higher compared with those of residents performing the operation. CONCLUSIONS: Surgical experience is not associated with reduced stress levels. Supervising a teaching case in cardiac surgery can be linked with more stress compared with the resident performing the procedure.


Assuntos
Ponte de Artéria Coronária , Internato e Residência , Estresse Psicológico/etiologia , Adulto , Frequência Cardíaca , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Sistema Nervoso Simpático/fisiologia , Nervo Vago/fisiologia
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