RESUMO
BACKGROUND: We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. METHODS: All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. RESULTS: Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend < .05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P < .05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P < .05) were significantly lower in the early-discharge cohort. CONCLUSIONS: In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Implante de Prótese de Valva Cardíaca , Adulto , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Tempo de Internação , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Valva Mitral/cirurgia , Alta do Paciente , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The wide breadth of vascular surgery (VS) training enables vascular surgeons to assist in nonvascular operations and rapidly respond to urgent and emergent needs for intervention. This study aims to evaluate VS secondary operative assistance and intraoperative consultations METHODS: Retrospective review of all operative interventions with a vascular surgeon as secondary surgeon between January 1, 2011 and January 31, 2020 at a single institution. Any cases with VS as primary service were excluded. Patient demographics, operative variables, and in-hospital outcomes were evaluated. RESULTS: Four hundred thirty-seven patients requiring interventions necessitating VS assistance were identified, this included elective, urgent, and emergent operative cases. One hundred thirty-one cases were urgent or emergent and 306 were elective. The median age was 58.0 years (IQR: 40-68.0). Most patients were male (237, 54.2%), White (298, 68.2%), and average BMI was 29.2 +/- 8.5 with ASA ≥4 (143, 32.7%). One hundred seventy (38.9%) cases involved intraoperative consultations, whereas, 267 (61.1%) provided advance notice of need for secondary assistance. The most common services requesting consultations were spine surgery (both orthopedic and neurosurgery) (83, 19%), cardiothoracic surgery (82, 18.8%), and surgical oncology (42, 9.6%). Vascular interventions included revascularization (108, 4.7%), hemorrhage control (94, 21.5%), and exposure (131, 30%). In-hospital mortality was 12.1%. CONCLUSIONS: With the armamentarium of open, endovascular, and hybrid interventions, vascular surgeons are prepared to respond and intervene in nonvascular cases in the event of unexpected vascular compromise, iatrogenic injury, or challenging exposure, as well as assist in planned elective operations. This study reinforces the role of VS in an institution's ability to offer safe and prompt surgical care.
Assuntos
Especialidades Cirúrgicas , Cirurgiões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversosRESUMO
BACKGROUND: Cardiogenic shock and cardiac arrest are life-threatening emergencies with high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA ECMO) and extracorporeal cardiopulmonary resuscitation (e-CPR) provide viable options for life sustaining measures when medical therapy fails. The purpose of this study is to determine the utilization and outcomes of VA ECMO and eCPR in patients that require emergent cardiac support at a single academic center. METHODS: A retrospective chart review of prospectively collected data was performed at an academic institution from January 1st, 2018 to June 30th, 2020. All consecutive patients who required VA ECMO were evaluated based on whether they underwent traditional VA ECMO or eCPR. The study variables include demographic data, duration on ECMO, length of stay, complications, and survival to discharge. RESULTS: A total of 90 patients were placed on VA ECMO for cardiac support with 44.4% (40) of these patients undergoing eCPR secondary to cardiac arrest and emergent placement on ECMO. A majority of the patients were male (n = 64, 71.1%) and the mean age was 58.8 ± 15.8 years. 44.4% of patients were transferred from outside hospitals for a higher level of care and 37.8% of patients required another primary therapy such as an Impella or IABP. The most common complication experienced by patients was bleeding (n = 41, 45.6%), which occurred less often in eCPR (n = 29, 58% vs. n = 12, 30%). Other complications included infections (n = 11, 12.2%), limb ischemia (n = 13, 14.4%), acute kidney injury (n = 17, 18.9%), and cerebral vascular accident (n = 4, 4.4%). The length of stay was longer for patients on VA ECMO (32.1 ± 40.7 days vs. 17.7 ± 18.2 days). Mean time on ECMO was 8.1 ± 8.3 days. Survival to discharge was higher in VA ECMO patients (n = 23, 46% vs. n = 8, 20%). CONCLUSION: VA ECMO provided an effective rescue therapy in patients in acute cardiogenic shock with a survival greater than the expected ELSO guidelines of 40%. While the survival of eCPR was lower than expected, this may reflect the severity of patient's condition and emphasizes the importance of careful patient selection and planning.
Assuntos
Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Feminino , Parada Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Choque Cardiogênico/terapiaRESUMO
OBJECTIVE: As the population ages, increasing number of older patients are undergoing adult cardiac surgery. The purpose of the study is to assess the impact of age on postoperative outcomes in patients that undergo coronary artery bypass grafting (CABG). METHODS: Patients that are ≥70 years old who underwent CABG were selected from the Nationwide/National Inpatient Sample from 2010 to 2015 using ICD-9-CM diagnosis and procedure codes. The patients who were 70-79 years old were compared to patients aged 80-89 years old to determine if the age difference of the patients had an impact on surgical outcomes. In addition, a secondary endpoint is to compare surgical outcomes between the 2 genders of the patients 80-89 years old. The rates of postoperative complications, and mortality were compared. RESULTS: A total of 67,568 patients were identified who were ≥ 70 years old and underwent CABG. Compared to the Septuagenarians, the Octogenarians were more likely to develop cardiac complications (OR [odds ratio] =1.20, 95% CI [confidence interval] 1.12-1.23. They were also more likely to develop renal complications (P < 0001), and respiratory complications (P < 0001). The Octogenarians were also more likely to bleed postoperatively (P < 0.0001) and have a higher mortality (P < 0001). Furthermore, the female Octogenarians had a higher mortality (OR 1.25 95% CI 1.07-1.46) compared to males in the same age group. CONCLUSIONS: The patients who were ≥ 80-89 years old had worse postoperative outcomes. The Octogenarians who were females had a higher mortality compared to their male counterparts.
Assuntos
Fatores Etários , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Razão de Chances , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores Sexuais , Resultado do TratamentoRESUMO
The molluscum contagiosum virus (MCV) uses a variety of immune evasion strategies to antagonize host immune responses. Two MCV proteins, MC159 and MC160, contain tandem death effector domains (DEDs). They are reported to inhibit innate immune signaling events such as NF-κB and IRF3 activation, and apoptosis. The RxDL motif of MC159 is required for inhibition of both apoptosis and NF-κB activation. However, the role of the conserved RxDL motif in the MC160 DEDs remained unknown. To answer this question, we performed alanine mutations to neutralize the arginine and aspartate residues present in the MC160 RxDL in both DED1 and DED2. These mutations were further modeled against the structure of the MC159 protein. Surprisingly, the RxDL motif was not required for MC160's ability to inhibit MAVS-induced IFNß activation. Further, unlike previous results with the MC159 protein, mutations within the RxDL motif of MC160 had no effect on the ability of MC160 to dampen TNF-α-induced NF-κB activation. Molecular modeling predictions revealed no overall changes to the structure in the MC160 protein when the amino acids of both RxDL motifs were mutated to alanine (DED1 = R67A D69A; DED2 = R160A D162A). Taken together, our results demonstrate that the RxDL motifs present in the MC160 DEDs are not required for known functions of the viral protein.