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BACKGROUND: Prophylactic embolization of the inferior mesenteric artery (IMA) during endovascular aneurysm repair (EVAR) is recommended to prevent type 2 endoleak (T2EL). However, the impact of patent lumbar arteries (LAs) on T2ELs and aneurysm diameter has not been elucidated. METHODS: Fifty-seven consecutive patients who underwent EVAR at our institution between January 2013 and September 2022 and whose IMA had been occluded preoperatively or newly occluded postoperatively were included in the study. Predictive factors for aneurysm sac enlargement, sac shrinkage, and T2EL were investigated. RESULTS: T2ELs occurred in 22.8% of the patients. The 4-year cumulative incidence rates of sac enlargement and shrinkage were 6.7% and 64.6%, respectively. The number of postoperative patent LAs was identified as a risk factor for T2ELs (95% confidence interval [CI]: 1.54-12.7, P = 0.0065). The number of postoperative patent LAs was found to be a significant predictor of sac enlargement (adjusted hazard ratio [AHR] 3.15, 95% CI: 1.43-6.96, P = 0.0045) and shrinkage (AHR 0.63, 95% CI: 0.43-0.91, P = 0.014). CONCLUSIONS: The current study demonstrated that the number of postoperative patent LAs had a significant impact on the development of T2ELs and the change in aneurysm diameter in patients in whom the IMA was occluded after EVAR.
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Aneurisma de la Aorta Abdominal , Implantación de Prótesis Vascular , Embolización Terapéutica , Procedimientos Endovasculares , Humanos , Endofuga/diagnóstico por imagen , Endofuga/etiología , Endofuga/cirugía , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Abdominal/complicaciones , Reparación Endovascular de Aneurismas , Resultado del Tratamiento , Implantación de Prótesis Vascular/efectos adversos , Procedimientos Endovasculares/efectos adversos , Aorta Abdominal/cirugía , Factores de Riesgo , Estudios Retrospectivos , Embolización Terapéutica/efectos adversosRESUMEN
BACKGROUND: There is no large-scale study comparing postoperative mortality after aortic valve replacement (AVR) for asymptomatic severe aortic stenosis (AS) between initial treatment with AVR vs. eventual AVR after conservative management. MethodsâandâResults: We analyzed data from a multicenter registry enrolling 3,815 consecutive patients with severe AS. Of 1,808 asymptomatic patients, 286 patients initially underwent AVR (initial AVR group), and 377 patients were initially managed conservatively and eventually underwent AVR (AVR after watchful waiting group). Mortality after AVR was compared between the 2 groups. Subgroup analysis according to peak aortic jet velocity (Vmax) at diagnosis was also conducted. There was no significant difference between the 2 groups in 5-year overall survival (OS; 86.0% vs. 84.1%, P=0.34) or cardiovascular death-free survival (DFS; 91.3% vs. 91.1%, P=0.61), but on subgroup analysis of patients with Vmax ≥4.5 m/s at diagnosis, the initial AVR group was superior to the AVR after watchful waiting group in both 5-year OS (88.4% vs. 70.6%, P=0.003) and cardiovascular DFS (91.9% vs. 81.7%, P=0.023). CONCLUSIONS: Asymptomatic severe AS patients who underwent AVR after watchful waiting had a postoperative survival rate similar to those who initially underwent AVR. In a subgroup of patients with Vmax ≥4.5 m/s at diagnosis, however, the AVR after watchful waiting group had worse postoperative survival rate than the initial AVR group.
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Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Espera Vigilante , Anciano , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/mortalidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Tasa de Supervivencia , Factores de Tiempo , Tiempo de TratamientoRESUMEN
BACKGROUND: We aimed to investigate the incidence and risk factors of postoperative acute pancreatitis (PAP) following thoracic aortic surgery with circulatory arrest. METHODS: One hundred fifty-two patients who underwent thoracic aortic surgery with circulatory arrest between February 2015 and March 2023 were retrospectively reviewed. Postoperative acute pancreatitis was defined as the presence of two or more of the following criteria: (1) abdominal pain, (2) postoperative amylase or lipase levels greater than three times the upper limit of normal, and (3) evidence of pancreatitis on postoperative computed tomography (CT) scan. Univariate and multivariate analyses were performed to find risk factors for PAP. RESULTS: Nine patients (5.9%) developed PAP without mortality. All of the nine patients had elevated pancreatic enzymes and evidence of pancreatitis on CT. They improved with conservative therapy. In multivariate analysis, only cross-clamp time was found to be a significant risk factor for PAP (adjusted odds ratio, 1.04; 95% confidence interval, 1-1.08; p = 0.042). CONCLUSION: The incidence of PAP after thoracic aortic surgery with circulatory arrest was 5.9%, and cross-clamp time is an independent risk factor for PAP.
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BACKGROUND: The impact of very low baseline levels of low-density lipoprotein cholesterol (LDL-C) on patients with coronary artery disease remains unclear. METHOD: We enrolled 39,439 patients of the pooled population from the CREDO-Kyoto registries Cohorts 1, 2, and 3. The study population consisted of 33,133 patients who had undergone their first coronary revascularization. We assessed the risk for mortality and cardiovascular events according to quintiles of the baseline LDL-C levels. RESULTS: Patients in the very low LDL-C quintile (<85â¯mg/dL) had more comorbidities than those in the other quintiles. Lower LDL-C levels were strongly associated with anemia, thrombocytopenia, and end-stage renal disease. The cumulative 4-year incidence of all-cause death increased as LDL-C levels decreased (very low: 19.4â¯%, low: 14.5â¯%, intermediate: 11.1â¯%, high: 10.0â¯%, and very high: 9.2â¯%; pâ¯<â¯0.001), which was driven by both the early and late events. After adjusting for baseline characteristics, the adjusted risks of the very low and low LDL-C quintiles relative to the intermediate LDL-C quintile remained significant for all-cause death (very low: HR 1.29, 95â¯% CI 1.16-1.44, pâ¯<â¯0.001; low: HR 1.15, 95â¯% CI 1.03-1.29, pâ¯=â¯0.01). The excess adjusted risks of the lowest LDL-C quintile relative to the intermediate LDL-C quintile were significant for clinical outcomes such as cardiovascular death (HR 1.17, 95â¯% CI 1.01-1.35), non-cardiovascular death (HR 1.35, 95â¯% CI 1.15-1.60), sudden death (HR 1.44, 95â¯% CI 1.01-2.06), and heart failure admission (HR 1.11 95â¯% CI 1.01-1.22), while there was no excess risk for the lowest LDL-C quintile relative to the intermediate LDL-C quintile for myocardial infarction and stroke. CONCLUSIONS: Lower baseline LDL-C levels were associated with more comorbidities and a significantly higher risk of death, regardless of cardiovascular or non-cardiovascular causes, in patients who underwent coronary revascularization.
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LDL-Colesterol , Enfermedad de la Arteria Coronaria , Sistema de Registros , Humanos , LDL-Colesterol/sangre , Masculino , Femenino , Anciano , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/mortalidad , Pronóstico , Persona de Mediana Edad , Revascularización Miocárdica , Causas de Muerte , Japón/epidemiología , Factores de RiesgoRESUMEN
BACKGROUND: There is a paucity of data regarding shorter life expectancy after aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). METHODS: Among 3815 patients with severe AS enrolled in the CURRENT AS (Contemporary outcomes after sURgery and medical tREatmeNT in patients with severe Aortic Stenosis) registry, there were 1469 patients (initial AVR: n = 647; conservative strategy: n = 822) with low surgical risk, 1642 patients (initial AVR: n = 433; conservative strategy: n = 1209) with intermediate surgical risk, and 704 patients (initial AVR: n = 117; conservative strategy: n = 587) with high surgical risk. Among 1163 patients who actually underwent surgical AVR as the initial strategy, patients were divided into 4 groups according to age <65 years (n = 185), 65 to 74 (n = 394), 75 to 80 (n = 345), and >80 (n = 239). The expected survival of the general Japanese population was obtained from the Statistics Bureau of Japan. The surgical risk was estimated using The Society of Thoracic Surgery (STS) score. RESULTS: The median follow-up was 3.7 years. The cumulative incidences of all-cause death were significantly lower in the initial AVR strategy than in the initial conservative strategy across the 3 STS groups. Shorter life expectancy after surgical AVR was seen especially in younger patients. The observed mortality in low-risk patients was comparable to the expected mortality across all the age-groups, while intermediate-risk patients aged <75 years, and high-risk patients across all age-groups had higher mortality compared with the expected mortality. CONCLUSIONS: The risk stratification according to age and STS score might be useful to estimate shorter life expectancy after AVR, and these findings have implications for decision making in the choice of surgical or transcatheter AVR.
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Estenosis de la Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Factores de Riesgo , Válvula Aórtica/cirugía , Esperanza de Vida , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: We assessed the clinical effectiveness of coronary artery bypass grafting (CABG) in comparison with that of percutaneous coronary intervention (PCI) in octogenarians with triple-vessel disease (TVD) or left main coronary artery (LMCA) disease. METHODS: From the CREDO-Kyoto registry cohort-2, 527 patients, who were ≥ 80 years of age and underwent the first coronary revascularization for TVD or LMCA disease, were divided into the CABG group (N = 151) and the PCI group (N = 376). RESULTS: The median and interquartile range of patient's age was 82 (81-84) in the CABG group and 83 (81-85) in the PCI group (P = 0.10). Patients > = 85 years of age accounted for 19% and 31% in the CABG and PCI groups, respectively (P = 0.01). The cumulative 5-year incidence of all-cause death was similar between CABG and PCI groups (35.8% vs. 42.9%, log-rank P = 0.18), while CABG showed a lower rate of the composite of cardiac death/MI than PCI (21.7% vs. 33.9%, log-rank P = 0.005). After adjusting for confounders, the lower risk of CABG relative to PCI was significant for all-cause death (HR 0.61, 95% CI 0.43-0.86, P = 0.005), any coronary revascularization (HR 0.25, 95% CI 0.14-0.43, P < 0.001) and the composite of cardiac death/MI (HR 0.52, 95% CI 0.32-0.85, P = 0.009). CONCLUSIONS: CABG compared with PCI was associated with a lower adjusted risk for all-cause death, any coronary revascularization, and a composite of cardiac death/MI in very elderly patients with TVD or LMCA disease. CABG seemed an acceptable option for selected octogenarians with severe coronary artery disease.
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Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Infarto del Miocardio , Intervención Coronaria Percutánea , Accidente Cerebrovascular , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Muerte , Humanos , Octogenarios , Intervención Coronaria Percutánea/efectos adversos , Accidente Cerebrovascular/epidemiología , Resultado del TratamientoRESUMEN
AIMS: There is a scarcity of studies comparing percutaneous coronary intervention (PCI) using new-generation drug-eluting stents (DES) with coronary artery bypass grafting (CABG) in patients with multi-vessel coronary artery disease. METHODS AND RESULTS: The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who underwent first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. The current study population consisted of 2464 patients who underwent multi-vessel coronary revascularization including revascularization of left anterior descending coronary artery (LAD) either with PCI using new-generation DES (N = 1565), or with CABG (N = 899). Patients in the PCI group were older and more often had severe frailty, but had less complex coronary anatomy, and less complete revascularization than those in the CABG group. Cumulative 5-year incidence of a composite of all-cause death, myocardial infarction or stroke was not significantly different between the 2 groups (25.0% versus 21.5%, P = 0.15). However, after adjusting confounders, the excess risk of PCI relative to CABG turned to be significant for the composite endpoint (HR 1.27, 95%CI 1.04-1.55, P = 0.02). PCI as compared with CABG was associated with comparable adjusted risk for all-cause death (HR 1.22, 95%CI 0.96-1.55, P = 0.11), and stroke (HR 1.17, 95%CI 0.79-1.73, P = 0.44), but with excess adjusted risk for myocardial infarction (HR 1.58, 95%CI 1.05-2.39, P = 0.03), and any coronary revascularization (HR 2.66, 95%CI 2.06-3.43, P<0.0001). CONCLUSIONS: In this observational study, PCI with new-generation DES as compared with CABG was associated with excess long-term risk for major cardiovascular events in patients who underwent multi-vessel coronary revascularization including LAD.
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Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Infarto del Miocardio , Intervención Coronaria Percutánea , Accidente Cerebrovascular , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/efectos adversos , Sistema de RegistrosRESUMEN
Background: Diabetes is a well-known risk factor for adverse outcomes after coronary revascularization. Objectives: This study sought to determine high-risk subgroups in whom the excess risks of diabetes relative to nondiabetes are particularly prominent and thus may benefit from more aggressive interventions. Methods: The study population consisted of 39,427 patients (diabetes: n = 15,561; nondiabetes: n = 23,866) who underwent first percutaneous coronary intervention (n = 33,144) or coronary artery bypass graft (n = 6,283) in the pooled CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Graft) registry. The primary outcome measure was major adverse cardiovascular and cerebral endpoints (MACCE), which was defined as a composite of all-cause death, myocardial infarction, and stroke. Results: With median follow-up of 5.6 years, diabetes was associated with significantly higher adjusted risks for MACCE. The excess adjusted risks of diabetes relative to nondiabetes for MACCE increased with younger age (≤64 years: adjusted HR: 1.30; 95% CI: 1.19-1.41; P < 0.001; 64-73 years: adjusted HR: 1.24; 95% CI: 1.16-1.33; P < 0.001; >73 years: adjusted HR: 1.17; 95% CI: 1.10-1.23; P < 0.001; P interaction < 0.001), mainly driven by greater excess adjusted mortality risk of diabetes relative to nondiabetes in younger tertile. No significant interaction was observed between adjusted risk of diabetes relative to nondiabetes for MACCE and other subgroups such as sex, mode of revascularization, and clinical presentation of acute myocardial infarction. Conclusions: The excess risk of diabetes relative to nondiabetes for MACCE was profound in the younger population. This observation suggests more aggressive interventions for secondary prevention in patients with diabetes might be particularly relevant in younger patients.
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OBJECTIVE: The objective of this investigation was to establish the effectiveness of sustained-release platelet-rich plasma (PRP) on perfusion and neovascularization in diabetic murine hind limb ischemia. METHODS: After surgery in streptozotocin-induced diabetic mice, the mice were randomly assigned to the following 4 experimental groups: control (C), 100 µl of the sustained-release form of platelet-poor plasma (PPP), 100 µl of the solution form of PRP (PRP-sol), and 100 µl of the sustained-release form of PRP (PRP-sr). Endpoint evaluations were: blood perfusion by laser Doppler perfusion imaging (LDPI), vascular density by anti-vWF, and mature vessel density by anti-smooth muscle actin antibody. RESULTS: This study demonstrated that a sustained release of PRP increases the perfusion of ischemic tissue as measured by LDPI (57 ± 12; 56 ± 9; 72 ± 7, and 98 ± 4 for the C, PPP, PRP-sol, and PRP-sr groups, respectively; p < 0.05), capillary density (151 ± 16; 158 ± 12; 189 ± 39, and 276 ± 39 for groups C, PPP, PRP-sol, and PRP-sr, respectively; p < 0.05), and mature vessel density (28 ± 2; 31 ± 3; 52 ± 10, and 85 ± 13 for the C, PPP, PRP-sol, and PRP-sr groups, respectively; p < 0.05). CONCLUSION: A sustained release of PRP containing potent angiogenic growth factors restores blood perfusion by stimulating angiogenesis and arteriogenesis.
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Capilares/fisiopatología , Diabetes Mellitus Experimental/complicaciones , Angiopatías Diabéticas/terapia , Isquemia/terapia , Músculo Esquelético/irrigación sanguínea , Neovascularización Fisiológica , Plasma Rico en Plaquetas/metabolismo , Proteínas Angiogénicas/sangre , Animales , Glucemia/metabolismo , Línea Celular , Proliferación Celular , Preparaciones de Acción Retardada , Diabetes Mellitus Experimental/sangre , Diabetes Mellitus Experimental/fisiopatología , Angiopatías Diabéticas/sangre , Angiopatías Diabéticas/etiología , Angiopatías Diabéticas/fisiopatología , Células Endoteliales/metabolismo , Miembro Posterior , Inmunohistoquímica , Péptidos y Proteínas de Señalización Intercelular/sangre , Isquemia/etiología , Isquemia/fisiopatología , Flujometría por Láser-Doppler , Masculino , Ratones , Ratones Endogámicos C57BL , Distribución Aleatoria , Recuperación de la Función , Flujo Sanguíneo Regional , Factores de TiempoRESUMEN
OBJECTIVES: Pulmonary hypertension during cardiac surgery is associated with increased morbidity and mortality. Inhaled nitric oxide serves as a selective pulmonary vasodilator and has other potential extrapulmonary protective roles. Its effects on pulmonary hypertension and organ functions after adult valve surgeries were evaluated. METHODS: From April 2017 to March 2000, 30 patients received inhaled nitric oxide therapy for pulmonary hypertension during weaning from cardiopulmonary bypass in valvular surgery (iNO group). The group was compared with a control group of 65 patients who developed pulmonary hypertension during weaning from cardiopulmonary bypass in valvular surgery and received conventional therapy from April 2014 to March 2017. Intraoperative hemodynamic changes and postoperative Sequential Organ Failure Assessment (SOFA) score were evaluated. RESULTS: The inhalation of nitric oxide lowered the pulmonary-to-systemic pressure ratio (Pp/Ps) (p < 0.0001) in the iNO group, and this ratio after the inhalation was significantly lower than that in the control group (p = 0.015). Moreover, norepinephrine requirement was lower in the iNO group than in the control group (p = 0.0060). The SOFA total scores, respiratory scores, coagulation scores, and the increase of renal scores within postoperative 2 days were lower in the iNO group than in the control group (p < 0.0001, p = 0.0002, p = 0.0013, and p = 0.037). CONCLUSIONS: Inhaled nitric oxide therapy ameliorated pulmonary hypertension and improved postoperative respiratory, coagulation, and renal functions in adult valve surgeries.
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Procedimientos Quirúrgicos Cardíacos , Hipertensión Pulmonar , Administración por Inhalación , Adulto , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Válvulas Cardíacas/cirugía , Humanos , Hipertensión Pulmonar/tratamiento farmacológico , Hipertensión Pulmonar/etiología , Óxido Nítrico , Vasodilatadores/uso terapéuticoRESUMEN
The treatment of coronary artery disease has substantially changed over the past two decades. However, it is unknown whether and how much these changes have contributed to the improvement of long-term outcomes after coronary revascularization. We assessed trends in the demographics, practice patterns and long-term outcomes in 24,951 patients who underwent their first percutaneous coronary intervention (PCI) (nâ¯=â¯20,106), or isolated coronary artery bypass grafting (CABG) (nâ¯=â¯4,845) using the data in a series of the CREDO-Kyoto PCI/CABG Registries (Cohort-1 [2000 to 2002]: nâ¯=â¯7,435, Cohort-2 [2005 to 2007]: nâ¯=â¯8,435, and Cohort-3 [2011 to 2013]: nâ¯=â¯9,081). From Cohort-1 to Cohort-3, the patients got progressively older across subsequent cohorts (67.0 ± 10.0, 68.4 ± 9.9, and 69.8 ± 10.2 years, ptrend < 0.001). There was increased use of PCI over CABG (73.5%, 81.9%, and 85.2%, ptrend < 0.001) and increased prevalence of evidence-based medications use over time. The cumulative 3-year incidence of all-cause death was similar across the 3 cohorts (9.0%, 9.0%, and 9.3%, pâ¯=â¯0.74), while cardiovascular death decreased over time (5.7%, 5.1%, and 4.8%, pâ¯=â¯0.03). The adjusted risk for all-cause death and for cardiovascular death progressively decreased from Cohort-1 to Cohort-2 (HR:0.89, 95%CI:0.80 to 0.99, pâ¯=â¯0.03, and HR:0.80, 95%CI:0.70 to 0.92, pâ¯=â¯0.002, respectively), and from Cohort-2 to Cohort-3 (HR:0.86, 95%CI:0.78 to 0.95, pâ¯=â¯0.004, and HR:0.77, 95%CI:0.67-0.89, p < 0.001, respectively). The risks for stroke and repeated coronary revascularization also improved over time. In conclusions, we found a progressive and substantial reduction of adjusted risk for all-cause death, cardiovascular death, stroke, and repeated coronary revascularization over the past two decades in Japan.
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Puente de Arteria Coronaria/tendencias , Enfermedad de la Arteria Coronaria/cirugía , Mortalidad/tendencias , Intervención Coronaria Percutánea/tendencias , Factores de Edad , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/mortalidad , Causas de Muerte , Estudios de Cohortes , Comorbilidad/tendencias , Diabetes Mellitus/epidemiología , Terapia Antiplaquetaria Doble/tendencias , Duración de la Terapia , Medicina Basada en la Evidencia , Femenino , Insuficiencia Cardíaca/epidemiología , Hemorragia/epidemiología , Humanos , Hipertensión/epidemiología , Japón/epidemiología , Fallo Renal Crónico/epidemiología , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Revascularización Miocárdica/tendencias , Complicaciones Posoperatorias/epidemiología , Hemorragia Posoperatoria/epidemiología , Sistema de Registros , Diálisis Renal , Reoperación , Fumar/epidemiología , Stents , Accidente Cerebrovascular/epidemiología , Trombosis/epidemiologíaRESUMEN
There is a scarcity of data comparing long-term clinical outcomes between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three-vessel coronary artery disease (3VD) in the new-generation drug-eluting stents era. CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who had undergone first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. We identified 2525 patients with 3VD (PCI: n = 1747 [69%], and CABG: n = 778 [31%]). The primary outcome measure was all-cause death. Median follow-up duration was 5.7 (interquartile range: 4.4 to 6.6) years. The cumulative 5-year incidence of all-cause death was significantly higher in the PCI group than in the CABG group (19.8% vs 13.2%, log-rank p = 0.001). After adjusting confounders, the excess risk of PCI relative to CABG for all-cause death remained significant (HR, 1.45; 95% CI, 1.14 to 1.86; p = 0.003), which was mainly driven by the excess risk for non-cardiovascular death (HR, 1.88; 95% CI, 1.30 to 2.79; p = 0.001), while there was no excess risk for cardiovascular death between PCI and CABG (HR, 1.19; 95% CI, 0.87 to 1.64; p = 0.29). There was significant excess risk of PCI relative to CABG for myocardial infarction (HR, 1.77; 95% CI, 1.19 to 2.69; p = 0.006), whereas there was no excess risk of PCI relative to CABG for stroke (HR, 1.24; 95% CI, 0.83 to 1.88; p = 0.30). In conclusion, in the present study population reflecting real-world clinical practice in Japan, PCI compared with CABG was associated with significantly higher risk for all-cause death, while there was no excess risk for cardiovascular death between PCI and CABG.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Stents Liberadores de Fármacos , Mortalidad , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Causas de Muerte , Estudios de Cohortes , Femenino , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Modelos de Riesgos Proporcionales , Sistema de Registros , Accidente Cerebrovascular/epidemiologíaRESUMEN
BACKGROUND: While single growth factor has limitation to induce optimal neovascularization, platelet-rich plasma (PRP) is an autologous reserver of various growth factors. However, little is known about the mechanism of PRP-related neovascularization.The objective of this investigation was to characterize the angiogenic and growth factor content of PRP and to determine, in vitro, its effect on endothelial cell proliferation. Additionally, this experiment sought to determine the effectiveness of different compositions of PRP (solution versus sustained release) on perfusion and neovascularization in a murine model of hind limb ischemia. METHODS: Different growth factors were measured by enzyme-linked immunosorbent assay (ELISA). In vivo study, we used gelatin hydrogel as a sustained release carrier for growth factors in PRP. We induced hind limb ischemia by excising right femoral artery in wild type C57BL6 mice. After surgery, mice were randomly assigned to four experimental groups; control (C), 100 muL of sustained release form of platelet-poor plasma (PPP), 100 muL of solution form of PRP (PRP-sol), 100 muL of sustained release form of PRP (PRP-sr); each formulation was administered via an intramuscular injection to the ischemic hind limb. Endpoint evaluations were blood perfusion by laser Doppler perfusion image, vascular density by anti Von Willebrand factor (vWF), and mature vessel density by anti smooth muscle actin (SMA) antibody. Green fluorescent protein (GFP+) transgenic mice were generated by transplantation of bone marrow derived mononuclear cells to wild type C57BL6 mice, and finally CD34+ cell in the ischemic site of transgenic mice was detected by staining with anti-CD34 antibody. RESULTS: In vitro study showed that PRP containing different growth factors induces endothelial cell proliferation and capillary tube formation. In vivo study demonstrated that sustained release of PRP increased perfusion of ischemic tissue as measured by laser Doppler perfusion imaging (LDPI) (57 +/- 12, 56 +/- 9, 72 +/- 7, 98 +/- 4 for groups C, PPP, PRP-sol, and PRP-sr, respectively; P < .05); capillary density (151 +/- 16, 158 +/- 12, 189 +/- 39, 276 +/- 39 for groups C, PPP, PRP-sol, and PRP-sr, respectively, P < .05) and mature vessel density (28 +/- 2, 31 +/- 3, 52 +/- 10, 85 +/- 13 for groups C, PPP, PRP-sol, and PRP-sr, respectively, P < .05) . Sustained release PRP also increases CD34+ cells in the ischemic site of transgenic mice (6 +/- 3 vs 18 +/- 5/mm(2) for groups control and PRP-sr respectively, P < .05). CONCLUSION: Sustained release of PRP containing potent angiogenic growth factors restores blood perfusion presumably by stimulating angiogenesis, arteriogenesis, as well as vasculogenesis in the mouse hind limb ischemia. CLINICAL RELEVANCE: PRP is a natural reserver of various growth factors that can be collected autologously and is costeffective. Thus for clinical use, no special considerations concerning antibody formation and infection risk are needed.Some clinical devices to automatically prepare PRP are available at present. PRP are consistently being used clinically inthe department of orthopedics and plastic surgery (oral, maxillary facial) for a long time. On the basis of researchevidence, some publications have reported positive results in either bone or soft tissue healing. However, some researchconcludes that there is no or little benefit from PRP. This is likely due to faster degradation of growth factors in PRP sincesome authors suggest using sustained release form of PRP to deliver optimal effect of PRP. Gelatin hydrogel is also beingused clinically as a slow, sustained release of carrier for growth factors in our center recently.
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Células Endoteliales/efectos de los fármacos , Miembro Posterior/irrigación sanguínea , Isquemia/tratamiento farmacológico , Neovascularización Fisiológica/efectos de los fármacos , Plasma Rico en Plaquetas/metabolismo , Animales , Proliferación Celular/efectos de los fármacos , Modelos Animales de Enfermedad , Células Endoteliales/metabolismo , Ensayo de Inmunoadsorción Enzimática , Miembro Posterior/efectos de los fármacos , Técnicas In Vitro , Masculino , Ratones , Ratones Endogámicos C57BL , Ratones Transgénicos , Probabilidad , Distribución Aleatoria , Sensibilidad y EspecificidadRESUMEN
AIMS: Tricuspid regurgitation (TR) has been reported to be associated with worse survival in various heart diseases, but there are few data in aortic stenosis (AS). METHODS AND RESULTS: In the Contemporary Outcomes after Surgery and Medical Treatment in Patients with Severe Aortic Stenosis (CURRENT AS) Registry enrolling 3815 consecutive patients with severe AS, there were 628 patients with moderate or severe TR (TR group) and 3187 patients with no or mild TR (no TR group). The study patients were subdivided into the initial aortic valve replacement (AVR) stratum (n = 1197) and the conservative stratum (n = 2618) according to treatment strategy. The primary outcome measure was a composite of aortic valve-related death or hospitalization due to heart failure. The 5-year freedom rate from the primary outcome measure was significantly lower in the TR group than in the no TR group (49.1% vs. 67.3%, P < 0.001). Even after adjusting for confounders, the excess risk of TR relative to no TR for the primary outcome measure remained significant [hazard ratio (HR): 1.25, 95% confidence interval (CI): 1.06-1.48; P = 0.008]. The trend for the excess adjusted risk in the TR group was consistent in the initial AVR and the conservative strata (HR 1.55, 95% CI: 0.97-2.48; P = 0.07; HR 1.22, 95% CI: 1.02-1.46; P = 0.03, respectively). In the initial AVR stratum, the 5-year freedom rate from the primary outcome measure was not different between the two groups with (n = 56) or without (n = 91) concomitant tricuspid annuloplasty (61.5% vs. 72.1%, P = 0.48). CONCLUSION: The presence of clinically significant TR concomitant with severe AS is associated with a poor long-term outcome, regardless of the initial treatment strategy.
Asunto(s)
Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/epidemiología , Implantación de Prótesis de Válvulas Cardíacas/métodos , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/epidemiología , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/fisiopatología , Estudios de Cohortes , Comorbilidad , Tratamiento Conservador/métodos , Ecocardiografía Doppler/métodos , Femenino , Humanos , Modelos Logísticos , Masculino , Análisis Multivariante , Pronóstico , Modelos de Riesgos Proporcionales , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento , Insuficiencia de la Válvula Tricúspide/fisiopatologíaRESUMEN
Worldwide, there is a growing number of patients with myocardial ischemia and limb ischemia associated with the aging population and an increased prevalence of atherosclerotic diseases. Medical therapy, percutaneous angioplasty and surgical revascularization are the present treatments of choice, but such treatments are not feasible for some patients with severe atherosclerosis. Therapeutic angiogenesis using growth factors or progenitor cells has drawn great attention as a favorable alternative treatment for such patients. This review discusses clinical trials using angiogenic growth factors for myocardial ischemia and limb ischemia, and also introduces a novel controlled release system for growth factors using a gelatin hydrogel.
Asunto(s)
Inductores de la Angiogénesis/uso terapéutico , Enfermedades Cardiovasculares/terapia , Preparaciones de Acción Retardada/uso terapéutico , Péptidos y Proteínas de Señalización Intercelular/uso terapéutico , Inductores de la Angiogénesis/administración & dosificación , Animales , Preparaciones de Acción Retardada/administración & dosificación , Terapia Genética/métodos , Humanos , Péptidos y Proteínas de Señalización Intercelular/administración & dosificación , Isquemia Miocárdica/terapia , Miocitos Cardíacos/trasplante , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Valve-sparing root replacement (VSRR) is an established therapy for aortic root pathology. However, late aortic valve dysfunction requiring reoperation remains a primary concern of this procedure. This study examines risk factors for late aortic insufficiency (AI) and aortic stenosis (AS) after David V VSRR. METHODS: A retrospective review from 2005 to 2015 at a US academic center identified 282 patients who underwent VSRR. Cox proportional hazards regression analysis was used to identify risk factors for late AI and AS after VSRR. RESULTS: The mean age was 46.4 years. Sixty-four patients (22.7%) had bicuspid valves, and 41 patients (14.5%) had Marfan syndrome. The incidence of reoperations was 27 (9.6%), and 42 cases (14.9%) presented with acute type A dissection. Operative mortality was 8 (2.8%). Seven-year survival was 90.9%. Seven-year cumulative incidence of reoperation, greater than 2+ AI and greater than moderate AS were 3.1%, 2.2%, and 0.8%, respectively. Multivariable analysis showed aortic root size 55 mm or larger (hazard ratio 3.44, 95% confidence interval: 1.27 to 9.29, p = 0.01) to be a risk factor for late AI whereas bicuspid valve (hazard ratio 16.07, 95% confidence interval: 3.12 to 82.68, p = 0.001) and cusp repair were found to be risk factors (hazard ratio 5.91, 95% confidence interval: 1.17 to 29.86, p = 0.03) for late AS. CONCLUSIONS: Valve-sparing root replacement can be performed with low operative risk and good overall long-term survival even in complex clinical settings. Durable valve function can be expected; however, aortic root size 55 cm or more, bicuspid valve anatomy, and cusp repair represent independent risk factors for late aortic valve dysfunction after these procedures.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/anomalías , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Adulto , Análisis de Varianza , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico , Insuficiencia de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Enfermedad de la Válvula Aórtica Bicúspide , Anuloplastia de la Válvula Cardíaca/métodos , Estudios de Cohortes , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Masculino , Síndrome de Marfan/mortalidad , Síndrome de Marfan/cirugía , Persona de Mediana Edad , Análisis Multivariante , Tratamientos Conservadores del Órgano/métodos , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/cirugía , Pronóstico , Modelos de Riesgos Proporcionales , Reoperación/métodos , Reoperación/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: Reoperative aortic root replacement is a challenging procedure associated with significant mortality and morbidity. The purpose of this study was to investigate the outcomes of reoperative aortic root replacement when performed in a number of complex clinical settings and to identify risk factors for operative mortality and long-term survival. METHODS: From 2006 to 2015, 280 consecutive patients at an academic center underwent reoperative aortic root replacement after a variety of previous aortic or cardiac operations. Logistic regression and extended Cox proportional hazards regression analyses were used to determine risk factors for operative mortality and long-term survival, respectively. RESULTS: The mean age of patients was 52.5 ± 14.1 years. Prior operations included proximal aortic replacement in 113 patients, valve surgery in 162 patients, and coronary artery bypass grafting in 46 patients. Concomitant procedures included arch replacement in 135 patients, coronary artery bypass grafting in 68 patients, and mitral valve repair/replacement in 18 patients. Operative mortality was 14.3%. Five-year survival was 74.0%. Univariable analysis did not find previous root replacement, prior proximal aortic surgery, and concomitant arch replacement to be risk factors for operative mortality. In the multivariable analysis, chronic lung disease, prior myocardial infarction, and concomitant mitral valve surgery were risk factors for operative mortality. Age, peripheral artery disease, emergency, and concomitant mitral valve surgery were risk factors for mortality in the late phase. CONCLUSIONS: Reoperative aortic root replacement represents complex procedures carrying significant morbidity and mortality. Chronic lung disease, prior myocardial infarction, and concomitant mitral valve surgery were risk factors for operative mortality. Age, peripheral artery disease, emergency, and concomitant mitral valve surgery were risk factors for long-term mortality.
Asunto(s)
Aorta/cirugía , Implantación de Prótesis Vascular , Reoperación , Factores de Edad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Urgencias Médicas , Femenino , Estudios de Seguimiento , Georgia/epidemiología , Humanos , Enfermedades Pulmonares/epidemiología , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Infarto del Miocardio/epidemiología , Enfermedad Arterial Periférica/epidemiología , Reoperación/efectos adversos , Reoperación/mortalidad , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Valve-sparing root replacement (VSRR) is an established therapy for aortic root pathology. Limited insight exists when the results of VSRR are compared with those of conventional root replacement with use of a bioprosthetic composite conduit (BIO). This study compares the operative and midterm results of VSRR and BIO. METHODS: A retrospective review from 2002 to 2015 at a United States academic center identified 282 patients who underwent VSRR and 425 patients who underwent BIO. Propensity-score matching was performed based on 20 preoperative characteristics, and 123 matched pairs were identified. RESULTS: The mean age (VSRR 53.5 ± 11.1, BIO 53.0 ± 13.0; p = 0.74) and left ventricular ejection fraction (VSRR 54.5 ± 9.2%, BIO 54.4 ± 9.4%; p = 0.99) were equivalent in both groups. The incidence of bicuspid valves (VSRR 26.0%, BIO 27.6%; p = 0.77), Marfan syndrome (VSRR 6.5%, BIO 4.9%; p = 0.58), type A dissection (VSRR 13.0%, BIO 13.0%; p = 0.99), reoperation (VSRR 15.4%, BIO 20.3%; p = 0.32) and arch replacement (VSRR 60.2%, BIO 63.4%; p = 0.60) were similar between the groups. Operative mortality was 5.7% in VSRR and 0.8% in BIO (p = 0.07). There were no significant differences in postoperative renal failure (VSRR 0.8%, BIO 0.0%; p = 0.99) or stroke (VSRR 3.3%, BIO 0.8%; p = 0.37) between the groups. The 7-year survival (VSSR 82.4%, BIO 83.0%; p = 0.53), 7-year freedom from reoperation (VSRR 97.4%, BIO 95.8%; p = 0.48), and 7-year freedom from greater than moderate aortic insufficiency (AI) (VSRR 98.1%, BIO 100.0%; p = 0.47) were similar between groups. CONCLUSIONS: VSRR and BIO result in equivalent operative mortality and morbidity with similar midterm survival and valve durability. VSRR is an effective alternative to BIO for aortic root pathologic conditions; however, careful patient selection is paramount.
Asunto(s)
Aorta/cirugía , Aneurisma de la Aorta/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis Vascular/métodos , Prótesis Vascular , Adulto , Anciano , Implantación de Prótesis Vascular/efectos adversos , Endocarditis/etiología , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
BACKGROUND: Valve-sparing root replacement (VSRR) is an attractive therapy for aortic root aneurysms; however, there is a paucity of data comparing VSRR with conventional root replacement using a mechanical valve-conduit (MECH). This study evaluates and compares outcomes of VSRR and MECH. METHODS: A retrospective review from 2002 to 2015 at a US academic center identified 444 patients who underwent VSRR (282 patients) or MECH (162 patients). Propensity score matching was performed, based on 22 preoperative and intraoperative characteristics, and 87 matched pairs were identified. RESULTS: There was no difference in mean age between the groups (VSRR 45.0 years, MECH 44.2 years, p = 0.59). The incidence of Marfan syndrome (VSRR 10.3%, MECH 12.6%, p = 0.63), type A acute aortic dissection (VSRR 25.3%, MECH 27.6%, p = 0.73), reoperation (VSRR 23.0%, MECH 21.8%, p = 0.86), and arch replacement (VSRR 54.0%, MECH 52.9%, p = 0.88) were similar in both groups. Ejection fraction was similar (VSRR 52.8% ± 10.9%, MECH 52.4% ± 11.7%, p = 0.83). Operative mortality was 2.3% with VSRR and 8.0% with MECH (p = 0.10). There were no significant differences in renal failure requiring dialysis (VSRR 1.1%, MECH 4.6%, p = 0.24), permanent neurologic dysfunction (VSRR 2.3%, MECH 6.9%, p = 0.16), and pacemaker implantation (VSRR 1.1%, MECH 1.1%, p = 0.99) between the groups. Survival at 7 years was significantly improved in patients who underwent VSSR (VSRR 85.5%, MECH 73.6%, p = 0.03). CONCLUSIONS: In comparison with patients undergoing MECH, there is improved midterm survival among patients undergoing VSRR, with similar operative mortality and morbidity. For appropriately selected patients, VSRR provides an attractive and potentially superior alternative to MECH.