RESUMEN
BACKGROUND: Atrial septal defects are a common form of CHD and dependent on the size and nature of atrial septal defects, closure may be warranted. The paper aims to compare outcomes of transcatheter versus surgical repair of atrial septal defects. METHODS: A comprehensive electronic literature search was conducted. Primary studies were included if they compared both closure techniques. Primary outcomes included procedural success, mortality, and reintervention rate. Secondary outcomes included residual defect and mean hospital stay. RESULTS: A total of 33 studies were included in meta-analysis. Mean total hospital stay was significantly shorter in the transcatheter cohort across both the adult (95% confidence interval, mean difference -4.05 (-4.78, -3.32) p < 0.00001) and paediatric populations (95% confidence interval, mean difference -4.78 (-5.97, -3.60) p < 0.00001). There were significantly fewer complications in the transcatheter group across both the adult (odds ratio 0.45, 95% confidence interval, [0.28, 0.72], p < 0.00001) and paediatric cohorts (odds ratio 0.26, 95% confidence interval, [0.14, 0.49], p < 0.00001). No significant difference in overall mortality was found between transcatheter versus surgical closure across the two groups, adult (odds ratio 0.76, 95% confidence interval, [0.40, 1.45], p = 0.41), paediatrics (odds ratio 0.62, 95% confidence interval, [0.21, 1.83], p = 0.39). CONCLUSION: Both transcatheter and surgical approaches are safe and effective techniques for atrial septal defect closure. Our study has demonstrated the benefits of transcatheter closure in terms of lower complication rates and mean hospital stay. However, surgery still has a place for more complex closure and, as we have demonstrated, shows no difference in mortality.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Defectos del Tabique Interatrial , Dispositivo Oclusor Septal , Adulto , Cateterismo Cardíaco , Niño , Defectos del Tabique Interatrial/cirugía , Humanos , Tiempo de Internación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Blood disorders that can contribute to abnormal bleeding can have a detrimental effect during cardiac surgery. Patients who are known to have such pathologies should be investigated thoroughly and cautious measures would need to be taken when cardiac surgery is needed in this cohort. The majority of current literature for cardiac surgery in patients with von Willebrand Disease and haemophilia are case reports. Nevertheless, evidence shows that optimising factor levels pre, intra and postoperatively offers outcomes similar to that of patients without these disorders. Preoperative screening followed by appropriate iron therapy reduces mortality for patients with anaemia. In this group, haemoglobin levels can be improved postoperatively through iron supplementation. The management strategy of cardiac surgery for people with blood disorders requires a multidisciplinary approach that is highly individualised for each patient. It is essential to adequately adjust preoperative, perioperative and postoperative care to the patient's blood disorder in order to achieve outcomes similar to that of patients without blood disorders.
Asunto(s)
Anemia , Procedimientos Quirúrgicos Cardíacos , Anemia/diagnóstico , Anemia/epidemiología , Anemia/etiología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , HierroRESUMEN
BACKGROUND: Type B aortic dissection (TBAD) occurs seldomly, particularly in pregnancy, but has disastrous consequences for both mother and fetus. The focus of immediate surgical repair of type A aortic dissection due to higher mortality of patients is less clear in its counterpart, TBAD, in which management is controversial and debated. This article collates knowledge so far on this rare event during pregnancy. METHODS: A comprehensive literature search was performed in PubMed, Scopus, Google Scholar, Embase, and Medline. Key search terms included "type B aortic dissection," "pregnancy," and corresponding synonyms. Non-English papers were excluded. RESULTS: Risk factors for TBAD include aortic wall stress due to hypertension, previous cardiac surgery, structural abnormalities (bicuspid aortic valve, aortic coarctation), and connective tissue disorders. In pregnancy, pre-eclampsia is a cause of increased aortic wall stress. Management of this condition is often conservative, but this is dependent on a number of factors, including gestation, cardiovascular stability of the patient, and symptomology. In most cases, a cesarean section before intervention is carried out unless certain indications are present. CONCLUSIONS: Due to a scarce number of cases across the decades, it is difficult to determine which management is optimal. The gold-standard management of TBAD has traditionally been the medical treatment for uncomplicated cases and open surgery for those needing urgent intervention, but with the advent of techniques, such as thoracic endovascular aortic repair, the management of these group of patients continues to develop.
Asunto(s)
Aneurisma de la Aorta Torácica , Disección Aórtica , Procedimientos Endovasculares , Complicaciones Cardiovasculares del Embarazo , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/cirugía , Cesárea , Femenino , Humanos , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Complicaciones Cardiovasculares del Embarazo/cirugía , Resultado del TratamientoRESUMEN
The aim of this review is to present the current options for cardiac output (CO) monitoring in children undergoing cardiac surgery. Current technologies for monitoring identified were a range of invasive, minimally invasive, and non-invasive technologies. These include pulmonary artery catheter, transoesophageal echocardiography, pulse contour analysis, electrical cardiography, and thoracic bioreactance. A literature search was conducted using evidence databases which identified two current guidelines; the NHS Greater Glasgow and Clyde guideline and Royal College of Anaesthetics Guideline. These were appraised using the AGREE II tool and the evidence identified was used to create an overview summary of each technological option for CO monitoring. There is limited evidence regarding the accuracy of modalities available for CO monitoring in paediatric patients during cardiac surgery. Each technology has advantages and disadvantages; however, none could be championed as the most beneficial. Furthermore, a gold standard for CO monitoring has not yet been identified for paediatric populations, nor is it apparent whether one modality is preferable based on the available evidence. Additional evidence using a standardised method for comparing CO measurements should be conducted in order to determine the best option for CO monitoring in paediatrics. Furthermore, cost-effectiveness assessment of each modality should be conducted. Only then will it be possible for clear, evidence-based guidance to be written.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Pediatría , Gasto Cardíaco , Niño , Humanos , Monitoreo Fisiológico , TermodiluciónRESUMEN
OBJECTIVE: To review current literature evidence on outcomes of cardiac surgery in Jehovah's Witness patients. METHODS: A comprehensive electronic literature search was done from 2010 to 20th August 2020 identifying articles that discussed optimisation/outcomes of cardiac surgery in Jehovah's Witness either as a solo cohort or as comparative to non-Jehovah's Witnesses. No limit was placed on place of publication and the evidence has been summarised in a narrative manner within the manuscript. RESULTS: The outcomes of cardiac surgery in Jehovah's Witness patients has been described, and also compared, to non-Witness patients within a number of case reports, case series and comparative cohort studies. Many of these studies note no significant differences between outcomes of the two groups for a number of variables, including mortality. Pre-, intra and post-operative optimisation of the patients by a multidisciplinary team is important to achieve good outcomes. CONCLUSION: The use of a bloodless protocol for Jehovah's Witnesses does not appear to significantly impact upon clinical outcomes when compared to non-Witness patients, and it has even been suggested that a bloodless approach could provide advantages to all patients undergoing cardiac surgery. Larger cohorts and research across multiple centres into the long term outcomes of these patients is required.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Testigos de Jehová , Transfusión Sanguínea , HumanosRESUMEN
OBJECTIVE: To review current literature evidence on outcomes of minimally invasive double valve surgeries (MIS). METHODS: A comprehensive electronic literature search was done from inception to 20th June 2020 identifying articles that discussed outcomes of minimally invasive approach in double valve surgeries either as a solo cohort or as comparative to conventional sternotomies. No limit was placed on time and place of publication and the evidence has been summarized in narrative manner within the manuscript. RESULTS: Majority of current literature reported similar perioperative and clinical outcomes between MIS and conventional median sternotomy; except that MIS has better cosmetic effects and pain control. Nevertheless, minimal invasive techniques are associated with longer cardiopulmonary bypass and aortic cross-clamp times which may have impact on the reported outcomes and overall morbidity and mortality rates. CONCLUSION: Minimally invasive double valve surgery continues to develop, but scarcity in the literature suggests uptake is slow, possibly due to the learning curve associated with MIS. Many outcomes appear to be comparable to conventional sternotomy. There is need for larger, multi-center, and randomized trial to fully evaluate and establish the early, mid- and long-term morbidity and mortality rates associated with both techniques.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Válvula Aórtica/cirugía , Puente Cardiopulmonar , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos , Esternotomía , Resultado del TratamientoRESUMEN
Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.
Asunto(s)
Procedimientos Médicos y Quirúrgicos sin Sangre/normas , Procedimientos Quirúrgicos Cardíacos/normas , Testigos de Jehová/psicología , Procedimientos Médicos y Quirúrgicos sin Sangre/métodos , Procedimientos Médicos y Quirúrgicos sin Sangre/estadística & datos numéricos , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Humanos , Estudios ProspectivosRESUMEN
OBJECTIVE: There is varying evidence on the role of skeletonization of internal mammary artery in reducing the risk of sternal wound infections and ischemia following bilateral internal mammary artery grafting. Post-operative clinical outcomes of skeletonized bilateral internal mammary artery versus pedicled bilateral internal mammary artery harvesting in patients undergoing coronary artery bypass surgery were compared. METHODS: A comprehensive electronic search was conducted using MEDLINE, Scopus, EMBASE, Cochrane database and Google Scholar from inception until 15 June 2020. All studies directly comparing skeletonized and pedicled bilateral internal mammary artery harvesting were included. Meta-analysis and trial sequential analysis were conducted. RESULTS: Nine studies (one randomized controlled trial and eight observational studies) consisting of 3649 patients (2050 patients with skeletonized bilateral internal mammary artery grafting and 1599 patients with pedicled bilateral internal mammary artery grafting) were included. Pooled effects analysis and trial sequential analysis reported significantly lower risk of sternal wound infection with skeletonized bilateral internal mammary artery harvesting (OR 0.27, 95% CI 0.20-0.51, p < 0.00001). CONCLUSIONS: Skeletonization reduces the risk of sternal wound infections by preserving vasculature as much as possible. This facilitates its use in patients at high risk of sternal wound infection.
Asunto(s)
Arterias Mamarias , Puente de Arteria Coronaria , Humanos , Anastomosis Interna Mamario-Coronaria/efectos adversos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
Acute coronary syndrome (ACS) represents a heterogenous spectrum of conditions. The Global Registry of Acute Coronary Events (GRACE) describes the epidemiology, management, and outcomes of patients with ACS. Data were collected from 11,543 patients enrolled in 14 countries. Of these patients, 30% had ST-segment elevation myocardial infarction (STEMI), 25% had non-ST-segment elevation myocardial infarction (NSTEMI), 38% had unstable angina pectoris, and 7% had other cardiac or noncardiac diagnoses. Over half of these patients (53%) were >/=65 years old. Reperfusion therapy was used in 62% of patients with STEMI. Percutaneous coronary intervention was performed in 40% of these subjects during the index admission. Intravenous glycoprotein IIb/IIIa blockers were used in 23%, 20%, and 7% of patients with STEMI, NSTEMI, and unstable angina, respectively (STEMI vs NSTEMI, p = 0.0018, and for either group vs unstable angina, p <0.001). Coronary artery bypass grafting was performed in 4%, 10%, and 5% of patients, respectively (p <0.0001). Hospital case fatality rates were markedly different among patients with STEMI, NSTEMI, and unstable angina (7%, 6%, and 3%, respectively; STEMI vs NSTEMI, p = 0.0459, and for either group vs unstable angina, p <0.001). Congestive heart failure complicated the hospital course in 18%, 18%, and 10% of the patients, respectively (p <0.0001), and recurrent angina with ST-segment changes occurred before discharge in 10%, 10%, and 9% of patients, respectively (p = 0.2644). GRACE provides a detailed and comprehensive global description of the spectrum of patients with ACS.
Asunto(s)
Angina Inestable , Infarto del Miocardio , Anciano , Análisis de Varianza , Angina Inestable/epidemiología , Angina Inestable/mortalidad , Angina Inestable/terapia , Femenino , Mortalidad Hospitalaria , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Síndrome , Resultado del TratamientoRESUMEN
Na psicanálise, a noção de sublimação ocupa uma posição paradoxal: do ponto de vista meta-psicológico ela nunca foi totalmente definida por Freud, no entanto ela é indispensável ao edifício teórico tanto do ponto de vista individual como coletivo pois supostamente ela demonstra o investimento libidinal de metas e objetos que não são originários das pulsões. Seu lugar é tão importante quanto o do recalque dado que ela constitui tanto na idade adulta a saída positiva em oposição à neurose, como na infância a alternativa precoce e criativa. Muito discutida do tempo de Freud até hoje, essa noção não conheceu modificações profundas apesar das contribuições sucessivas que puseram em questão certos aspectos ou acrescentaram outros. Mais do que uma noção, é de um conceito organizador que se trata, do mesmo nível que o conceito de Pulsão, em torno do qual gravitam os questionamentos sobre os sentimentos de ternura e de amizade, os laços sociais, a atividade profissional, as realizações artísticas, literárias, científicas, esportivas etc., e o prazer que adultos e crianças sentem ao encarar os enigmas e tentar resolvê-los, o prazer do pensamento. A autora se esforçou para resumir neste texto suas contribuições para pensar essa noção.
The notion of sublimation in psychoanalysis occupies a paradoxical position: never having been completely defined by Freud from a metapsychological point of view, it is nonetheless indispensable to the theoretical premise, from an individual point of view as well as a collective one, as it supposedly explains the libidinal investment in goals and objectives which are not original to the drives. It holds the same importance as repression, because it constitutes either the positive outlet in adult life in opposition to neurosis, or the precocious and creative alternative in childhood. Much discussed from Freud's days to ours, the idea of sublimation has not undergone great modifications, in spite of successive contributions which dealt with certain aspects of it, and added others. More than a notion, it is of an organizational concept which is at the same level as the concept of drive, around which gravitate the ponderings about feelings of fondness and friendship, social ties, professional activity, as well as artistic, literary, scientific, and sports-related achievements, not to mention the pleasure felt by adults and children alike when they face conundrums and try to solve them, and also the pleasure of thought. The author strives to summarize the contributions proposed to brainstorm this notion.
La noción de sublimación en el psicoanálisis ocupa una posición paradójico: nunca totalmente definida por Freud del punto de vista meta-psicológico, y mientras tanto indispensable para el edificio teórico tanto desde el punto de vista individual como colectivo porque supuestamente da cuenta de la inversión libidinal y objetos que no son originarios de las pulsiones. Su lugar es tan importante como aquel del recalque pues ella constituye la salida positiva la edad adulta en oposición a la neurosis, siendo en la infancia la alternativa precoz y creativa. Muy discutida desde los tiempos de Freud hasta hoy, esta noción no ha tenido modificaciones profundas a pesar de las sucesivas contribuciones que cuestionaron ciertos aspectos y acrecentaron otros. Más que una noción, se trata de un concepto organizador, del mismo nivel que el concepto de Unidad, en torno al cual gravitan los cuestionamientos sobre los sentimientos de ternura y amistad, los lazos sociales, la actividad profesional, las realizaciones artísticas, literarias, científicas, deportivas, etc., y el placer que adultos y niños sienten al encarar los enigmas e intentar resolverlos, el placer del pensamiento. La autora se esfuerza para resumir las contribuciones que propone para pensar en esa noción.
RESUMEN
Pretende-se, nesse artigo, relacionar o trabalho da sublimação com a constituição dos ideais que caracterizam a economia narcísica do sujeito freudiano. Partindo da diferenciação, sublinhada por Freud, entre sublimação e idealização, demonstra-se de que modo o processo sublimatório se aproxima do trabalho de desidealização promovido pelo humor. Na sublimação, assim como no humor, assiste-se a uma ôereção do eu no euõ, ao mesmo tempo em que se elabora o luto pelos objetos idealizado da infância. O papel da pulsão de morte para a emergência de processos criativos é também analisado
The intention of this article is to relate the work of the sublimation with that of the constitution of the ideas that characterise the narcissistic economy of the Freudian subject. Based on the differentiation, highlighted by Freud, between sublimation and idealization, the article aims to demonstrate in what manner the sublimate process approaches the work of breaking down the defence mechanism through humour. In sublimation, as with humour, are we witnessing the erecting of I in the Self? While we elaborate the mourning for the idealized objects of childhood. The role of the death drive in the emergence of the creative process is also analysed
Le but de cet article est celui d'articuler le travail de sublimation avec la constitution des idéaux qui caractérisent l'économie narcissique du sujet freudien. En partant de la différenciation, soulignée para Freud, entre la sublimation et l'idéalisation, la manière par laquelle le procès sublimatoire s'approche du travail de desidéalisation promu par l'humour est démontrée. Dans la sublimation, ainsi que dans l'humour, on assiste à une érection du moi dans le moi, en même temps que s'élabore le deuil des objets idéalisés de l'enfance. Le rôle de la pulsion de mort dans le surgissement du procès créatif est aussi analysé
En este artículo, se pretende relacionar el trabajo de la sublimación con la constitución de los ideales que caracterizan la economía narcisista del sujeto freudiano. Partiendo de la diferenciación, anotada por Freud, entre sublimación e idealización, se demuestra de qué forma el proceso sublimatorio se aproxima del trabajo de desidealización promovido por el humor. En la sublimación, así como en el humor asistimos a ¿una erección del yo en el yo?, al mismo tiempo que elaboramos el luto por los objetos idealizado de la infancia. El papel de la pulsión de la muerte para la emergencia de procesos creativos también es analizado
Asunto(s)
Humanos , Mecanismos de Defensa , Ego , Teoría Freudiana , Sublimación PsicológicaRESUMEN
Baseado nas noções de imagem do corpo (P. Schilder) e depathosformel (A. Warburg), este estudo se propõe a revisitar a obra pictóricade Botticelli do ponto de vista da adolescência percebida como ficçãoidealizada e que repousa em um sofrimento triplo: a busca inacessívelda pureza, a dimensão do excesso maníaco em relação ao tempo futuro e adesaparição nostálgica do tempo irremediavelmente perdido da infância.O método seguido é o das interações da psicanálise, isto é, não se aplicao método psicanalítico à decodificação da obra de arte, opta-se por relacionara escuta sensível da obra de arte com a clínica psicanalítica da adolescência.
Based on the notions of body image (P. Schilder) andpathosformel (A. Warburg) this study revisits Botticellis pictorial work fromthe point of view of adolescence, perceived as an idealized fiction that restsupon a triple suffering: an inaccessible search for purity, a maniacal excessregarding the future, and the nostalgic disappearance of infancy. We follow apsychoanalytic interactions method, that is, the traditional psychoanalyticmethod is not applied to a decoding of the work of art, but we choose to relatea sensitive listening to art with the psychoanalytic clinic of adolescence.
Asunto(s)
Humanos , Adolescente , Adolescente , Imagen Corporal , Psicoanálisis , Cuerpo HumanoRESUMEN
Este artigo tem por objetivo apontar a forma pela qual as crianças se deparam com a diferença sexual e os recursos aos quais recorrem para poderem lidar com tal enigma. O autor pretende demonstrar que a forma infantil de significar o enigma da sexualidade, ou o enigma da origem, diverge da lógica do adulto, marcada pela racionalidade e raciocínio objetivo. Nos relatos infantis, os mitos mostram ter uma função operacional que consiste na convivência de pensamentos opostos, que se excluiriam pela lógica ou/ou, mas que são experimentados numa adição que só enriquece e amplia esta questão. Assim, enquanto o sujeito do conhecimento busca a compreensão a partir da dedução e da síntese, a criança lida com a contradição de sentidos, entre o mágico e o racional, ampliando seus espaços e buscando uma resposta própria frente ao enigma da sexualidade.
This article strives to point out the way in which children deal with sexual difference and the resources they use in order to solve this enigma. The author intends to show that the infantile way of signifying the sexual enigma, or the origin enigma, diverges from the adults logic, which is marked by rationality and objective reasoning. In childrens accounts, the myths have an operational function that consists in joining opposite thoughts, which would exclude themselves by the logic of or/or, but that are experienced in an addition that enriches and amplifies this issue. Therefore, while the subject of knowledge searches for comprehension through deduction and synthesis, the child deals with the contradiction of meanings, between what is magical and what is rational, by amplifying its spaces and searching for its own answer to the enigma of sexuality.