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BACKGROUND: Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG. METHODS AND RESULTS: Consecutive patients with stable ischemic heart disease and unprotected left main or 3-vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI-recommended; (2) CABG-eligible but refused CABG (CABG-refusal); and (3) CABG-ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI-recommended, n=1718 [46.6%]), CABG-refusal (n=1595 [43.3%]), and CABG-ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG-ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI-recommended, CABG-refusal, and CABG-ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG-refusal (hazard ratio [HR], 1.67 [95% CI, 1.08-3.56]; P=0.02) and CABG-ineligible patients (HR, 3.26 [95% CI, 1.28-3.65]; P=0.004) groups compared with the reference PCI-recommended group, driven by increased death and stroke. CONCLUSIONS: Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real-world data to inform shared decision-making discussions.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/efectos adversos , Masculino , Puente de Arteria Coronaria/efectos adversos , Femenino , Anciano , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Persona de Mediana Edad , Resultado del Tratamiento , Estudios Retrospectivos , Factores de Riesgo , Medición de Riesgo , Selección de Paciente , Toma de Decisiones ClínicasRESUMEN
AIMS: Feasibility and efficacy of mitral repair in the elderly remain controversial. This study aims to compare outcomes of mitral repair and replacement in octogenarians. METHODS AND RESULTS: We compared the outcomes of 322 consecutive octogenarian patients (mean age 82.6 ± 2.2 years) who underwent mitral repair (n = 227, 70%) or replacement (n = 95, 30%) at Mount Sinai Medical Center and Leipzig Herzzentrum between 1998 and 2008 using propensity score adjustment and univariate and multivariate analyses. Patients undergoing aortic valve replacement were excluded. Coronary bypass was performed in 47.5% (n = 153), and 31.1% (n = 100) required tricuspid repair. Propensity score adjustment yielded comparable groups. Thirty-day mortality in patients undergoing primary elective mitral repair for degenerative disease was 5.1% (2/39). Overall 90-day mortality was 18.9% (43/227) for repair compared with 31.6% (30/95) for replacement (P = 0.014). Pre-discharge echocardiography revealed less than moderate residual regurgitation in 99% of patients (231/232). Adjusted 1-, 3-, and 5-year survival for patients undergoing mitral repair was 71 ± 3, 61 ± 4, and 59 ± 4%, respectively, compared with 56 ± 5, 50 ± 6, and 45 ± 6% for patients undergoing mitral replacement (P = 0.046). Multivariate analysis demonstrated emergency surgery, previous myocardial infarction, concomitant coronary artery bypass surgery, and mitral replacement to be strong independent predictors of early mortality; mitral valve replacement was an independent predictor of reduced survival in degenerative patients. CONCLUSION: Elective mitral repair can be performed with low operative mortality and good long-term outcomes in selected octogenarians with degenerative mitral disease, and is associated with better long-term survival than mitral replacement. The survival benefit associated with surgery for non-degenerative disease is more questionable.
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Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral/métodos , Insuficiencia de la Válvula Mitral/cirugía , Anciano de 80 o más Años , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Tiempo de Internación , Masculino , Anuloplastia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/mortalidad , Puntaje de Propensión , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: Currently, established renal failure is a well-recognized risk factor for operative mortality in patients undergoing coronary artery bypass graft (CABG) surgery. The authors aimed to establish the relative impact of dialysis-dependent renal failure (DRF) and nondialysis-dependent renal failure (NDRF) on early and late outcome after CABG surgery. DESIGN: A retrospective cohort study. SETTING: A single teaching hospital. PARTICIPANTS: The authors analyzed prospectively collected data from 2,960 adult patients who underwent isolated CABG surgery between 1998 and 2006 at the authors' institution, according to whether they had preoperative NDRF based on preoperative creatinine >2.5 mg/dL, DRF, or neither (controls). INTERVENTIONS: CABG surgery. MEASUREMENTS AND MAIN RESULTS: Outcome measures included hospital mortality, postoperative complications, length of stay, and survival. Hospital mortality was 1.8% (n = 52). Patients in the NDRF and DRF groups had a significantly increased mortality (8.3%, n = 13) compared with the control group (1.4%, n = 39), and both NDRF (odds ratio [OR] = 6.2; 95% confidence interval, 2.3-16.5; p < 0.001) and DRF (OR = 4.0; 95% confidence interval, 1.6-10.0; p = 0.004) were found to be independent predictors of operative mortality. The overall mean follow-up was 3.9 +/- 2.5 years. Multivariate analysis revealed DRF (OR = 5.1) to be an independent predictor of late mortality after cardiac surgery, whereas NDRF was not found to be an independent predictor of late mortality. CONCLUSIONS: Preoperative renal failure is an independent risk factor for adverse early and late outcomes after CABG surgery. NDRF is associated with increased hospital mortality and major morbidity compared with patients with lesser degrees of renal dysfunction, but also compared with DRF patients.
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Puente de Arteria Coronaria/mortalidad , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/mortalidad , Complicaciones Posoperatorias/mortalidad , Diálisis Renal/mortalidad , Anciano , Estudios de Cohortes , Puente de Arteria Coronaria/efectos adversos , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Diálisis Renal/efectos adversos , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
AIMS: Fibromuscular dysplasia (FMD) is a poorly understood disease that predominantly affects women during middle-life, with features that include stenosis, aneurysm, and dissection of medium-large arteries. Recently, plasma proteomics has emerged as an important means to understand cardiovascular diseases. Our objectives were: (i) to characterize plasma proteins and determine if any exhibit differential abundance in FMD subjects vs. matched healthy controls and (ii) to leverage these protein data to conduct systems analyses to provide biologic insights on FMD, and explore if this could be developed into a blood-based FMD test. METHODS AND RESULTS: Females with 'multifocal' FMD and matched healthy controls underwent clinical phenotyping, dermal biopsy, and blood draw. Using dual-capture proximity extension assay and nuclear magnetic resonance-spectroscopy, we evaluated plasma levels of 981 proteins and 31 lipid sub-classes, respectively. In a discovery cohort (Ncases = 90, Ncontrols = 100), we identified 105 proteins and 16 lipid sub-classes (predominantly triglycerides and fatty acids) with differential plasma abundance in FMD cases vs. controls. In an independent cohort (Ncases = 23, Ncontrols = 28), we successfully validated 37 plasma proteins and 10 lipid sub-classes with differential abundance. Among these, 5/37 proteins exhibited genetic control and Bayesian analyses identified 3 of these as potential upstream drivers of FMD. In a 3rd cohort (Ncases = 506, Ncontrols = 876) the genetic locus of one of these upstream disease drivers, CD2-associated protein (CD2AP), was independently validated as being associated with risk of having FMD (odds ratios = 1.36; P = 0.0003). Immune-fluorescence staining identified that CD2AP is expressed by the endothelium of medium-large arteries. Finally, machine learning trained on the discovery cohort was used to develop a test for FMD. When independently applied to the validation cohort, the test showed a c-statistic of 0.73 and sensitivity of 78.3%. CONCLUSION: FMD exhibits a plasma proteogenomic and lipid signature that includes potential causative disease drivers, and which holds promise for developing a blood-based test for this disease.
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Proteínas Sanguíneas/genética , Displasia Fibromuscular/sangre , Displasia Fibromuscular/genética , Proteogenómica , Proteínas Adaptadoras Transductoras de Señales/sangre , Proteínas Adaptadoras Transductoras de Señales/genética , Adulto , Anciano , Estudios de Casos y Controles , Proteínas del Citoesqueleto/sangre , Proteínas del Citoesqueleto/genética , Femenino , Displasia Fibromuscular/diagnóstico , Marcadores Genéticos , Predisposición Genética a la Enfermedad , Ensayos Analíticos de Alto Rendimiento , Humanos , Lípidos/sangre , Aprendizaje Automático , Persona de Mediana Edad , Fenotipo , Valor Predictivo de las Pruebas , Prueba de Estudio Conceptual , Reproducibilidad de los Resultados , Biología de Sistemas , Adulto JovenRESUMEN
OBJECTIVES: Patients with a kidney allograft are at high risk for the development of cardiovascular diseases that may require surgical intervention. Little is known about the outcome of cardiac surgery in these patients. DESIGN: A retrospective study. SETTING: A university hospital (single institution). PARTICIPANTS: Twenty-nine patients with a kidney allograft who underwent cardiac surgery between January 1998 and December 2006. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Main outcome measures were hospital mortality, postoperative complications, allograft function, and late survival. Twenty-nine patients (mean age, 53 +/- 14 years; 18 (62%) male; 22 preserved allograft function, 2 acute failure, and 5 chronic failure) were identified. Hospital mortality was 3.4% (n = 1). Temporary allograft dysfunction determined by a >30% increase of creatinine and blood urea nitrogen was noticed in 5 (23%) patients with preserved allograft and recovered before discharge. Two patients required postoperative dialysis (1 temporary and 1 permanent). Six (21%) other major complications occurred and included respiratory failure (n = 4, 14%) and sepsis (n = 2, 7%). One- and 5-year survival was 89% +/- 6% and 50% +/- 14%, respectively. Four of 9 patients who died during follow-up had chronic allograft failure. CONCLUSIONS: Cardiac surgery can be performed safely in kidney transplant recipients with low mortality and acceptable morbidities. Allograft dysfunction is a common finding, but it is transient with early functional recovery. Late survival of kidney recipients with chronic allograft failure undergoing cardiac procedures is limited when compared with that of the general cardiac surgery population. The present data suggest that these patients should be considered for cardiac surgery in reference centers with expertise in complex cardiac procedures and perioperative management of these highly specific patients.
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Procedimientos Quirúrgicos Cardíacos/tendencias , Trasplante de Riñón/tendencias , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/mortalidad , Femenino , Humanos , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to investigate the incidence and predictors of deep sternal wound infection (DSWI) in a contemporary cohort of patients undergoing cardiac surgery. The early and late outcomes of patients with this complication also were analyzed. DESIGN: A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. SETTING: A university hospital (single institution). PARTICIPANTS: Five thousand seven hundred ninety-eight patients who underwent cardiac surgery between January 1998 and December 2005 including isolated coronary artery bypass graft (CABG) (n = 2,749, 47%), single- or multiple-valve surgery (n = 1,280, 22%), combined valve and CABG procedures (n = 934, 16%), and surgery involving the ascending aorta or the aortic arch (n = 835, 15%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The overall incidence of DSWI was 1.8% (n = 106). The highest rate of DSWI occurred after combined valve/CABG surgery (2.4%, n = 22) and aortic procedures (2.4%, n = 19). Multivariate analysis revealed 11 predictors of DSWI: obesity (odds ratio [OR] = 2.2), previous myocardial infarction (OR = 2.1), diabetes (OR = 1.7), chronic obstructive pulmonary disease (OR = 2.3), preoperative length of stay >3 days (OR = 1.9), aortic calcification (OR = 2.7), aortic surgery (OR = 2.4), combined valve/CABG procedures (OR = 1.9), cardiopulmonary bypass time (OR = 1.8), re-exploration for bleeding (OR = 6.3), and respiratory failure (OR = 3.2). The mortality rate was 14.2% (n = 15) versus 3.6% (n = 205) in the control group (p < 0.001). One- and 5-year survival after DSWI were significantly decreased (72.4% +/- 4.4% and 55.8% +/- 5.6% v 93.8% +/- 0.3% and 82.0% +/- 0.6%, p < 0.001). CONCLUSION: DSWI remains a rare but devastating complication and is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Esternón/cirugía , Infección de la Herida Quirúrgica/epidemiología , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Femenino , Estudios de Seguimiento , Hongos , Bacterias Gramnegativas , Bacterias Grampositivas , Humanos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Estudios Retrospectivos , Factores de Riesgo , Infección de la Herida Quirúrgica/microbiología , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
The abnormal origin of left circumflex artery from the right sinus of Valsalva with a retroaortic course is a well-known coronary anomaly usually without consequences. In patients undergoing aortic valve replacement, this finding becomes crucial because the left circumflex is at risk of injury during the procedure. The scenario is even more complex in patients undergoing multi-valve surgery. We report the diagnosis and successful operative strategy in a patient with anomalous left circumflex arising from the proximal right sinus of Valsalva undergoing double aortic and tricuspid valve surgery for active bacterial endocarditis.
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Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Anomalías de los Vasos Coronarios/cirugía , Endocarditis Bacteriana/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Seno Aórtico/anomalías , Infecciones Estafilocócicas/cirugía , Staphylococcus epidermidis , Válvula Tricúspide/cirugía , Puente Cardiopulmonar , Terapia Combinada , Angiografía Coronaria , Anomalías de los Vasos Coronarios/diagnóstico , Remoción de Dispositivos , Ecocardiografía Transesofágica , Endocarditis Bacteriana/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Marcapaso Artificial , Complicaciones Posoperatorias/diagnóstico , Infecciones Relacionadas con Prótesis/cirugía , Infecciones Estafilocócicas/diagnóstico , Tomografía Computarizada EspiralRESUMEN
The aim of this study was to analyze the incidence, topography, and mechanisms of stroke, independent predictors, and late outcome after cardiac valve operations. We retrospectively analyzed prospectively collected data from 2,808 patients (mean age 63 +/- 15 years, n = 1,610, 55% men) who underwent valve surgery with or without concomitant coronary artery bypass grafting from January 1998 to December 2006. Stroke was defined as any new permanent focal neurologic deficit. Overall incidence of stroke was 2.2% (n = 63) and decreased during the study period from 3.3% (1998 to 2002) to 1.3% (2003 to 2006; p = 0.001). The highest stroke rate was observed after double aortic/mitral valve replacement (5.4%) and valve/coronary artery bypass grafting procedures (3.6%). Brain imaging was positive in 74% (n = 43 of 58) and showed ischemic stroke in all patients and hemorrhagic conversion in 28%. Distribution of acute stroke was large territory embolic artery (n = 33, 77%), watershed (n = 7, 16%), and mixed pattern (n = 3, 7%). Multivariate analysis revealed calcified ascending aorta (odds ratio [OR] 2.7), female gender (OR 2.6), ejection fraction <30% (OR 2.3), diabetes (OR 2.2), age >70 years (OR 2.0), and cardiopulmonary bypass time >120 minutes (OR 3.7) as predictors of stroke. Hospital mortality was 24% and 4.6% in patients with and without stroke, respectively. Survival of stroke patients was 78% and 54% at 1 year and 5 years, respectively, and was significantly decreased compared with patients without stroke. Valve pathology including endocarditis did not influence the incidence of stroke. Intraoperative epiaortic scanning may contribute in decreasing the incidence of this complication and may be warranted in all patients undergoing valvular surgery. In conclusion, stroke after valvular surgery is associated with an increased hospital mortality and morbidity and decreased long-term survival.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Accidente Cerebrovascular/epidemiología , Tomografía Computarizada por Rayos X/métodos , Anciano , Intervalos de Confianza , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , New York/epidemiología , Oportunidad Relativa , Complicaciones Posoperatorias , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/etiología , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
BACKGROUND: Respiratory failure (RF) is a serious complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, making prior investigations of RF after cardiac surgery less relevant to the current population. This study was designed to analyze the incidence, predictors of RF, and early and late outcomes following this complication in a large contemporary cardiac surgery population. METHODS: We retrospectively analyzed prospectively collected data from the New York State Department of Health database including 5,798 patients undergoing cardiac surgery between January 1998 and December 2005. Patients with RF (intubation time > or = 72 h) were compared to patients without RF. RESULTS: The incidence of RF was 9.1% (n = 529). The highest incidence of RF was observed following combined valve/coronary artery bypass graft (14.8%) and aortic procedures (13.5%). Multivariate analysis revealed preoperative and operative predictors of RF such as renal failure (odds ratio [OR], 2.3), aortic procedures (OR, 2.6), hemodynamic instability (OR, 3.2), and intraaortic balloon pump (OR, 2.6). The mortality rate following RF was 15.5% (n = 82), compared to 2.4% (n = 126) in the no-RF group (p < 0.001). Kaplan-Meier survival curves showed significantly poorer survival among RF patients (p < 0.001) compared to the no-RF group. CONCLUSION: RF remains a serious and common complication following cardiac surgery, particularly in patients undergoing complex procedures. RF is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival. Future research efforts should focus on a more precise identification of patients at risk and the development of new treatment modalities that would potentially prevent the occurrence of this complication.
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Procedimientos Quirúrgicos Cardíacos/métodos , Cardiopatías/cirugía , Complicaciones Posoperatorias , Insuficiencia Respiratoria/epidemiología , Anciano , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Pronóstico , Sistema de Registros , Insuficiencia Respiratoria/etiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Few previous studies have reported on the outcome of patients with renal failure (RF) undergoing valvular surgery, particularly with regard to choice of valve prosthesis. METHODS: We retrospectively analyzed prospectively collected data from 155 patients with RF (mean age 62 +/- 14, 42% female) who underwent left-sided valve surgery from January 1998 to December 2006. Patients were divided into two groups: Group 1 (non-dialysis-dependent renal failure (NDRF); creatinine >2.5 mg/dl; n = 47, 40%) and Group 2 (renal failure dialysis (DRF); n = 108, 60%). Mechanical valves were implanted in 50 (32%) patients and bioprostheses in 63 (41%). Isolated mitral valve reconstruction was performed in 27% (n = 42) of patients. Outcome measures included hospital mortality, major postoperative complications, length of hospital stay, discharge planning and late survival. RESULTS: The overall hospital mortality was 19.3% (n = 30) and was not different between Groups 1 (23%) and 2 (18%). Ejection fraction, peripheral vascular disease, aortic valve replacement and reoperation were independent predictors of hospital mortality. One- and five-year survival rates were 74.4 +/- 7.8% and 53.1 +/- 10.1% in Group 1 and 75.8 +/- 4.6% and 49.1 +/- 7.1% in Group 2 (P = ns), respectively. According to the type of prostheses, hospital mortality and freedom from reoperation were similar in patients with mechanical and biological valves. Five-year survival rate was 51 +/- 10.7 for biological valves versus 55 +/- 8.4 for mechanical valves (P = ns). CONCLUSIONS: Hospital mortality and morbidity remain high in patients with RF undergoing valvular surgery and it is not different in NDRF and DRF patients. This study suggests that the type of valve prosthesis does not appear to have an impact on early and late survival but is limited by sample size. It may be that bioprostheses should be more widely used in patients with RF requiring valve replacement.
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Procedimientos Quirúrgicos Cardiovasculares/instrumentación , Prótesis Valvulares Cardíacas , Válvulas Cardíacas/cirugía , Insuficiencia Renal/mortalidad , Anciano , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Diseño de Prótesis , Diálisis Renal , Insuficiencia Renal/terapia , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tasa de SupervivenciaRESUMEN
BACKGROUND AND AIM OF THE STUDY: Previous studies have been unable to identify independent valve-related risk factors for the occurrence of renal failure requiring dialysis (RF-D) in patients undergoing valve surgery. The study aim was to determine the incidence and predictors of renal failure in these patients, and to create a model based on these risk factors that could serve as a tool to predict this complication. METHODS: Between January 1998 and December 2006, a total of 2,690 consecutive patients (1,546 males, 1,144 females; mean age 64 +/- 15 years) underwent valve or combined valve/coronary artery bypass graft (CABG) surgery at the authors' institution. The main outcome investigated was postoperative RF-D; other postoperative parameters investigated included hospital mortality, major morbidity, length of hospital stay, discharge condition and late survival. RESULTS: RF-D occurred in 70 patients (2.6%). Multivariate analysis revealed preoperative renal failure (creatinine >2.5 mg/dl) (OR = 4.3), endocarditis (OR = 3.0), congestive heart failure (OR = 2.4), reoperation (OR = 2.3), diabetes (OR = 3.1) and cardiopulmonary bypass time >180 min (OR = 1.7) as independent predictors for postoperative RF-D. Hospital mortality among patients with RF-D was 50% (n = 35) compared to a mortality rate of 3.2% (n = 87) in patients without this complication (p <0.001). The long-term survival of discharged patients with RF-D was significantly decreased compared to those without RF-D. A logistic equation which included the coefficients of the regression analysis was generated to calculate an individual patient's risk for the development of renal failure. The predictive accuracy of the model and validation was measured (ROC area under the curve = 0.750). CONCLUSION: Renal failure requiring dialysis is a well-known complication, particularly in patients undergoing complex valve operations, such as surgery for endocarditis and double-valve procedures. The poor long-term survival of patients with RF-D underlines the need to direct more resources towards the prevention and treatment of this complication in valve surgery patients.
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Enfermedades de las Válvulas Cardíacas/cirugía , Modelos Cardiovasculares , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias , Insuficiencia Renal/epidemiología , Puente de Arteria Coronaria , Diabetes Mellitus/epidemiología , Endocarditis/epidemiología , Femenino , Insuficiencia Cardíaca/epidemiología , Prótesis Valvulares Cardíacas , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , New York/epidemiología , Diálisis Renal , Insuficiencia Renal/etiología , Insuficiencia Renal/terapia , Reoperación , Medición de Riesgo , Factores de TiempoAsunto(s)
Anestesia/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Puente de Arteria Coronaria/métodos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Esternotomía , Anciano de 80 o más Años , Arteria Axilar/cirugía , Arteria Axilar/trasplante , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ventilación Unipulmonar , Cuidados Posoperatorios , Reoperación , Taquicardia Ventricular/complicacionesRESUMEN
OBJECTIVES: An increasing number of patients are referred for coronary artery bypass graft surgery while treated with clopidogrel. This agent inhibits the platelet P2Y12 adenosine-5'-diphosphate (ADP) receptor, which results in an inhibition of platelet aggregation. The aim of this study was to determine the effect of preoperative clopidogrel treatment on postoperative bleeding, mortality, and morbidity in patients after coronary artery bypass graft surgery. DESIGN: Retrospective cohort study. SETTING: University hospital (single institution). PARTICIPANTS: One hundred forty-four patients who underwent isolated coronary artery bypass graft surgery. INTERVENTIONS: Seventy-two patients who received clopidogrel during the preoperative period formed the study group. Seventy-two patients (matched based on age, sex, and preoperative risk profile) served as the control group. MEASUREMENTS AND MAIN RESULTS: Clopidogrel-treated patients received significantly more platelet (4.4 +/- 5.7 v 1.3 +/- 3.2 U, p < 0.001) and red blood cell (5.1 +/- 4.2 v 2.6 +/- 2.6 U, p < 0.001) transfusions compared with the control group. All-cause mortality and morbidity were significantly higher in clopidogrel-treated patients (n = 7, 9% v n = 1, 1%; p = 0.031). In addition, the lengths of stay in the intensive care unit and the hospital were significantly longer in these patients (2.5 +/- 2.7 v 1.4 +/- 0.9 days, p = 0.002; 9.9 +/- 11 v 6 +/- 2.5 days, p = 0.003). Despite an increased morbidity in the clopidogrel group, the midterm survival was similar between the 2 groups (1-year and 5-year survival 97% +/- 2% and 95.7% +/- 3% v 100% +/- 0% and 87% +/- 10%, respectively; p = 0.885). CONCLUSIONS: Preoperative clopidogrel is associated with increased transfusion requirement after coronary artery bypass graft surgery. The present data suggest that all-cause mortality and major morbidity may also increase in these patients. In clopidogrel-treated patients, coronary artery bypass graft surgery should be delayed in the absence of specific medical indications as recommended by recent American Heart Association guidelines.
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Puente de Arteria Coronaria , Mortalidad Hospitalaria , Inhibidores de Agregación Plaquetaria/efectos adversos , Hemorragia Posoperatoria/etiología , Ticlopidina/análogos & derivados , Anciano , Pruebas de Coagulación Sanguínea , Clopidogrel , Estudios de Cohortes , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Transfusión de Eritrocitos/estadística & datos numéricos , Femenino , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Masculino , Persona de Mediana Edad , Transfusión de Plaquetas/estadística & datos numéricos , Cuidados Preoperatorios , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Ticlopidina/efectos adversos , Factores de TiempoRESUMEN
OBJECTIVES: The aim of the study was to investigate the incidence and predictors of renal failure requiring dialysis (RF-D) in a contemporary cohort of patients undergoing cardiac surgery. The authors also analyzed early and late outcome of patients with this complication. DESIGN: A retrospective study of consecutive patients undergoing cardiac surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. SETTING: A university hospital (single institution). PARTICIPANTS: Six thousand four hundred forty-nine patients who underwent cardiac surgery between January 1998 and December 2006 including isolated coronary artery bypass graft (CABG) surgery (n = 2,819, 44%), single- or multiple-valve surgery (n = 1,378, 21%), combined valve and CABG procedures (n = 1,032, 16%), and surgery involving the ascending aorta or the aortic arch (n = 1,220, 19%). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The incidence of RF-D was 2.2% (n = 139). The incidence per type of procedure was as follows: CABG surgery (0.8%), valve/CABG surgery (2.7%), valve surgery (2.9%), and aortic surgery (4%) (p = 0.001). Multivariate analysis revealed preoperative renal dysfunction (odds ratio [OR] = 5.5), hemodynamic instability (OR = 5.2), diabetes (OR = 2.6), aortic surgery (OR = 2.2), congestive heart failure (CHF) (OR = 2.1), peripheral vascular disease (PVD) (OR = 1.9), and reoperation (OR = 1.8) as independent predictors of RF-D. The hospital mortality after RF-D was 36.7% (n = 51) compared with 2.9% (n = 180) in the control group (p < 0.001). Long-term survival after RF-D was significantly decreased (1-year and 5-year survival 48.5% +/- 6.1% and 28.7% +/- 7.2% v 94.5% +/- 0.3% and 83.5% +/- 0.6% in the control group, p < 0.001). Hypertension, CHF, and PVD were independent predictors of late mortality. CONCLUSION: The authors observed an increase in the overall incidence of RF-D compared with previous studies, probably related to an increased prevalence of patients undergoing more complex procedures with a worsening risk profile. Postoperative RF-D was not only associated with increased hospital mortality and morbidity, but also with a significant reduction of long-term survival in discharged patients. Seven independent predictors of RF-D were identified. Future research efforts should focus on a more precise identification of patients at risk and the development of new treatment modalities, which would potentially prevent the occurrence of this complication.
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Procedimientos Quirúrgicos Cardiovasculares/efectos adversos , Procedimientos Quirúrgicos Cardiovasculares/tendencias , Diálisis Renal/tendencias , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Valor Predictivo de las Pruebas , Estudios Prospectivos , Insuficiencia Renal/epidemiología , Insuficiencia Renal/etiología , Insuficiencia Renal/terapia , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
We describe a 42-year-old male with primary carcinoid tumor of the ileum, secondary liver metastases, and subsequent severe carcinoid heart disease with quadruple valve involvement. The patient underwent tricuspid and pulmonic bioprosthetic valve replacement, mitral and aortic valve reconstruction. Transthoracic echocardiography at 25 months showed competent mitral and aortic valves with only mild regurgitation. Valve reconstruction is rarely performed in patients with carcinoid heart disease. However, in selected cases it is a valuable alternative technique with good mid-term outcome.
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Cardiopatía Carcinoide/cirugía , Tumor Carcinoide/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Válvulas Cardíacas/patología , Válvulas Cardíacas/cirugía , Neoplasias del Íleon/patología , Adulto , Cardiopatía Carcinoide/patología , Tumor Carcinoide/patología , Ecocardiografía , Válvulas Cardíacas/diagnóstico por imagen , Humanos , Neoplasias Hepáticas/secundario , Masculino , Síndrome Carcinoide Maligno/cirugíaRESUMEN
BACKGROUND AND AIM: Plasma B-type natriuretic peptide (BNP) level may be increased in patients with valvular disease. Recent studies have suggested that in patients undergoing aortic valve replacement, an increased preoperative BNP is associated with a worse operative outcome. Little is known about the perioperative value of BNP in patients undergoing mitral valve (MV) surgery. We measured the preoperative and postoperative BNP levels in this population and analyzed the impact of the increased BNP level on surgical outcome. METHODS: From March 2004 to February 2005, 42 patients (mean age 64 +/- 12 years, 18 [42%] male) were enrolled in a prospective study. All patients underwent surgery for severe mitral regurgitation. The mean ejection fraction was 49 +/- 13%, and 26 (62%) patients presented with atrial fibrillation (AF). RESULTS: The median preoperative and postoperative BNP levels were 108 (9.7 to 995) and 357 (143 to 904) pg/mL, respectively (p = 0.002). Heart failure (p = 0.03), atrial fibrillation (AF) (p = 0.01), and ejection fraction (p = 0.01) were associated with an increased preoperative BNP level. In a multivariate analysis, the only independent predictor of the increased BNP level was AF (p = 0.01). In a univariate analysis, the preoperative BNP level was a significant predictor for inotropic support (p < 0.001), ventilation time (p = 0.003), intensive care unit (ICU; p = 0.01), and hospital length of stay (p = 0.02). In the multivariate analysis, BNP was not a predictor of these variables. CONCLUSIONS: Preoperative plasma BNP level presents with a high individual variability in patients with MV regurgitation. AF was the only independent predictor of an increased preoperative BNP level. The preoperative BNP level was not a predictor of surgical outcome. Further studies are required to confirm these findings and evaluate the potential role of this marker for patient selection.
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Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Péptido Natriurético Encefálico/sangre , Fibrilación Atrial , Biomarcadores/sangre , Intervalos de Confianza , Femenino , Humanos , Tiempo de Internación , Modelos Lineales , Masculino , Persona de Mediana Edad , Válvula Mitral/patología , Análisis Multivariante , Valor Predictivo de las Pruebas , Estudios Prospectivos , Volumen Sistólico , Resultado del TratamientoRESUMEN
The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.
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Anciano/estadística & datos numéricos , Anestesia , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Envejecimiento/fisiología , Anestesia/efectos adversos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Humanos , Atención Perioperativa , Complicaciones Posoperatorias/epidemiología , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
Mesenchymal stem cells (MSCs) reportedly exist in a vascular niche occupying the outer adventitial layer. However, these cells have not been well characterized in vivo in medium- and large-sized arteries in humans, and their potential pathological role is unknown. To address this, healthy and diseased arterial tissues were obtained as surplus surgical specimens and freshly processed. We identified that CD90 marks a rare adventitial population that co-expresses MSC markers including PDGFRα, CD44, CD73, and CD105. However, unlike CD90, these additional markers were widely expressed by other cells. Human adventitial CD90+ cells fulfilled standard MSC criteria, including plastic adherence, spindle morphology, passage ability, colony formation, and differentiation into adipocytes, osteoblasts, and chondrocytes. Phenotypic and transcriptomic profiling, as well as adoptive transfer experiments, revealed a potential role in vascular disease pathogenesis, with the transcriptomic disease signature of these cells being represented in an aortic regulatory gene network that is operative in atherosclerosis.
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Arterias/embriología , Arterias/metabolismo , Células Madre Mesenquimatosas/citología , Células Madre Mesenquimatosas/metabolismo , Antígenos Thy-1/genética , Biomarcadores , Diferenciación Celular/genética , Perfilación de la Expresión Génica , Humanos , Inmunofenotipificación , Isquemia/etiología , Isquemia/metabolismo , Neovascularización Fisiológica/genética , Antígenos Thy-1/metabolismoRESUMEN
BACKGROUND: Diabetes is an independent risk factor for the development of neointimal hyperplasia and subsequent vein graft failure after coronary or peripheral artery bypass grafting. We evaluate a new mouse model of surgical vein grafting to investigate the mechanisms of neointimal formation in the setting of type 2 diabetes. METHODS AND RESULTS: Surgical vein grafts were created by inserting vein segments from age-matched C57BL/KsJ wild-type mice into the infra-renal aorta of lepr(db/db) diabetic and C57BL/KsJ wild-type mice. Mice were euthanized &4 weeks later, and vein grafts were analyzed using morphometric and immunohistochemical techniques. A significant increase in neointimal formation was noted in lepr(db/db) mice (139+/-64 versus 109+/-62 mm2; P=0.008) after 4 weeks. This difference was mainly secondary to an increase in collagen formation within the lesion in the vein grafts from lepr(db/db) mice (0.53+/-0.4 versus 0.44+/-0.05; P<0.001), whereas only slight increases (P=not significant) in alpha actin-stained smooth muscle cells were noted in the lepr(db/db) mice. CONCLUSIONS: We established a new physiologically relevant model of surgical vein grafting in mice. In this report, type 2 diabetes was associated with significant increase in extracellular matrix deposition in addition to increased smooth muscle cell deposition. This new model may allow mechanistic studies of cellular and molecular pathways of increased neointimal formation in the setting of diabetes.
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Aorta Abdominal/cirugía , Bioprótesis , Prótesis Vascular , Diabetes Mellitus Tipo 2/complicaciones , Modelos Animales de Enfermedad , Túnica Íntima/patología , Vena Cava Inferior/trasplante , Actinas/biosíntesis , Animales , Implantación de Prótesis Vascular , Colágeno/biosíntesis , Diabetes Mellitus Tipo 2/genética , Elastina/análisis , Matriz Extracelular/metabolismo , Hiperplasia , Masculino , Ratones , Ratones Endogámicos C57BL , Ratones Mutantes , Músculo Liso Vascular/metabolismo , Músculo Liso Vascular/patología , Receptores de Superficie Celular/deficiencia , Receptores de Superficie Celular/genética , Receptores de Leptina , Trasplante Heterotópico , Vena Cava Inferior/patologíaRESUMEN
BACKGROUND: Ischemic mitral regurgitation (IMR) is associated with asymmetric changes in annular and ventricular geometry. Surgical repair with standard symmetric annuloplasty rings results in a high incidence of residual or recurrent mitral regurgitation (MR). The Carpentier-McCarthy-Adams (CMA) IMR ETlogix annuloplasty ring is the first remodeling ring specifically designed to treat asymmetric leaflet tethering and annular dilatation. We used quantitative 2-dimensional echo to examine early results of mitral valve (MV) repair with the CMA IMR ETlogix annuloplasty ring in patients with IMR. METHODS AND RESULTS: Fifty-nine patients (aged 68+/-12 years) with grade > or = 2+ IMR (graded on a scale of 0 to 4+) underwent MV repair with the CMA IMR ETlogix annuloplasty ring. We assessed the mitral annular diameter (MAD), tethering area (TA), and tenting height (TH) of the MV in 4-chamber, 2-chamber, and long axis views at mid-systole before and 3 to 10 days after surgery. After surgery, 57 of 59 (97%) patients had grade 0 or 1+ MR, whereas 2 patients had 2+ MR. MV repair with the CMA IMR ETlogix ring significantly reduced MAD, TA, and TH (P<0.001, for all 3 echo views), particularly in the long axis and 4-chamber views. CONCLUSIONS: Surgical repair of IMR with the novel asymmetric CMA IMR ETlogix annuloplasty ring provided excellent early results with effective reduction of MR, MAD, and leaflet tethering. This novel etiology-specific strategy may result in improved outcomes in IMR patients.