RESUMEN
BACKGROUND/PURPOSE: General Anesthesia (GA) and conscious sedation (CS) are anesthetics for transfemoral transcatheter aortic valve replacement (TF-TAVR). We compared TF-TAVR outcomes using a novel anesthetic approach with fascia iliaca block (FIB) plus minimal CS (MCS) versus GA. METHODS: This retrospective propensity-matched study included consecutive TF-TAVR patients from January 2013 to December 2017 and dichotomized into FIB-MCS vs. GA. Data were collected from electronic records, Society of Thoracic Surgery (STS) database, and the Transcatheter Valve Therapies (TVT) Registry. Primary endpoints were operating room (OR) time, intensive care unit (ICU) and hospital length of stay (LOS). Secondary endpoints were 30-day, 1-year mortality, quality of life, 30-day re-hospitalization rate, failure of FIB-MCS, and hospital safety outcomes. RESULTS: A total of 304 TF-TAVR patients; FIB-MCS (nâ¯=â¯219) vs. GA (nâ¯=â¯85). Propensity matched 162 patients; FIB-MCS (nâ¯=â¯108) vs. GA (nâ¯=â¯54). FIB-MCS had shorter OR time (197.6⯱â¯56.3 vs. 248.2⯱â¯46.3â¯min, pâ¯<â¯0.001), ICU (67.8⯱â¯71.7 vs. 84.9⯱â¯72.1â¯h, pâ¯=â¯0.004) and hospital LOS (3.2⯱â¯3.7 vs. 5.9⯱â¯3.5 d, pâ¯<â¯0.001). FIB-MCS had lower rate of blood transfusion. FIB-MCA vs. GA 30-day and 1-year mortality were similar in the entire (2.3 vs. 2.4%, pâ¯=â¯1.0; and 8.2 vs. 5.9%, pâ¯=â¯0.49) and matched cohorts (0 vs. 3.7%, pâ¯=â¯0.11 and 7.4 vs. 5.6%, pâ¯=â¯0.75). FIB-MCS were less likely to be re-hospitalized [Odd Ratio: 0.32, CI:0.13-0.76] and 2% to 3% higher KCCQ-12 score. CONCLUSION: TF-TAVR using FIB-MCS is feasible and safe with shorter OR time, ICU and hospital LOS, lower risk of 30-day re-hospitalization, similar 30-day and 1-year mortality with better quality of life at 1-year follow-up.
Asunto(s)
Anestesia General , Estenosis de la Válvula Aórtica/cirugía , Cateterismo Periférico , Sedación Consciente , Arteria Femoral , Bloqueo Nervioso , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Anestesia General/efectos adversos , Anestesia General/mortalidad , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/mortalidad , Sedación Consciente/efectos adversos , Sedación Consciente/mortalidad , Bases de Datos Factuales , Registros Electrónicos de Salud , Femenino , Humanos , Tiempo de Internación , Masculino , Bloqueo Nervioso/efectos adversos , Bloqueo Nervioso/mortalidad , Tempo Operativo , Readmisión del Paciente , Punciones , Calidad de Vida , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del TratamientoRESUMEN
Importance: It is not clear how often patients receive aspirin (acetylsalicylic acid) while receiving oral anticoagulation with warfarin sodium without a clear therapeutic indication for aspirin, such as a mechanical heart valve replacement, recent percutaneous coronary intervention, or acute coronary syndrome. The clinical outcomes of such patients treated with warfarin and aspirin therapy compared with warfarin monotherapy are not well defined to date. Objective: To evaluate the frequency and outcomes of adding aspirin to warfarin for patients without a clear therapeutic indication for combination therapy. Design, Setting, and Participants: A registry-based cohort study of adults enrolled at 6 anticoagulation clinics in Michigan (January 1, 2010, to December 31, 2017) who were receiving warfarin therapy for atrial fibrillation or venous thromboembolism without documentation of a recent myocardial infarction or history of valve replacement. Exposure: Aspirin use without therapeutic indication. Main Outcomes and Measures: Rates of any bleeding, major bleeding events, emergency department visits, hospitalizations, and thrombotic events at 1, 2, and 3 years. Results: Of the study cohort of 6539 patients (3326 men [50.9%]; mean [SD] age, 66.1 [15.5] years), 2453 patients (37.5%) without a clear therapeutic indication for aspirin were receiving combination warfarin and aspirin therapy. Data from 2 propensity score-matched cohorts of 1844 patients were analyzed (warfarin and aspirin vs warfarin only). At 1 year, patients receiving combination warfarin and aspirin compared with those receiving warfarin only had higher rates of overall bleeding (cumulative incidence, 26.0%; 95% CI, 23.8%-28.3% vs 20.3%; 95% CI, 18.3%-22.3%; P < .001), major bleeding (5.7%; 95% CI, 4.6%-7.1% vs 3.3%; 95% CI, 2.4%-4.3%; P < .001), emergency department visits for bleeding (13.3%; 95% CI, 11.6%-15.1% vs 9.8%; 95% CI, 8.4%-11.4%; P = .001), and hospitalizations for bleeding (8.1%; 6.8%-9.6% vs 5.2%; 4.1%-6.4%; P = .001). Rates of thrombosis were similar, with a 1-year cumulative incidence of 2.3% (95% CI, 1.6%-3.1%) for those receiving combination warfarin and aspirin therapy compared with 2.7% (95% CI, 2.0%-3.6%) for those receiving warfarin alone (P = .40). Similar findings persisted during 3 years of follow-up as well as in sensitivity analyses. Conclusions and Relevance: Compared with warfarin monotherapy, receipt of combination warfarin and aspirin therapy was associated with increased bleeding and similar observed rates of thrombosis. Further research is needed to better stratify which patients may benefit from aspirin while anticoagulated with warfarin for atrial fibrillation or venous thromboembolism; clinicians should be judicious in selecting patients for combination therapy.
Asunto(s)
Aspirina/administración & dosificación , Fibrilación Atrial/tratamiento farmacológico , Hemorragia/epidemiología , Sistema de Registros , Medición de Riesgo/métodos , Tromboembolia/prevención & control , Warfarina/administración & dosificación , Anciano , Anticoagulantes/administración & dosificación , Fibrilación Atrial/complicaciones , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Inhibidores de Agregación Plaquetaria/administración & dosificación , Estudios Retrospectivos , Factores de Riesgo , Tromboembolia/etiología , Estados Unidos/epidemiologíaAsunto(s)
Apéndice Atrial/diagnóstico por imagen , Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Ecocardiografía Transesofágica/métodos , Imagenología Tridimensional , Tomografía Computarizada Multidetector/métodos , Accidente Cerebrovascular/prevención & control , Anciano de 80 o más Años , Apéndice Atrial/cirugía , Fibrilación Atrial/complicaciones , Fibrilación Atrial/diagnóstico , Humanos , Masculino , Periodo Preoperatorio , Impresión Tridimensional , Accidente Cerebrovascular/etiologíaRESUMEN
AIMS: We report the use of a novel endovascular approach using chemical neurolysis, via periadventitial injection of dehydrated ethanol (EtOH) to perform renal artery denervation. METHODS AND RESULTS: A novel, three-needle delivery device was introduced into the renal arteries of adult swine using fluoroscopic guidance. EtOH was injected bilaterally with one injection per artery, via the three needles into the adventitial and periadventitial space, using EtOH doses 0.15 ml/artery; n=3, 0.30 ml/artery; n=3, and 0.60 ml/artery; n=3, with saline injection as a sham control (0.4 ml/artery; n=3), and naive subjects (n=7) as a true negative control. The renal parenchymal norepinephrine (NE) concentration at two-week follow-up was the primary efficacy endpoint. The mean renal NE reduction was 54%, 78% and 88% at doses of 0.15 ml, 0.30 ml and 0.60 ml, respectively (p<0.0001 vs. controls). Histological examination revealed marked, and deep, circumferential renal nerve injury at depths of 2-8 mm from the intimal surface. There was no evidence of device-related or EtOH-induced injury to the intimal layers. In some samples at the higher EtOH doses, there was focal loss of smooth muscle cells in the outer media. Angiography at 45 days demonstrated normal appearing renal arteries with no detectable stenoses (n=8). CONCLUSIONS: Circumferential adventitial delivery of very low doses of EtOH may be a promising alternative to energy-based systems to achieve dose-dependent, and predictable renal denervation. Further study is warranted.
Asunto(s)
Técnicas de Ablación , Procedimientos Endovasculares , Etanol/administración & dosificación , Riñón/irrigación sanguínea , Riñón/inervación , Simpatectomía Química/métodos , Animales , Relación Dosis-Respuesta a Droga , Riñón/metabolismo , Riñón/patología , Modelos Animales , Norepinefrina/metabolismo , Arteria Renal , Porcinos , Factores de TiempoAsunto(s)
Cardiomiopatías/diagnóstico , Divertículo/diagnóstico , Aneurisma Cardíaco/diagnóstico , Cardiomiopatías/diagnóstico por imagen , Angiografía Coronaria , Divertículo/complicaciones , Divertículo/diagnóstico por imagen , Aneurisma Cardíaco/complicaciones , Aneurisma Cardíaco/diagnóstico por imagen , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana EdadRESUMEN
The diagnosis of an acute coronary syndrome associated with heparin-induced thrombocytopenia is an increasingly recognized complication of heparin exposure. We describe a case of an acute myocardial infarction 2 weeks after elective aortobifemoral bypass surgery, subsequent subacute coronary artery stent thrombosis, and the treatment strategies available.
Asunto(s)
Anticoagulantes/efectos adversos , Vasos Coronarios , Heparina/efectos adversos , Stents/efectos adversos , Trombocitopenia/inducido químicamente , Trombocitopenia/complicaciones , Trombosis/etiología , Anticoagulantes/uso terapéutico , Femenino , Heparina/uso terapéutico , Humanos , Persona de Mediana Edad , Procedimientos Quirúrgicos VascularesRESUMEN
Assessment of coronary lesion length using visual estimation or quantitative coronary angiography can be unreliable. We tested the accuracy of a new handheld caliper device to measure lesion length in a bench-top model and in eight patients undergoing percutaneous coronary intervention (PCI). Caliper-derived length measurements were compared to the known reference distance in the bench-top model and visual or intravascular ultrasound (IVUS)-derived measurements in vivo. In the coronary model, caliper-derived measurements were accurate and correlated well with known reference distances regardless of the angiographic projection. During PCI, there was a poor correlation between the best visual estimate of length and IVUS-derived measurements. In contrast, caliper-derived measurements correlated closely with IVUS-derived measurements. This handheld caliper provides a simple and accurate method of assessing intracoronary lesion length and may be particularly useful during coronary stenting and when adjunctive brachytherapy is performed.
Asunto(s)
Angioplastia Coronaria con Balón , Angiografía Coronaria/instrumentación , Enfermedad Coronaria/patología , Vasos Coronarios/patología , Radiografía Intervencional/instrumentación , Angiografía Coronaria/métodos , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/terapia , Humanos , Variaciones Dependientes del Observador , Radiografía Intervencional/métodosRESUMEN
Preview Medical clearance for patients who need surgery is commonly requested of primary care physicians. A focused evaluation of the cardiovascular and other major body systems is the key to assessing preoperative risk. Which diagnostic tools and laboratory tests are most helpful? And which findings are most significant? The authors answer these questions and suggest ways primary care doctors can help minimize complications in the perioperative period.