RESUMEN
There is a rich history of surgery for cardiac arrhythmias, spanning from atrial fibrillation and Wolff-Parkinson-White syndrome to inappropriate sinus tachycardia and ventricular tachycardia. This review describes the history of these operations, their evolution over time, and the current state of practice. We devote considerable time to the discussion of atrial fibrillation, the most common cardiac arrhythmia addressed by surgeons. We discuss ablation of atrial fibrillation as a stand-alone operation and as a concomitant operation performed at the time of cardiac surgery. We also discuss the emergence of newer procedures to address atrial fibrillation in the past decade, such as the convergent procedure and totally thoracoscopic ablation, and their outcomes relative to historic approaches such as the Cox maze procedure.
RESUMEN
BACKGROUND: The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures. METHODS: The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status. RESULTS: A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726). CONCLUSIONS: In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.
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Procedimientos Quirúrgicos Cardíacos , Transfusión de Eritrocitos , Humanos , Transfusión de Eritrocitos/métodos , Puente de Arteria Coronaria , Procedimientos Quirúrgicos Cardíacos/métodos , Transfusión Sanguínea , Hemoglobinas , Estudios RetrospectivosRESUMEN
A 64-year-old man with diffusely diseased iliofemoral vessels and an ejection fraction of 20% to 25% presented with a non-ST elevation myocardial infarction and proximal left anterior descending (LAD) and left circumflex (LCx) coronary artery disease, with a chronically occluded right coronary artery. The iliofemoral system was not suitable for Impella placement, and bilateral axillary arteries were heavily calcified. The proximal left brachial artery was chosen for placement of both an Impella CP (Abiomed, Danvers, MA, USA) and percutaneous coronary intervention (PCI) sheath through a graft sewn to the brachial artery in this single-access technique. A 6 mm graft was sewn to the brachial artery, through which the Impella CP was placed. The Impella CP sheath was then used to introduce a 7F sheath for PCI. Successful PCI with drug-eluting stents was carried out to the LAD and LCx arteries, the Impella was weaned and removed, and the graft was stapled. The patient was discharged without any access or PCI complications. This report demonstrates the feasibility of the single-access Impella technique through a brachial artery cutdown approach.
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Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Masculino , Humanos , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/cirugía , Arteria AxilarRESUMEN
Alternative access transcatheter aortic valve replacement (TAVR) consists primarily of 4 different options: transcaval, transaxillary, transcarotid, and transapical. While many centers have a preferred alternative access site, few papers have compared the outcomes of TAVR with each alternative access site. In this review, we examine the outcomes of TAVR at each alternative access site, focusing on mortality, stroke, bleeding, pacemaker insertion, paravalvular leakage, and discharge to home. Notable findings include higher mortality in the transapical group and higher stroke rate in the transaxillary group. On the basis of these data, we suggest that transcarotid TAVR might represent the second choice of approach for TAVR when alternate access is required.
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Estenosis de la Válvula Aórtica , Accidente Cerebrovascular , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Factores de Riesgo , Resultado del Tratamiento , Accidente Cerebrovascular/epidemiologíaAsunto(s)
Fibrilación Atrial , Procedimientos Quirúrgicos Cardíacos , Accidente Cerebrovascular , Cirujanos , Administración Oral , Anticoagulantes/efectos adversos , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , Vitamina KRESUMEN
Importance: Myocardial replacement fibrosis has been reported to occur in one-third of patients with mitral valve prolapse (MVP) and significant mitral regurgitation (MR). However, it remains unknown whether there are detectable changes in myocardial metabolism suggestive of inflammation or ischemia that accompany the development of fibrosis. Objectives: To characterize the burden and distribution of fluorine 18-labeled (18F) fluorodeoxyglucose (FDG) uptake and late gadolinium enhancement (LGE) in patients with degenerative MVP and ventricular ectopy. Design, Setting, and Participants: Prospective observational study of 20 patients with MVP and significant primary degenerative MR who were referred for mitral valve repair and underwent hybrid positron emission tomography/magnetic resonance imaging (PET/MRI). Ventricular arrhythmias were categorized as either complex (n = 12) or minor (n = 8). Coregistered hybrid 18F FDG-PET and MRI LGE images were assessed and categorized. Recruitment occurred in the new patient clinic of a mitral valve repair reference center. This study was conducted from January 11, 2018, to June 26, 2019. Exposures: Simultaneous cardiac 18F FDG-PET and MRI with LGE imaging on a hybrid PET/MRI system and ambulatory rhythm monitoring. Main Outcomes and Measures: Patients were categorized by the presence and pattern of FDG uptake and LGE, the severity of ventricular arrhythmias, and the indication for mitral valve surgery. Results: In the cohort of 20 patients, the median age was 59.5 years (interquartile range, 52.5-63.2 years). Focal, or focal-on-diffuse uptake, of 18F-FDG (PET positive) was detected in 17 of 20 patients (85%). The FDG uptake coexisted with areas of LGE (PET/MRI positive) in 14 patients (70%). Of the 5 asymptomatic patients with normal ventricular indices and absence of any surgical indications, all were PET/MRI positive. Conclusions and Relevance: In this pilot study, we demonstrate a novel association between degenerative MVP and FDG uptake, a surrogate for myocardial inflammation and/or ischemia. Such evidence of myocardial injury, even in asymptomatic patients, suggests an ongoing subclinical disease process. These findings warrant further investigation into whether imaging for myocardial inflammation, ischemia, and scar has a role in arrhythmic risk stratification and whether it provides incremental prognostic value in patients with chronic severe mitral regurgitation undergoing active surveillance.
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Arritmias Cardíacas/etiología , Imagen por Resonancia Cinemagnética/métodos , Prolapso de la Válvula Mitral/diagnóstico , Tomografía de Emisión de Positrones/métodos , Arritmias Cardíacas/diagnóstico , Femenino , Fluorodesoxiglucosa F18/farmacología , Humanos , Masculino , Persona de Mediana Edad , Prolapso de la Válvula Mitral/complicaciones , Proyectos Piloto , Estudios Prospectivos , Radiofármacos/farmacología , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: The proximal and distal extent of surgery for type A dissection is the subject of this review article. METHODS: In this review, we summarize select series that illumine the issue at hand and provide insight into the surgical approach at our institution to DeBakey type I aortic dissections. RESULTS: For proximal extent, we discuss preservation of the aortic valve in the presence of aortic insufficiency and management of the aortic root in the setting of root dilation. Distal extent of surgery for type A dissection has been a much more controversial topic. At our institution, we subscribe to the philosophy of ascending or hemiarch replacement alone for dissection under most circumstances. We describe when we believe a more aggressive arch replacement for type A dissection may be considered and detail the reports of other groups that have performed this operation more routinely. We also touch on the frozen elephant trunk operation and its role in type A dissection, although we believe it should be reserved for high-volume dedicated aortic centers. Finally, we conclude by discussing the role of experience in choosing aortic operations for type A dissection. CONCLUSIONS: In our opinion, there is no single correct operation for a patient with type A dissection, but there is a correct operation for each surgeon and clinical scenario.
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Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Anuloplastia de la Válvula Cardíaca/métodos , Toma de Decisiones Clínicas , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/mortalidad , Anuloplastia de la Válvula Cardíaca/mortalidad , Femenino , Humanos , Masculino , Selección de Paciente , Pronóstico , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVE: Postoperative myocardial infarction remains a serious complication in cardiac surgery. The incidence and impact of this condition in acute type A aortic dissection are poorly understood. METHODS: A total of 1445 patients with acute type A aortic dissection who underwent surgery were enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2013. Individuals with preoperative myocardial infarction at hospital presentation and a history of myocardial infarction were excluded. Patients with postoperative myocardial infarction (n = 38, 2.6%) were compared with those without postoperative myocardial infarction (n = 1407, 97.4%). RESULTS: The postoperative myocardial infarction group was more often of white race (100% vs 90%, P = .043) with bicuspid aortic valve (15.6% vs 4.5%, P = .015). Imaging demonstrated more aortic root involvement (75.8% vs 49.5%, P = .003), pericardial effusion (65.5% vs 44.1%, P = .022), and coronary artery compromise (27.3% vs 10.2%, P = .022). Patients with postoperative myocardial infarction were more frequently hypotensive or in shock during surgery (42.9% vs 25.5%, P = .021). Patients with postoperative myocardial infarction were more likely to have undergone root replacement (54.5% vs 33.3%, P = .011), coronary artery bypass grafting (28.6% vs 7.4%, P < .001), or aortic valve replacement (40.0% vs 23.8%, P = .027), and less likely to have had complete arch replacement (2.8% vs 14.0%, P = .050). Median circulatory arrest time was higher in postoperative myocardial infarction (60 vs 38 minutes, P = .024). In-hospital mortality (57.9% vs 16.3%, P < .001) and Kaplan-Meier estimates of 5-year mortality (P = .007) were distinctly higher in postoperative myocardial infarction. CONCLUSIONS: Postoperative myocardial infarction is a devastating complication of type A aortic dissection repair. It is associated with bicuspid aortic valve, root involvement, pericardial effusion, and extent of surgical repair. Patients with postoperative myocardial infarction have higher serious postoperative complications, in-hospital mortality, and 5-year mortality rates than those without postoperative myocardial infarction.