RESUMEN
INTRODUCTION: In this report we describe the clinical presentation, laboratory findings and outcomes of four patients that were referred for urgent cardiothoracic intervention and tested positive for COVID-19. METHODS: The St. Elizabeth's Medical Center Institutional Review Board exempted the study from review (waived review). In each case, verbal informed consent was obtained by the study participant or health care proxy. RESULTS: The majority of the patients undergoing surgery had low Society of Thoracic Surgeons score and uneventful operating time. The mortality was very high and driven primarily by the viral syndrome. Laboratory markers that have been associated with disease severity in the general population were also prognostic in our population. CONCLUSION: Our study shows that these patients have very high mortality, whereas prevention and preoperative screening is required in preventing nosocomial spreading of the disease.
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COVID-19/epidemiología , Procedimientos Quirúrgicos Cardíacos/métodos , Cardiopatías/cirugía , Pandemias , Anciano , Anciano de 80 o más Años , Comorbilidad , Resultado Fatal , Femenino , Cardiopatías/epidemiología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The typical cause of bioprosthetic valve dysfunction over years is calcification of leaflets, pannus formation, or tears due to structural degeneration. Thrombosis is rare as the valves get endothelialized early on, and, hence, anticoagulation is not recommended beyond 6 months after valve replacement. While bioprosthetic valve thrombosis is unusual (0.03% to 0.34%/year), it can be associated with significant mortality and morbidity. Here, we present a case of a middle-aged man with history of bioprosthetic mitral valve who presented with syncopal episode and was referred to us for mitral valve replacement for tentative bioprosthetic valve degeneration and stenosis. However, preoperative work up revealed prosthetic valve thrombosis which was successfully treated with anticoagulation.
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Bioprótesis/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/etiología , Válvula Mitral/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Falla de Prótesis/efectos adversos , Trombosis/etiología , Anticoagulantes/uso terapéutico , Ecocardiografía Transesofágica , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/tratamiento farmacológico , Índice de Severidad de la Enfermedad , Trombosis/diagnóstico por imagen , Trombosis/tratamiento farmacológico , Resultado del Tratamiento , Warfarina/uso terapéuticoRESUMEN
Unicuspid aortic valve (UAV) offers unique challenges to transcatheter aortic valve replacement (TAVR), due to asymmetric expansion and apposition of the prosthesis during implantation. Although TAVR in bicuspid is now a well described experience, TAVR in unicuspid valve has not yet been described. A challenging case is described with TAVR in UAV using a Edwards Sapiens prosthesis via transapical approach. © 2016 Wiley Periodicals, Inc.
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Válvula Aórtica/cirugía , Cardiopatías Congénitas/cirugía , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/anomalías , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Ecocardiografía Doppler en Color , Ecocardiografía Tridimensional , Ecocardiografía Transesofágica , Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/fisiopatología , Prótesis Valvulares Cardíacas , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Resultado del TratamientoRESUMEN
OBJECTIVES: The study sought to investigate the impact of different computing methods for composite endpoints other than time-to-event (TTE) statistics in a large, multicenter registry of unprotected left main coronary artery (ULMCA) disease. BACKGROUND: TTE statistics for composite outcome measures used in ULMCA studies consider only the first event, and all the contributory outcomes are handled as if of equal importance. METHODS: The TTE, Andersen-Gill, win ratio (WR), competing risk, and weighted composite endpoint (WCE) computing methods were applied to ULMCA patients revascularized by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at 14 international centers. RESULTS: At a median follow-up of 1,295 days (interquartile range: 928 to 1,713 days), all analyses showed no difference in combinations of death, myocardial infarction, and cerebrovascular accident between PCI and CABG. When target vessel revascularization was incorporated in the composite endpoint, the TTE (p = 0.03), Andersen-Gill (p = 0.04), WR (p = 0.025), and competing risk (p < 0.001) computing methods showed CABG to be significantly superior to PCI in the analysis of 1,204 propensity-matched patients, whereas incorporating the clinical relevance of the component endpoints using WCE resulted in marked attenuation of the treatment effect of CABG, with loss of significance for the difference between revascularization strategies (p = 0.10). CONCLUSIONS: In a large study of ULMCA revascularization, incorporating the clinical relevance of the individual outcomes resulted in sensibly different findings as compared with the conventional TTE approach. In particular, using the WCE computing method, PCI and CABG were no longer significantly different with respect to the composite of death, myocardial infarction, cerebrovascular accident, or target vessel revascularization at a median of 3 years.
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Puente de Arteria Coronaria/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/terapia , Modelos Estadísticos , Intervención Coronaria Percutánea/estadística & datos numéricos , Sistema de Registros/estadística & datos numéricos , Proyectos de Investigación/estadística & datos numéricos , Anciano , Trastornos Cerebrovasculares/etiología , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Interpretación Estadística de Datos , Stents Liberadores de Fármacos , Determinación de Punto Final/estadística & datos numéricos , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Cadenas de Markov , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/mortalidad , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.
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Procedimientos Quirúrgicos Cardíacos/métodos , Enfermedades de las Válvulas Cardíacas/cirugía , Válvula Mitral/cirugía , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Válvula Mitral/diagnóstico por imagen , Selección de Paciente , Guías de Práctica Clínica como Asunto , Periodo Preoperatorio , Radiografía TorácicaRESUMEN
Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.
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Procedimientos Quirúrgicos Cardíacos/métodos , Enfermedades de las Válvulas Cardíacas/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Válvula Mitral/cirugía , Endoscopía/métodos , Humanos , Selección de Paciente , Cuidados Posoperatorios , Guías de Práctica Clínica como Asunto , Procedimientos Quirúrgicos Robotizados/métodos , Esternotomía/métodos , Toracotomía/métodos , Resultado del TratamientoRESUMEN
Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.
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Procedimientos Quirúrgicos Cardíacos/instrumentación , Válvula Mitral/cirugía , Procedimientos Quirúrgicos Robotizados/educación , Procedimientos Quirúrgicos Cardíacos/educación , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/educación , Procedimientos Quirúrgicos Mínimamente Invasivos/instrumentación , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Selección de Paciente , Guías de Práctica Clínica como Asunto , Procedimientos Quirúrgicos Robotizados/métodos , Procedimientos Quirúrgicos Robotizados/normas , Estados UnidosRESUMEN
AIMS: Our aim was to compare, in a large unprotected left main coronary artery (ULMCA) all-comer registry, the long-term clinical outcome after percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) in patients with acute coronary syndrome (ACS). METHODS AND RESULTS: Of a total of 2,775 patients enrolled in the Drug Eluting Stents for Left Main Coronary Artery Disease (DELTA) multicentre registry, 379 (13.7%) patients with ACS treated with PCI (n=272) or CABG (n=107) were analysed. Baseline demographics were considerably different in the two groups before propensity matching. No significant differences emerged for the composite endpoint of all-cause death, myocardial infarction (MI), and cerebrovascular accident (HR 1.11, 95% CI: 0.63-1.94; p=0.727), all-cause death (HR 1.26, 95% CI: 0.68-2.32; p=0.462), the composite endpoint of all-cause death and MI (HR 1.02, 95% CI: 0.56-1.84; p=0.956), and major adverse cardiac and cerebrovascular events (HR 0.82, 95% CI: 0.50-1.36; p=0.821). However, a higher incidence of target vessel revascularisation (HR 4.67, 95% CI: 1.33-16.47; p=0.008) was observed in the PCI compared with the CABG group, which was confirmed in the propensity score-matched analysis. CONCLUSIONS: In the DELTA all-comer, multinational registry, PCI for ACS in ULMCA is associated with comparable clinical outcomes to those observed with CABG at long-term follow-up, despite the use of first-generation DES.
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Síndrome Coronario Agudo/terapia , Puente de Arteria Coronaria , Estenosis Coronaria/terapia , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Adulto , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/métodos , Sistema de Registros , Accidente Cerebrovascular , Resultado del TratamientoAsunto(s)
Plaquetas/efectos de los fármacos , Puente de Arteria Coronaria , Hemorragia/inducido químicamente , Inhibidores de Agregación Plaquetaria/efectos adversos , Pruebas de Función Plaquetaria/métodos , Sistemas de Atención de Punto , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Receptores Purinérgicos P2Y12/efectos de los fármacos , Ticlopidina/análogos & derivados , Femenino , Humanos , MasculinoRESUMEN
Clinical right ventricular (RV) impairment can occur with left ventricular assist device (LVAD) use, thereby compromising the therapeutic effectiveness. The underlying mechanism of this RV failure may be related to induced abnormalities of septal wall motion, RV distension and ischemia, decreased LV filling, and aberrations of LVAD flow. Inhaled nitric oxide (NO), a potent pulmonary vasodilator, may reduce RV afterload, and thereby increase LV filling, LVAD flow, and cardiac output (CO). To investigate the mechanisms associated with LVAD-induced RV dysfunction and its treatment, we created a swine model of hypoxia-induced pulmonary hypertension and acute LVAD-induced RV failure and assessed the physiological effects of NO. Increased LVAD speed resulted in linear increases in LVAD flow until pulse pressure narrowed. Higher speeds induced flow instability, LV collapse, a precipitous fall of both LVAD flow and CO. Nitric oxide (20 ppm) treatment significantly increased the maximal achievable LVAD speed, LVAD flow, CO, and LV diameter. Nitric oxide resulted in decreased pulmonary vascular resistance and RV distension, increased RV ejection, promoted LV filling and improved LVAD performance. Inhaled NO may thus have broad utility for the management of biventricular disease managed by LVAD implantation through the effects of NO on LV and RV wall dynamics.
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Corazón Auxiliar/efectos adversos , Hemodinámica/efectos de los fármacos , Óxido Nítrico/farmacología , Disfunción Ventricular Derecha/etiología , Disfunción Ventricular Derecha/prevención & control , Administración por Inhalación , Animales , Modelos Animales de Enfermedad , Insuficiencia Cardíaca/cirugía , Ventrículos Cardíacos/efectos de los fármacos , Sus scrofaRESUMEN
BACKGROUND: Guidelines recommend delaying coronary artery bypass grafting (CABG) for 5 days after discontinuing clopidogrel. However, platelet function may recover quicker in certain individuals. HYPOTHESIS: We hypothesized that perioperative measurement of platelet function with a point-of-care P2Y12 inhibitor assay could predict bleeding during CABG in patients exposed to clopidogrel. METHODS: Verify Pre-Op TIMI 45 was a prospective pilot study of 39 patients on clopidogrel who subsequently underwent CABG. Preoperative on-treatment platelet reactivity was assessed with VerifyNow P2Y12 Reaction Units (PRU), with higher PRU indicating more reactive platelets. Outcomes were stratified by PRU quartiles, as well as prespecified cutpoints for the lowest quartile (PRU 173), a cutpoint for major bleeding determined by the Youden index using receiver operator curve analysis (PRU 207), and clopidogrel resistance (PRU 230). RESULTS: Patients in higher PRU quartiles experienced smaller decreases in hemoglobin and hematocrit (P < 0.05 for all comparisons), less major bleeding (P = 0.021), and less major or minor bleeding (P = 0.003). Patients above the PRU 207 and 230 cutpoints had less chest-tube output (P = 0.041 and P = 0.012, respectively), less major bleeding (P = 0.005 and P = 0.036, respectively), and less major or minor bleeding (P = 0.013 and P < 0.001, respectively). By receiver operator curve analysis, preoperative PRU ≤ 207 discriminated between patients with and without major bleeding during surgery (area under the curve: 0.76, 95% confidence interval: 0.59-0.94, P = 0.018). CONCLUSIONS: In this pilot study, we found that point-of-care platelet function assessment could predict bleeding in patients recently exposed to clopidogrel undergoing CABG.
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Plaquetas/efectos de los fármacos , Puente de Arteria Coronaria , Hemorragia/inducido químicamente , Inhibidores de Agregación Plaquetaria/efectos adversos , Pruebas de Función Plaquetaria/métodos , Sistemas de Atención de Punto , Antagonistas del Receptor Purinérgico P2Y/efectos adversos , Receptores Purinérgicos P2Y12/efectos de los fármacos , Ticlopidina/análogos & derivados , Anciano , Área Bajo la Curva , Plaquetas/metabolismo , Clopidogrel , Puente de Arteria Coronaria/efectos adversos , Resistencia a Medicamentos , Femenino , Hemorragia/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Valor Predictivo de las Pruebas , Estudios Prospectivos , Curva ROC , Receptores Purinérgicos P2Y12/sangre , Medición de Riesgo , Factores de Riesgo , Ticlopidina/efectos adversos , Resultado del Tratamiento , Estados UnidosRESUMEN
Women typically present with coronary artery disease later than men with more unfavorable clinical and anatomic characteristics. It is unknown whether differences exist in women undergoing treatment for unprotected left main coronary artery (ULMCA) disease. Our aim was to evaluate long-term clinical outcomes in women treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG). All consecutive women from the Drug-Eluting stent for LefT main coronary Artery disease registry with ULMCA disease were analyzed. A propensity matching was performed to adjust for baseline differences. In total, 817 women were included: 489 (59.8%) underwent treatment with PCI with drug-eluting stents versus 328 (40.2%) with CABG. Propensity score matching identified 175 matched pairs, and at long-term follow-up there were no differences in all-cause (odds ratio [OR] 0.722, 95% confidence interval [CI] 0.357 to 1.461, p=0.365) or cardiovascular (OR 1.100, 95% CI 0.455 to 2.660, p=0.832) mortality, myocardial infarction (MI; OR 0.362, 95% CI 0.094 to 1.388, p=0.138), or cerebrovascular accident (CVA; OR 1.200, 95% CI 0.359 to 4.007, p=0.767) resulting in no difference in the primary study objective of death, MI, or CVA (OR 0.711, 95% CI 0.387 to 1.308, p=0.273). However, there was an advantage of CABG in major adverse cardiovascular and cerebrovascular events (OR 0.429, 95% CI 0.254 to 0.723, p=0.001), driven exclusively by target vessel revascularization (OR 0.185, 95% CI 0.079 to 0.432, p<0.001). In women with significant ULMCA disease, no difference was observed after PCI or CABG in death, MI, and CVA at long-term follow-up.
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Puente de Arteria Coronaria/métodos , Estenosis Coronaria/cirugía , Vasos Coronarios/cirugía , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea/métodos , Sistema de Registros , Anciano , Angiografía Coronaria , Estenosis Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Puntaje de Propensión , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to report the long-term clinical outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for ostial/midshaft lesions in an unprotected left main coronary artery (ULMCA). BACKGROUND: Data regarding outcomes in these patients are limited. METHODS: Of a total of 2,775 patients enrolled in the DELTA multinational registry, 856 patients with isolated ostial/midshaft lesions in an ULMCA treated by PCI with DES (n = 482) or CABG (n = 374) were analyzed. RESULTS: At a median follow-up period of 1,293 days, there were no significant differences in the propensity score-adjusted analyses for the composite endpoint of all-cause death, myocardial infarction (MI), and cerebrovascular accident (hazard ratio [HR]: 1.21, 95% confidence interval [CI]: 0.79 to 1.86; p = 0.372), all-cause death (HR: 1.35, 95% CI: 0.80 to 2.27; p = 0.255), the composite endpoint of all-cause death and MI (HR: 1.33, 95% CI: 0.83 to 2.12; p = 0.235) and major adverse cardiac and cerebrovascular events (HR: 1.34, 95% CI: 0.93 to 1.93; p = 0.113). These results were sustained after propensity-score matching. However, a higher incidence of target vessel revascularization (HR: 1.94, 95% CI: 1.03 to 3.64; p = 0.039) was observed in the PCI compared with the CABG group, with a trend toward higher target lesion revascularization (HR: 2.00, 95% CI: 0.90 to 4.45; p = 0.090). CONCLUSIONS: This study demonstrates that PCI for ostial/midshaft lesions in an ULMCA is associated with clinical outcomes comparable to those observed with CABG at long-term follow-up, despite the use of older first-generation DES.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea , Anciano , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Europa (Continente) , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Sistema de Registros , República de Corea , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Factores de Tiempo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Since the first aortic valve replacement through a right thoracotomy was reported in 1993, upper hemisternotomy and right anterior thoracotomy have become the predominant approaches for minimally invasive aortic valve replacement. Clinical studies have documented equivalent operative mortality, less bleeding, and reduced intensive care/hospital stay compared with conventional sternotomy despite longer procedure times. However, comparative trials face challenges due to patient preference, surgeon bias, and the lack of a standardized minimally invasive surgical approach. METHODS: Twenty cardiothoracic surgeons from 19 institutions across the United States, with a combined experience of nearly 5000 minimally invasive aortic valve replacement operations, formed a working group to develop a basis for a standardized approach to patient evaluation, operative technique, and postoperative care. In addition, a stepwise learning program for surgeons was outlined. RESULTS: Improved cosmesis, less pain and narcotic use, and faster recovery have been reported and generally accepted by patients and by surgeons performing minimally invasive aortic valve replacement. These benefits are more likely to be verified with standardization of the procedure itself, which will greatly facilitate the design and implementation of future clinical studies. CONCLUSIONS: Surgeons interested in learning and performing minimally invasive aortic valve replacement must have expertise in conventional aortic valve replacement at centers with adequate case volumes. A team approach that coordinates efforts of the surgeon, anesthesiologist, perfusionist, and nurses is required to achieve the best clinical outcomes. By first developing fundamental minimally invasive skills using specialized cannulation techniques, neck lines, and long-shafted instruments in the setting of conventional full sternotomy, the safest operative environment is afforded to patients.
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Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Esternotomía , Toracotomía , Válvula Aórtica/diagnóstico por imagen , Competencia Clínica , Educación de Postgrado en Medicina , Enfermedades de las Válvulas Cardíacas/diagnóstico , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/educación , Humanos , Curva de Aprendizaje , Radiografía , Esternotomía/efectos adversos , Esternotomía/educación , Toracotomía/efectos adversos , Toracotomía/educación , Resultado del Tratamiento , UltrasonografíaRESUMEN
OBJECTIVES: The aim of this study was to compare, in a large all-comer registry, the long-term clinical outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for ostial/mid-shaft lesions versus distal bifurcation lesions in unprotected left main coronary artery (ULMCA) stenosis. BACKGROUND: Limited data are available regarding clinical outcomes following DES implantation at the different ULMCA sites. METHODS: Patients with ULMCA stenosis treated by PCI with DES were analyzed in this multinational registry. RESULTS: A total of 1,612 patients were included: 482 were treated for ostial/mid-shaft lesions versus 1,130 for distal bifurcation lesions. At a median follow-up period of 1,250 (interquartile range: 987 to 1,564) days, PCI for distal bifurcation lesions was associated with a higher incidence of major adverse cardiac events (propensity-score adjusted hazard ratio [HR]: 1.48, 95% confidence interval [CI]: 1.16 to 1.89; p = 0.001), largely because of the higher target vessel revascularization rate observed in this group as compared to the ostial/mid-shaft lesions group (propensity-score adjusted HR: 1.68, 95% CI: 1.19 to 2.38; p = 0.003). These results were sustained following propensity-score matched analysis. With regard to all-cause death and the composite endpoint of all-cause death and myocardial infarction, propensity-score adjusted analysis suggested a trend toward higher rates of these in the distal ULMCA PCI group, although this was not observed in the propensity-score matched analysis. CONCLUSIONS: This study demonstrates that PCI for ostial/mid-shaft lesions is associated with better clinical outcomes than are distal bifurcation lesions in ULMCA, largely because there is a lower need for repeat revascularization in ostial/mid-shaft lesions.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/terapia , Estenosis Coronaria/terapia , Intervención Coronaria Percutánea , Anciano , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Estenosis Coronaria/diagnóstico , Estenosis Coronaria/mortalidad , Estenosis Coronaria/cirugía , Stents Liberadores de Fármacos , Europa (Continente)/epidemiología , Femenino , Humanos , Incidencia , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/mortalidad , Puntaje de Propensión , Sistema de Registros , República de Corea/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Although echocardiography is commonly performed before coronary artery bypass surgery, there has yet to be a study examining the incremental prognostic value of a complete echocardiogram. METHODS AND RESULTS: Patients undergoing isolated coronary artery bypass surgery at 2 hospitals were divided into derivation and validation cohorts. A panel of quantitative echocardiographic parameters was measured. Clinical variables were extracted from the Society of Thoracic Surgeons database. The primary outcome was in-hospital mortality or major morbidity, and the secondary outcome was long-term all-cause mortality. The derivation cohort consisted of 667 patients with a mean age of 67.2±11.1 years and 22.8% females. The following echocardiographic parameters were found to be optimal predictors of mortality or major morbidity: severe diastolic dysfunction, as evidenced by restrictive filling (odds ratio, 2.96; 95% confidence interval, 1.59-5.49), right ventricular dysfunction, as evidenced by fractional area change <35% (odds ratio, 3.03; 95% confidence interval, 1.28-7.20), or myocardial performance index >0.40 (odds ratio, 1.89; 95% confidence interval, 1.13-3.15). These results were confirmed in the validation cohort of 187 patients. When added to the Society of Thoracic Surgeons risk score, the echocardiographic parameters resulted in a net improvement in model discrimination and reclassification with a change in c-statistic from 0.68 to 0.73 and an integrated discrimination improvement of 5.9% (95% confidence interval, 2.8%-8.9%). In the Cox proportional hazards model, right ventricular dysfunction and pulmonary hypertension were independently predictive of mortality over 3.2 years of follow-up. CONCLUSIONS: Preoperative echocardiography, in particular right ventricular dysfunction and restrictive left ventricular filling, provides incremental prognostic value in identifying patients at higher risk of mortality or major morbidity after coronary artery bypass surgery.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/epidemiología , Enfermedad de la Arteria Coronaria/mortalidad , Ecocardiografía , Cuidados Preoperatorios , Anciano , Anciano de 80 o más Años , Canadá , Estudios de Cohortes , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Hipertensión Pulmonar/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Morbilidad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Estados Unidos , Disfunción Ventricular Derecha/diagnóstico por imagenRESUMEN
OBJECTIVE: In this study, we aim to investigate the association between aortic sclerosis and mortality and major morbidity in patients with established coronary artery disease undergoing coronary artery bypass grafting (CABG). DESIGN: Preoperative echocardiograms of consecutive patients undergoing isolated CABG between 2007 and 2009 (n=1150) were analysed, excluding patients without an echocardiogram in the 30 days prior to surgery (n=483). Using logistic regression, we evaluated the association between aortic sclerosis and inhospital mortality and major morbidity. Using Cox proportional hazards, the effect on long-term all-cause mortality was determined. SETTING: Massachusetts General Hospital, Boston. PATIENTS: Patients undergoing isolated CABG between 2007 and 2009. INTERVENTIONS: Analysis of echocardiograms. MAIN OUTCOME MEASURES: Inhospital mortality and major morbidity, and long-term all-cause mortality. RESULTS: 627 patients were suitable for enrolment; 207 (33%) had significant aortic sclerosis. These patients had higher rates of traditional cardiovascular risk factors. Significant aortic sclerosis was associated with an increased risk of inhospital mortality or major morbidity (OR 1.95; 95% CI 1.25 to 3.04). Following adjustment for baseline clinical and echocardiographic variables, the association remained significant (OR 1.90; 95% CI 1.15 to 3.11). The HR for adjusted all-cause mortality was 2.52 (mean follow-up 2.7 years). CONCLUSIONS: Aortic sclerosis is a common finding in patients undergoing CABG. In these patients, its presence is associated with a higher risk of inhospital mortality or major morbidity, and is associated with a higher risk of all-cause long-term mortality independent of other risk factors.
Asunto(s)
Enfermedades de la Aorta/complicaciones , Aterosclerosis/complicaciones , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/mortalidad , Anciano , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/mortalidad , Aterosclerosis/diagnóstico por imagen , Aterosclerosis/mortalidad , Causas de Muerte/tendencias , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/cirugía , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Massachusetts/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendenciasAsunto(s)
Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco/normas , Implantación de Prótesis de Válvulas Cardíacas/normas , Estenosis de la Válvula Aórtica/diagnóstico , Cateterismo Cardíaco/efectos adversos , Medicina Basada en la Evidencia , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Selección de Paciente , Valor Predictivo de las Pruebas , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoAsunto(s)
Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco/normas , Cardiología/normas , Implantación de Prótesis de Válvulas Cardíacas/normas , Estenosis de la Válvula Aórtica/diagnóstico , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/mortalidad , Ecocardiografía/normas , Medicina Basada en la Evidencia/normas , Prótesis Valvulares Cardíacas/normas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Valor Predictivo de las Pruebas , Diseño de Prótesis , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to compare, in a large all-comers registry, major adverse cardiac and cerebrovascular events (MACCE) after percutaneous coronary intervention (PCI) with first-generation drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) stenosis. BACKGROUND: Percutaneous coronary intervention with DES implantation in ULMCA has been shown to be a feasible and safe approach at midterm clinical follow-up. METHODS: All consecutive patients with ULMCA stenosis treated by PCI with DES versus CABG were analyzed in this multinational registry. A propensity score analysis was performed to adjust for baseline differences in the overall cohort. RESULTS: In total 2,775 patients were included: 1,874 were treated with PCI versus 901 with CABG. At 1,295 (interquartile range: 928 to 1,713) days, there were no differences, at the adjusted analysis, in the primary composite endpoint of death, cerebrovascular accidents, and myocardial infarction (MI) (adjusted hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 0.85 to 1.42; p = 0.47), mortality (adjusted HR: 1.16; 95% CI: 0.87 to 1.55; p = 0.32), or composite endpoint of death and MI (adjusted HR: 1.25; 95% CI: 0.95 to 1.64; p = 0.11). An advantage of CABG over PCI was observed in the composite secondary endpoint of MACCE (adjusted HR: 1.64; 95% CI: 1.33 to 2.03; p < 0.0001), driven exclusively by the higher incidence of target vessel revascularization with PCI. CONCLUSIONS: In our multinational all-comers registry, no difference was observed in the occurrence of death, cerebrovascular accidents, and MI between PCI and CABG. An advantage of CABG over PCI was observed in the incidence of MACCE, driven by the higher incidence of target vessel revascularization with PCI.