RESUMEN
BACKGROUND AND AIMS: Ischemic or bleeding events might occur after transcatheter aortic valve replacement (TAVR), with the potential to hamper clinical outcomes. This study aimed to characterize the average daily ischemic risks (ADIRs) and the average daily bleeding risks (ADBRs) over 1-year in all consecutive patients undergoing TAVR. METHODS: ADBR included all bleeding events according to VARC-2 definition, and ADIR included cardiovascular deaths, myocardial infarction and ischemic stroke. ADIRs and ADBRs were assessed within different timeframes post TAVR: acute (0-30 days), late (31-180 days), and very late (>181 days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparison of ADIRs and ADBRs. Our analysis was performed in the overall cohort and according to antithrombotic strategy (LT-OAC vs No LT-OAC). RESULTS: Ischemic burden was higher than bleeding burden, independently from the indication to LT-OAC, and in all timeframes examined. In the overall population, ADIRs were three-fold ADBRs (0.0467 [95% CI, 0.0431-0.0506] vs 0.0179 [95% CI, 0.0174-0.0185]; p < 0.001*). While ADIR was significantly higher in the acute phase, ADBR was relatively stable in all timeframes analysed. Of note, in LT-OAC population, OAC + SAPT group showed lower ischemic risk and higher bleeding events compared with OAC alone (ADIR: 0.0447 [95% CI: 0.0417-0.0477] vs 0.0642 [95% CI: 0.0557-0.0728]; p < 0.001*, ADBR 0.0395 [95% CI: 0.0381-0.0409] vs 0.0147 [95% CI: 0.0138-0.0156]; p < 0.001*). CONCLUSIONS: In patients undergoing TAVR Average daily risk fluctuates over time. However, ADIRs overcome ADBRs in all timeframes, especially in the acute phase and regardless of antithrombotic strategy adopted.
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Estenosis de la Válvula Aórtica , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Fibrinolíticos/efectos adversos , Resultado del Tratamiento , Hemorragia/inducido químicamente , Hemorragia/diagnóstico , Hemorragia/epidemiología , Isquemia , Sistema de Registros , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Factores de RiesgoRESUMEN
BACKGROUND: Well-developed collaterals are assumed as a marker of viability and ischemia in chronic total occlusions (CTO). We aim to correlate viability and ischemia with collateral presence and extent in CTO patients by cardiac magnetic resonance (CMR). METHODS: Multicentre study of 150 CTO patients undergoing stress-CMR, including adenosine if normal systolic function, high-dose-dobutamine for patients with akinetic/>2 hypokinetic segments and EF ≥35%, otherwise low-dose-dobutamine (LDD); all patients underwent late gadolinium enhancement (LGE) imaging. Viability was defined as mean LGE transmurality ≤50% for adenosine, as functional improvement for dobutamine-stress-test, ischemia as ≥1.5 segments with perfusion defects outside the scar zone. RESULTS: Rentrop 3/CC 2 defined well-developed (WD, n = 74) vs poorly-developed collaterals (PD, n = 76). Viability was equally prevalent in WD vs PD: normo-functional myocardium with ≤50% LGE in 52% vs 58% segments, p = 0.76, functional improvement by LDD in 48% vs 52%, p = 0.12. Segments with none, 1-25%,26-50%,51-75% LGE showed viability by LDD in 90%,84%,81%,61% of cases, whilst in 12% if 76-100% LGE (p < 0.01). There was no difference in WD vs PD for ischemia presence (74% vs 75%, p = 0.99) and extent (2.7 vs 2.8 segments, p = 0.77). CONCLUSIONS: In a large cohort of CTO patients, presence and extent of collaterals did not predict viability and ischemia by stress-CMR. Scar extent up to 75% LGE was still associated with viability, whereas ischemia was undetectable in 25% of patients, suggesting that the assessment of CTO patients with CMR would lead to a more comprehensive evaluation of viability and ischemia to guide revascularization.
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Medios de Contraste , Isquemia Miocárdica , Humanos , Gadolinio , Miocardio/patología , Dobutamina , Adenosina , Isquemia/patología , Valor Predictivo de las Pruebas , Imagen por Resonancia Cinemagnética/métodos , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/patologíaRESUMEN
OBJECTIVE: The correction of functional mitral regurgitation (FMR) with transcatheter edge-to-edge repair (TEER) can favorably affect patients' hemodynamic profile. However, the procedure requires inter-atrial trans-septal access and the hemodynamic relevance of the residual iatrogenic atrium septal defect (iASD) is still debated. This study aimed at investigating the hemodynamic modifications during TEER with MitraClip, before and after the iASD creation, in patients with heart failure with reduced ejection fraction (HFrEF) and severe FMR. METHODS: Thirty-nine HFrEF patients with 3+ or 4+/4+ FMR were included. Right heart catheterization was performed at baseline after general anesthesia induction and at the end of TEER, both before and after removing the device guiding catheter. RESULTS: Compared with baseline, MitraClip positioning was followed by a significant immediate improvement in cardiac output (respectively: 3.36 vs 5.05 ml/min), pulmonary artery wedge pressure (23.7 vs 18.2 mmHg), mean pulmonary artery pressure (34.4 vs 27.7 mmHg) and pulmonary vascular resistance (3.6 vs 2.2 Wood Units) (all p < 0.001). No further significant modifications occurred after removing the device guiding catheter. CONCLUSIONS: Our data suggest that the acute hemodynamic modifications after TEER are not influenced by the induction of iASD in patients with FMR.
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Insuficiencia Cardíaca , Defectos del Tabique Interatrial , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Cateterismo Cardíaco/métodos , Defectos del Tabique Interatrial/complicaciones , Defectos del Tabique Interatrial/cirugía , Hemodinámica , Humanos , Enfermedad Iatrogénica , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Volumen Sistólico , Resultado del TratamientoAsunto(s)
Ablación por Catéter/efectos adversos , Síndrome de Hipersensibilidad a Medicamentos/etiología , Complicaciones Posoperatorias/etiología , Adulto , Síndrome de Hipersensibilidad a Medicamentos/diagnóstico , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico , Complejos Prematuros Ventriculares/cirugíaRESUMEN
El estado de los ganglios axilares es el factor de predicción de sobrevida más importante en pacientes con cáncer de mama, siendo además considerado para la decisión de indicación de tratamientos adyuvantes.La biopsia del ganglio centinela (GC) es actualmente el procedimiento estándar para la estadificación axilar en cáncer de mama con axila clínicamente negativa. Esto redujo el número de ganglios axilares a ser estudiados por el patólogo; de un promedio de 15 a 20 ganglios en una pieza de linfadenectomía axilar a 1 a 3 ganglios en los casos de biopsia de GC. Asimismo, permitió un estudio más exhaustivo del GC y con ello aumentó la detección de metástasis de menor tamaño, sean estas micrometástasis (MMT) o células tumorales aisladas (CTA). Las primeras presentan un tamaño entre 0,2 mm y no mayor a 2,0 mm, y las segundas un tamaño que no supera los 0,2 mm. En la actualidad existen controversias respecto al impacto clínico y manejo de las MMT y CTA. El siguiente trabajo muestra la experiencia en el manejo de estos casos en el Hospital Universitario CEMIC y realiza una revisión de la literatura.
Asunto(s)
Mama , Micrometástasis de Neoplasia , Biopsia del Ganglio Linfático CentinelaAsunto(s)
Canales de Potasio Éter-A-Go-Go/genética , Mutación del Sistema de Lectura/genética , Síndrome de QT Prolongado/genética , Adulto , Canal de Potasio ERG1 , Electrocardiografía , Femenino , Humanos , Síndrome de QT Prolongado/diagnóstico , Síndrome de QT Prolongado/terapia , Datos de Secuencia Molecular , Adulto JovenRESUMEN
An active surveillance for nosocomial infections has been lead in a Thoracic Surgery with the intention, first to point out their frequency and characteristics, and then to outline all the measures to remove the main risk factors checking the results obtained. A prospective incidence study has been promoted in a Thoracic Surgery in the years 2000, 2001, 2002. The analysis has been lead weekly gathering all necessary data from the health records and making laboratory tests to look for microbes growth in the air of Thoracic Surgery Operating Rooms. A nosocomial infections incidence of 13.3% among surgically treated patients has been registered in 2000. Deep surgical site infections were the most frequent localizations, and microbes isolated were Staphylococcus aureus and coagulase negative Staphylococcus with an high oxacillin resistance (70.6%-76.5%). From the observation of the risk factors the sterilization system has been modified and the assistance and environmental protocols have been improved. In the further evaluation period, a global reduction of nosocomial infections incidence (7.1%), of surgical site infections (from 10.1% to 4.5%) (p = 0.007), of Staphylococcus aureus and coagulase negative Staphylococcus isolations have been obtained even if short results in antibiotic resistances have been registered. Thoracic Surgery has to be considered an area at medium-high risk of nosocomial infections. The quite high incidence of nosocomial infections recorded at the beginning of the study in presence of prevalent deep surgical site infections from staphylococci with an high oxacillin resistance compelled to promote corrections. These lead to a remarkable decrease in incidence of nosocomial infections even if the same results can not be reached in antibiotic resistances.
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Infección Hospitalaria/epidemiología , Calidad de la Atención de Salud , Infecciones Estafilocócicas/epidemiología , Staphylococcus aureus/aislamiento & purificación , Infección de la Herida Quirúrgica/epidemiología , Cirugía Torácica , Antibacterianos/farmacología , Infección Hospitalaria/microbiología , Infección Hospitalaria/prevención & control , Farmacorresistencia Bacteriana , Humanos , Incidencia , Italia/epidemiología , Oxacilina/farmacología , Vigilancia de la Población , Estudios Prospectivos , Infecciones Estafilocócicas/prevención & control , Staphylococcus aureus/efectos de los fármacos , Staphylococcus aureus/enzimología , Infección de la Herida Quirúrgica/microbiología , Infección de la Herida Quirúrgica/prevención & controlRESUMEN
BACKGROUND AND PURPOSE: Atherosclerosis occurs later and is less extensive in intracranial arteries than in extracranial arteries. However, the mechanisms responsible are poorly understood. A previous study has suggested a better antioxidant protection of intracranial arteries. METHODS: To assess the influence of age on arterial activity of antioxidant enzymes and atherogenesis, we compared intracranial and extracranial arteries of humans of different ages who retrospectively lacked confounding classic risk factors (48 premature fetuses aged 6.4+/-0.8 months [mean+/-SD], 58 children aged 7.9+/-3.8 years, 42 adults aged 42.5+/-5.1 years, and 40 elderly subjects aged 71.8+/-3.4 years; all males). Lesions were quantified by computer-assisted imaging analysis of sections of the middle cerebral and basilar arteries, the left anterior descending coronary artery, the common carotid artery, and the abdominal aorta. Macrophages, apolipoprotein B, oxidized LDL, and matrix metalloproteinase-9 in lesions were determined by immunocytochemistry. The effect of aging on atherogenesis was then compared with that on the activity of 4 antioxidant enzymes in the arterial wall. RESULTS: Atherosclerosis was 6- to 19-fold greater (P<0.01) in extracranial arteries than in intracranial arteries, and it increased linearly with age. Intracranial arteries showed significantly greater antioxidant enzyme activities than did extracranial arteries. However, the antioxidant protection of intracranial arteries decreased significantly in older age, coinciding with a marked acceleration of atherogenesis. An increase in matrix metalloproteinase-9 protein expression and in gelatinolytic activity consistent with the degree of intracranial atherosclerosis was also observed. CONCLUSIONS: These results suggest that a greater activity of antioxidant enzymes in intracranial arteries may contribute to their greater resistance to atherogenesis and that with increasing age intracranial arteries respond with accelerated atherogenesis when their antioxidant protection decreases relatively more than that of extracranial arteries.
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Arterias Cerebrales/enzimología , Arteriosclerosis Intracraneal/enzimología , Arteriosclerosis Intracraneal/etiología , Adulto , Factores de Edad , Anciano , Antioxidantes/análisis , Apolipoproteínas B/análisis , Apolipoproteínas B/inmunología , Arterias/química , Arterias/enzimología , Arterias/patología , Arterias Cerebrales/química , Arterias Cerebrales/patología , Niño , Progresión de la Enfermedad , Humanos , Inmunohistoquímica , Arteriosclerosis Intracraneal/patología , Peroxidación de Lípido , Lipoproteínas LDL/análisis , Lipoproteínas LDL/inmunología , Masculino , Metaloproteinasa 9 de la Matriz/metabolismo , Estudios Retrospectivos , Factores de Riesgo , Superóxido Dismutasa/análisis , Superóxido Dismutasa/inmunologíaRESUMEN
This study aimed to analyze the role of DNA tsting in cervical cancer. In 1995, the International Agency for Research on Cancer defined the association between infections with human papilloma virus (HPV) and cervical cancer (CC), sustained in numerous epidemiologic and experimental evidences. However, even if the infection develops as a necessary condition to generate a CC in almost the 100 por ciento of the cases, it would not be sufficient enough without the support of other associated factors to break out the tumoral growth. Thus, human papilloma viruses are receiving increasing attention for their role in the pathogenesis of ulterine cervix cancer, and therefore efforts should be dedicated to avoid this infection as a mean to prevent CC, development of an effective vaccine. We examined a group of 111 females in order to evaluate the results obtained with human papilloma virus DNA testing aimed to generate indications to improve the managements condition of cost-effectiveness
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Humanos , Femenino , Adulto , Cuello del Útero/patología , ADN/diagnósticoRESUMEN
This study aimed to analyze the role of DNA tsting in cervical cancer. In 1995, the International Agency for Research on Cancer defined the association between infections with human papilloma virus (HPV) and cervical cancer (CC), sustained in numerous epidemiologic and experimental evidences. However, even if the infection develops as a necessary condition to generate a CC in almost the 100 por ciento of the cases, it would not be sufficient enough without the support of other associated factors to break out the tumoral growth. Thus, human papilloma viruses are receiving increasing attention for their role in the pathogenesis of ulterine cervix cancer, and therefore efforts should be dedicated to avoid this infection as a mean to prevent CC, development of an effective vaccine. We examined a group of 111 females in order to evaluate the results obtained with human papilloma virus DNA testing aimed to generate indications to improve the management's condition of cost-effectiveness
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Humanos , Femenino , Adulto , Cuello del Útero/patología , ADNRESUMEN
AIM OF THE STUDY: 1) To verify the usefulness of ketorolac administration (30 mg i.v.) before a surgical operation in terms of postoperative analgesia improvement; 2) To evaluate the impact of preoperative ketorolac administration on perioperative renal function and on intraoperative water balance; 3) to evaluate the presence of adverse effect due to preoperative NSAID use. DESIGN: Prospective randomized trial. SETTING: University surgical department. PATIENTS AND METHODS: Forty adult patients undergoing major abdominal surgery, randomized in 2 groups: in group 1 ketorolac (30 mg i.v.) was administered immediately after the induction and, for postoperative analgesia, ketorolac (30 mg i.v.) was administered beginning at the time of skin closure; in group 2 no ketorolac was administered before the operation and postoperative treatment was the same. Buprenorphine (0.3 mg i.m.) was administered in case of unsatisfactory analgesia. Fluids infused and diuresis were measured intraoperatively. One, 6 and 24 hours after the end of operation pain was evaluated using pain intensity score and VAS. The day after the operation serum creatinine and urea were measured. RESULTS: No statistically significant differences were found between groups regarding fluids infused, intraoperative diuresis, postoperative pain, adverse effects and number of bleeding episodes. More than 50% of patients, in either groups, required opioids administration. CONCLUSIONS: Ketorolac (30 mg i.v.) administration before a major abdominal operation does not improve postoperative analgesia nor determines significant alterations in renal function or increase in the frequency of abnormal bleedings. Opiate administration is necessary in more than 50% of the patients to achieve adequate analgesia.