RESUMO
Peripheral pulmonary artery stenosis is a quite rare condition that can lead to misdiagnosis, particularly in adults. We describe the case of a 48-year-old woman with multiple stenoses, challenging anatomy and Eisenmenger-like presentation, who was treated percutaneously with a coronary technique.
Assuntos
Angioplastia com Balão/métodos , Complexo de Eisenmenger/terapia , Artéria Pulmonar/anormalidades , Stents , Anormalidades Múltiplas , Cateterismo Cardíaco , Constrição Patológica , Dextrocardia , Complexo de Eisenmenger/diagnóstico por imagem , Feminino , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/etiologia , Hipertrofia Ventricular Direita/etiologia , Pessoa de Meia-Idade , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/patologiaRESUMO
BACKGROUND: Pulmonary hypertension (PH) is a well-known independent prognostic factor in chronic obstructive pulmonary disease (COPD) and a sufficient criterion for lung transplant candidacy. Limited data are currently available on the hemodynamic and clinical effect of phosphodiesterase 5 inhibitors in patients with severe PH associated with COPD. This study assessed the effect of sildenafil on pulmonary hemodynamics and gas exchange in severe PH associated with COPD. METHODS: After screening, this multicenter, randomized, placebo-controlled double-blind trial randomized patients to receive 20 mg sildenafil or placebo 3 times a day (ratio 2:1) for 16 weeks. The primary end point was the reduction in pulmonary vascular resistance. Secondary end points included BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index, 6-minute walk test, and quality of life questionnaire. Changes in the partial pressure of arterial oxygen were evaluated as a safety parameter. RESULTS: The final population included 28 patients, 18 in the sildenafil group and 10 in the placebo group. At 16 week, patients treated with sildenafil had a decrease in pulmonary vascular resistance (mean difference with placebo -1.4 WU; 95% confidence interval, ≤ -0.05; p = 0.04). Sildenafil also improved the BODE index, diffusion capacity of the lung for carbon monoxide percentage, and quality of life. Change from baseline in the partial pressure of arterial oxygen was not significantly different between the sildenafil and placebo groups. CONCLUSIONS: This pilot study found that treatment with sildenafil reduced pulmonary vascular resistance and improved the BODE index and quality of life, without a significant effect on gas exchange.
Assuntos
Hipertensão Pulmonar/tratamento farmacológico , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Troca Gasosa Pulmonar/efeitos dos fármacos , Citrato de Sildenafila/administração & dosagem , Resistência Vascular/efeitos dos fármacos , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalos de Confiança , Relação Dose-Resposta a Droga , Método Duplo-Cego , Esquema de Medicação , Feminino , Seguimentos , Hemodinâmica/efeitos dos fármacos , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/diagnóstico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Projetos Piloto , Doença Pulmonar Obstrutiva Crônica/complicações , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Valores de Referência , Medição de Risco , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Acute type A retrograde aortic dissection is characterized by a port of entry located in the descending aorta near the subclavian take-off, and is currently treated with surgery. Our experience with two patients who underwent a complicated postoperative course stimulated a review of the current literature and discussion of possible alternative strategies in light of recent advances in endovascular treatment.
Assuntos
Aneurisma da Aorta Torácica/terapia , Dissecção Aórtica/terapia , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/métodos , Adulto , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Aortografia , Humanos , Masculino , Pessoa de Meia-Idade , Stents , Resultado do TratamentoAssuntos
Remoção de Dispositivo/métodos , Ventrículos do Coração/patologia , Coração Auxiliar/efeitos adversos , Terapia Trombolítica/métodos , Trombose/diagnóstico , Trombose/terapia , Idoso , Comportamento de Escolha , Estudos de Coortes , Feminino , Coração Auxiliar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Terapia Trombolítica/tendências , Trombose/etiologiaRESUMO
Coarctation of aorta (CoA) is a narrowing of the aorta leading to a pressure gradient (ΔP) across the coarctation, increased afterload and reduced peripheral perfusion pressures. Indication to invasive treatment is based on values of maximal (systolic) trans-coarctation ΔP. A computational fluid dynamic (CFD) approach is herein presented for the non-invasive haemodynamic assessment of ΔP across CoA. Patient-specific CFD simulations were created from contrast-enhanced computed tomography (CT) and appropriate flow boundary conditions. Computed ΔP was validated with invasive intravascular trans-CoA pressure measurements. Haemodynamic indices, including pressure loss coefficient (PLc), time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI), were also quantified. CFD-estimated ΔP values were comparable to the invasive ones. Moreover, the aorta proximal to CoA was exposed to altered TAWSS and OSI suggesting hypertension. PLc was found as a further geometric marker of CoA severity. Finally, CFD-estimated ΔP confirmed a significant reduction after percutaneous balloon dilatation and stenting of the CoA in one patient (e.g. from ΔPâ¼52 mmHg to ΔPâ¼3 mmHg). The validation of the ΔP computations with catheterisation measurements suggests that CFD simulation, based on CT-derived anatomical data, is a useful tool to readily quantify CoA severity.
RESUMO
Thoracic aortic diseases are life-threatening conditions causing significant mortality and morbidity despite advances in diagnostic and surgical treatments. Computational methods combined with imaging techniques provide quantitative information of disease progression, which may improve clinical treatments and therapeutic strategies for clinical practice. Since hemodynamic and wall mechanics play important roles in the natural history and progression of aortic diseases, we reviewed the potential application of computational modeling of the thoracic aorta. We placed emphasis on the clinical relevance of these techniques for the assessment of aortic dissection, thoracic aortic aneurysm, and aortic coarctation. Current clinical guidelines and treatment are also described.
Assuntos
Aorta Torácica , Doenças da Aorta/diagnóstico , Modelagem Computacional Específica para o Paciente , Dissecção Aórtica/diagnóstico , Aorta Torácica/fisiopatologia , Aneurisma Aórtico/diagnóstico , Coartação Aórtica/diagnóstico , Doenças da Aorta/fisiopatologia , Fenômenos Biomecânicos , Diagnóstico por Imagem , Progressão da Doença , Hemodinâmica , Humanos , Guias de Prática Clínica como AssuntoRESUMO
We present preliminary data on the flow-induced haemodynamic and structural loads exerted on a penetrating atherosclerotic aortic ulcer (PAU). Specifically, one-way fluid-structure interaction analysis was performed on the aortic model reconstructed from a 66-year-old male patient with a PAU that evolved into an intramural haematoma and rupture of the thoracic aorta. The results show that elevated blood pressure (117 mmHg) and low flow velocity at the aortic wall (0.15 m/s(2)) occurred in the region of the PAU. We also found a low value of time-averaged wall shear stress (1.24 N/m(2)) and a high value of the temporal oscillation in the wall shear stress (oscillatory shear index = 0.13) in the region of the PAU. After endovascular treatment, these haemodynamic parameters were distributed uniformly on the luminal surface of the stent graft. These findings suggest that wall shear stress could be considered one of the major haemodynamic factors indicating the structural fragility of the PAU wall, which ultimately lead to PAU growth and rupture.
Assuntos
Aorta Torácica/fisiopatologia , Doenças da Aorta/fisiopatologia , Ruptura Aórtica/fisiopatologia , Aterosclerose/fisiopatologia , Simulação por Computador , Hemodinâmica , Modelos Cardiovasculares , Úlcera/fisiopatologia , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Doenças da Aorta/diagnóstico por imagem , Doenças da Aorta/cirurgia , Ruptura Aórtica/diagnóstico por imagem , Ruptura Aórtica/cirurgia , Aortografia/métodos , Pressão Arterial , Aterosclerose/diagnóstico por imagem , Aterosclerose/cirurgia , Velocidade do Fluxo Sanguíneo , Implante de Prótese Vascular , Procedimentos Endovasculares , Hematoma/fisiopatologia , Humanos , Masculino , Fluxo Sanguíneo Regional , Estresse Mecânico , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Úlcera/diagnóstico por imagem , Úlcera/cirurgiaRESUMO
PATIENTS AND METHODS: In-stent hemodynamics were studied by transesophageal echocardiography (TEE) in a group of 54 patients after left main coronary artery stenting, during a 6-month follow-up. TEE was performed within 24 hours after stenting and at 1- and 3-month follow-up. Pulsed wave and color Doppler signals were enhanced by IV administration of Levovist. RESULTS: Angiographic immediate success was obtained in all patients. No in-hospital death occurred. Ten patients (18.4%) complained of recurrent angina at the follow-up of 4.8 ± 1.2 months. Both TEE and coronary angiography confirmed in-stent restenosis in all. Thirty-nine patients (68.5%) remained symptoms free. Mean late loss in these patients was 0.69 ± 0.20 mm. A linear significant positive relation between mean late loss values and diastolic coronary velocity (r: 0.89, P < 0.001) was found. After 3- and 6-month follow-up, PDV showed a significant increase in comparison with basal values (0.7 ± 0.3 and 0.6 ± 0.26 vs. 0.32 ± 0.2 cm/sec, P < 0.01). All patients with restenosis showed a significant increase of diastolic coronary velocity in comparison with basal values (2.89 ± 0.25 cm/sec, P < 0.001). CONCLUSION: TEE can predict the development of in-stent intimal hyperplasia in patients with unprotected left main coronary artery stenting.
Assuntos
Circulação Coronária , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/fisiopatologia , Ecocardiografia Transesofagiana/métodos , Oclusão de Enxerto Vascular/diagnóstico por imagem , Oclusão de Enxerto Vascular/fisiopatologia , Stents/efeitos adversos , Meios de Contraste , Reestenose Coronária/etiologia , Feminino , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Polissacarídeos , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Resultado do TratamentoRESUMO
BACKGROUND: The appropriate treatment strategy for secondary stroke prevention in patients with cryptogenic stroke and patent foramen ovale (PFO) remains challenging. The aim of this study was to describe a case series of patients with PFO and complex septal anatomy who underwent percutaneous correction using a FIGULLA (Occlutech) septal occluder (FSO). PATIENTS: Ten consecutive patients (6 females, 4 males, mean age 41.6 ± 16.0 years, range 17-52 years; group 1) with cryptogenetic stroke and/or transient cerebral ischemia and complex septal anatomy, as defined by intraprocedural transesophageal echocardiogram (TEE) were compared with a group of 25 patients (10 females, 15 males, mean age 43.7 ± 12.3 years; group 2) with usual tunnel-like PFO anatomy in whom PFO was closed by an Amplatzer septal occluder (ASO; AGA). RESULTS: No significant differences were noted between group 1 and group 2 for immediate success rate, residual intraprosthetic shunt at the end of the procedure, discharge, 1, 6 and 12 months follow up, number of attempts, procedure time, fluoroscopy time, or cardiac complication (atrial arrhythmias, device embolism). The only significant difference was shown for delivery sheath size (11 ± 2 versus 9 ± 1 F) and incidence of local hematoma (30% versus 12%) between group 1 and group 2, without any clinical consequence (need of transfusion) or increase in length of stay. CONCLUSION: FSO shows high performance in patients with PFO and complex septal anatomy when compared with patients with PFO and uncomplicated atrial anatomy treated by ASO. Its favorable behavior is probably related to fabric features such as the total amount of metal and the presence of titanium.
Assuntos
Forame Oval Patente/patologia , Forame Oval Patente/cirurgia , Septos Cardíacos/patologia , Septos Cardíacos/cirurgia , Dispositivo para Oclusão Septal , Adolescente , Adulto , Ecocardiografia , Feminino , Seguimentos , Forame Oval Patente/diagnóstico por imagem , Septos Cardíacos/anatomia & histologia , Humanos , Ataque Isquêmico Transitório/prevenção & controle , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento , Adulto JovemRESUMO
We prospectively evaluated 46 patients who underwent aortic valve repair (AVR) for AV regurgitation. Rest/stress echocardiography follow-up was performed. Follow-up duration was 30.7 months, age 56 ± 14 years, ejection fraction% 57.5 ± 10.5%. Preoperative bicuspid AV was present in 14 (30.4%), leaflets calcifications in 8 (17.4%), thickening in 17 (37.0%) and prolapse in 22 (47.8%). Surgical technique included commissuroplasty (22, 47.8%), leaflet remodelling (17, 37.0%), decalcification (7, 15.2%) and raphe removal (14, 30.4%). At follow-up, rest/stress echocardiography median AV regurgitation (rest 1.0 vs. stress 1.0) and mean indexed AV area (IAVA) (rest 2.6 ± 0.74 cm(2)/m(2) vs. stress 2.8 ± 0.4 cm(2)/m(2)) were unchanged (P = ns). Mean (rest 4.7 ± 3.9 mmHg vs. stress 9.7 ± 5.8 mmHg) and peak (rest 9.5 ± 7.2 mmHg vs. stress 19.0 ± 10.5 mmHg) transvalvular gradients were significantly increased (P < 0.0001). At linear regression, there was an independent inverse correlation between commissuroplasty and AV gradients during stress (B = -9.9, P = 0.01, confidence interval= -17.7 to -2.1). Although follow-up haemodynamics of repaired AVs are satisfactory, there was a fixed IAVA and significant increase in AV gradients. We were not able to identify any pre-existing anatomical condition independently related to this non-physiological behaviour under stress. Moreover, commissuroplasty seems to prevent abnormal increase of the AV gradients.
Assuntos
Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos , Ecocardiografia Doppler de Pulso , Ecocardiografia sob Estresse , Teste de Esforço , Adulto , Idoso , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/fisiopatologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Hemodinâmica , Humanos , Itália , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
OBJECTIVES: To verify whether the use of a small, oval-shaped patch limits the trend toward re-dilatation compared to endoventricular circular patch plasty and leads to different geometrical and functional results in surgical anterior restoration. METHODS: Thirty-seven patients with ischemic cardiomyopathy after anterior myocardial infarction end-systolic volume index of > or =45 ml/m2, ejection fraction of < or =35%, and no combined mitral procedures, underwent surgical anterior ventricular restoration between January 2000 and April 2003: 18 patients (group 1) were operated on using the endoventricular circular patch plasty technique (mean patch area 9.6 cm2) and 19 patients (group 2) received a small, obliquely oriented, oval-shaped patch (mean patch area 6.2 cm2). Ten geometrical parameters were studied preoperatively and at least 6 and 12 months after surgery. Data were analyzed using repeated-measures ANOVA, chi2, paired and unpaired Student's t-test, and binary logistic regression. RESULTS: Group 1 showed a worsening over time in systolic and diastolic longitudinal length, end-diastolic volume (P < 0.001), end-diastolic volume index (P = 0.006), end-systolic volume (P = 0.005), and end-systolic volume index (P = 0.03). Group 2 showed an improvement in percentage of akinesia and wall motion score index (P < 0.001) and a worsening only in end-systolic diameter (P = 0.03) and end-diastolic volume (P = 0.04). At 12-month follow-up, ANOVA revealed that the oval patch positively influenced end-diastolic volume (P = 0.03), end-systolic volume (P = 0.03), and end-systolic volume index (P = 0.05), and group 2 had a significantly higher number of patients with an end-systolic volume index of <45 ml/m2 (P = 0.01). CONCLUSION: The use of a small, narrow, obliquely oriented, oval patch may help to prevent adverse ventricular remodeling over time.
Assuntos
Bioprótese , Ventrículos do Coração/cirurgia , Infarto do Miocárdio/complicações , Isquemia Miocárdica/cirurgia , Idoso , Análise de Variância , Animais , Procedimentos Cirúrgicos Cardíacos/métodos , Bovinos , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária , Ecocardiografia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/etiologia , Isquemia Miocárdica/fisiopatologia , Projetos Piloto , Resultado do Tratamento , Remodelação VentricularRESUMO
BACKGROUND: Long-term morphofunctional outcome may vary widely in surgical anterior left ventricular wall restoration, suggesting variability in post-surgical remodeling similar to that observed following acute myocardial infarction. The aim of this pilot study was to demonstrate that surgical restoration obtained with a particular shape of endoventricular patch leads to steady morphofunctional ventricular improvement when geometry, volume and residual akinesia can be restored as normal as possible. METHODS: This study involved 12 consecutive patients with previous anterior myocardial infarction, dilated cardiomyopathy and no mitral procedures, who underwent left ventricular reconstruction and coronary revascularization between May 2002 and May 2003 using a small, narrow, oval patch aiming at a volume Assuntos
Ventrículos do Coração/cirurgia
, Função Ventricular Esquerda
, Idoso
, Procedimentos Cirúrgicos Cardíacos/métodos
, Seguimentos
, Humanos
, Masculino
, Pessoa de Meia-Idade
, Projetos Piloto
, Resultado do Tratamento
RESUMO
OBJECTIVES: Although patients with aortic stenosis, who receive 19-mm valves, are at high risk for prosthesis-patient mismatch, most of them show a significant left ventricular mass (LVM) regression postoperatively. The aim of this study was to identify factors predicting postoperative relative LVM regression in this subgroup of patients. METHODS: A population of 44 patients operated on for pure aortic stenosis and receiving a 19-mm valve was studied by echocardiography at 1.4 +/- 0.5 years postoperatively. RESULTS: The mean relative LVM regression was -19.3 +/- 18.9%, the mean gradient drop was -31.6 +/- 13.3 mmHg, and the mean Delta increase in aortic area index (postoperative aortic area index minus preoperative aortic area index) was 0.30 +/- 0.14 cm/m. Thirty-two patients had an indexed effective orifice area of less than 0.8 cm/m. At multivariate analysis (r = 0.63; r = 40%; P < 0.0001) preoperative LVM (P = 0.006), hypertension (P = 0.018) and Delta aortic area index (P = 0.049) were independent predictors of relative LVM regression. CONCLUSIONS: Our study shows that, at least 1 year postoperatively, in patients receiving a 19-mm valve, LVM regression is influenced by several parameters, in particular preoperative LVM, hypertension and the magnitude of the increase in aortic area.
Assuntos
Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas/efeitos adversos , Hipertrofia Ventricular Esquerda/etiologia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia Doppler , Feminino , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/fisiopatologia , Modelos Lineares , Masculino , Valor Preditivo dos Testes , Desenho de Prótese/efeitos adversos , Projetos de Pesquisa , Fatores de Risco , Volume Sistólico , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
BACKGROUND: Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. METHODS AND RESULTS: The indexed EOA (EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi < or =0.80 cm2/m2 and was correlated with overall mortality and cardiac events. PPM was present in 47% of patients. The 5-year overall survival and cardiac event-free survival were 82+/-3% and 75+/-4%, respectively, in patients with PPM compared with 93+/-3% and 87+/-4% in patients with no PPM (P< or =0.01). In multivariate analysis, PPM was associated with a 4.2-fold (95% CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold (95% CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. CONCLUSIONS: PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation.
Assuntos
Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Tamanho Corporal , Próteses Valvulares Cardíacas/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Causas de Morte , Comorbidade , Intervalo Livre de Doença , Ecocardiografia Doppler , Feminino , Humanos , Hipertensão/mortalidade , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prevalência , Prognóstico , Fatores de Risco , Análise de SobrevidaRESUMO
The case of a young boy with an extremely rare and complex cardiac malformation is described. Situs inversus, dextrocardia, double discordance with pulmonary atresia, absence of true pulmonary arteries, and systemico-pulmonary collateral arteries was the original diagnosis. Three preparatory operations were necessary to reconstruct and unifocalize the pulmonary vascular tree. At the age of 7 years complete correction with intraoperative stenting of the left neopulmonary artery was successfully performed. After more than 3 years from the definitive operation, the patient is alive with no physical limitations.
Assuntos
Cardiopatias Congênitas/cirurgia , Artéria Pulmonar/anormalidades , Criança , Humanos , Lactente , Masculino , Artéria Pulmonar/cirurgia , ReoperaçãoAssuntos
Arteriopatias Oclusivas/cirurgia , Prótese Vascular , Cuidados Intraoperatórios , Artéria Pulmonar/cirurgia , Stents , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/fisiopatologia , Criança , Ecocardiografia Doppler em Cores , Fluoroscopia , Comunicação Interventricular/diagnóstico , Comunicação Interventricular/fisiopatologia , Comunicação Interventricular/cirurgia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/cirurgia , Humanos , Masculino , Artéria Pulmonar/diagnóstico por imagem , Pressão VentricularRESUMO
OBJECTIVE: To identify the effects of the time between myocardial infarction and surgery, the site of infarction, mitral involvement on ventricular geometry, and clinical outcome in the treatment of ischemic cardiomyopathy in patients with heart failure. METHODS: Sixty-nine consecutive patients with ischemic cardiomyopathy, indexed end-systolic volume > or =50 mL/m(2), ejection fraction < or =35%, and heart failure underwent surgery 81.9 +/- 100.8 months after myocardial infarction, using different techniques of ventricular restoration. Thirteen geometric parameters were studied pre- and postoperatively. Paired and unpaired t tests and general linear model for multivariate analysis were used to analyze subgroups. Logistic regression and Kaplan-Meier survival curves with pairwise log-rank were used to correlate covariates to clinical outcome. RESULTS: Longer time to surgery and posterior necrosis linearly correlated with higher left ventricular volumes (r(2) =.66) and diameters (r(2) =.40). High grade of mitral regurgitation was always present in posterior infarctions. Hospital mortality was 4.3%. Complicated postoperative course was predicted by mitral surgery (P =.004) and longer time to surgery (P =.04). Survival was significantly lower in the posterior infarction (P =.0002) and mitral surgery (P =.001) subgroups. At a mean follow-up of 1.9 +/- 1.3 years, functional status and geometrical restoration are influenced by the studied covariates. CONCLUSIONS: Longer time to surgery after myocardial infarction, its posterior location, and significant mitral regurgitation can affect left ventricular remodeling, surgical restoration, and clinical outcome in patients with ischemic cardiomyopathy.
Assuntos
Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/cirurgia , Remodelação Ventricular/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Ponte de Artéria Coronária/métodos , Ecocardiografia Doppler , Feminino , Testes de Função Cardíaca , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/mortalidade , Isquemia Miocárdica/complicações , Isquemia Miocárdica/diagnóstico por imagem , Isquemia Miocárdica/mortalidade , Cuidados Pré-Operatórios/métodos , Probabilidade , Prognóstico , Recidiva , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVES: The results of current surgical options for the treatment of permanent atrial fibrillation (AF) associated with mitral surgery are widely different, particularly in very enlarged left atria. The aim of this study was to assess the mid-term efficacy of cardiac autotransplantation for this goal, through a consistent reduction of left atrium volume and a complete isolation of the pulmonary veins. METHODS: From April 2000 to September 2002, 30 patients (male/female 5/25) underwent cardiac autotransplantation for the treatment of mitral valve disease and concomitant permanent AF (>1 year). Surgical technique of bicaval heart transplantation was modified maintaining the connection of inferior vena cava in all but three cases. Twenty-eight patients had mitral valve replacement and two had mitral valve repair. Associated procedures were: aortic valve replacement (6 cases), tricuspid valve repair (2 cases), coronary re-vascularization (2 cases) and right atrium volume reduction (4 cases). RESULTS: No hospital death occurred; 1 patient died 3 months post-operatively for pneumonia. At a mean follow-up of 21.1+/-7.7 months (range 6-35), 26 patients (89.7%) were in sinus rhythm and 3 (10.3%) in AF. Santa Cruz Score was 0 in 3 patients, 2 in 2 patients and 4 in the remaining 24 patients (82.7%). Mean left atrial diameter and volume decreased from 65.1+/-16.4 mm (range 50-130 mm) to 49.9+/-8.4 mm (range 37-78) (P < 0.001) and from 118.3+/-68.4 ml (range 60-426) to 69.4+/-34.1 ml (range 31-226) (P = 0.001), respectively, after the operation. CONCLUSIONS: Cardiac autotransplantation is a safe and effective option for the treatment of permanent AF in patients with mitral valve disease and severe dilation of left atrium.