RESUMO
Kommerrell's diverticulum of the right aberrant subclavian artery is a rare disease, its treatment is still controversial. We report the case of a patient with a six cm aneurysmal dilation successfully treated in a hybrid surgical/endovascular way.
Assuntos
Implante de Prótese Vascular , Anormalidades Cardiovasculares/cirurgia , Divertículo/cirurgia , Procedimentos Endovasculares , Artéria Subclávia/anormalidades , Idoso , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Anormalidades Cardiovasculares/diagnóstico por imagem , Divertículo/diagnóstico por imagem , Procedimentos Endovasculares/instrumentação , Humanos , Masculino , Artéria Subclávia/diagnóstico por imagem , Artéria Subclávia/cirurgia , Resultado do TratamentoRESUMO
Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, pâ¯=â¯0.006 and HR 0.807, 95% CI 0.65 to 0.99, pâ¯=â¯0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.
Assuntos
Bloqueio Atrioventricular/epidemiologia , Bradicardia/epidemiologia , Estimulação Cardíaca Artificial , Procedimentos Cirúrgicos Cardíacos , Mortalidade , Marca-Passo Artificial , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Bloqueio Atrioventricular/terapia , Bradicardia/terapia , Ponte de Artéria Coronária , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/terapia , Modelos de Riscos Proporcionais , Estudos RetrospectivosRESUMO
BACKGROUND: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking. METHODS: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes. RESULTS: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score <12), or advanced CTP class B (MELD score >12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P = .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P = .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P = .238). CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.
Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiopatias/cirurgia , Cirrose Hepática/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Idoso , Comorbidade , Feminino , Seguimentos , Cardiopatias/epidemiologia , Humanos , Itália/epidemiologia , Cirrose Hepática/diagnóstico , Masculino , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: Left atrial dissection (LatD) is a rare and heterogeneous condition affecting many cardiovascular areas. The present article, by the means of personal case report illustration and systemic review of different clinical management, is aimed to give to clinicians further knowledge on this controversial topic. BACKGROUND: LatD is an exceedingly rare but potentially fatal complication of cardiac surgery or catheter-based interventional procedures. Most of the cases are iatrogenic and its incidence is expected to grow due to an increase in the number of percutaneous coronary intervention and structural heart disease procedures. The management of this complication is controversial, and it may depend on related etiologies. METHODS: We have reported our single-case experience and review of the scientific literature, focusing on the decision-making process and the strategical approach by multimodality imaging techniques. RESULTS: Our case of LatD with initial hemodynamic instability was surgically treated. Conservative approach is often employed in literature despite the fact that conservative versus surgical approach is debatable, depending on clinical presentation, hemodynamic stability, multimodal imaging findings, and personal experience of the center. CONCLUSIONS: According to systematic literature review, a watchful-waiting strategy supported by multimodality imaging could be a safe and effective management in stable LatD.
Assuntos
Átrios do Coração/cirurgia , Traumatismos Cardíacos/cirurgia , Hematoma/cirurgia , Doença Iatrogênica , Intervenção Coronária Percutânea/efeitos adversos , Idoso , Função do Átrio Esquerdo , Tomada de Decisão Clínica , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/lesões , Átrios do Coração/fisiopatologia , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/fisiopatologia , Hematoma/diagnóstico por imagem , Hematoma/etiologia , Hematoma/fisiopatologia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Imagem Multimodal , Seleção de Pacientes , Recuperação de Função Fisiológica , Resultado do TratamentoRESUMO
Penetrating cardiac trauma has been increasing in clinical experience and is joined to important morbidity and mortality. A case of a 38-year-old female with history of postpartum depression was reported, admitted to our department for cardiac tamponade due to penetrating self-inflicted multiple stab wound of the chest complicated by rupture of anterior left ventricular wall and traumatic ventricular septal defect. Following the unstable hemodynamic instability, a combined therapeutic strategy was chosen: surgery and transcatheter implantation to correct free wall ventricle damage and traumatic ventricular septal defect, respectively.
Assuntos
Tamponamento Cardíaco/etiologia , Traumatismos Cardíacos/etiologia , Ferimentos Penetrantes/complicações , Adulto , Tamponamento Cardíaco/cirurgia , Angiografia Coronária , Ecocardiografia , Traumatismos Cardíacos/cirurgia , Humanos , Masculino , Equipe de Assistência ao Paciente , Comportamento Autodestrutivo/complicações , Ferimentos Penetrantes/cirurgiaRESUMO
Abstract Penetrating cardiac trauma has been increasing in clinical experience and is joined to important morbidity and mortality. A case of a 38-year-old female with history of postpartum depression was reported, admitted to our department for cardiac tamponade due to penetrating self-inflicted multiple stab wound of the chest complicated by rupture of anterior left ventricular wall and traumatic ventricular septal defect. Following the unstable hemodynamic instability, a combined therapeutic strategy was chosen: surgery and transcatheter implantation to correct free wall ventricle damage and traumatic ventricular septal defect, respectively.
Assuntos
Humanos , Masculino , Adulto , Ferimentos Penetrantes/complicações , Tamponamento Cardíaco/etiologia , Traumatismos Cardíacos/etiologia , Equipe de Assistência ao Paciente , Ferimentos Penetrantes/cirurgia , Ecocardiografia , Tamponamento Cardíaco/cirurgia , Comportamento Autodestrutivo/complicações , Angiografia Coronária , Traumatismos Cardíacos/cirurgiaAssuntos
Líquido Ascítico/diagnóstico por imagem , Eletrocardiografia , Derrame Pericárdico/diagnóstico por imagem , Idoso , Feminino , Humanos , Neoplasias Pancreáticas/patologia , Derrame Pericárdico/etiologia , Cavidade Peritoneal/diagnóstico por imagem , Neoplasias Peritoneais/complicações , Neoplasias Peritoneais/secundárioAssuntos
Migração de Corpo Estranho/diagnóstico por imagem , Comunicação Interatrial/diagnóstico por imagem , Dispositivo para Oclusão Septal/efeitos adversos , Valva Tricúspide/diagnóstico por imagem , Adulto , Ecocardiografia Transesofagiana , Feminino , Migração de Corpo Estranho/cirurgia , Comunicação Interatrial/cirurgia , Humanos , Valva Tricúspide/cirurgiaAssuntos
Apêndice Atrial/anormalidades , Procedimentos Cirúrgicos Cardíacos/métodos , Ecocardiografia Transesofagiana/métodos , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Insuficiência da Valva Mitral/diagnóstico , Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/cirurgia , Diagnóstico Diferencial , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Neoplasias Cardíacas/diagnóstico , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/complicações , Insuficiência da Valva Mitral/cirurgiaRESUMO
The long-term sequelae of mantle therapy include, especially lung and cardiac disease but also involve the vessels and the organs in the neck and thorax (such as thyroid, aorta, and esophagus). We presented the case of 66-year-old female admitted for congestive heart failure in radiation-induced heart disease. The patient had undergone to massive radiotherapy 42 years ago for Hodgkin's disease (type 1A). Transesophageal echocardiography was performed unsuccessfully with difficulty because of the rigidity and impedance of esophageal walls. Our case is an extraordinary report of radiotherapy's latency effect as a result of dramatic changes in the structure of mediastinum, in particular in the esophagus, causing unavailability of a transesophageal echocardiogram.
Assuntos
Estenose Coronária/diagnóstico por imagem , Anomalias dos Vasos Coronários/diagnóstico por imagem , Infarto do Miocárdio sem Supradesnível do Segmento ST/etiologia , Idoso , Angiografia Coronária , Ponte de Artéria Coronária , Estenose Coronária/complicações , Estenose Coronária/cirurgia , Anomalias dos Vasos Coronários/complicações , Anomalias dos Vasos Coronários/cirurgia , Feminino , Humanos , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgiaRESUMO
BACKGROUND: Bleeding after cardiac surgery requiring surgical reexploration and blood component transfusion is associated with increased morbidity and mortality. Although prothrombin complex concentrate (PCC) has been used satisfactorily in bleeding disorders, studies on its efficacy and safety after cardiopulmonary bypass are limited. METHODS: Between January 2005 and December 2013, 3454 consecutive cardiac surgery patients were included in an observational study aimed at investigating the efficacy and safety of PCC as first-line coagulopathy treatment as a replacement for fresh frozen plasma (FFP). Starting in January 2012, PCC was introduced as solely first-line treatment for bleeding following cardiac surgery. RESULTS: After one-to-one propensity score-matched analysis, 225 pairs of patients receiving PCC (median dose 1500 IU) and FFP (median dose 2 U) were included. The use of PCC was associated with significantly decreased 24-h post-operative blood loss (836 ± 1226 vs. 935 ± 583 ml, p < 0.0001). Propensity score-adjusted multivariate analysis showed that PCC was associated with significantly lower risk of red blood cell (RBC) transfusions (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.31-0.80), decreased amount of RBC units (ß unstandardised coefficient -1.42, 95% CI -2.06 to -0.77) and decreased risk of transfusion of more than 2 RBC units (OR 0.53, 95% CI 0.38-0.73). Patients receiving PCC had an increased risk of post-operative acute kidney injury (AKI) (OR 1.44, 95% CI 1.02-2.05) and renal replacement therapy (OR 3.35, 95% CI 1.13-9.90). Hospital mortality was unaffected by PCC (OR 1.51, 95% CI 0.84-2.72). CONCLUSIONS: In the cardiac surgery setting, the use of PCC compared with FFP was associated with decreased post-operative blood loss and RBC transfusion requirements. However, PCC administration may be associated with a higher risk of post-operative AKI.
Assuntos
Fatores de Coagulação Sanguínea/efeitos adversos , Fatores de Coagulação Sanguínea/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Cirúrgicos Torácicos/métodos , Fatores de Tempo , Idoso , Transfusão de Componentes Sanguíneos/efeitos adversos , Transfusão de Eritrócitos/métodos , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Plasma , Pontuação de PropensãoAssuntos
Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/cirurgia , Hemangiossarcoma/diagnóstico , Hemangiossarcoma/cirurgia , Adulto , Animais , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Cateterismo , Bovinos , Angiografia Coronária , Ponte de Artéria Coronária , Ecocardiografia , Feminino , Átrios do Coração/cirurgia , Humanos , Imageamento por Ressonância Magnética , Pericárdio/transplante , Veia Safena/transplante , ToracotomiaRESUMO
Open repair of ascending aortic pseudoaneurysm (AscAP) carries high risks and mortality rate. Previous papers reported the off-label use of standard thoracic or abdominal endograft in very selected cases. We present the case of a 57-year-old man with an AscAP successfully managed with a new custom-designed endograft.
Assuntos
Falso Aneurisma/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares , Prótese Vascular , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de PróteseRESUMO
OBJECTIVES: The aim of this study was to evaluate the immediate and late outcome of emergency coronary artery bypass grafting (CABG) in a multicenter setting. DESIGN: Multicenter, retrospective study. SETTING: Four university hospitals. PARTICIPANTS: 596 patients were included in this study. INTERVENTIONS: Included patients underwent isolated, emergency CABG. MEASUREMENTS AND MAIN RESULTS: Sixty patients (absolute rate: 10.1%, pooled rate: 8.7%) died during the in-hospital stay period. Increasing emergency CABG classes (p<0.0001), recent myocardial infarction (p=0.019), left ventricular ejection fraction≤30% (p=0.034), on-pump surgery (p=0.012), and participating centers (p<0.0001) were independent predictors of in-hospital mortality. Survival rates at 1, 3, and 5 years were 86.4%, 81.6%, and 76.1%, respectively. Extracorporeal membrane oxygenation was used in 6 patients and 3 of them (50.0%) survived the immediate postoperative period. Patient populations of participating centers differed significantly in most of baseline characteristics. The preoperative use of intra-aortic balloon pump (8% to 51%) and off-pump surgery (2.8% to 56.3%) varied significantly between institutions. In-hospital mortality (2.8%, 5.9%, 7.7% and 19.8%, p<0.0001), as well as midterm survival, significantly differed between institutions (at 3 years, 90.6%, 89.8%, 81.2%, and 67.2%, p<0.0001). CONCLUSIONS: The outcome after emergency CABG is satisfactory despite a significant operative risk. However, the results of emergency CABG significantly differed between the participating institutions, likely due to differences in the referral pathways and perioperative treatment strategies. Evaluation of these factors is crucial for implementation of treatment in centers with suboptimal results.
Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Ponte de Artéria Coronária sem Circulação Extracorpórea/estatística & dados numéricos , Feminino , Finlândia/epidemiologia , Mortalidade Hospitalar , Humanos , Balão Intra-Aórtico/estatística & dados numéricos , Itália/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
OBJECTIVES: The aim of this study was to evaluate the impact of red blood cell (RBC) transfusions on the occurrence of stroke and transient ischaemic attack (TIA) after cardiac surgery. METHODS: Data on 14 956 patients undergoing coronary artery bypass grafting (CABG) and valve surgery (with or without concomitant CABG) were retrieved at three European University Hospitals. The prognostic impact of RBC transfusion on postoperative stroke and TIA was investigated by logistic regression and multilevel propensity score analysis. RESULTS: Postoperative stroke was observed in 147 (1.0%) patients and combined stroke/TIA in 238 (1.6%). Of the total population, 6439 (43%) patients received RBC transfusion with a median of 2 units (25th-75th percentile, 2-4 units). When adjusted for other significant risk factors, RBC transfusion was an independent predictor of stroke [odds ratio (OR) 1.14; 95% confidence interval (CI) 1.11-1.17 per unit] and stroke/TIA (OR 1.12; 95% CI 1.09-1.15 per unit). Increase in the amount of transfused RBC units was associated with higher rates of stroke (no RBC transfusion: 0.5%, 1-2 RBC units: 1.0%, OR 1.42; >2 RBC units: 2.7%, OR 3.10) and stroke/TIA (no RBC transfusion: 0.8%, 1-2 RBC units: 1.8%, OR 1.49; >2 RBC units: 4.0%, OR 2.72). Multilevel propensity score analysis confirmed these findings and showed a very high risk of stroke (3.9%; OR 3.85; 95% CI 2.30-6.45) and stroke/TIA (5.9%; OR 3.30; 95% CI 2.17-5.02) associated with transfusion of ≥6 units of RBCs. CONCLUSIONS: Transfusion of more than 2 units of RBCs after cardiac surgery is associated with a significantly increased risk of postoperative stroke and TIA.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Transfusão de Eritrócitos/efeitos adversos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Ataque Isquêmico Transitório/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Distribuição de Qui-Quadrado , Ponte de Artéria Coronária/mortalidade , Transfusão de Eritrócitos/mortalidade , Europa (Continente) , Feminino , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/mortalidade , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Pontuação de Propensão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Atrial fibrillation (AF) remains the most common complication after cardiac surgery. The present study aim was to derive an effective bedside tool to predict postoperative AF and its related complications. METHODS AND RESULTS: Data of 17 262 patients undergoing adult cardiac surgery were retrieved at 3 European university hospitals. A risk score for postoperative AF (POAF score) was derived and validated. In the overall series, 4561 patients (26.4%) developed postoperative AF. In the derivation cohort age, chronic obstructive pulmonary disease, emergency operation, preoperative intra-aortic balloon pump, left ventricular ejection fraction <30%, estimated glomerular filtration rate <15 mL/min per m(2) or dialysis, and any heart valve surgery were independent AF predictors. POAF score was calculated by summing weighting points for each independent AF predictor. According to the prediction model, the incidences of postoperative AF in the derivation cohort were 0, 11.1%; 1, 20.1%; 2, 28.7%; and ≥3, 40.9% (P<0.001), and in the validation cohort they were 0, 13.2%; 1, 19.5%; 2, 29.9%; and ≥3, 42.5% (P<0.001). Patients with a POAF score ≥3, compared with those without arrhythmia, revealed an increased risk of hospital mortality (5.5% versus 3.2%, P=0.001), death after the first postoperative day (5.1% versus 2.6%, P<0.001), cerebrovascular accident (7.8% versus 4.2%, P<0.001), acute kidney injury (15.1% versus 7.1%, P<0.001), renal replacement therapy (3.8% versus 1.4%, P<0.001), and length of hospital stay (mean 13.2 versus 10.2 days, P<0.001). CONCLUSIONS: The POAF score is a simple, accurate bedside tool to predict postoperative AF and its related or accompanying complications.
Assuntos
Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Técnicas de Apoio para a Decisão , Sistemas Automatizados de Assistência Junto ao Leito , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Europa (Continente)/epidemiologia , Feminino , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Acute kidney injury (AKI) is a vexing complication of cardiac surgery. Since exposure to contrast agents is a relevant contributing factor in the development of postoperative AKI, the optimal timing between cardiac catheterization and surgery is decisive. METHODS: A total of 2504 consecutive nonemergent patients undergoing isolated coronary artery bypass grafting (CABG), valve surgery (with or without concomitant CABG), and proximal aortic procedures were enrolled. AKI was defined by consensus RIFLE (Risk, Injury, Failure, Loss of function, End-stage renal disease) criteria. The association of postoperative AKI and time between cardiac catheterization and operation was evaluated using multivariable logistic regression modeling and propensity-matched analysis. RESULTS: Postoperative AKI occurred in 230 (9%) patients. The median number of days from cardiac catheterization to operation was 5 (25th to 75th percentile: 2 to 10). The incidence of AKI was significantly higher in patients operated on ≤1 day after cardiac catheterization compared to those operated on >1 day after (13% vs. 8%, p=0.004). The time interval between cardiac catheterization and surgery (tested both as a continuous and a categorical variable) was not an independent AKI predictor in the propensity-matched population or the pre-matched one. Contrast exposure≤1 day before surgery was independently associated with postoperative AKI in patients undergoing valve surgery with concomitant CABG only (post-matched: OR 3.68, 95%CI 1.30 to 10.39, p=0.014). CONCLUSIONS: Delaying cardiac surgery beyond 24h of exposure to contrast agents seems to be justified only in patients undergoing valve surgery with concomitant CABG.
Assuntos
Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/etiologia , Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/efeitos adversos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at providing a contribution to this issue. METHODS: Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%. RESULTS: Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement (P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% (P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively (P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively (P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001). CONCLUSIONS: Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates.
Assuntos
Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral/cirurgia , Isquemia Miocárdica/complicações , Idoso , Doença Crônica , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Itália , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Anuloplastia da Valva Mitral/efeitos adversos , Anuloplastia da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/fisiopatologia , Análise Multivariada , Isquemia Miocárdica/mortalidade , Isquemia Miocárdica/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
BACKGROUND: Delirium after cardiac operations is associated with significant morbidity and death. Statins have been recently suggested to exert protective cerebral effects. This study investigated whether preoperative statins were associated with decreased incidence of postoperative delirium in patients undergoing coronary artery bypass grafting. METHODS: The study enrolled 4,659 consecutive patients (21% women; age, 67.8±9.2 years) undergoing coronary artery bypass grafting. A propensity score-based optimal-matching algorithm was used to match 1,577 patients receiving preoperative statins with a control group (1:1). Patients were screened for delirium in the intensive care unit according to the Confusion Assessment Method for the intensive care unit. RESULTS: Delirium affected 89 patients (3%), and preoperative statin administration was not multivariably associated with a decreased incidence of delirium (odds ratio, 1.52; 95% confidence interval, 0.97 to 2.37; p=0.18) and was also unrelated to a delirium decrease in patient subgroups undergoing isolated coronary artery bypass grafting (odds ratio, 1.31; 95% confidence interval, 0.68 to 2.52; p=0.51) or combined valvular procedures (odds ratio, 1.72; 95% confidence interval, 0.96 to 3.07, p=0.08). Similar results were observed for age groups and cardiopulmonary bypass durations. Patients affected by postoperative delirium experienced a longer hospital stay (25th to 75th percentile) of 11 (7 to 18 days) vs 7 days (7 to 8 days, p<0.001) and 12% hospital mortality vs 1% (p<0.001). CONCLUSIONS: Preoperative statins were not associated with a decreased incidence of delirium in patients undergoing coronary revascularization.