RESUMO
OBJECTIVES: Valve-sparing aortic root replacement requires expertise to predict repair results and prevent secondary aortic clamping for valve repair or replacement secondary to aortic valve insufficiency. Thus, intraoperative evaluation of the aortic valve using diastolic pressure at the aortic root may be helpful. The goal of this retrospective study was to compare the early and mid-term results of aortic valve repair with those of valve-sparing aortic root replacement using intraoperative endoscopic evaluation. METHODS: We included 158 patients who underwent aortic valve repair with valve-sparing aortic root replacement at our hospital between December 2003 and January 2022. The patients were divided into a non-endoscopic evaluation group (group NE, n = 97; mean age 55 years) and an endoscopic evaluation group (group E, n = 61; mean age 51 years). RESULTS: The incidence of a second aortic clamping for aortic valve insufficiency was significantly greater in group NE (17.5%) than in group E (1.6%; P = 0.002). The presence of none or trivial aortic valve insufficiency on transthoracic echocardiography at discharge in group E (87.6%) was significantly lower than in group NE (98.4%; P = 0.017). No significant difference in the cumulative incidence of recurrence of moderate AI (P = 0.47), hospitalization for heart failure (P = 0.84) and reoperation (P = 0.25) between groups NE and E. CONCLUSIONS: Intraoperative endoscopic evaluation during aortic valve repair with valve-sparing aortic root replacement correlated with a lower incidence of second aortic clamping because of aortic valve insufficiency and effective aortic valve insufficiency control.
RESUMO
INTRODUCTION: Post-myocardial infarction ventricular septal defect (PIVSD) is a life-threatening mechanical complication of acute myocardial infarction (AMI). Delayed elective surgical repair can be considered in patients who respond well to aggressive heart failure therapy. Impella has been reported as a bridge to allow the deferment of surgery for PIVSD. PRESENTATION OF CASE: This report describes our case of a 62-year-old male with PIVSD and cardiogenic shock. Impella was placed to ensure hemodynamic stability. Subsequently, right heart failure was suspected to be caused by insufficient circulatory support from Impella alone. Emergency surgery was considered, but it was high risk and only a few days had passed since the onset. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was implanted to treat right heart failure and delay surgical repair as long as possible. Six days after Impella implantation, the patient underwent a successful surgical repair via the right ventricle without associated adverse events. DISCUSSION: Impella support can be insufficient for critically ill patients such as those with a larger ventricular septal defect and involvement of right ventricular function. VA-ECMO was implanted to support circulation, reduce the preload in the right ventricle, and avoid shunt inversion induced by increasing Impella flow. The patient was able to undergo a successful delayed repair with VA-ECMO at least one week after the onset of the AMI with hemodynamic stability and no associated adverse events. CONCLUSION: Additional VA-ECMO could help patients who fail to bridge to surgery with Impella to avoid emergency surgery, leading to successful delayed surgical repair.
RESUMO
OBJECTIVE: Postprocedural ischaemic and bleeding risks after transcatheter aortic valve replacement (TAVR) remain a major concern. Nevertheless, no reliable risk models incorporating both possibilities are currently available. We aimed to assess the accuracy of percutaneous coronary intervention (PCI)-derived models and the performance of a recalibrated model that included variables more applicable to TAVR. METHODS: This study included 26 869 patients who had been enrolled in a national registry. Ischaemic events were defined as myocardial infarction, stroke, transient ischaemic attack or peripheral embolism at 1 year. Bleeding events were defined as any bleeding based on the Valve Academic Research Consortium-2 consensus document at 1 year. Patterns of Non-adherence to Anti-Platelet Regimen in Stented Patients (PARIS) and Coronary Revascularisation Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) integer scoring systems were tested. The models were recalibrated by applying new variables using the Fine and Gray method. RESULTS: The 1-year cumulative incidences for ischaemic and bleeding events were 2.7% and 3.1%. Patients with high PARIS and CREDO-Kyoto risk scores had higher incidences of both ischaemic (3.3% vs 2.4% vs 2.4%, p<0.001 and 2.8% vs 2.0% vs 0.8%, p<0.001) and bleeding events (3.3% vs 2.5% vs 0.8%, p<0.001 and 3.7% vs 3.0% vs 2.4%, p<0.001) when compared with intermediate and low-risk patients. The receiver operating characteristic area under the curves for these models were 0.53, 0.58, 0.56 and 0.55, respectively. After the models were recalibrated to incorporate variables more applicable to TAVR, the performance of ischaemic and bleeding models modestly improved (0.58 and 0.61, respectively). CONCLUSIONS: The PCI-derived models demonstrated modest accuracy but was inadequate for risk stratification of TAVR patients at 1-year follow-up. TRIAL REGISTRATION NUMBER: 3395.
Assuntos
Estenose da Valva Aórtica , Intervenção Coronária Percutânea , Substituição da Valva Aórtica Transcateter , Humanos , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/etiologia , Hemorragia/epidemiologia , Hemorragia/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento , JapãoRESUMO
BACKGROUND: The association between renal morphological findings and changes in renal function in patients undergoing transcatheter aortic valve implantation (TAVI) is unexplored. AIMS: We aimed to investigate the association between renal morphological findings and changes in renal function in patients undergoing TAVI. METHODS: Among 283 consecutive patients undergoing TAVI between 2018 and 2021, the study sample included 224 patients. Renal morphological measurements were performed by preoperative multidetector computed tomography. Estimated glomerular filtration rate (eGFR) improvement and deterioration were defined as positive or negative changes in an eGFR of ≥10% one month after TAVI. The renal cortex thickness index was defined as the ratio of total renal cortex thickness to body surface area. RESULTS: The incidences of eGFR improvement and deterioration were 33.9% and 24.1%, respectively. The renal cortex thickness index had a significant correlation with changes in eGFR (r=0.34, p<0.01). The index of the area under the curve of renal cortex thickness for eGFR improvement and deterioration were 0.73 and 0.68, respectively. The cut-off values were 5.82 mm/m2 for eGFR improvement (odds ratio [OR]: 0.10; 95% confidence interval: 0.05-0.20; p<0.01) and 4.89 mm/m2 for eGFR deterioration (OR: 9.07; 95% confidence interval: 4.55-18.6; p<0.01). CONCLUSIONS: The renal cortex thickness index was associated with changes in renal function in patients who underwent TAVI. Its measurements might be useful for predicting the renal function change in patients undergoing TAVI.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Taxa de Filtração Glomerular , Humanos , Rim/diagnóstico por imagem , Rim/fisiologia , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoRESUMO
Prior to the widespread adoption of the arterial switch operation, patients with transposition of the great arteries (TGA) commonly underwent atrial switch operation (Mustard or Senning). It is not uncommon for these patients to progress to end stage heart failure and increasingly ventricular assist devices (VADs) are used to support these patients as a bridge to transplantation, though there is limited experience with this worldwide. A retrospective review of our institution's VAD database was undertaken and revealed seven adult patients with a history of TGA and subsequent systemic ventricular failure were implanted with a VAD: four of whom received the VAD as a bridge to transplantation (BTT) at the time of implantation, two who were initially designated as destination therapy secondary to severe pulmonary hypertension, and one who was designated as destination therapy secondary to a high risk of life-threatening non-compliance. Seven patient cases who received a VAD for severe systemic ventricular failure were included in this study. The mean age of the patients was 40 years and the majority of patients were male (6/7, 85%). Five of the patients (71.4%) had previously undergone an atrial switch operation and all of these were Mustard procedures. Two of the seven patients (28.5%) had congenitally corrected transposition of the great arteries (CC-TGA). Two of the seven patients (28.5%) had supra-systemic pulmonary pressures before VAD implantation and were designated as destination therapy (DT). One of these patients was later designated as BTT as an improvement in his pulmonary vascular resistance was observed, and subsequently underwent heart transplantation. Because of anatomic considerations, four of the patients (57%) underwent redo-sternotomy with outflow cannula anastomosis to the ascending aorta, one patient underwent VAD implantation via a left subcostal incision with anastomosis of the outflow graft to the descending thoracic aorta, and two patients (28.5%) underwent VAD implantation via a left thoracotomy and anastomosis of the outflow cannula to the descending thoracic aorta. Six of the seven patients had a HeartWare HVAD VAD implanted; one received a Thoratec Heartmate II VAD. Two patients underwent VAD explant and orthotopic heart transplant, 222 days and 444 days after VAD implant, respectively. One patient died on postoperative day 17 after complications from recurrent VAD thrombosis despite multiple pump exchanges. Four patients remain on VAD support, three of these patients are awaiting transplantation at last follow-up (mean days on support, 513 days). Bridge to transplantation with a durable VAD is technically feasible and relatively safe in patients with TGA. Multiple redo-sternotomies can be avoided with a left posterior thoracotomy approach and outflow graft anastomosis to the descending thoracic aorta after careful anatomic considerations.
Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Implantação de Prótese/efeitos adversos , Transposição dos Grandes Vasos/complicações , Adulto , Aorta Torácica/transplante , Transposição das Grandes Artérias , Estudos de Viabilidade , Feminino , Seguimentos , Insuficiência Cardíaca/etiologia , Transplante de Coração , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Transposição dos Grandes Vasos/cirurgia , Resultado do Tratamento , Enxerto Vascular/métodos , Listas de Espera , Adulto JovemRESUMO
OBJECTIVES: Higher rates of incomplete revascularization (IR) and reduced patency are possible drawbacks of off-pump coronary artery bypass grafting (OPCAB); both may adversely affect outcome after surgery. This study was conducted to shed light on the relationships among IR, angiographic patency, and midterm results after OPCAB surgery. METHODS: A total of 1604 consecutive patients underwent OPCAB during a 6-year period; 1581 patients (95%) underwent systematic postoperative angiography. Complete follow-up was achieved in 99.5% (median, 3.2 years; up to 6.5 years). A total of 216 patients had IR (13%), and 225 had at least 1 graft failure (FitzGibbon B or O). RESULTS: All the event-free survival rates for all-cause mortality (P < .001), cardiac death (P = .020), and major adverse cardiac and cerebrovascular events (P < .001) were lower in the IR group. By using the Cox proportional hazards model, IR was an independent risk factor for all-cause mortality (hazard ratio [HR], 1.80; 95% confidence interval [CI], 1.15-2.81). Of those who underwent postoperative angiography, the patients with graft failure experienced reintervention more frequently than those with all grafts patent (HR, 5.49; 95% CI, 3.43-8.77). Even with excluding patients who had undergone reintervention immediately after angiography, graft failure was still an independent risk factor for reintervention afterwards (HR, 2.41; 95% CI, 1.30-4.47). CONCLUSIONS: Incomplete revascularization was relevant to higher midterm mortality after OPCAB, whereas the risk of reintervention was higher for patients with occluded grafts. Complete revascularization, coupled with achievement of a higher patency rate, could be expected to improve follow-up outcomes after OPCAB surgery.
Assuntos
Angiografia Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/cirurgia , Grau de Desobstrução Vascular , Idoso , Feminino , Humanos , Masculino , Revascularização Miocárdica , Estudos Prospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: Myocarditis is considered one of the major causes of dilated cardiomyopathy. Hepatocyte growth factor (HGF) has pleiotropic activities that promote tissue regeneration and facilitate functional improvement of injured tissue. We investigated whether the epicardial sustained-release of HGF, using gelatin hydrogel sheets, improves cardiac function in a chronic myocarditis rat model. METHODS: Six weeks after Lewis rats were immunized with porcine cardiac myosin to establish autoimmune myocarditis, HGF- or normal saline (NS)-incorporated gelatin hydrogel sheets were applied to the epicardium (G-HGF and G-NS, respectively). At either 2 or 4 weeks after treatment, these were compared with the Control myocarditis group. Cardiac function was evaluated by echocardiography and cardiac catheterization. Development of fibrosis was determined by histological study and expression of transforming growth factor-ß1 (TGF-ß1). Bax and Bcl-2 levels were measured to evaluate apoptotic activity. RESULTS: At both points, fractional shortening and end-systolic elastance were higher in the G-HGF group than in the Control and G-NS groups (P < 0.01). Fractional shortening at 2 weeks of each group were as follows: 31.0 ± 0.9%, 24.8 ± 2.7% and 48.6 ± 2.6% (Control, G-NS and G-HGF, respectively). The ratio of the fibrotic area of the myocardium was lower in the G-HGF group than in the Control and G-NS groups at 2 weeks (G-HGF, 8.8 ± 0.9%; Control, 17.5 ± 0.2%; G-NS, 15.6 ± 0.7%; P < 0.01). The ratio at 4 weeks was lower in the G-HGF group than in the G-NS group (10.9 ± 1.4% vs 18.5 ± 1.3%; P < 0.01). The mRNA expression of TGF-ß1 in the G-HGF group was lower than in the Control group at 2 weeks (0.6 ± 0.1 vs 1.1 ± 0.2) and lower than that in the G-NS group at 4 weeks (0.7 ± 0.1 vs 1.3 ± 0.2). The Bax-to-Bcl-2 ratios at both points were lower in the G-HGF group than in the Control group. CONCLUSIONS: Sustained-released HGF markedly improves cardiac function in chronic myocarditis rats. The antifibrotic and antiapoptotic actions of HGF may contribute to the improvement. HGF-incorporated gelatin hydrogel sheet can be a new therapeutic modality for myocarditis.
Assuntos
Doenças Autoimunes/prevenção & controle , Miosinas Cardíacas/imunologia , Fármacos Cardiovasculares/administração & dosagem , Fator de Crescimento de Hepatócito/administração & dosagem , Imunização , Miocardite/prevenção & controle , Animais , Apoptose , Doenças Autoimunes/genética , Doenças Autoimunes/imunologia , Doenças Autoimunes/metabolismo , Doenças Autoimunes/patologia , Doenças Autoimunes/fisiopatologia , Química Farmacêutica , Doença Crônica , Preparações de Ação Retardada , Modelos Animais de Doenças , Portadores de Fármacos , Fibrose , Gelatina/química , Regulação da Expressão Gênica , Hidrogéis , Masculino , Contração Miocárdica/efeitos dos fármacos , Miocardite/genética , Miocardite/imunologia , Miocardite/metabolismo , Miocardite/patologia , Miocardite/fisiopatologia , Miocárdio/metabolismo , Miocárdio/patologia , RNA Mensageiro/metabolismo , Ratos , Suínos , Fatores de Tempo , Fator de Crescimento Transformador beta1/genética , Fator de Crescimento Transformador beta1/metabolismo , Função Ventricular Esquerda/efeitos dos fármacos , Proteína X Associada a bcl-2/metabolismoRESUMO
OBJECTIVES: One of the potential drawbacks of off-pump coronary artery bypass is reduced patency compared with conventional coronary artery bypass. This study examined the systematic angiographic evaluation after off-pump coronary artery bypass. METHODS: Of the 1604 consecutive patients who underwent off-pump coronary artery bypass over 6 years, 1422 (89%) who underwent postoperative angiography were analyzed. Generalized estimating equations logistic analyses were used to investigate potential predictors of graft failure (FitzGibbon B or O). RESULTS: Bilateral internal thoracic arteries were used in 78% of the patients. The mean number of distal anastomoses was 3.7 ± 1.2. The in-hospital mortality rate was 0.4%. Recipient coronary diameter less than 1.5 mm (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.24-2.11) was an independent predictor of graft failure, whereas percent stenosis diameter greater than 75% (OR, 0.71; 95% CI, 0.53-0.93), sequential graft (OR, 0.69; 95% CI, 0.51-0.94), and left main disease (OR, 0.72; 95% CI, 0.53-0.96) were protective factors. In the subanalyses for each conduit, percent stenosis diameter was protective against left internal thoracic artery failure (OR, 0.61), whereas smaller recipient coronary diameter was associated with right gastroepiploic artery and saphenous vein graft failure (OR, 2.37 and 2.36, respectively). Left circumflex artery was associated with gastroepiploic artery graft failure, whereas sequential graft was again protective for the gastroepiploic artery (OR, 4.39 and 0.33, respectively). CONCLUSIONS: Smaller coronary diameter would be a predictor of graft failure, whereas percent stenosis diameter greater than 75%, sequential graft, and left main disease would be protective factors for off-pump bypass grafts.
Assuntos
Angiografia Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea , Doença da Artéria Coronariana/cirurgia , Reestenose Coronária/diagnóstico por imagem , Estenose Coronária/cirurgia , Vasos Coronários/cirurgia , Oclusão de Enxerto Vascular/diagnóstico por imagem , Idoso , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Reestenose Coronária/etiologia , Reestenose Coronária/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Vasos Coronários/diagnóstico por imagem , Feminino , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/mortalidade , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Grau de Desobstrução VascularRESUMO
OBJECTIVE: Sinus node dysfunction is commonly associated with atrial fibrillation. There is little information about the long-term results of pulmonary vein isolation in relation to sinus node function. The present study was conducted to investigate whether sinus node dysfunction affects the late outcome of pulmonary vein isolation in patients with persistent/permanent atrial fibrillation. METHODS: Among 76 consecutive patients with persistent/permanent atrial fibrillation who had undergone cut-and-sew pulmonary vein isolation, 66 patients without evidence of intra-atrial thrombus by transesophageal echography, and who were able to tolerate cardioversion, were enrolled. Sinus node recovery time after cardioversion was examined intraoperatively. All of the patients underwent valvular surgery concomitantly (mitral in 62). RESULTS: Sinus node dysfunction was detected in 18 patients. These patients had a significantly lower f wave voltage in V(1) of the electrocardiogram and a larger cardiothoracic ratio than patients with normal sinus node function. Hospital mortality was 3%, and 3 late deaths were observed. Follow-up was conducted for up to 72 months (mean 30 months), with a 100% complete follow-up rate. There were no significant differences in actuarial survival and freedom from cardiac events between patients with normal and abnormal sinus node function. No thromboembolic events occurred. A significantly higher proportion of patients with normal sinus node function (82%) were free of atrial fibrillation at 4 years than patients with sinus node dysfunction (25%; P < .0001). CONCLUSIONS: The atrial fibrillation cure rate after pulmonary vein isolation may be influenced by sinus node function in both the early and late stages. Although further examinations are required, pulmonary vein isolation may be an adequate treatment for persistent/permanent atrial fibrillation in patients with normal sinus node function.
Assuntos
Fibrilação Atrial/cirurgia , Criocirurgia , Veias Pulmonares/cirurgia , Síndrome do Nó Sinusal/complicações , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Criocirurgia/efeitos adversos , Criocirurgia/mortalidade , Intervalo Livre de Doença , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Feminino , Valvas Cardíacas/fisiopatologia , Valvas Cardíacas/cirurgia , Mortalidade Hospitalar , Humanos , Japão , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Veias Pulmonares/fisiopatologia , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Nó Sinusal/mortalidade , Síndrome do Nó Sinusal/fisiopatologia , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Left ventricular assist devices are used in patients with end-stage dilated cardiomyopathy as a "bridge to recovery." However, physiologic and histologic changes under prolonged mechanical unloading have not been elucidated. Thus, we investigated these changes in the rat heart with dilated cardiomyopathy under mechanical unloading after heterotopic transplantation. METHODS: Six weeks after induction of autoimmunized dilated cardiomyopathy in Lewis rats, 2 types of hearts were compared (n = 6 each): (1) an unloaded dilated cardiomyopathy heart (DCM-UL) and (2) a dilated cardiomyopathy heart (DCM). The hearts were evaluated 2 and 4 weeks after transplantation. RESULTS: Four weeks after transplantation, developed tension of the papillary muscle (indicator of myocardial contractility) and ß-adrenergic response to isoproterenol were better in DCM-UL than in DCM (P = 0.0025 and P <0.0001, respectively). However, half-relaxation time of the papillary muscle (indicator of myocardial relaxation) was worse in the DCM-UL group (P < .0001). The ratio of the fibrotic area of the myocardium and the number of terminal dUTP nick end-labeling-positive myocytes (indicator of myocardial apoptosis) were higher in DCM-UL than in DCM (P = .0072 and P = .0039, respectively). The mRNA expression of collagen Ia was also higher in DCM-UL. CONCLUSIONS: Mechanical unloading preserved myocardial contractility and ß-adrenergic response but worsened myocardial relaxation. Furthermore, prolonged mechanical unloading has a tendency to increase the ratio of the fibrotic area and myocardial apoptosis. These unfavorable responses, although secondary to prolonged mechanical unloading, may have a negative impact on the bridge to recovery in patients with dilated cardiomyopathy.
Assuntos
Apoptose , Cardiomiopatia Dilatada/terapia , Transplante de Coração , Coração Auxiliar , Contração Miocárdica , Miocárdio/patologia , Músculos Papilares/fisiopatologia , Função Ventricular Esquerda , Agonistas Adrenérgicos beta/farmacologia , Animais , Cardiomiopatia Dilatada/genética , Cardiomiopatia Dilatada/patologia , Cardiomiopatia Dilatada/fisiopatologia , Cardiomiopatia Dilatada/cirurgia , Colágeno Tipo I/genética , Colágeno Tipo I/metabolismo , Diástole , Modelos Animais de Doenças , Relação Dose-Resposta a Droga , Elasticidade , Fibrose , Isoproterenol/farmacologia , Masculino , Contração Miocárdica/efeitos dos fármacos , Músculos Papilares/efeitos dos fármacos , Músculos Papilares/metabolismo , RNA Mensageiro/metabolismo , Ratos , Ratos Endogâmicos Lew , Sístole , Fatores de Tempo , Função Ventricular Esquerda/efeitos dos fármacosAssuntos
Anastomose Cirúrgica/instrumentação , Ponte de Artéria Coronária/instrumentação , Veia Safena/transplante , Técnicas de Sutura/instrumentação , Grau de Desobstrução Vascular , Idoso , Comorbidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/instrumentação , Doença das Coronárias/epidemiologia , Doença das Coronárias/cirurgia , Feminino , Oclusão de Enxerto Vascular/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , StentsRESUMO
OBJECTIVE: Wound infection is a rare but life-threatening complication after coronary artery bypass grafting. Risk factors for wound infection after off-pump bypass grafting and the validity of using bilateral internal thoracic arteries harvested in a skeletonized fashion remain unclear, especially in patients with diabetes. METHODS: The data of 1500 consecutive patients having off-pump bypass grafting were prospectively collected from our database based on EuroSCORE. This cohort represents 95% of all patients undergoing coronary bypass during that period and 77% of patients undergoing off-pump bypass grafting who received bilateral internal thoracic artery grafts. Univariate and multivariate analyses were performed for patients with and without wound infection and in the diabetic subgroup. RESULTS: Ninety-eight patients had wound infections: 76, impaired wound healing; 7, superficial sternal wound infection; and 12, deep sternal wound infection. Patients with wound infections had a higher prevalence of female gender, atrial fibrillation, history of congestive heart failure, chronic renal failure, peripheral vascular disease, and diabetes. Patients with a wound infection more frequently had bilateral internal thoracic artery grafting, longer operation time, longer hospital stay, and a higher mortality rate. Blood transfusions were required in 43.9% of patients with wound infections and 28.1% of those without wound infections. On logistic regression analysis, female gender and history of congestive heart failure, chronic renal failure, and diabetes mellitus were independent risk factors for wound infection. In patients with diabetes, female gender, atherosclerosis obliterans, chronic renal failure, and use of bilateral internal thoracic artery grafts were independent risk factors for wound infection. CONCLUSIONS: Risk factors for wound infection after off-pump coronary artery bypass grafting are comparable with those previously reported for conventional bypass grafting. In patients with diabetes, the use of bilateral internal thoracic arteries, even when harvested in a skeletonized fashion, is a risk factor. Thus, appropriate precautions should be taken in patients with diabetes.
Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Doença das Coronárias/cirurgia , Angiopatias Diabéticas/cirurgia , Artéria Torácica Interna/transplante , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Análise de Variância , Antibioticoprofilaxia/métodos , Angiografia Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Doença das Coronárias/diagnóstico por imagem , Doença das Coronárias/mortalidade , Angiopatias Diabéticas/diagnóstico , Feminino , Seguimentos , Rejeição de Enxerto , Sobrevivência de Enxerto , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Probabilidade , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Taxa de Sobrevida , Coleta de Tecidos e Órgãos/normas , Coleta de Tecidos e Órgãos/tendências , Resultado do TratamentoRESUMO
Endoscopic saphenous vein harvesting (ESVH) requires a high degree of technical expertise. However, few studies have investigated the influence of SV caliber on the technical difficulty and outcome of ESVH. We analyzed 86 consecutive patients who underwent ESVH using a VirtuoSaph(trade mark) system. SV caliber was measured in the above-knee portion by ultrasound. Patients were then divided into two groups: group A (SV caliber <3 mm, n=16), and group B (the remaining patients, n=70). ESVH procedure time and SV characteristics were compared between the groups. In group A, the SV had a larger number of side branches (11.7+/-1.2 in A, 9.8+/-0.4 in B, P=0.043) and required a longer operation time (A, 57.5+/-3.7 min; B, 43.9+/-1.9 min, P=0.0024), whereas the time required for endoscopy did not differ. Graft length (A, 27.7+/-5.0 cm; B, 25.7+/-3.7 cm) and ratio of repaired side branches (A, 26.6+/-20.5%; B, 25.7+/-23.9%) showed no significant differences. ESVH using a VirtuoSaph(trade mark) system is feasible, regardless of SV caliber. SV with a caliber of <3 mm has a larger number of side branches, thus prolonging the procedure time.
Assuntos
Endoscopia/métodos , Veia Safena/cirurgia , Coleta de Tecidos e Órgãos/métodos , Idoso , Ponte de Artéria Coronária/métodos , Doença das Coronárias/cirurgia , Humanos , Estudos Prospectivos , Reprodutibilidade dos Testes , Veia Safena/diagnóstico por imagem , Veia Safena/transplante , UltrassonografiaAssuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna , Artéria Pulmonar , Fístula Vascular , Idoso de 80 Anos ou mais , Doenças da Aorta/complicações , Calcinose , Doença da Artéria Coronariana/complicações , Feminino , Humanos , Fístula Vascular/congênitoRESUMO
BACKGROUND: We evaluated the effects of coronary artery bypass with off-pump skeletonized bilateral internal thoracic artery grafting in patients with insulin-dependent diabetes. METHODS: One hundred eighty-five consecutive patients with insulin-dependent diabetes who underwent isolated coronary artery bypass grafting with bilateral internal thoracic grafts were retrospectively compared according to surgical technique, ie, off-pump grafting with skeletonized internal thoracic artery (n = 162) or on-pump grafting with pedicled internal thoracic artery (n = 23). RESULTS: The on-pump group was younger (62.3 +/- 9.2 versus 69.9 +/- 8.5 years; p = 0.02) and had fewer distal anastomoses (3.5 +/- 1.0 versus 4.0 +/- 1.1; p = 0.02) than the off-pump group. No 30-day mortality occurred in either group. The incidence of deep sternal infection was significantly lower in the off-pump group than in the on-pump group (0.6% versus 13.0%; p = 0.01). The early angiographic results did not differ between the two groups. The median duration of follow-up was 3.4 years (range, 0.1 to 9.9 years). Rates of survival, freedom from cardiac mortality, and freedom from cardiac-related events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, repeat coronary artery bypass grafting, and congestive heart failure) did not differ between the two groups. Dialysis, peripheral vascular disease, ejection fraction less than 0.40, and age were independent risk factors of late death. CONCLUSIONS: Overall, our results support the surgical management of coronary artery bypass grafting in insulin-dependent diabetics using off-pump skeletonized bilateral internal thoracic artery grafting.
Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Diabetes Mellitus Tipo 1/complicações , Anastomose de Artéria Torácica Interna-Coronária/métodos , Idoso , Angiografia Coronária , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos RetrospectivosRESUMO
BACKGROUND: We evaluated the perioperative and long-term results of bilateral internal thoracic artery grafting in dialysis patients. METHODS: One hundred one consecutive patients on chronic dialysis who underwent isolated coronary artery bypass grafting were retrospectively compared according to the surgical technique, bilateral internal thoracic artery (BITA) grafting (n = 76) or single internal thoracic artery (SITA) grafting (n = 25). RESULTS: Hospital mortality was 5.3% in the BITA group and 8.0% in the SITA group (p = not significant). The incidence of mediastinitis was not different (7.9% in the BITA group and 8.0% in the SITA group). The median duration of follow-up was 3.1 years (range, 0.1 to 10.9). Survival and freedom from cardiac mortality were not different between the two groups, but the BITA group had a trend toward better results. Freedom from cardiac events (including cardiac-related death, myocardial infarction, percutaneous coronary intervention, redo coronary artery bypass grafting, and congestive heart failure) was superior in the BITA group (p = 0.03). Calcification of the ascending aorta, peripheral vascular disease, insulin-dependent diabetes mellitis, and age were the independent risk factors of late death. CONCLUSIONS: Perioperative results of BITA grafting in dialysis patients were not different from the results of SITA grafting. However, the long-term results of BITA grafting in dialysis patients were better than the results of SITA grafting. Overall, our results support the continued use of BITA grafting in dialysis patients.
Assuntos
Estenose Coronária/cirurgia , Anastomose de Artéria Torácica Interna-Coronária/métodos , Diálise Renal , Idoso , Estenose Coronária/complicações , Feminino , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
OBJECTIVE: The purpose of this study was to investigate (1) the early and midterm patency rates in saphenous vein grafts that were anastomosed with the Symmetry Aortic Connector System (St Jude Medical, Inc, St Paul, Minn) and (2) risk factors for graft occlusion. METHODS: Thirty-one patients underwent off-pump coronary artery bypass grafting for proximal saphenous vein graft anastomoses with the aortic connector system. Intraoperative graft flow was studied with transit time flowmetry, and angiography was performed before discharge in 29 cases. Midterm (at least 1 year after the operation) saphenous vein graft patency was assessed by coronary angiography or 3-dimensional coronary computed tomography in 27 cases. RESULTS: Postoperative angiography demonstrated a 100% patency rate and no significant stenosis at the connector-anastomosed sites. The 1-year patency rate of the saphenous vein grafts with the aortic connector system was 92.6%, with 2 cases of saphenous vein graft occlusion. Both of these cases had low graft flow and poor left ventricular function documented during the operation. CONCLUSION: Once surgical errors had been ruled out, the 1-year patency rate of proximal saphenous vein grafts anastomosed with the aortic connector system was favorable. Poor left ventricular function and low graft flow during the operation were risk factors for midterm graft occlusion. Selection of the target vessel and its runoff may also be an important determinant of long-term patency.