RESUMO
BACKGROUND: High levels of arterial oxygen pressures (PaO2) have been associated with increased mortality in extracorporeal cardiopulmonary resuscitation (ECPR), but there is limited information regarding possible mechanisms linking hyperoxia and death in this setting, notably with respect to its hemodynamic consequences. We aimed therefore at evaluating a possible association between PaO2, circulatory failure and death during ECPR. METHODS: We retrospectively analyzed 44 consecutive cardiac arrest (CA) patients treated with ECPR to determine the association between the mean PaO2 over the first 24 h, arterial blood pressure, vasopressor and intravenous fluid therapies, mortality, and cause of deaths. RESULTS: Eleven patients (25%) survived to hospital discharge. The main causes of death were refractory circulatory shock (46%) and neurological damage (24%). Compared to survivors, non survivors had significantly higher mean 24 h PaO2 (306 ± 121 mmHg vs 164 ± 53 mmHg, p < 0.001), lower mean blood pressure and higher requirements in vasopressors and fluids, but displayed similar pulse pressure during the first 24 h (an index of native cardiac recovery). The mean 24 h PaO2 was significantly and positively correlated with the severity of hypotension and the intensity of vasoactive therapies. Patients dying from circulatory failure died after a median of 17 h, compared to a median of 58 h for patients dying from a neurological cause. Patients dying from neurological cause had better preserved blood pressure and lower vasopressor requirements. CONCLUSION: In conclusion, hyperoxia is associated with increased mortality during ECPR, possibly by promoting circulatory collapse or delayed neurological damage.
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Reanimação Cardiopulmonar/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Parada Cardíaca/complicações , Hiperóxia/etiologia , Choque/etiologia , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Hiperóxia/mortalidade , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Estudos RetrospectivosRESUMO
BACKGROUND: Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve. METHODS: SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected. RESULTS: The study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study. CONCLUSIONS: These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.
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Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Valva Mitral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Duração da Cirurgia , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Reoperação , Resultado do TratamentoRESUMO
Adult patients with uncorrected congenital heart diseases and chronic intracardiac shunt may develop Eisenmenger syndrome (ES) due to progressive increase of pulmonary vascular resistance, with significant morbidity and mortality. Acute decompensation of ES in conditions promoting a further increase of pulmonary vascular resistance, such as pulmonary embolism or pneumonia, can precipitate major arterial hypoxia and death. In such conditions, increasing systemic oxygenation with veno-venous extracorporeal membrane oxygenation (VV-ECMO) could be life-saving, serving as a bridge to treat a potential reversible cause for the decompensation, or to urgent lung transplantation. Anticipating the effects of VV-ECMO in this setting could ease the clinical decision to initiate such therapeutic strategy. Here, we present a series of equations to accurately predict the effects of VV-ECMO on arterial oxygenation in ES and illustrate this point by a case of ES decompensation with refractory hypoxaemia consecutive to an acute respiratory failure due to viral pneumonia.
Assuntos
Complexo de Eisenmenger , Oxigenação por Membrana Extracorpórea , Pneumonia Viral , Síndrome do Desconforto Respiratório , Adulto , Complexo de Eisenmenger/complicações , Complexo de Eisenmenger/diagnóstico , Complexo de Eisenmenger/terapia , HumanosRESUMO
For a decade, aortic valve replacement (AVR) surgery has been simplified thanks to the development of sutureless or rapid deployment valves (SU-RD valves), which offer an alternative to sutured valves. These SU-RD valves, inspired by the TAVI (Transcatheter Aortic Valve Implantation), allow significant operating time reduction and facilitate minimally invasive surgery. They are particularly indicated for patients that are more fragile and in combined procedures (for example AVR associated with coronary bypass surgery). Recent studies report high reliability and excellent outcomes with lower morbidity and mortality compared to other AVR modalities, including TAVI. Considering the constant technical improvement, SU-DR valves may become the new standard in AVR.
Depuis une décennie, la chirurgie du remplacement valvulaire aortique (RVA) s'est simplifiée grâce à l'apparition de valves dites « sutureless ¼ ou à « déploiement rapide ¼ (valves SU-DR) qui offrent une alternative aux valves suturées. Ces valves SU-DR, inspirées du Transcatheter Aortic Valve Implantation (TAVI), permettent un gain de temps opératoire important et facilitent la chirurgie mini-invasive. Elles sont notamment indiquées chez les patients plus fragiles et lors de procédures combinées (par exemple, RVA et pontages coronariens associés). Des études récentes rapportent une grande fiabilité et d'excellents résultats avec une moindre morbi-mortalité par rapport aux autres modalités de RVA, y compris le TAVI. Considérant l'amélioration technique constante, les valves SU-RD pourraient bien devenir le nouveau standard dans le RVA.
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Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Humanos , Reprodutibilidade dos TestesRESUMO
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a life-saving technology that provides transient respiratory and circulatory support for patients with profound cardiogenic shock or refractory cardiac arrest. Among its potential complications, VA-ECMO may adversely affect lung function through various pathophysiological mechanisms. The interaction of blood components with the biomaterials of the extracorporeal membrane elicits a systemic inflammatory response which may increase pulmonary vascular permeability and promote the sequestration of polymorphonuclear neutrophils within the lung parenchyma. Also, VA-ECMO increases the afterload of the left ventricle (LV) through reverse flow within the thoracic aorta, resulting in increased LV filling pressure and pulmonary congestion. Furthermore, VA-ECMO may result in long-standing pulmonary hypoxia, due to partial shunting of the pulmonary circulation and to reduced pulsatile blood flow within the bronchial circulation. Ultimately, these different abnormalities may result in a state of persisting lung inflammation and fibrotic changes with concomitant functional impairment, which may compromise weaning from VA-ECMO and could possibly result in long-term lung dysfunction. This review presents the mechanisms of lung damage and dysfunction under VA-ECMO and discusses potential strategies to prevent and treat such alterations.
Assuntos
Oxigenação por Membrana Extracorpórea , Fenômenos Fisiológicos Respiratórios , Humanos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Isquemia/etiologia , Isquemia/fisiopatologia , Tecido Parenquimatoso/lesões , Tecido Parenquimatoso/fisiopatologiaRESUMO
BACKGROUND: Venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) after refractory cardiogenic shock or cardiac arrest has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuroprognostication are limited. We examined the prognostic value of clinical neurologic examination, using an automated device for the quantitative measurement of pupillary light reactivity. METHODS: An observational cohort of sedated, mechanically ventilated VA-ECMO patients was analyzed during the early phase after ECMO insertion (first 72 h). Using the NPi-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 h) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated. RESULTS: One hundred consecutive patients were studied (51 with refractory cardiogenic shock and 49 with refractory cardiac arrest; 12-h PREDICT VA-ECMO, 40%; observed 90-day survival, 43%). Nonsurvivors (n = 57) had significantly lower NPi than did survivors at all time points (all P < .01). Abnormal NPi (< 3, at any time from 24 to 72 h) was 100% specific for 90-day mortality, with 0% false positives. Adding the 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity, 100% [95% CI, 92%-100%]; sensitivity, 60% [95% CI, 46%-72%]; area under the receiver operating characteristic curve, 0.82). CONCLUSIONS: Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.
Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca/terapia , Exame Neurológico/métodos , Reflexo Pupilar , Choque Cardiogênico/terapia , Idoso , Coma , Feminino , Parada Cardíaca/mortalidade , Humanos , Pessoa de Meia-Idade , Prognóstico , Sensibilidade e Especificidade , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , SuíçaRESUMO
BACKGROUND: Cardiopulmonary bypass (CPB) is often associated with degrees of complex inflammatory response mediated by various cytokines. This response can, in severe cases, lead to systemic hypotension and organ dysfunction. Cytokine removal might therefore improve outcomes of patients undergoing cardiac surgery. CytoSorb® (Cytosorbents, NJ, USA) is a recent device designed to remove cytokine from the blood using haemoadsorption (HA). This trial aims to evaluate the potential of CytoSorb® to decrease peri-operative cytokine levels in cardiac surgery. METHODS: We have conducted a single-centre pilot randomized controlled trial in 30 patients undergoing elective cardiac surgery and deemed at risk of complications. Patients were randomly allocated to either standard of care (n = 15) or CytoSorb® HA (n = 15) during cardiopulmonary bypass (CPB). Our primary outcome was the difference between the two groups in cytokines levels (IL-1a, IL-1b, IL-2, IL-4, IL-5, IL-6, IL-10, TNF-α, IFN-γ, MCP-1) measured at anaesthesia induction, at the end of CPB, as well as 6 and 24 h post-CPB initiation. In a consecutive subgroup of patients (10 in HA group, 11 in control group), we performed cross-adsorber as well as serial measurements of coagulation factors' activity (antithrombin, von Willebrand factor, factor II, V, VIII, IX, XI, and XII). RESULTS: Both groups were similar in terms of baseline and peri-operative characteristics. CytoSorb® HA during CPB was not associated with an increased incidence of adverse event. The procedure did not result in significant coagulation factors' adsorption but only some signs of coagulation activation. However, the intervention was associated neither with a decrease in pro- or anti-inflammatory cytokine levels nor with any improvement in relevant clinical outcomes. CONCLUSIONS: CytoSorb® HA during CPB was not associated with a decrease in pro- or anti-inflammatory cytokines nor with an improvement in relevant clinical outcomes. The procedure was feasible and safe. Further studies should evaluate the efficacy of CytoSorb® HA in other clinical contexts. TRIAL REGISTRATION: ClinicalTrials.gov NCT02775123 . Registered 17 May 2016.
Assuntos
Ponte Cardiopulmonar/efeitos adversos , Citocinas/efeitos adversos , Hemofiltração/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/métodos , Quimiocina CCL2/análise , Quimiocina CCL2/sangue , Citocinas/sangue , Citocinas/metabolismo , Feminino , Hemofiltração/métodos , Hemofiltração/normas , Humanos , Interleucina-10/análise , Interleucina-10/sangue , Interleucina-1alfa/análise , Interleucina-1alfa/sangue , Interleucina-1beta/análise , Interleucina-1beta/sangue , Interleucina-2/análise , Interleucina-2/sangue , Interleucina-4/análise , Interleucina-4/sangue , Interleucina-5/análise , Interleucina-5/sangue , Interleucina-6/análise , Interleucina-6/sangue , Masculino , Taxa de Depuração Metabólica , Pessoa de Meia-Idade , Projetos Piloto , Complicações Pós-Operatórias/prevenção & controle , Fator de Necrose Tumoral alfa/análise , Fator de Necrose Tumoral alfa/sangueRESUMO
BACKGROUND: Endocarditis is a rare complication of transcatheter aortic valve implantation (TAVI), with an estimated 1-year incidence of 0.50% [Circulation 2015]. However, ensuing consequences are often dire, and its surgical treatment poses unique problems, due to the frequent underlying frailty of TAVI recipients. CASE REPORT: We report the case of an 84-year-old woman, who developed Staphylococcus aureus prosthetic valve endocarditis (PVE) 7 days after transfemoral TAVI (ACURATE neo™, Boston Scientific or Symetis, further complicated by an aortic annular abscess with fistulization into the right atrium. The patient underwent successful operative aortic annulus repair, using pericardial patches, and aortic valve replacement with a sutureless Perceval S bioprosthesis (LivaNova). CONCLUSION: Our case documents the treatment of an active fistulizing Symetis ACURATE neo ™ prosthetic aortic valve endocarditis by using a sutureless LivaNova Perceval S prosthesis with satisfying hemodynamic results and an encouraging 1-year outcome, further corroborating its usefulness in such circumstances.
Assuntos
Abscesso/terapia , Bioprótese , Endocardite Bacteriana/terapia , Próteses Valvulares Cardíacas , Pericárdio/transplante , Infecções Relacionadas à Prótese/terapia , Infecções Estafilocócicas/terapia , Substituição da Valva Aórtica Transcateter , Abscesso/diagnóstico por imagem , Abscesso/microbiologia , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/microbiologia , Feminino , Humanos , Desenho de Prótese , Infecções Relacionadas à Prótese/diagnóstico por imagem , Infecções Relacionadas à Prótese/microbiologia , Infecções Estafilocócicas/diagnóstico por imagem , Infecções Estafilocócicas/microbiologiaRESUMO
Solitary fibrous tumors are rare mesenchymal tumors most commonly arising from the pleura. When associated with paraneoplastic syndrome of hypoglycemia caused by the secretion of a high-molecular-weight form of insulin-like growth factor II, it is referred to as the Doege-Potter syndrome. Surgery with complete tumor resection is the only curative treatment. We present here the case of a 93-year-old female diagnosed with a Doege-Potter syndrome who underwent three repetitive surgical resections of recurrent solitary fibrous tumor.
RESUMO
INTRODUCTION: Paraganglioma is a rare neuroendocrine tumor and may sometimes be located in the membranous part of the trachea. PRESENTATION OF CASE: We report the case of a 52-year-old man presenting a paraganglioma just above the carina with obstructive symptoms. The patient successfully underwent a non-circumferential tracheal membranous resection, followed by latissimus dorsi muscle flap repair, under peripheral extra-corporeal membrane oxygenation (ECMO). DISCUSSION: Complex carinal resection can be avoided for tracheal membranous tumors and replaced with non-circumferential resection and direct reconstruction with a muscle flap. In addition, ECMO support may be used for airway resection and reconstruction. CONCLUSION: Tracheal membranous tumors can be managed without circumferential resection or direct anastomosis.
Assuntos
Calcinose/diagnóstico por imagem , Aneurisma Cardíaco/diagnóstico por imagem , Ventrículos do Coração/diagnóstico por imagem , Calcinose/etiologia , Calcinose/patologia , Aneurisma Cardíaco/etiologia , Aneurisma Cardíaco/patologia , Ventrículos do Coração/patologia , Humanos , Radiografia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicaçõesRESUMO
Fenestrated aortic valve is a frequent condition which is, for most of the time, asymptomatic and generally has no influence on aortic valve competence. However, aortic valve regurgitation could occur, especially in the case of fibrous strand rupture. In this situation, acute aortic regurgitation is poorly tolerated and requires urgent surgical correction. Herein is presented the case of a 70-year-old patient who was admitted as an emergency for acute heart failure after coital exertion. Echocardiography revealed severe acute aortic regurgitation due to leaflet prolapse. Intraoperative inspection of the valve showed a strand rupture of the isolated fenestration.
Assuntos
Insuficiência da Valva Aórtica/etiologia , Valva Aórtica , Coito , Ruptura Cardíaca/etiologia , Idoso , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/cirurgia , Ecocardiografia Transesofagiana , Ruptura Cardíaca/diagnóstico por imagem , Ruptura Cardíaca/fisiopatologia , Ruptura Cardíaca/cirurgia , Implante de Prótese de Valva Cardíaca , Hemodinâmica , Humanos , Masculino , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
A 74-year-old woman was admitted for right coronary angioplasty. During the procedure, she complained about chest pain, and contrast injection showed an iatrogenic dissection of the ascending aorta. A contrast computed tomography (CT) scan confirmed the diagnosis via visualization of a large non-circulating false lumen, which involved nearly the entire ascending aorta. The patient remained hemodynamically stable and asymptomatic while receiving medical therapy alone. Another CT scan performed 3 days later showed complete regression of the false lumen. This case suggests that uncomplicated iatrogenic dissection of the ascending aorta, even when large, may be managed successfully by medical therapy.
RESUMO
An unusual case of localized amyloid light-chain (AL) amyloidosis and extramedullary plasmacytoma of the mitral valve is described. The worsening of a mitral regurgitation led to investigations and surgery. The valve presented marked distortion and thickening by type AL amyloid associated with a monotypic CD138+ immunoglobulin lambda plasma cell proliferation. Systemic staging showed a normal bone marrow and no evidence of amyloid deposition in other localizations. The patient's outcome after mitral valve replacement was excellent. To our knowledge, this is the first description of a localized AL amyloidosis as well as of a primary extramedullary plasmacytoma of the mitral valve.
Assuntos
Amiloidose/patologia , Neoplasias Cardíacas/patologia , Doenças das Valvas Cardíacas/patologia , Valva Mitral/patologia , Plasmocitoma/patologia , Idoso , Feminino , HumanosRESUMO
Transapical aortic valve implantation is indicated in high-risk patients with aortic stenosis and peripheral vascular disease requiring aortic valve replacement. Minimally invasive direct coronary artery bypass grafting is also a valid, minimally invasive option for myocardial revascularization in patients with critical stenosis on the anterior descending coronary artery. Both procedures are performed through a left minithoracotomy, without cardiopulmonary bypass, aortic cross-clamping, and cardioplegic arrest. We describe a successful combined transapical aortic valve implantation and minimally invasive direct coronary bypass in a high-risk patient with left anterior descending coronary artery occlusion and severe aortic valve stenosis.
Assuntos
Valva Aórtica/cirurgia , Ponte de Artéria Coronária/métodos , Implante de Prótese de Valva Cardíaca/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Idoso , Idoso de 80 Anos ou mais , Humanos , MasculinoRESUMO
A 56-year-old patient admitted to hospital for the suspicion of an acute coronary syndrome underwent coronary angiography without detection of significant lesions. Seven days later the echocardiography showed acute severe aortic valve insufficiency. Intraoperatively we found a perforated leaflet probably due to lesion during transcatheter procedure.