RESUMO
OBJECTIVES: While a minimalist transcatheter aortic valve replacement (TAVR) approach has shown safety and efficacy at civilian hospitals, limited data exist regarding developing this approach at Veterans Affairs (VA) medical centers (VAMCs). We implemented TAVR with minimalist approach (MA) using conscious sedation (CS) with transthoracic echocardiography (TTE) and compared safety and outcomes with general anesthesia (GA) with transesophageal echocardiography (TEE) at a university-affiliated VAMC. METHODS: A total of 258 patients underwent transfemoral TAVR at a VAMC between November 2013 and October 2019. Ninety-three patients underwent GA/TEE and 165 patients underwent CS/TTE with dexmedetomidine and remifentanil. Propensity-score matching with nearest-neighbor matching was used to account for baseline differences, yielding 227 participants (81 GA, 146 CS). RESULTS: MA-TAVR had no effect on 30-day mortality or paravalvular leakage. No differences were found in permanent pacemaker implantation, major vascular complications, or postoperative hemodynamics. In this population, MA-TAVR did not reduce procedural time, hospital length of stay, or intensive care unit length of stay. CONCLUSIONS: Unlike civilian hospitals, MA with CS/TTE did not reduce overall length of stay in the veteran population; however, it was safe and effective for transfemoral TAVR without impacting clinical outcomes of mortality, major vascular complications, and paravalvular leakage.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Veteranos , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/cirurgia , Hospitais , Humanos , Tempo de Internação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoAssuntos
Parada Cardíaca/terapia , Massagem Cardíaca/métodos , Idoso , Automação , Evolução Fatal , Humanos , MasculinoRESUMO
The reported adverse effects of perioperative transesophageal echocardiography (TEE) are mostly associated with the insertion and manipulation of the TEE probe. Recent data suggest that blind probe insertion may be associated with greater morbidity than reported previously. Although this morbidity appears to be subclinical with unknown effects on patient outcome, evaluation of strategies for insertion is warranted. Herein, we present a novel insertion technique using a soft-tipped esophageal bougie as a guide for blind TEE probe insertion in a patient undergoing cardiac surgery. The potential advantages and related safety issues are discussed.
Assuntos
Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Aneurisma Cardíaco/diagnóstico por imagem , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/microbiologia , Insuficiência da Valva Aórtica/cirurgia , Endocardite Bacteriana/complicações , Endocardite Bacteriana/microbiologia , Aneurisma Cardíaco/microbiologia , Aneurisma Cardíaco/cirurgia , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/microbiologia , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral , Valor Preditivo dos Testes , Resultado do Tratamento , Estreptococos Viridans/isolamento & purificaçãoAssuntos
Valva Aórtica/microbiologia , Valva Aórtica/cirurgia , Endocardite Bacteriana/microbiologia , Aorta Torácica/patologia , Aorta Torácica/cirurgia , Angiopatias Diabéticas/complicações , Angiopatias Diabéticas/patologia , Ecocardiografia Transesofagiana , Endocardite Bacteriana/patologia , Febre/patologia , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Pleurisia/patologia , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/patologiaAssuntos
Seio Coronário/anormalidades , Veia Cava Inferior/anormalidades , Idoso , Artroplastia do Joelho , Seio Coronário/diagnóstico por imagem , Ecocardiografia Transesofagiana , Átrios do Coração , Testes de Função Cardíaca , Valvas Cardíacas/diagnóstico por imagem , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/fisiopatologia , Masculino , Veia Cava Inferior/diagnóstico por imagem , Veia Cava Inferior/cirurgiaRESUMO
We report the case of a 60-year-old man requiring combined mitral valve repair and coronary artery bypass grafting. A unique minimally invasive approach was used combining robotic internal mammary artery harvesting, partial lower sternotomy, and single vessel coronary artery bypass grafting using an automated distal coronary artery anastomotic device. Issues in approaching the commonly encountered patient with mitral valve disease and coronary artery disease using minimally invasive techniques are discussed.
Assuntos
Anastomose Cirúrgica/instrumentação , Ponte de Artéria Coronária/métodos , Vasos Coronários/cirurgia , Artéria Torácica Interna/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Valva Mitral/cirurgia , Robótica , Anastomose Cirúrgica/métodos , Ecocardiografia Transesofagiana , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Esterno/cirurgiaAssuntos
Valva Aórtica/diagnóstico por imagem , Endocardite/diagnóstico por imagem , Próteses Valvulares Cardíacas/efeitos adversos , Complicações Pós-Operatórias/diagnóstico por imagem , Idoso , Valva Aórtica/microbiologia , Valva Aórtica/cirurgia , Endocardite/microbiologia , Endocardite/cirurgia , Fístula/diagnóstico por imagem , Fístula/microbiologia , Fístula/cirurgia , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/microbiologia , Átrios do Coração/cirurgia , Próteses Valvulares Cardíacas/microbiologia , Humanos , Masculino , Complicações Pós-Operatórias/microbiologia , Complicações Pós-Operatórias/cirurgia , UltrassonografiaRESUMO
STUDY OBJECTIVE: Because fentanyl has ventilatory depressing effects, alternative methods for analgesia may be beneficial for management of bariatric surgery. We evaluated whether dexmedetomidine infusion could replace fentanyl for facilitation of open gastric bypass surgery. DESIGN: Randomized, single blinded, open label. SETTING: University teaching hospital. PATIENTS: Twenty bariatric patients with an average body mass index of 54 to 61 kg/m2 undergoing surgery for open gastric bypass. INTERVENTIONS: Patients were randomized to receive either fentanyl (0.5-microg/kg bolus, 0.5 microg.kg(-1).h(-1), n = 10) or dexmedetomidine (0.5-microg/kg bolus, 0.4 microg.kg(-1).h(-1), n = 10) for intraoperative analgesia. In both groups, end-tidal desflurane was adjusted to maintain the bispectral index at 45 to 50. MEASUREMENTS: In the operating room, blood pressure and heart rate were measured at 5-minute intervals. Bispectral index and end-tidal desflurane concentration were measured every hour. During recovery in the postanesthesia care unit, patient-evaluated pain scores and morphine use by patient-controlled analgesia pump were determined. MAIN RESULTS: During surgery, desflurane concentrations necessary to maintain the bispectral index at 45 to 50 were decreased, and blood pressure and heart rate were lower with in the dexmedetomidine compared with fentanyl group. In the postanesthesia care unit, pain scores and morphine use were decreased in the dexmedetomidine group. CONCLUSIONS: Dexmedetomidine, when used to substitute for fentanyl during gastric bypass surgery, attenuates blood pressure and provides postoperative analgesia.