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1.
JACC Clin Electrophysiol ; 5(8): 944-954, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31439296

RESUMO

OBJECTIVES: This study aimed to evaluate incidence, clinical significance, and predictors of early ventricular arrhythmias (VAs) in left ventricular assist device (LVAD) recipients. BACKGROUND: LVAD implantation is increasingly used in patients with end-stage heart failure. Early VAs may occur during the 30-day post-operative period, but many questions remain unanswered regarding their incidence and clinical impact. METHODS: This observational study was conducted in 19 centers between 2006 and 2016. Early VAs were defined as sustained ventricular tachycardia and/or ventricular fibrillation occurring <30 days post-LVAD implantation and requiring appropriate implantable cardioverter-defibrillator therapy, external electrical shock, or medical therapy. RESULTS: A total of 652 patients (median age: 59.8 years; left ventricular ejection fraction: 20.7 ± 7.4%; HeartMate 2: 72.8%; HeartWare: 19.5%; Jarvik 2000: 7.7%) were included in the analysis. Early VAs occurred in 162 patients (24.8%), most frequently during the first week after LVAD implantation. Multivariable analysis identified history of VAs prior to LVAD and any combined surgery with LVAD as 2 predictors of early VAs. The occurrence of early VAs with electrical storm was the strongest predictor of 30-day post-operative mortality, associated with a 7-fold increase of 30-day mortality. However, in patients discharged alive from hospital, occurrence of early VAs did not influence long-term survival. CONCLUSIONS: Early VAs are common after LVAD implantation and increase 30-day post-operative mortality, without affecting long-term survival. Further studies will be needed to analyze whether pre- or pre-operative ablation of VAs may improve post-operative outcomes. (Determination of Risk Factors of Ventricular Arrhythmias After Implantation of Continuous Flow Left Ventricular Assist Device With Continuous Flow Left Ventricular Assist Device [ASSIST-ICD]; NCT02873169).

2.
Artif Organs ; 2019 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-31318978

RESUMO

Left ventricular assist devices (LVADs) are used as an alternative therapy for heart transplantation in patients with advanced heart failure. However, the mortality rate of these patients remains relatively high. A large proportion of deaths after LVAD implantation occur during intensive care unit (ICU) stay. We conducted a retrospective study to identify the risk factors for all-cause ICU mortality in patients with an implanted LVAD. Between January 1, 2008 and December 31, 2016, 70 consecutive patients who had received an LVAD were analyzed. The median ICU length of stay was 14 days (IQR: 8-31) and 16 patients (22.9% [95%CI: 13.1-32.7]) died in the ICU. The 90-day mortality rate was 25.7% (95%CI: 15.5-35.9). The main causes of ICU mortality were: multiple organ failure, stroke, and hemorrhagic events. The univariate analysis identified the following perioperative risk factors for all-cause ICU mortality: hypertension, preoperative platelet count, preoperative white cell count, inotropic support before LVAD implantation, mechanical ventilation before LVAD implantation, renal replacement therapy before LVAD implantation, short-term mechanical support before LVAD implantation, INTERMACS class 1 to 2, low intraoperative platelet count, low early postoperative hemoglobin level, low early postoperative platelet count, low early postoperative pH, and massive perioperative blood transfusion. In the multivariate logistic regression analysis, only mechanical ventilation before LVAD implantation was retained as an independent risk factor for ICU mortality (OR = 11.96 [95%CI: 2.67-53.45], P < .01). These findings confirm that most deaths after LVAD implantation occur in the ICU. Patients that receive mechanical ventilation preoperatively have the highest risk of death. This confirms the need to actively treat respiratory failure and to wean patients from respiratory support before LVAD implantation. Such a strategy offers the best opportunity to initiate active rehabilitation.

3.
Am Heart J ; 214: 69-76, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174053

RESUMO

BACKGROUND: Left ventricular assist device (LVAD)-associated infections may be life-threatening and impact patients' outcome. We aimed to identify the characteristics, risk factors, and prognosis of LVAD-associated infections. METHODS: Patients included in the ASSIST-ICD study (19 centers) were enrolled. The main outcome was the occurrence of LVAD-associated infection (driveline infection, pocket infection, or pump/cannula infection) during follow-up. RESULTS: Of the 652 patients enrolled, 201 (30.1%) presented a total of 248 LVAD infections diagnosed 6.5 months after implantation, including 171 (26.2%), 51 (7.8%), and 26 (4.0%) percutaneous driveline infection, pocket infection, or pump/cannula infection, respectively. Patients with infections were aged 58.7 years, and most received HeartMate II (82.1%) or HeartWare (13.4%). Most patients (62%) had implantable cardioverter-defibrillators (ICDs) before LVAD, and 104 (16.0%) had ICD implantation, extraction, or replacement after the LVAD surgery. Main pathogens found among the 248 infections were Staphylococcus aureus (n = 113' 45.4%), Enterobacteriaceae (n = 61; 24.6%), Pseudomonas aeruginosa (n = 34; 13.7%), coagulase-negative staphylococci (n = 13; 5.2%), and Candida species (n = 13; 5.2%). In multivariable analysis, HeartMate II (subhazard ratio, 1.56; 95% CI, 1.03 to 2.36; P = .031) and ICD-related procedures post-LVAD (subhazard ratio, 1.43; 95% CI, 1.03-1.98; P = .031) were significantly associated with LVAD infections. Infections had no detrimental impact on survival. CONCLUSIONS: Left ventricular assist device-associated infections affect one-third of LVAD recipients, mostly related to skin pathogens and gram-negative bacilli, with increased risk with HeartMate II as compared with HeartWare, and in patients who required ICD-related procedures post-LVAD. This is a plea to better select patients needing ICD implantation/replacement after LVAD implantation.

4.
J Cardiothorac Surg ; 14(1): 94, 2019 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-31113456

RESUMO

BACKGROUND: Sparing Aortic Valve procedure requires to reproduction of the geometry of the physiologic anatomy of the aortic root. Thus, the materials adopted may make a difference. CARDIOROOT is a one-piece collagen-coated woven vascular graft with pseudo-sinuses, which was designed for use in the treatment of aortic root disease. We report the results of a prospective, multicenter, observational post-market surveillance study evaluating the safety and performance of the CARDIOROOT in patients requiring aortic root surgery. METHODS: Patients with aortic root disease suitable for treatment with a vascular graft with pseudo-sinuses CARDIOROOT graft were eligible for participation. The enrolled patients were assessed intraoperatively, post-operatively, at discharge and at 1-year. Sites assessed complications at each visit, and recorded any reported adverse events. The study endpoint was mortality and complications through 1-year post-procedure. RESULTS: Fifty-two patients were enrolled from 6 European centers. All procedures were technically successful. Operative mortality was 1.9%: one patient suffered hemorrhagic shock unrelated to the graft 1 day following surgery. At 1-year follow-up the survival rate was 96.2%, with a late death due to pneumonia 5 months post-procedure. Eleven serious adverse events occurred in 7 patients, which included cardiac complications (pericardial effusion, myocardial infarction and ventricular arrhythmia), infection (pericardial infection, deep sternal infection and superficial sternal infection), vascular disorders, including hemorrhagic shock and pleural effusion requiring drainage. Nine of the 11 events were deemed procedure-related by the local investigator, and all were deemed unrelated to the device. There were no reports of graft-related adverse events, infection, occlusion or graft failure. CONCLUSIONS: The results of this 1-year follow-up study showed that the CARDIOROOT vascular graft is safe and effective for the treatment of aneurysmal aortic root in immediate and mid-term follow-up. However, longer term follow-up is needed before conclusions can be made on the long-term safety and effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01609270. Registered 31 May 2012.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/instrumentação , Adulto , Idoso , Aneurisma da Aorta Torácica/mortalidade , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Vigilância de Produtos Comercializados , Estudos Prospectivos , Desenho de Prótese , Taxa de Sobrevida , Adulto Jovem
5.
JACC Clin Electrophysiol ; 4(8): 987-995, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30139499

RESUMO

OBJECTIVES: The authors report the first acute clinical experience of atrial fibrillation ablation with PEF-both epicardial box lesions during cardiac surgery, and catheter-based PV isolation. BACKGROUND: Standard energy sources rely on time-dependent conductive heating/cooling and ablate all tissue types indiscriminately. Pulsed electric field (PEF) energy ablates nonthermally by creating nanoscale pores in cell membranes. Potential advantages for atrial fibrillation ablation include: 1) cardiomyocytes have among the lowest sensitivity of any tissue to PEF-allowing tissue selectivity, thereby minimizing ablation of nontarget collateral tissue; 2) PEF is delivered rapidly over a few seconds; and 3) the absence of coagulative necrosis obviates the risk of pulmonary vein (PV) stenosis. METHODS: PEF ablation was performed using a custom over-the-wire endocardial catheter for percutaneous transseptal PV isolation, and a linear catheter for encircling the PVs and posterior left atrium during concomitant cardiac surgery. Endocardial voltage maps were created pre- and post-ablation. Continuous and categorical data are summarized and presented as mean ± SD and frequencies. RESULTS: At 2 centers, 22 patients underwent ablation under general anesthesia: 15 endocardial and 7 epicardial. Catheter PV isolation was successful in all 57 PVs in 15 patients (100%) using 3.26 ± 0.5 lesions/PV: procedure time 67 ± 10.5 min, catheter time (PEF catheter entry to exit) 19 ± 2.5 min, total PEF energy delivery time <60 s/patient, and fluoroscopy time 12 ± 4.0 min. Surgical box lesions were successful in 6 of 7 patients (86%) using 2 lesions/patient. The catheter time for epicardial ablation was 50.7 ± 19.5 min. There were no complications. CONCLUSIONS: These data usher in a new era of tissue-specific, ultrarapid ablation of atrial fibrillation.

6.
J Nucl Cardiol ; 2018 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-29948892

RESUMO

BACKGROUND: The usage of left-ventricular-assist device (LVAD) is increasing in patients presenting with advanced heart failure. However, device-related infections are a challenge to recognize and to treat, with an important morbidity and mortality rate. The role of nuclear medicine imaging remains not well established for LVAD infections. The present study compared the accuracy of positron emission tomography/computed tomography with 18F-fludeoxyglucose (18F-FDG PET/CT) and radiolabeled leucocyte scintigraphy for the diagnosis of infections in patients supported with a continuous-flow LVAD. METHODS: From a prospectively maintained database, we retrospectively analyzed the diagnostic performance of radiolabeled leucocyte scintigraphy and 18F-FDG PET/CT in 24 patients who had a LVAD with a suspected device-related infection. Both examinations were routinely performed in all patients. Infection was assessed by the International Society for Heart and Lung Transplantation criteria. RESULTS: Twenty-four patients were included: 15 had a specific VAD infection (5 cardiac-LVAD and 10 driveline), 6 had a VAD-related infection, while 3 patients had a non-VAD-related infection. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.2%, 66.7%, 95.2%, 66.7%, and 91.6%, respectively, for 18F-FDG-PET; and 71.4%, 100%, 100%, 33.3%, and 75%, respectively, for leucocyte scintigraphy. 18F-FDG PET/CT showed significantly higher sensitivity (P = 0.01) than leucocyte scintigraphy. CONCLUSION: 18F-FDG PET/CT and radiolabeled leucocyte scintigraphy single-photon emission computed tomography carry high performance in the diagnostic of LVAD infections. 18F-FDG PET/CT shows significantly higher sensitivity and could be proposed as first-line nuclear medicine procedure.

8.
Arch Cardiovasc Dis ; 111(5): 332-339, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29217463

RESUMO

BACKGROUND: Ventricular arrhythmia is common after left ventricular assist device (LVAD) implantation, especially in the early postoperative phase (<30 days). AIM: To identify the incidence of and risk factors for electrical storm (ES) occurring within 30 days of HeartMate® II implantation. METHODS: We reviewed data from all consecutive patients undergoing HeartMate® II device implantation at our institution from January 2008 to December 2014. Patient demographic data, pharmacotherapies and outcomes were collected. The primary endpoint was occurrence of early ES (within 30 days of surgery), defined as three or more separate episodes of sustained ventricular arrhythmia within a 24-hour interval, requiring appropriate therapy. RESULTS: Forty-three patients (mean age 56.7±11.2 years; 39 men) were included. At HeartMate® II implantation, mean left ventricular ejection fraction was 20±5%, 32 (74.4%) patients had ischaemic cardiomyopathy and 31 (72.1%) were implanted with an indication of bridge to cardiac transplantation. During follow-up, 12 (27.9%) patients experienced early ES after HeartMate® II implantation (median delay 9.1±7.8 days). Early ES was more frequent in larger patients (body surface area 1.99 vs 1.81 m2; P<0.01), tended to be associated with previous sustained ventricular tachycardia (50.0% vs 22.6%; P=0.08), previous implantable cardioverter-defibrillator implantation (66.7% vs 38.7%; P=0.09), discontinuation of long-term beta-blocker therapy (75.0% vs 45.2%; P=0.08), weaning of adrenergic drugs after the third day (66.7% vs 35.5%; P=0.06) and the use of extracorporeal life support (50% vs 22.6%; P=0.079), but was not associated with the cardiomyopathy aetiology or the indication for assistance. Catheter ventricular tachycardia ablation was performed in six (14.0%) patients. Early ES was associated with a significantly higher all-cause mortality rate at the 30th day (33.3% vs 6.5%; P=0.02). CONCLUSION: ES is a common and pejorative feature in the early postoperative period.


Assuntos
Arritmias Cardíacas/epidemiologia , Cardiomiopatias/terapia , Coração Auxiliar , Implantação de Prótese/instrumentação , Função Ventricular Esquerda , Idoso , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Cardiomiopatias/diagnóstico , Cardiomiopatias/mortalidade , Cardiomiopatias/fisiopatologia , Feminino , França/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Implantação de Prótese/efeitos adversos , Implantação de Prótese/mortalidade , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento
10.
J Am Soc Echocardiogr ; 29(12): 1217-1228, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27751650

RESUMO

BACKGROUND: Left ventricular (LV) afterload could be associated with reduced myocardial contractility. The aim of this study was to evaluate the relative impact of increased afterload on LV myocardial deformation indices in chronic aortic constriction, with regard to hypertrophy, myocardial fibrosis, and mitochondrial function, and to differentiate acute versus chronic afterload effect. METHODS: Young pigs underwent aortic banding (n = 11) or sham (n = 7) operations. Nineteen weeks later, LV morphology and systolic function, including myocardial deformation, were assessed by echocardiography before and after banding release or acute aortic constriction (in the sham group). After the animals were euthanized, mitochondrial function and LV interstitial fibrosis were assessed. RESULTS: The chronic banding group (n = 8) presented with significant LV hypertrophy compared with the sham group (n = 7), and longitudinal strain (LS) was significantly altered (16.9 ± 0.7% vs 20.3 ± 0.7%, P = .001) while circumferential, radial strain, and ejection fraction were not. LS abnormalities were situated mostly on the basal and mid segments and on the septal wall. There was also significantly more myocardial fibrosis in the chronic banding group compared with the sham group, while mitochondrial function was preserved. The relative contributions of hypertrophic and fibrotic remodeling and of afterload to alter global LS were 62%, and 38%, respectively. Acute aortic banding also significantly altered LS. The ratio of LS to septal wall thickness enabled differentiation between chronic and acute afterload increase (1.9 ± 0.2 in the chronic group vs 2.9 ± 0.3 in the acute group, P = .001). CONCLUSIONS: LS is susceptible to both hypertrophic and fibrotic remodeling and afterload increase, particularly on the basal and mid LV segments of the septum. The ratio of LS to septal wall thickness enables differentiation of acute from chronic afterload LS alteration.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Pressão Sanguínea , Contração Miocárdica , Volume Sistólico , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia , Animais , Estenose da Valva Aórtica/complicações , Ecocardiografia/métodos , Módulo de Elasticidade , Técnicas de Imagem por Elasticidade/métodos , Masculino , Reprodutibilidade dos Testes , Sensibilidade e Especificidade , Estresse Mecânico , Suínos , Disfunção Ventricular Esquerda/etiologia
11.
Circ Arrhythm Electrophysiol ; 8(3): 592-7, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25870335

RESUMO

BACKGROUND: Left ventricular assist devices (LVADs) are increasingly used as a bridge to cardiac transplantation or as destination therapy. Patients with LVADs are at high risk for ventricular arrhythmias. This study describes ventricular arrhythmia characteristics and ablation in patients implanted with a Heart Mate II device. METHODS AND RESULTS: All patients with a Heart Mate II device who underwent ventricular arrhythmia catheter ablation at 9 tertiary centers were included. Thirty-four patients (30 male, age 58±10 years) underwent 39 ablation procedures. The underlying cardiomyopathy pathogenesis was ischemic in 21 and nonischemic in 13 patients with a mean left ventricular ejection fraction of 17%±5% before LVAD implantation. One hundred and ten ventricular tachycardias (VTs; cycle lengths, 230-740 ms, arrhythmic storm n=28) and 2 ventricular fibrillation triggers were targeted (25 transseptal, 14 retrograde aortic approaches). Nine patients required VT ablation <1 month after LVAD implantation because of intractable VT. Only 10/110 (9%) of the targeted VTs were related to the Heart Mate II cannula. During follow-up, 7 patients were transplanted and 10 died. Of the remaining 17 patients, 13 were arrhythmia-free at 25±15 months. In 1 patient with VT recurrence, change of turbine speed from 9400 to 9000 rpm extinguished VT. CONCLUSIONS: Catheter ablation of VT among LVAD recipients is feasible and reasonably safe even soon after LVAD implantation. Intrinsic myocardial scar, rather than the apical cannula, seems to be the dominant substrate.


Assuntos
Ablação por Cateter , Insuficiência Cardíaca/terapia , Coração Auxiliar , Taquicardia Ventricular/cirurgia , Função Ventricular Esquerda , Potenciais de Ação , Idoso , Técnicas Eletrofisiológicas Cardíacas , Europa (Continente) , Estudos de Viabilidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Coração Auxiliar/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de Risco , Volume Sistólico , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
12.
J Interv Cardiol ; 28(1): 41-50, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25689547

RESUMO

OBJECTIVES: To investigate the outcome of patients with acute myocardial infarction (AMI) complicated by refractory cardiogenic shock (CS) who underwent mechanical circulatory support with Impella 2.5. BACKGROUND: AMI complicated by CS remains a highly fatal condition. A potent and minimally invasive left ventricular assist device might improve patient outcomes. METHODS: We analyzed the procedural characteristics and outcomes of 22 consecutive patients who underwent, between July 2008 and December 2012, a percutaneous coronary intervention and Impella 2.5 support for AMI complicated by CS refractory to first-line therapy with inotropes and/or Intra-aortic balloon pump. RESULTS: In this analysis, patients were relatively young with a mean age of 57.9 ± 11.6 year old and 59.1% were male. The majority of patients (77.3%) were admitted in CS and 40.9% sustained cardiac arrest prior to admission. Hemodynamics improved significantly upon initiation of support, end-organ and tissue perfusion improved subsequently demonstrated by a significant decrease in lactate levels from 6.37 ± 5.3 mmol/L to 2.41 ± 2.1 mmo/L, (P = 0.008) after 2 days of support. Thirteen (59.1%) patients were successfully weaned-off Impella 2.5 and 4 (18.2%) were transitioned to another device. We observed a functional recovery of the left ventricle when compared to baseline (43 ± 10% vs. 27 ± 9%, P < 0.0001). The survival rate at 6 months and 1 year was 59.1% and 54.5%, respectively. CONCLUSION: Impella 2.5 was initiated as a last resort therapy to support very sick patients with refractory CS after failed conventional therapy. The use of the device yielded favorable short and mid-term survival results with recovery being the most frequently observed outcome.


Assuntos
Coração Auxiliar , Infarto do Miocárdio/terapia , Choque Cardiogênico/complicações , Choque Cardiogênico/mortalidade , Circulação Sanguínea , Cardiotônicos/efeitos adversos , Feminino , França/epidemiologia , Hemodinâmica , Humanos , Balão Intra-Aórtico/efeitos adversos , Ácido Láctico/sangue , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea , Falha de Tratamento
13.
Heart Rhythm ; 12(6): 1209-15, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25708882

RESUMO

BACKGROUND: Pacemaker infection in pacing-dependent patients is challenging. After extraction, temporary pacing usually is utilized before delayed reimplantation (after an appropriate course of antibiotics), resulting in prolonged hospital stays. A single combined procedure of epicardial (EPI) pacemaker implantation and system extraction may prevent this. OBJECTIVE: The purpose of this study was to evaluate the feasibility and safety of these 2 approaches by comparing clinical outcome for both strategies over 1 year. METHODS: In center 1, 80 consecutive pacemaker-dependent patients underwent extraction with an externalized pacemaker and delayed implantation on the contralateral side (ENDO group). In center 2, 80 consecutive patients had 2 epicardial ventricular leads surgically implanted with extraction of the infected pacemaker during the same procedure (EPI group). Patients were followed-up for 12 months. RESULTS: One hundred sixty pacing-dependent patients were successfully implanted and extracted (ENDO group 71 ± 13 years vs EPI group 73 ± 14, P = NS). In the EPI group, 2 patients developed significant pericardial bleeding. In-hospital mortality was 0% in the ENDO group and 2.5% in the EPI group. Total hospitalization time was 15 ± 7 days in the ENDO group vs 9 ± 6 days in the EPI group (P <.001). At 1 year, no infection recurrences occurred in either group, and mortality was equal (5% in each group). Median 1-year pacing thresholds were lower in the ENDO vs the EPI group (0.8 ± 0.6 V vs 1.1 ± 0.6 V, P = .02). CONCLUSION: The ENDO and EPI strategies had an excellent success rate and low risk of complications. A single procedure using surgical epicardial lead implantation was associated with a shorter duration of hospital stay.


Assuntos
Remoção de Dispositivo/métodos , Infecção/etiologia , Marca-Passo Artificial/efeitos adversos , Implantação de Prótese/métodos , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pericárdio , Resultado do Tratamento
14.
J Interv Card Electrophysiol ; 41(3): 245-51, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25381645

RESUMO

PURPOSE: Little is presently known about the outcome of atrial lesions performed with high-intensity focused ultrasound (HIFU) for atrial fibrillation ablation. We aimed to assess endocardial atrial lesions 6 months after epicardial HIFU ablation (Epicor(™)) and to evaluate the benefit of a combined ablation approach. METHODS: Thirty patients (21 males, mean age 68 ± 12 years old) undergoing HIFU atrial fibrillation ablation during cardiac surgery were enrolled. Electrophysiological study (EPS) was performed 6 months after HIFU ablation, and endovascular radiofrequency was delivered in case of conduction gaps. Patients were followed up for at least 6 months after the EPS. RESULTS: At EPS, ten patients (38 %) had achieved complete or near-complete "box" isolation and four (15 %) had no visible lesion. Using this technology, freedom from symptomatic atrial arrhythmia at 6 months was 60 % (n = 18/30) (64 % for paroxysmal and 56 % for persistent subgroups) improving to 81 % (n = 21/26) (90 % for paroxysmal and 73 % for persistent subgroups) at 12 months after a facultative percutaneous endocardial approach was performed. Using an UltraCinch device sized below 10 improved the rate of complete lesion as assessed 6 months after surgery (58 % of complete or near-complete box isolation with UltraCinch device <10 vs 21 % when ≥11; p = 0.05). CONCLUSION: Six months after HIFU ablation, only 38 % of the patients had complete or near-complete box isolation, and the recurrence rate of symptomatic atrial arrhythmia was 40 %. The latter was reduced to 19 % 6 months after complementary percutaneous approach.


Assuntos
Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Ablação por Ultrassom Focalizado de Alta Intensidade/instrumentação , Ablação por Ultrassom Focalizado de Alta Intensidade/métodos , Idoso , Técnicas Eletrofisiológicas Cardíacas , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Estudos Longitudinais , Masculino , Resultado do Tratamento
15.
J Thorac Cardiovasc Surg ; 148(6): 3119-25.e1, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25212058

RESUMO

OBJECTIVES: This study evaluated platelet function for an extended period of time in patients with a HeartMate II continuous-flow left ventricular assist device (Thoratec Corporation, Pleasanton, Calif) with light transmission aggregometry and investigated the potential role of this test in clinical management. METHODS: Twenty-four patients were studied prospectively after implantation. Mean duration of support was 8.5 months. Platelet functions were assessed with light transmission aggregometry induced by thrombin receptor agonist peptide, ristocetin, or arachidonic acid. All patients received an aspirin regimen that was progressively increased until arachidonic acid-triggered platelet aggregation dropped lower than 20%. Plasma levels of von Willebrand factor were also determined when ristocetin-induced platelet agglutination was impaired. RESULTS: Intensity of platelet aggregation with thrombin receptor agonist peptide was little changed in patients with a HeartMate II relative to control subjects. Aspirin dose greater than 160 mg/d was progressively required in 46% of patients. Ristocetin-induced platelet agglutination was impaired in 4 patients in association with a lack of high molecular weight von Willebrand factor multimers. Three patients had thromboembolic events (12.5%) and 8 (33%) suffered from major bleeding complications. CONCLUSIONS: High platelet reactivity during treatment with aspirin is common in patients with a HeartMate II. Moreover, light transmission aggregometry may detect impaired ristocetin-induced platelet agglutination, enabling dosage of aspirin to be adjusted. Our strategy showed no major improvements in terms of thrombosis rate when compared with published data, although bleeding frequency was somewhat reduced. Benefits of light transmission aggregometry testing need to be assessed in a larger randomized study with a longer follow-up.


Assuntos
Aspirina/administração & dosagem , Monitoramento de Medicamentos/métodos , Insuficiência Cardíaca/terapia , Coração Auxiliar , Inibidores da Agregação de Plaquetas/administração & dosagem , Agregação Plaquetária/efeitos dos fármacos , Testes de Função Plaquetária/métodos , Tromboembolia/prevenção & controle , Função Ventricular Esquerda , Idoso , Ácido Araquidônico , Aspirina/efeitos adversos , Esquema de Medicação , Feminino , França , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Coração Auxiliar/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Valor Preditivo dos Testes , Estudos Prospectivos , Desenho de Prótese , Fatores de Risco , Ristocetina , Tromboembolia/sangue , Tromboembolia/diagnóstico , Tromboembolia/etiologia , Fatores de Tempo , Resultado do Tratamento
16.
J Cardiothorac Vasc Anesth ; 27(6): 1101-7, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24060469

RESUMO

OBJECTIVE: Infrarenal aortic cross-clamping (ACC) induces hemodynamic disturbances that may affect respiratory-induced variations in stroke volume and, therefore, affect the ability of dynamic parameters such as pulse-pressure variation (PPV) to predict fluid responsiveness. Since this issue has not been investigated yet to authors' knowledge, the hypothesis was tested that ACC may change PPV and impair its ability to predict fluid responsiveness. DESIGN: Prospective laboratory experiment. SETTING: A university research laboratory. PARTICIPANTS: Nineteen anesthetized and mechanically ventilated pigs. INTERVENTIONS: Two courses of volume expansion were performed using 500 mL of saline before and during ACC. Animals were monitored using a systemic arterial catheter, and a pulmonary arterial catheter (stroke volume, central venous pressure, pulmonary arterial occlusion pressure). Animals were defined as responders to volume expansion if stroke volume increased ≥ 15%. RESULTS: Before ACC, 13 animals were responders. Fluid responsiveness was predicted by a PPV ≥ 14% with a sensitivity of 77% (95% CI = 46%-95%) and a specificity of 83% (95% CI = 36%-97%). The area under the receiver operating characteristic curve was 0.90(95% CI = 0.67-0.99) and was higher than those generated for central venous pressure and pulmonary arterial occlusion pressure. ACC induced an increase in PPV (p<0.0005). During ACC, 8 animals were responders. An 18% PPV threshold discriminated between responders and non-responders to volume expansion, with a sensitivity of 87% (95% CI = 47%-98%) and a specificity of 54% (95% CI = 23%-83%). The area under the receiver operating characteristic curve was 0.72 (95% CI = 0.47-0.90) and was not different from those generated for central venous pressure and pulmonary arterial occlusion pressure. CONCLUSIONS: ACC induced a significant increase in PPV and reduced its ability to predict fluid responsiveness.


Assuntos
Aorta Torácica/fisiologia , Hidratação/métodos , Animais , Gasometria , Pressão Sanguínea/fisiologia , Débito Cardíaco/fisiologia , Cateterismo , Pressão Venosa Central/fisiologia , Constrição , Eletrólitos/sangue , Hemodinâmica/fisiologia , Respiração com Pressão Positiva , Valor Preditivo dos Testes , Artéria Pulmonar/fisiologia , Pulso Arterial , Curva ROC , Respiração Artificial , Suínos
17.
J Cardiothorac Vasc Anesth ; 27(3): 467-73, 2013 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-23541362

RESUMO

OBJECTIVES: During sequential double-lung transplantation (DLT), the newly implanted first lung receives the entire cardiac output during the implantation of the second one. This may be responsible for the increased hydrostatic pressure that causes severe interstitial and alveolar edema that can lead to allograft dysfunction. The authors tested the hypothesis that CPB started after first graft implantation and before second recipient lung removal should improve post-transplantation oxygenation and clinical outcomes. DESIGN: Observational during 2 consecutive 1-year periods. SETTING: University hospital. PARTICIPANTS: Nine consecutive patients undergoing sequential DLT with CPB started after first graft implantation and before second recipient lung removal were compared to controls, who were 10 consecutive patients who underwent sequential DLT but without CPB the year before. MEASUREMENTS AND MAIN RESULTS: Oxygenation after transplantation was assessed. The use of CPB during the implantation of the second lung was associated with an increased mean postoperative ratio of PaO2 to the fraction of inspired oxygen at 1 hour (363±51 v 240±113, p = 0.01) and 6 hours (430±111 v 280±103, p = 0.03). The mean duration of CPB was 111±19 min. The occurrence of primary graft dysfunction and the need for extracorporeal membrane oxygenation tended to be lower, but did not reach significance. Similarly, mortality rate was comparable between both groups, as was the rate of blood transfusions. CONCLUSIONS: The authors' results suggest that the use of CPB started after first graft implantation and before second recipient lung removal appears to benefit oxygenation and reduces the occurrence of severe pulmonary edema in the first transplanted lung.


Assuntos
Ponte Cardiopulmonar/métodos , Transplante de Pulmão/fisiologia , Consumo de Oxigênio/fisiologia , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ecocardiografia Transesofagiana , Feminino , Humanos , Pneumopatias/cirurgia , Transplante de Pulmão/efeitos adversos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Período Pós-Operatório , Circulação Pulmonar/fisiologia , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/terapia , Resultado do Tratamento
18.
Eur J Cardiothorac Surg ; 43(5): 1050-7, 2013 May.
Artigo em Inglês | MEDLINE | ID: mdl-23100292

RESUMO

OBJECTIVES: Cell loss during cardiac injection and hostility of the host-tissue microenvironment have the potential to diminish the overall effect of stem cell therapy. The purposes of this study were to evaluate the effect of a hypoxic preconditioning of mesenchymal stromal cells (MSC), to determine its safety and effectiveness, and to improve the efficacy of cell therapy using MSC in the setting of chronic myocardial ischaemia in swine. METHODS: Myocardial ischaemia was induced by an ameroid constrictor. Human MSC were cultured under normoxic (20% O2) or hypoxic conditions (1.5% O2) before transplantation. One month after ischaemia, pigs were randomly assigned to saline injection (sham), and 1 × 10(6)/kg normoxic or hypoxic MSC transplantation into the ischaemic inferior-lateral zone. RESULTS: Twenty-seven pigs were operated on and the mortality rate was 33.3%. The remaining 18 animals were randomly assigned to sham (n = 4), normoxic (n = 8) or hypoxic MSC (n = 6) treatment. Global systolic (left ventricle ejection fraction, P = 0.04) and diastolic (E/Ea, P = 0.008) functions were increased in the hypoxic group compared with other groups. The peak of 2-dimensional longitudinal strain was less altered in the hypoxic group compared with other groups (P < 0.001). Haemodynamic data showed that dP/dT max was improved in the hypoxic group compared with the other group (P < 0.01). Capillary density was increased in the hypoxic group (P = 0.001). MSC density was significantly higher in the ischaemic zone in the hypoxic group (P < 0.01). CONCLUSION: MSC engraftment with hypoxic preconditioning significantly improves capillary density and cell survival, resulting in improvement in global, regional and diastolic left ventricular functions. This highlights the therapeutic potential of transplanting hypoxic-preconditioned MSC in the setting of chronic ischaemic heart failure.


Assuntos
Transplante de Células-Tronco Mesenquimais/métodos , Células-Tronco Mesenquimais/citologia , Isquemia Miocárdica/cirurgia , Análise de Variância , Animais , Hipóxia Celular/fisiologia , Modelos Animais de Doenças , Coração/fisiopatologia , Hemodinâmica , Histocitoquímica , Humanos , Células-Tronco Mesenquimais/metabolismo , Isquemia Miocárdica/fisiopatologia , Distribuição Aleatória , Suínos
19.
J Thorac Cardiovasc Surg ; 146(2): 302-5, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-22964353

RESUMO

OBJECTIVES: Management of pacemaker infection in pacing-dependent patients is often challenging. Typically, temporary pacing is used while antibiotic therapy is given for a number of days before reimplantation of a new endocardial system. This results in a prolonged hospital stay and complications associated with temporary pacing. In this study, we examine the feasibility of performing a single combined procedure of epicardial pacemaker implantation followed by system extraction. METHODS: One hundred consecutive infected pacemaker-dependent patients underwent implantation of 2 epicardial ventricular leads and were converted to a ventricular demand pacing system. The infected pacing system was then extracted during the same procedure. Patients were followed up for 12 months. RESULTS: Significant pericardial bleeding developed during the procedure in 3 patients. The presence of the pericardial drain positioned during the implantation of the epicardial pacing system meant that cardiac tamponade did not occur, allowing surgical repair with sternotomy to be carried out under stable hemodynamic conditions. Two of these 100 patients died in the 30-day postoperative period; 1 death was due to septic shock and 1 to pulmonary distress. Median 1-year epicardial pacing thresholds were stable and excellent (1.4 ± 0.9 volts). However, 1 of the 2 leads developed increased thresholds in 6 patients, which led to the exclusive use of other ventricular lead. CONCLUSIONS: A single combined procedure of surgical epicardial pacemaker implantation and pacemaker system extraction appears to be a safe and effective method for managing pacemaker-dependent patients with infected pacemakers.


Assuntos
Estimulação Cardíaca Artificial/efeitos adversos , Remoção de Dispositivo/métodos , Contaminação de Equipamentos , Falha de Equipamento , Marca-Passo Artificial , Complicações Pós-Operatórias/cirurgia , Infecções Estafilocócicas/cirurgia , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Perda Sanguínea Cirúrgica , Estimulação Cardíaca Artificial/mortalidade , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/mortalidade , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/microbiologia , Complicações Pós-Operatórias/mortalidade , Reoperação , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/microbiologia , Infecções Estafilocócicas/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
J Card Surg ; 27(5): 605-6, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22978837

RESUMO

The Impella Recover LP 5.0® (Abiomed, Inc. Danvers, MA, USA) is an aortic transvalvular microaxial pump designed to unload the left ventricle and to ensure a systemic flow in severe left ventricular dysfunction. Surgical implantation using femoral or right subclavian approach may be difficult in certain circumstances, such as encountered in peripheral vascular disease, patients with small vessels or during substantial use of vasoactive drugs responsible for vasospasm. We propose a simple and effective technique for implantation of the Impella 5.0 LVAD by means of a mini-sternotomy in patients with postinfarction refractory cardiogenic shock.


Assuntos
Balão Intra-Aórtico/instrumentação , Infarto do Miocárdio/complicações , Choque Cardiogênico/cirurgia , Esternotomia/métodos , Anestesia Geral/métodos , Desenho de Equipamento , Segurança de Equipamentos , Feminino , Seguimentos , Coração Auxiliar , Humanos , Balão Intra-Aórtico/métodos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Infarto do Miocárdio/diagnóstico , Medição de Risco , Amostragem , Índice de Gravidade de Doença , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento
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