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1.
Cardiol Young ; : 1-3, 2019 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-31601284

RESUMO

BACKGROUND: The Fontan procedure is the final stage of surgical palliation for a single-ventricle circulation. Significant complications are common including rhythm disturbance necessitating implantation of a permanent pacemaker. This has been widely considered a negative prognostic indicator. METHODS: This single-centre, retrospective case control study involved all patients who underwent the Fontan procedure at the Leeds Congenital Heart Unit between 1990 and 2015 and have had regular follow-up in Yorkshire and Humber, United Kingdom. 167 Fontan patients were identified of which 2 were excluded for having a pre-procedure pacemaker. Of the remainder, 23 patients required a pacemaker. Outcomes were survival, early and late complications, need for further intervention and oxygen saturation in long-term follow-up. RESULTS: There was no difference in survival (30-day survival pacemaker 92.6%, sinus rhythm 90.5%, p = 0.66, 1-year pacemaker 11.1%, sinus rhythm 10.1%, p = 1). The pacemaker group was more likely to have cerebral or renal complications in the first-year post-procedure (acute kidney injury: sinus rhythm 0.8%, pacemaker 19.1%, p = 0.002). No difference was observed in longer term complications including protein losing enteropathy (sinus rhythm 3.5%, pacemaker 0% p = 1). There was no difference in saturations between the two groups at follow-up. Paced patients were more likely to have required further intervention, with a higher incidence of cardiopulmonary bypass procedures (sinus rhythm 6.3%, pacemaker 35%, p < 0.001). CONCLUSIONS: Despite an increase in early complications and the need for further interventions, pacemaker requirement does not appear to affect long-term survival following the Fontan procedure.

2.
Obes Rev ; 2019 May 17.
Artigo em Inglês | MEDLINE | ID: mdl-31099480

RESUMO

This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002-2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002-2014). Products were classified as UPFD/non-UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%-44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%-86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m2 for men (P < .001) and 0.072 kg/m2 for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m2 for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population-level BMI trajectories.

3.
Circ Res ; 124(4): 553-563, 2019 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-30582441

RESUMO

RATIONALE: Familial recurrence studies provide strong evidence for a genetic component to the predisposition to sporadic, nonsyndromic Tetralogy of Fallot (TOF), the most common cyanotic congenital heart disease phenotype. Rare genetic variants have been identified as important contributors to the risk of congenital heart disease, but relatively small numbers of TOF cases have been studied to date. OBJECTIVE: We used whole exome sequencing to assess the prevalence of unique, deleterious variants in the largest cohort of nonsyndromic TOF patients reported to date. METHODS AND RESULTS: Eight hundred twenty-nine TOF patients underwent whole exome sequencing. The presence of unique, deleterious variants was determined; defined by their absence in the Genome Aggregation Database and a scaled combined annotation-dependent depletion score of ≥20. The clustering of variants in 2 genes, NOTCH1 and FLT4, surpassed thresholds for genome-wide significance (assigned as P<5×10-8) after correction for multiple comparisons. NOTCH1 was most frequently found to harbor unique, deleterious variants. Thirty-one changes were observed in 37 probands (4.5%; 95% CI, 3.2%-6.1%) and included 7 loss-of-function variants 22 missense variants and 2 in-frame indels. Sanger sequencing of the unaffected parents of 7 cases identified 5 de novo variants. Three NOTCH1 variants (p.G200R, p.C607Y, and p.N1875S) were subjected to functional evaluation, and 2 showed a reduction in Jagged1-induced NOTCH signaling. FLT4 variants were found in 2.4% (95% CI, 1.6%-3.8%) of TOF patients, with 21 patients harboring 22 unique, deleterious variants. The variants identified were distinct to those that cause the congenital lymphoedema syndrome Milroy disease. In addition to NOTCH1, FLT4 and the well-established TOF gene, TBX1, we identified potential association with variants in several other candidates, including RYR1, ZFPM1, CAMTA2, DLX6, and PCM1. CONCLUSIONS: The NOTCH1 locus is the most frequent site of genetic variants predisposing to nonsyndromic TOF, followed by FLT4. Together, variants in these genes are found in almost 7% of TOF patients.

5.
Cardiol Young ; 28(12): 1431-1435, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30309400

RESUMO

OBJECTIVES: The objectives of this study were to describe the approach to stenting arterial shunts in adult congenital patients with single-ventricle physiology and to assess the medium-term clinical and haemodynamic outcomes following stent insertion. BACKGROUND: Adult patients with single-ventricle physiology and pulmonary blood flow dependent on a surgically placed arterial shunt who did not progress to venous palliation are extremely challenging to manage. Progressive cyanosis secondary to narrowing of the shunt has a marked impact on exercise tolerance and results in intolerable well-being for these patients. Stenting arterial shunts in adult patients is one method that can help improve pulmonary blood flow. There is very limited information in the literature about this patient. METHODS: This is a retrospective study for arterial shunts stenting conducted between 2008 and 2016. The peripheral oxygen saturations, the NYHA status, the haemoglobin, and the degree of atrio-ventricular valve regurgitation as assessed on transthoracic echo were compared before and 6-12 months after procedures. RESULTS: There was a short-term improvement in oxygen saturations; the pre-procedure mean was 75.8 (SD 2.55)% (range 70-85%) and post-procedure mean was 83 (SD 2.52)% (range 78-87%), with a p value of 0.04. Haemoglobin level decreased from a pre-procedure mean of 22.06-20.28 g/L 6 months post procedure (range 18.1-24.4 to 13-23.3 g/L), with a p value of 0.44. NYHA class decreased from a mean of 3.2-2.2 post procedure. Left atrial volume for four of the cases did not change (22.6-76.6 ml [mean 48.4 ml] to 29.6-72.9 ml [mean 52 ml], p value: 0.83). CONCLUSIONS: Stenting stenotic arterial shunts is a useful method to gain a medium-term improvement on the oxygen saturation and clinical symptoms, and may act as a useful intermediate step for further management plans.

6.
Lancet ; 391(10132): 1774, 2018 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-29739567
7.
Lancet Diabetes Endocrinol ; 6(6): e6-e15, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29803268

RESUMO

BACKGROUND: Diabetes and high body-mass index (BMI) are associated with increased risk of several cancers, and are increasing in prevalence in most countries. We estimated the cancer incidence attributable to diabetes and high BMI as individual risk factors and in combination, by country and sex. METHODS: We estimated population attributable fractions for 12 cancers by age and sex for 175 countries in 2012. We defined high BMI as a BMI greater than or equal to 25 kg/m2. We used comprehensive prevalence estimates of diabetes and BMI categories in 2002, assuming a 10-year lag between exposure to diabetes or high BMI and incidence of cancer, combined with relative risks from published estimates, to quantify contribution of diabetes and high BMI to site-specific cancers, individually and combined as independent risk factors and in a conservative scenario in which we assumed full overlap of risk of diabetes and high BMI. We then used GLOBOCAN cancer incidence data to estimate the number of cancer cases attributable to the two risk factors. We also estimated the number of cancer cases in 2012 that were attributable to increases in the prevalence of diabetes and high BMI from 1980 to 2002. All analyses were done at individual country level and grouped by region for reporting. FINDINGS: We estimated that 5·7% of all incident cancers in 2012 were attributable to the combined effects of diabetes and high BMI as independent risk factors, corresponding to 804 100 new cases. 187 600 (24·5%) of 766 000 cases of liver cancer and 121 700 (38·4%) of 317 000 cases of endometrial cancer were attributable to these risk factors. In the conservative scenario, about 4·5% (629 000 new cases) of all incident cancers assessed were attributable to diabetes and high BMI combined. Individually, high BMI (544 300 cases) was responsible for almost twice as many cancer cases as diabetes (293 300 cases). 25·8% of diabetes-related cancers (equating to 75 600 new cases) and 31·9% of high BMI-related cancers (174 040 new cases) were attributable to increases in the prevalence of these risk factors from 1980 to 2002. INTERPRETATION: A substantial number of cancer cases are attributable to diabetes and high BMI. As the prevalence of these cancer risk factors increases, clinical and public health efforts should focus on identifying optimal preventive and screening measures for whole populations and individual patients. FUNDING: NIHR and Wellcome Trust.

8.
Circulation ; 137(6): 581-588, 2018 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-29084734

RESUMO

BACKGROUND: Infants born with cardiac abnormalities causing dependence on the arterial duct for pulmonary blood flow are often palliated with a shunt usually between the subclavian artery and either pulmonary artery. A so-called modified Blalock-Taussig shunt allows progress through early life to an age and weight at which repair or further more stable palliation can be safely achieved. Modified Blalock-Taussig shunts continue to present concern for postprocedural instability and early mortality such that other alternatives continue to be explored. Duct stenting (DS) is emerging as one such alternative with potential for greater early stability and improved survival. METHODS: The purpose of this study was to compare postprocedural outcomes and survival to next-stage palliative or reparative surgery between patients undergoing a modified Blalock-Taussig shunt or a DS in infants with duct-dependent pulmonary blood flow. All patients undergoing cardiac surgery and congenital interventions in the United Kingdom are prospectively recruited to an externally validated national outcome audit. From this audit, participating UK centers identified infants <30 days of age undergoing either a Blalock-Taussig shunt or a DS for cardiac conditions with duct-dependent pulmonary blood flow between January 2012 and December 31, 2015. One hundred seventy-one patients underwent a modified Blalock-Taussig shunt, and in 83 patients, DS was attempted. Primary and secondary outcomes of survival and need for extracorporeal support were analyzed with multivariable logistic regression. Longer-term mortality before repair and reintervention were analyzed with Cox proportional hazards regression. All multivariable analyses accommodated a propensity score to balance patient characteristics between the groups. RESULTS: There was an early (to discharge) survival advantage for infants before next-stage surgery in the DS group (odds ratio, 4.24; 95% confidence interval, 1.37-13.14; P=0.012). There was also a difference in the need for postprocedural extracorporeal support in favor of the DS group (odds ratio, 0.22; 95% confidence interval, 0.05-1.05; P=0.058). Longer-term survival outcomes showed a reduced risk of death before repair in the DS group (hazard ratio, 0.25; 95% confidence interval, 0.07-0.85; P=0.026) but a slightly increased risk of reintervention (hazard ratio, 1.50; 95% confidence interval, 0.85-2.64; P=0.165). CONCLUSIONS: DS is emerging as a preferred alternative to a surgical shunt for neonatal palliation with evidence for greater postprocedural stability and improved patient survival to destination surgical treatment.

9.
Lancet Diabetes Endocrinol ; 6(2): 95-104, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29195904

RESUMO

BACKGROUND: Diabetes and high body-mass index (BMI) are associated with increased risk of several cancers, and are increasing in prevalence in most countries. We estimated the cancer incidence attributable to diabetes and high BMI as individual risk factors and in combination, by country and sex. METHODS: We estimated population attributable fractions for 12 cancers by age and sex for 175 countries in 2012. We defined high BMI as a BMI greater than or equal to 25 kg/m2. We used comprehensive prevalence estimates of diabetes and BMI categories in 2002, assuming a 10-year lag between exposure to diabetes or high BMI and incidence of cancer, combined with relative risks from published estimates, to quantify contribution of diabetes and high BMI to site-specific cancers, individually and combined as independent risk factors and in a conservative scenario in which we assumed full overlap of risk of diabetes and high BMI. We then used GLOBOCAN cancer incidence data to estimate the number of cancer cases attributable to the two risk factors. We also estimated the number of cancer cases in 2012 that were attributable to increases in the prevalence of diabetes and high BMI from 1980 to 2002. All analyses were done at individual country level and grouped by region for reporting. FINDINGS: We estimated that 5·6% of all incident cancers in 2012 were attributable to the combined effects of diabetes and high BMI as independent risk factors, corresponding to 792 600 new cases. 187 600 (24·5%) of 766 000 cases of liver cancer and 121 700 (38·4%) of 317 000 cases of endometrial cancer were attributable to these risk factors. In the conservative scenario, about 4·5% (626 900 new cases) of all incident cancers assessed were attributable to diabetes and high BMI combined. Individually, high BMI (544 300 cases) was responsible for twice as many cancer cases as diabetes (280 100 cases). 26·1% of diabetes-related cancers (equating to 77 000 new cases) and 31·9% of high BMI-related cancers (174 040 new cases) were attributable to increases in the prevalence of these risk factors from 1980 to 2002. INTERPRETATION: A substantial number of cancer cases are attributable to diabetes and high BMI. As the prevalence of these cancer risk factors increases, clinical and public health efforts should focus on identifying optimal preventive and screening measures for whole populations and individual patients. FUNDING: NIHR and Wellcome Trust.

10.
Lancet Diabetes Endocrinol ; 5(3): 196-213, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28126460

RESUMO

BACKGROUND: Worldwide implementation of risk-based cardiovascular disease (CVD) prevention requires risk prediction tools that are contemporarily recalibrated for the target country and can be used where laboratory measurements are unavailable. We present two cardiovascular risk scores, with and without laboratory-based measurements, and the corresponding risk charts for 182 countries to predict 10-year risk of fatal and non-fatal CVD in adults aged 40-74 years. METHODS: Based on our previous laboratory-based prediction model (Globorisk), we used data from eight prospective studies to estimate coefficients of the risk equations using proportional hazard regressions. The laboratory-based risk score included age, sex, smoking, blood pressure, diabetes, and total cholesterol; in the non-laboratory (office-based) risk score, we replaced diabetes and total cholesterol with BMI. We recalibrated risk scores for each sex and age group in each country using country-specific mean risk factor levels and CVD rates. We used recalibrated risk scores and data from national surveys (using data from adults aged 40-64 years) to estimate the proportion of the population at different levels of CVD risk for ten countries from different world regions as examples of the information the risk scores provide; we applied a risk threshold for high risk of at least 10% for high-income countries (HICs) and at least 20% for low-income and middle-income countries (LMICs) on the basis of national and international guidelines for CVD prevention. We estimated the proportion of men and women who were similarly categorised as high risk or low risk by the two risk scores. FINDINGS: Predicted risks for the same risk factor profile were generally lower in HICs than in LMICs, with the highest risks in countries in central and southeast Asia and eastern Europe, including China and Russia. In HICs, the proportion of people aged 40-64 years at high risk of CVD ranged from 1% for South Korean women to 42% for Czech men (using a ≥10% risk threshold), and in low-income countries ranged from 2% in Uganda (men and women) to 13% in Iranian men (using a ≥20% risk threshold). More than 80% of adults were similarly classified as low or high risk by the laboratory-based and office-based risk scores. However, the office-based model substantially underestimated the risk among patients with diabetes. INTERPRETATION: Our risk charts provide risk assessment tools that are recalibrated for each country and make the estimation of CVD risk possible without using laboratory-based measurements. FUNDING: National Institutes of Health.


Assuntos
Doenças Cardiovasculares/diagnóstico , Medição de Risco/métodos , Adulto , Idoso , Doenças Cardiovasculares/epidemiologia , Feminino , Saúde Global , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
11.
Nat Genet ; 48(8): 940-946, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27399966

RESUMO

Systemic lupus erythematosus (SLE; OMIM 152700) is a genetically complex autoimmune disease. Genome-wide association studies (GWASs) have identified more than 50 loci as robustly associated with the disease in single ancestries, but genome-wide transancestral studies have not been conducted. We combined three GWAS data sets from Chinese (1,659 cases and 3,398 controls) and European (4,036 cases and 6,959 controls) populations. A meta-analysis of these studies showed that over half of the published SLE genetic associations are present in both populations. A replication study in Chinese (3,043 cases and 5,074 controls) and European (2,643 cases and 9,032 controls) subjects found ten previously unreported SLE loci. Our study provides further evidence that the majority of genetic risk polymorphisms for SLE are contained within the same regions across both populations. Furthermore, a comparison of risk allele frequencies and genetic risk scores suggested that the increased prevalence of SLE in non-Europeans (including Asians) has a genetic basis.


Assuntos
Grupo com Ancestrais do Continente Asiático/genética , Grupo com Ancestrais do Continente Europeu/genética , Loci Gênicos/genética , Estudo de Associação Genômica Ampla , Lúpus Eritematoso Sistêmico/genética , Polimorfismo de Nucleotídeo Único/genética , Estudos de Casos e Controles , Predisposição Genética para Doença , Humanos
12.
Nat Genet ; 47(12): 1457-1464, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26502338

RESUMO

Systemic lupus erythematosus (SLE) is a genetically complex autoimmune disease characterized by loss of immune tolerance to nuclear and cell surface antigens. Previous genome-wide association studies (GWAS) had modest sample sizes, reducing their scope and reliability. Our study comprised 7,219 cases and 15,991 controls of European ancestry, constituting a new GWAS, a meta-analysis with a published GWAS and a replication study. We have mapped 43 susceptibility loci, including ten new associations. Assisted by dense genome coverage, imputation provided evidence for missense variants underpinning associations in eight genes. Other likely causal genes were established by examining associated alleles for cis-acting eQTL effects in a range of ex vivo immune cells. We found an over-representation (n = 16) of transcription factors among SLE susceptibility genes. This finding supports the view that aberrantly regulated gene expression networks in multiple cell types in both the innate and adaptive immune response contribute to the risk of developing SLE.


Assuntos
Imunidade Adaptativa/genética , Regulação da Expressão Gênica , Estudos de Associação Genética , Marcadores Genéticos/genética , Imunidade Inata/genética , Lúpus Eritematoso Sistêmico/genética , Lúpus Eritematoso Sistêmico/patologia , Estudos de Casos e Controles , Loci Gênicos , Predisposição Genética para Doença , Humanos , Lúpus Eritematoso Sistêmico/imunologia , Metanálise como Assunto , Polimorfismo de Nucleotídeo Único/genética , Fatores de Risco
13.
J Thorac Cardiovasc Surg ; 149(6): 1502-8.e1, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25869088

RESUMO

OBJECTIVE: To compare early postoperative outcomes, angiographic, and intervention findings and 1-year survival between 2 groups of infant patients: those receiving a standard right-ventricle-to-pulmonary-artery (RV-PA) conduit versus a ring-reinforced RV-PA conduit, in undergoing Norwood stage-1 surgery for hypoplastic left heart syndrome (HLHS). The technique of using such a ring-reinforced graft, placed through a limited ventriculotomy, has theoretic advantages in preserving right ventricular function, compared with the standard technique of RV-PA conduit creation. METHODS: This retrospective cohort study was performed between July 2006 and July 2013. A total of 87 patients with HLHS underwent Norwood stage-1 surgery during this period; 48 received a standard nonreinforced RV-PA conduit; 39 received a ring-reinforced conduit. Primary and secondary outcomes were survival and need for cardiac reintervention up to age 12 months. RESULTS: No difference was found in transplant-free survival by age 12 months (87% ring-reinforced vs 73% nonreinforced, P = .12). The group with the nonreinforced, versus ring-reinforced, grafts had more interventions in the first year (69% vs 35%, respectively; P < .01). Before stage 2, the pulmonary artery pulse pressure was greater in the group with ring-reinforced grafts (9.1 ± 4.1 vs 4.8 ± 3.1 mm Hg, P < .001), with no difference in mean pressure (15.2 ± 3.32 vs 14.3 ± 3.48 mm Hg, P = .27). The corrected pulmonary artery index (Nakata) was greater in the group with ring-reinforced grafts (213 ± 76 vs 134 ± 68 mm(2)/m(2), P < .0001). CONCLUSIONS: A ring-reinforced conduit is associated with reduced intervention, as well as higher pulse pressures and improved pulmonary artery growth, in infants undergoing stage-1 palliation for HLHS.


Assuntos
Implante de Prótese Vascular/instrumentação , Prótese Vascular , Ventrículos do Coração/cirurgia , Síndrome do Coração Esquerdo Hipoplásico/cirurgia , Procedimentos de Norwood/instrumentação , Artéria Pulmonar/cirurgia , Pressão Arterial , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Implante de Prótese Vascular/mortalidade , Boston , Criança , Pré-Escolar , Feminino , Ventrículos do Coração/anormalidades , Ventrículos do Coração/fisiopatologia , Humanos , Síndrome do Coração Esquerdo Hipoplásico/diagnóstico , Síndrome do Coração Esquerdo Hipoplásico/mortalidade , Síndrome do Coração Esquerdo Hipoplásico/fisiopatologia , Lactente , Masculino , Procedimentos de Norwood/efeitos adversos , Procedimentos de Norwood/métodos , Procedimentos de Norwood/mortalidade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Desenho de Prótese , Artéria Pulmonar/diagnóstico por imagem , Artéria Pulmonar/crescimento & desenvolvimento , Radiografia , Reoperação , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
14.
Catheter Cardiovasc Interv ; : NA, 2013 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-23813943

RESUMO

OBJECTIVES: To describe early clinical experience with the amplatzer ductal occluder II additional sizes (ADO II AS) for percutaneous arterial duct occlusion in infants and small children. METHODS: Pre-, intra- and postprocedural data analysis of all patients undergoing arterial duct occlusion with the ADO II AS from three tertiary referral centers. RESULTS: 17 patients (10 female) with a median age of 6 months (range 1.0-48.1 months) and a median weight of 5.7 kg (range 1.7-17.4 kg) underwent attempted transcatheter ductal closure with the ADO II AS. Retrograde arterial approach was used in eight patients with transvenous femoral approach used in nine. The mean minimal ductal diameter was 2.2 ± 0.7 mm with mean ductal length of 6.8 ± 1.7 mm. Device sizes used were 5/6 (n = 5), 3/4 (n = 4), 4/4 (n = 3), 4/6 (n = 3), and 5/4 (n = 2) with four French delivery sheaths used in all cases. The median fluoroscopy time was 5.7 ± 1.8 min. Two patients underwent delivery under exclusive echocardiography guidance. Complete ductal occlusion was achieved by the end of the procedure in 13 patients. Device embolization to the left pulmonary artery occurred in one patient with successful surgical removal and ligation of the arterial duct. Three patients required device resizing following deployment of the initial device. Complete ductal occlusion without aortic arch or left pulmonary artery stenosis has been identified in all 16 remaining patients on transthoracic echocardiographic follow-up at median of 4.2 months. CONCLUSIONS: The new amplatzer ductal occluder II AS achieves excellent ductal closure rates through low profile delivery systems in small infants and children with variable ductal anatomy. © 2012 Wiley Periodicals, Inc. © 147.

15.
Am J Cardiol ; 111(5): 731-6, 2013 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-23276470

RESUMO

The aim of this study was to describe the clinical impact of management of coarctation of the aorta by transcatheter stent placement in the context of longer term management of systemic hypertension. In the long term, poor outlook associated with untreated coarctation of the aorta is likely to relate to uncontrolled systemic hypertension. Transcatheter stent placement to treat native and recurrent coarctation of the aorta is an established therapy in adolescents and adults. There remains confusion about longer term outcomes, particularly the relation between procedural success and improvement in blood pressure (BP) control. Improvement in lifelong systemic BP control after transcatheter stent placement remains unproved. Forty patients underwent transcatheter stent placement over a 10-year period (2001 to 2010) at the Yorkshire Heart Centre. The average age at the time of procedure was 25 years (range 14 to 57). There was a reduction in peak systolic gradient across the coarcted segment from 25 to <10 mm Hg in 35 of 39 patients. After stent placement, there was a significant improvement in systolic BP control at early and later follow-up (mean 155 mm Hg before the procedure and 134 mm Hg at 2.81-year follow-up, p <0.0001). There was 1 early procedural adverse event (stent embolization) and 1 late adverse event (lower limb claudication). In conclusion, transcatheter stent placement for the management of aortic coarctation is associated with a reduction in systolic BP that is maintained over the medium term. A significant minority of patients remain significantly hypertensive, and the best management strategy for this group of patients remains unclear.


Assuntos
Coartação Aórtica/cirurgia , Pressão Sanguínea/fisiologia , Stents , Adolescente , Adulto , Coartação Aórtica/epidemiologia , Coartação Aórtica/fisiopatologia , Eletrocardiografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
16.
Catheter Cardiovasc Interv ; 82(3): 428-35, 2013 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-22915552

RESUMO

OBJECTIVE: To describe the cases of percutaneous valve failure following implantation of the Medtronic Melody™ and the Edwards Sapien™ valve in the tricuspid position. BACKGROUND: There have been recent reports of the use of percutaneously delivered valves to manage failing bioprosthetic tricuspid valves. Total patient numbers remain small and follow-up times are limited. METHODS: We describe four procedures in three patients from two centers where implantation of percutaneous valves within the scaffold of a bioprosthetic tricuspid valve was technically successful but there was early valve failure. RESULTS: In all cases, immediate results suggested excellent valve function; however, valve failure occurred early in three and later in one. Two patients elected for valve explantation and surgical placement of a further tricuspid valve. The third patient underwent a second percutaneous valve-in-valve procedure though this valve is also showing early signs of failure. CONCLUSIONS: Transcatheter placement of percutaneous valves in the tricuspid position is technically a relatively straightforward procedure but early valve failure raises some concerns about the viability of the valve in this position, at least in some patients.


Assuntos
Bioprótese , Cateterismo Cardíaco/instrumentação , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Falha de Prótese , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Adulto , Cateterismo Cardíaco/efeitos adversos , Remoção de Dispositivo , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Masculino , Desenho de Prótese , Reoperação , Índice de Gravidade de Doença , Fatores de Tempo , Falha de Tratamento , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/diagnóstico , Insuficiência da Valva Tricúspide/fisiopatologia , Adulto Jovem
17.
Catheter Cardiovasc Interv ; 82(4): 534-40, 2013 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-22718329

RESUMO

OBJECTIVES: To describe early clinical experience with the amplatzer ductal occluder II additional sizes (ADO II AS) for percutaneous arterial duct occlusion in infants and small children. METHODS: Pre-, intra- and postprocedural data analysis of all patients undergoing arterial duct occlusion with the ADO II AS from three tertiary referral centers. RESULTS: 17 patients (10 female) with a median age of 6 months (range 1.0-48.1 months) and a median weight of 5.7 kg (range 1.7-17.4 kg) underwent attempted transcatheter ductal closure with the ADO II AS. Retrograde arterial approach was used in eight patients with transvenous femoral approach used in nine. The mean minimal ductal diameter was 2.2 ± 0.7 mm with mean ductal length of 6.8 ± 1.7 mm. Device sizes used were 5/6 (n = 5), 3/4 (n = 4), 4/4 (n = 3), 4/6 (n = 3), and 5/4 (n = 2) with four French delivery sheaths used in all cases. The median fluoroscopy time was 5.7 ± 1.8 min. Two patients underwent delivery under exclusive echocardiography guidance. Complete ductal occlusion was achieved by the end of the procedure in 13 patients. Device embolization to the left pulmonary artery occurred in one patient with successful surgical removal and ligation of the arterial duct. Three patients required device resizing following deployment of the initial device. Complete ductal occlusion without aortic arch or left pulmonary artery stenosis has been identified in all 16 remaining patients on transthoracic echocardiographic follow-up at median of 4.2 months. CONCLUSIONS: The new amplatzer ductal occluder II AS achieves excellent ductal closure rates through low profile delivery systems in small infants and children with variable ductal anatomy.


Assuntos
Cateterismo Cardíaco/instrumentação , Permeabilidade do Canal Arterial/terapia , Fatores Etários , Ligas , Cateterismo Cardíaco/efeitos adversos , Pré-Escolar , Remoção de Dispositivo , Permeabilidade do Canal Arterial/diagnóstico , Inglaterra , Feminino , Migração de Corpo Estranho/etiologia , Migração de Corpo Estranho/cirurgia , Humanos , Lactente , Irlanda , Ligadura , Masculino , Desenho de Prótese , Artéria Pulmonar/cirurgia , Radiografia Intervencionista , Estudos Retrospectivos , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção
18.
Am J Cardiol ; 110(7): 1046-50, 2012 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-22728003

RESUMO

The aim of this study was to describe the clinical importance and methods of transcatheter closure of systemic venous baffle leaks after atrial redirection procedures for transposed great vessels. Until the late 1970s, atrial redirection surgery was the principal surgical palliative approach to manage transposed great vessels. Baffle leaks are among the many long-term complications of this type of surgery, and their prevalence increases over time. The clinical consequences of baffle leaks in this population are poorly understood, and the indications for closure are incompletely defined. During outpatient follow-up of 126 patients after atrial redirection surgery, 15 baffle leaks were detected in 11 patients. All underwent transcatheter closure using either an occluding device or a covered stent if there was concomitant baffle obstruction. The average age at the time of the procedure was 26 years (range 6 to 42). Ten of 11 patients were cyanosed at rest or on a simple walk test (median oxygen saturation level 80%, range 65% to 96%). Six of 11 patients were polycythemic before leak closure (median hemoglobin concentration 19 g/dl, range 13.8 to 23). After closure, there was a significant improvement in saturation (median 97%, p <0.0001) and a significant reduction in hemoglobin concentration at 6 months after the procedure (median 14.8 g/dl, p <0.05). There were no procedural adverse events. One patient experienced late device embolization necessitating surgical removal. In conclusion, transcatheter closure of baffle leaks is a technically feasible although frequently complex and lengthy procedure. Closure is associated with an improvement in oxygen saturations and a reduction in polycythaemia.


Assuntos
Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Átrios do Coração/cirurgia , Consumo de Oxigênio , Policitemia/metabolismo , Implantação de Prótese/métodos , Transposição dos Grandes Vasos/cirurgia , Adolescente , Adulto , Procedimentos Cirúrgicos Cardíacos/mortalidade , Criança , Feminino , Seguimentos , Humanos , Masculino , Policitemia/etiologia , Desenho de Prótese , Artéria Pulmonar/cirurgia , Estudos Retrospectivos , Stents , Taxa de Sobrevida/tendências , Fatores de Tempo , Transposição dos Grandes Vasos/complicações , Transposição dos Grandes Vasos/mortalidade , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto Jovem
19.
J Interv Cardiol ; 25(5): 501-4, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22672406

RESUMO

OBJECTIVE: To describe the technical aspects and outcome of duct occlusion in adults over a 12-year period. METHODS: A single center review of all transcatheter duct closures performed between 2000 and 2012. RESULTS: Of 518 transcatheter duct closures performed, 31 patients were over the age of 16 at the time of procedure (6%). In 10 of the 31 cases, it was not possible to cross the duct from the pulmonary artery. In 4 of those, the duct was small enough to be closed with coils delivered from the aorta (although 1 required a second procedure for a residual shunt). In the remaining 6 cases, it was necessary to cross the duct from the aorta and create an arterio-venous "circuit" using a snare to deliver an Amplatzer device from the femoral vein. In none of the 487 children who underwent transcatheter duct closure during the same time period was it necessary to deliver the device using an arterio-venous wire circuit. The increased complexity of the procedure in adults compared with children was further reflected by longer procedure times (median of 37 minutes in adults vs. 24 minutes in children [P < 0.01]) and longer fluoroscopy times (median of 8.4 minutes in adults vs. 4.3 minutes in children [P < 0.025]). There were no major complications. CONCLUSIONS: Closure of the arterial duct in adults is safe and effective but ductal anatomy may differ from that seen in childhood, making transcatheter closure technically much more demanding than in children.


Assuntos
Cateterismo Cardíaco/métodos , Permeabilidade do Canal Arterial/terapia , Dispositivo para Oclusão Septal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Permeabilidade do Canal Arterial/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Adulto Jovem
20.
Cardiol Young ; 22(5): 610-4, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22398200

RESUMO

OBJECTIVE: To describe endovascular stent placement using partially covered stents to preserve flow in head and neck vessels. BACKGROUND: Endovascular stent placement has become established as a first-line therapy for native coarctation of the aorta or re-coarctation in older children and adults. Increasingly covered stents are becoming the preferred option over bare-metal stents because of the perceived lower risk of aneurysm formation. Open-cell bare-metal stents are chosen when there is a high likelihood of jailing a head and neck vessel. Here we describe partial uncovering of a covered stent before implantation to allow flow through the uncovered portion of the stent to the branch vessel but preserve the covering over the majority of the remaining stent. METHODS: We describe two cases with aortic arch hypoplasia and re-coarctation, both of which required two partially uncovered stents for a satisfactory result. CONCLUSIONS: Endovascular stent placement is becoming the preferred option in the management of coarctation of the aorta in older children and adults. Strategies to deal with transverse arch hypoplasia and multiple levels of aortic arch obstruction frequently involving branch vessels or aneurysms need to be considered before these procedures are embarked upon. Partially uncovering stents may afford more protection than using bare-metal stents in the transverse and distal arch while preserving flow in head and neck branches, and is a technically straightforward procedure.


Assuntos
Aorta Torácica/cirurgia , Coartação Aórtica/cirurgia , Prótese Vascular , Procedimentos Endovasculares/métodos , Cabeça/irrigação sanguínea , Pescoço/irrigação sanguínea , Stents , Adolescente , Aorta Torácica/diagnóstico por imagem , Coartação Aórtica/diagnóstico por imagem , Aortografia , Criança , Seguimentos , Humanos , Masculino , Desenho de Prótese
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