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1.
Artigo em Inglês | MEDLINE | ID: mdl-31948740
2.
Artigo em Inglês | MEDLINE | ID: mdl-31810650

RESUMO

OBJECTIVES: Residual mitral regurgitation reduces the efficacy of mitral repair and is associated with worse outcomes. We adopted a policy using a second bypass run for patients with residual mitral regurgitation (>+1) and described our decision-making algorithm and outcomes. METHODS: From January 1, 2011, to December 31, 2016, 40 patients with degenerative disease underwent a second bypass run to address residual mitral regurgitation. The echocardiographic criteria for a second bypass run was the presence of moderate or greater mitral regurgitation or mild mitral regurgitation with unfavorable mechanism. RESULTS: A second bypass run was used in 40 patients. The mean age was 57.3 ± 13.5 years (21-79 years), and 14 patients (35%) were asymptomatic. Residual mitral regurgitation was mild in 25 patients, moderate in 9 patients, and moderate/severe in 6 patients. The cause of postbypass mitral regurgitation was technical or residual pathology in 35 patients and systolic anterior motion in 5 patients. Re-repair techniques were cleft closure in 22 patients, primary suture repair in 13 patients, and expanded polytetrafluoroethylene chordoplasty in 9 patients. After re-repair, 34 patients (85%) had no mitral regurgitation, 4 patients (10%) had trace mitral regurgitation, and 2 patients (5%) had mild mitral regurgitation. Median total cardiopulmonary bypass time was 208.5 minutes, first crossclamp time was 106 minutes, and second crossclamp time was 34 ± 12 minutes. Median intensive care stay was 2 days, and hospital stay was 8 days. On discharge, there was no mitral regurgitation in 13 patients (33%), trace in 23 patients (58%), and mild mitral regurgitation in 4 patients (10%). Freedom from moderate or greater mitral regurgitation at 5 years was 100%. CONCLUSIONS: Residual mitral regurgitation can be effectively treated using a second bypass run with good long-term outcome and minimal incremental risk.

3.
Ann Med Surg (Lond) ; 47: 5-12, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31641493

RESUMO

Introduction: Mitral valve repair has been established as the preferred treatment option in the management of degenerative mitral valve disease. Compared with other surgical treatment options, mitral valve repair is associated with increased survival and decreased rates of both complications and reoperations. However, among patients undergoing mitral valve repair, little is known about the predictors of postoperative outcomes. The purpose of this study is to identify preoperative patient risk factors associated with postoperative morbidity and mortality within 30 days of mitral valve repair. Methods: Data was derived from the American College of Surgeons National Surgical Quality Improvement Program database to assess patients who underwent mitral valve repair from 2011 through 2017. Preoperative risk factors were analyzed to determine their association with a variety of postoperative 30-day outcome measures. Results: One thousand three hundred and sixty-six patients underwent mitral valve repair; 849 (62.2%) males and 517 (37.8%) females. Ages ranged from 18 to 90 years, with a mean age of 64 years. The overall 30-day mortality was 3.1% (43 patients). Among the 12 identified risk factors associated with increased mortality on univariate analysis, pre-operative hematocrit level was the only variable significantly correlated with mortality after undergoing multivariate analysis. 259 patients (19.1%) were discharged to a location other than home, an outcome associated with 22 identified risk factors. Among these risk factors, female gender, age, dialysis, pre-operative serum sodium, pre-operative serum albumin, and partial or full living dependency remained statistically significant following multivariate analysis. 126 patients (9.2%) experienced unplanned readmission. This outcome was associated with five risk factors, of which only dyspnea upon mild exertion was significant on multivariate analysis. Reoperation occurred in 105 patients (7.7%). Of the seven identified variables associated with reoperation, patient age, pre-operative platelet count, dyspnea upon mild exertion were independent predictors on multivariate analysis. 53 patients (3.9%) underwent reintubation, which was associated with 11 identified risk factors. Among them, patient age and pre-operative INR value were predictive of reintubation on multivariate analysis. 26 patients (1.9%) experienced stroke, of whom age was the only associated risk factor on both univariate and multivariate analysis. 31 patients (2.3%) experienced acute renal failure, which correlated with 11 risk factors on univariate analysis. Of these, only patient age and pre-operative hematocrit were identified as independent predictors on multivariate analysis. Conclusions: Outcomes are good following mitral valve repair. Although a substantial number of risk factors were found to be associated with adverse outcomes, only a small subset remained statistically significant following multivariate analysis. Identification of these risk factors may help guide clinical decision making with respect to which patients are the best candidates to undergo mitral valve repair.

10.
Ann Med Surg (Lond) ; 33: 16-23, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30147870

RESUMO

Background: Cardiac events (CE) following surgery have been associated with morbidity and mortality. Defining risk factors that contribute to CE is essential to improve surgical outcomes. Study design: This was a retrospective study at a large urban teaching hospital for surgery performed from 2013 to 2015. Adult patients (≥18 years) that underwent general and vascular surgery were analyzed. Patients were grouped into those who experienced postoperative CE and those who did not. Univariate and multivariate regression analyses were used to identify predictors of postoperative CE, and association of CE with adverse postoperative outcomes. Separate subgroup analyses were also conducted for general and vascular surgery patients to assess predictors of CE. Results: Out of 8441 patients, 157 (1.9%) experienced CE after major general and vascular surgery. Underlying predictors for CE included age >65 years(OR 4.9, 95%CI 3.4-6.9,p < 0.01), ASA >3(OR 12.0, 95%CI 8.5-16.9,p < 0.01), emergency surgery(OR 3.7, 95%CI 2.7-5.1,p = 0.01), CHF(OR 11.2, 95%CI 6.4-16.7,p = 0.02), COPD(OR 3.9, 95%CI 2.4-6.4,p = 0.04), acute renal failure or dialysis(OR 8.0, 95%CI 5.2-12.1,p = 0.04), weight loss(OR 3.3, 95%CI 1.7-6.7,p < 0.01), preoperative creatinine >1.2 mg/dL(OR 5.1, 95%CI 3.7-7.1,p = 0.01), hematocrit <34%(OR 4.0, 95%CI 2.8-5.7,p < 0.01), and operative time >240 min(OR 2.0, 95%CI 1.3-3.3,p = 0.02). Following surgery, CE was associated with increased mortality(OR 3.5, 95%CI 1.2-6.5,p < 0.01), pulmonary complications(OR 5.0, 95%CI 3.1-8.9,p < 0.01), renal complications(OR 2.3, 95%CI 1.9-4.5,p < 0.01), neurologic complications(OR 2.5, 95%CI 1.4-5.2,p < 0.01), systemic sepsis(OR 2.2, 95%CI 1.7-4.0,p < 0.01), postoperative RBC transfusion(OR 4.4, 95%CI 2.7-6.5,p < 0.01), unplanned return to operating room(OR 4.0, 95%CI 2.3-6.9,p < 0.01), and prolonged hospitalization (OR 5.5, 95%CI 3.1-8.8,p = 0.03). There was no statistical difference in incidence of CE between general and vascular surgery patients (p = 0.44); however, predictors of CE differed between the two surgical groups. Conclusion: Postoperative CE are associated with significant morbidity and mortality. Identified predictors of CE should allow for adequate risk stratification and optimization of perioperative surgical management.

11.
J Surg Educ ; 75(6): 1575-1582, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29709469

RESUMO

OBJECTIVE: To evaluate the effect of resident involvement in thoracic endovascular aortic repair (TEVAR). SUMMARY OF BACKGROUND DATA: Although the influence of resident intraoperative involvement in several types of surgical procedures has been reported, the effect of resident participation in TEVAR is unknown. We evaluated patient outcomes in resident-involved TEVAR procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was analyzed for TEVAR performed from 2010 to 2012. Current procedural terminology codes were used to identify adult patients (≥18 y) who underwent TEVAR. Patients were grouped into those with and without resident involvement. Descriptive and binomial logistic statistics were used to determine the effect of resident involvement on post-TEVAR outcomes. p values < 0.05 were considered statistically significant. RESULTS: A total of 676 patients met inclusion criteria for this study. Of these, 517 (76.5%) had residents involved. Overall mortality was 9.8%, with no significant difference between the 2 groups (p = 0.88). Resident involvement was not a significant predictor of any post-TEVAR complication. Postoperative pneumonia (3.5% vs 6.9%, p = 0.06), prolonged mechanical ventilation (11.8% vs 11.9%, p = 0.96), stroke (2.7% vs 5.7%, p = 0.07), urinary tract infection (3.3% vs 4.4%, p = 0.50), progressive renal insufficiency (1.2% vs 2.5%, p = 0.22), acute renal failure (4.1% vs 5.0%, p = 0.60), cardiac arrest (2.9% vs 5.0%, p = 0.20), myocardial infarction (1.7% vs 1.9%, p = 0.91), deep venous thrombosis (1.7% vs 1.3%, p = 0.67), red blood cells transfusions (29.2% vs 36.5%, p = 0.08), sepsis (2.9% vs 4.4%, p = 0.35), septic shock (1.9% vs 3.8%, p = 0.18), and unplanned reintubation (8.7% vs 9.4%, p = 0.78) were not significantly affected. Additionally, resident involvement did not significantly affect operative time (176.1 ± 122.8 min vs 180.3 ± 119.1 min, p = 0.71) and anesthesia time (282.1 ± 146.6 min vs 278.3 ± 140.5 min, p = 0.78). CONCLUSIONS: The participation of residents in TEVAR did not significantly affect all 30-day patient outcomes. Resident involvement in TEVAR is safe and should be encouraged. MINI ABSTRACT: This study evaluated the effect of resident participation on postoperative outcomes of thoracic endovascular aortic repair (TEVAR) using the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database. Results showed that resident involvement in TEVAR does not negatively affect patient outcomes.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Procedimentos Endovasculares , Internato e Residência , Complicações Pós-Operatórias/mortalidade , Idoso , Competência Clínica , Feminino , Humanos , Masculino , Morbidade , Complicações Pós-Operatórias/epidemiologia , Resultado do Tratamento
12.
Respirology ; 23(8): 771-779, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29611244

RESUMO

BACKGROUND AND OBJECTIVE: Molecular biomarkers are needed to refine prognostication and phenotyping of pulmonary hypertension (PH) patients. S100A12 is an emerging biomarker of various inflammatory diseases. This study aims to determine the prognostic value of S100A12 in PH. METHODS: Exploratory microarray analysis performed on peripheral blood mononuclear cells (PBMC) collected from idiopathic pulmonary fibrosis (IPF) patients suggested an association between S100A12 and both PH and mortality. So the current study was designed to evaluate for an association between S100A12 in peripheral blood collected from two well-phenotyped PH cohorts in two other centres to derive and validate an association between S100A12 protein serum concentrations and mortality. RESULTS: The majority of the patients in the discovery and validation cohorts were either World Health Organization (WHO) group 1 (pulmonary arterial hypertension (PAH)) or 3 (lung disease-associated) PH. In the discovery PH cohort, S100A12 was significantly increased in patients with PH (n = 51) compared to controls (n = 22) (29.8 vs 15.7 ng/mL, P < 0.001) and negatively correlated with cardiac output (r = -0.58, P < 0.001) in PH patients. When S100A12 data were pooled from both cohorts, PAH and non-PAH PH patients had higher S100A12 compared to healthy external controls (32.6, 30.9, 15.7 ng/mL; P < 0.001). S100A12 was associated with an increased risk in overall mortality in PH patients in both the discovery (n = 51; P = 0.008) and validation (n = 40; P < 0.001) cohorts. CONCLUSION: S100A12 levels are increased in PH patients and are associated with increased mortality.


Assuntos
Débito Cardíaco , Hipertensão Pulmonar/sangue , Hipertensão Pulmonar/mortalidade , Proteína S100A12/sangue , Adulto , Idoso , Biomarcadores/sangue , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Hipertensão Pulmonar/fisiopatologia , Leucócitos Mononucleares , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prognóstico
13.
Respir Med ; 134: 42-46, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29413506

RESUMO

Pulmonary hypertension (PH) is a clinical syndrome that is subdivided into five groups per the World Health Organization (WHO) classification, based largely on hemodynamic and pathophysiologic criteria. WHO Group 1 PH, termed pulmonary arterial hypertension (PAH), is a clinically progressive disease that can eventually lead to right heart failure and death, and it is hemodynamically characterized by pre-capillary PH and increased pulmonary vascular resistance in the absence of elevated left ventricular filling pressures. PAH can be idiopathic, heritable, or associated with a variety of conditions. Connective tissue diseases make up the largest portion of these associated conditions, most commonly systemic sclerosis (SSc), followed by mixed connective tissue disease and systemic lupus erythematous. These etiologies (namely SSc and Lupus) have been grouped together as connective tissue disease-associated PAH, however emerging evidence suggests they differ in pathogenesis, clinical course, prognosis, and treatment response. This review highlights the differences between SSc-PAH and Lupus-PAH. After introducing the diagnosis, screening, and pathobiology of PAH, we discuss connective tissue disease-associated PAH as a group, and then explore SSc-PAH and SLE-PAH separately, comparing these 2 PAH etiologies.


Assuntos
Hipertensão Pulmonar/etiologia , Lúpus Eritematoso Sistêmico/complicações , Escleroderma Sistêmico/complicações , Humanos , Hipertensão Pulmonar/tratamento farmacológico , Hipertensão Pulmonar/epidemiologia , Fatores Imunológicos/uso terapêutico , Lúpus Eritematoso Sistêmico/tratamento farmacológico , Lúpus Eritematoso Sistêmico/epidemiologia , Escleroderma Sistêmico/tratamento farmacológico , Escleroderma Sistêmico/epidemiologia
14.
Eur J Cardiothorac Surg ; 52(3): 432-439, 2017 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-28605428

RESUMO

OBJECTIVES: The COMMENCE trial was conducted to evaluate the safety and effectiveness of a novel bioprosthetic tissue for surgical aortic valve replacement (AVR). METHODS: Patients underwent clinically indicated surgical AVR with the Carpentier-Edwards PERIMOUNT™ Magna Ease™ aortic valve with RESILIA™ tissue (Model 11000A) in a prospective, multinational, multicentre (n = 27), single-arm, FDA Investigational Device Exemption trial. Events were adjudicated by an independent Clinical Events Committee; echocardiograms were analysed by an independent Core Laboratory. RESULTS: Between January 2013 and February 2016, 689 patients received the study valve. Mean age was 67.0 ± 11.6 years; 71.8% were male; 26.3% were New York Heart Association Class III/IV. Mean STS PROM was 2.0 ± 1.8 (0.3-17.5). Isolated AVR was performed in 59.1% of patients; others had additional concomitant procedures, usually CABG. Thirty-day outcomes for all patients included all-cause mortality 1.2%, thromboembolism 2.2%, bleeding 0.9%, major paravalvular leak 0.1% and permanent pacemaker implantation 4.7%. Median intensive care unit and hospital length of stay were 2 (range: 0.2-66) and 7 days (3.0-121.0), respectively. At 2 years, New York Heart Association class improved in 65.7%, effective orifice area was 1.6 ± 0.5 cm2; mean gradient was 10.1 ± 4.3 mmHg; and paravalvular leak was none/trivial in 94.5%, mild in 4.9%, moderate in 0.5% and severe in 0.0%. One-year actuarial freedom from all-cause mortality for isolated AVR and for all patients was 98.2% and 97.6%, respectively. Two-year actuarial freedom from mortality in these groups was 95.3% and 94.3%, respectively. CONCLUSIONS: These data demonstrate excellent early safety and effectiveness of aortic valve replacement with a novel bioprosthetic tissue (RESILIA™). Clinical trial registration: clinicaltrials.gov: NCT01757665.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Bioprótese , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico , Causas de Morte/tendências , Ecocardiografia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
15.
J Am Coll Cardiol ; 2017 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-28476349

RESUMO

BACKGROUND: Degenerative mitral valve repair rates remain highly variable, despite established benefits of repair over replacement. The contribution of surgeon-specific factors is poorly defined. OBJECTIVES: This study evaluated the influence of surgeon case volume on degenerative mitral valve repair rates and outcomes. METHODS: A mandatory New York State database was queried and 5,475 patients were identified with degenerative mitral disease who underwent mitral valve operations between 2002 and 2013. Mitral repair rates, mitral reoperations within 12 months of repair, and survival were analyzed using multivariable Cox modeling and restricted cubic spline function. RESULTS: Median annual surgeon volume of any mitral operations was 10 (range 1 to 230), with a mean repair rate of 55% (n = 20,797 of 38,128). In the subgroup of patients with degenerative disease, the mean repair rate was 67% (n = 3,660 of 5,475), with a range of 0% to 100%. Mean repair rates ranged from 48% (n = 179 of 370) for surgeons with total annual volumes of ≤10 mitral operations to 77% (n = 1,710 of 2,216) for surgeons with total annual volumes of >50 mitral operations (p < 0.001). Higher total annual surgeon volume was associated with increased repair rates of degenerative mitral valve disease (adjusted odds ratio [OR]: 1.13 for every additional 10 mitral operations; 95% confidence interval [CI]: 1.10 to 1.17; p < 0.001); a steady decrease in reoperation risk until 25 total mitral operations annually; and improved 1-year survival (adjusted hazard ratio: 0.95 for every additional 10 operations; 95% CI: 0.92 to 0.98; p = 0.001). For surgeons with a total annual volume of ≤25 mitral operations, repair rates were higher (63.8%; n = 180 of 282) if they operated in the same institution as a surgeon with total annual mitral volumes of >50 and degenerative mitral valve repair rates of >70%, compared with surgeons operating in the other institutions (51.3%; n = 580 of 1,130) (adjusted OR: 1.79; 95% CI: 1.24 to 2.60; p < 0.001). CONCLUSIONS: This study suggests that individual surgeon volume is a determinant of not only mitral repair rates, but also freedom from reoperation, and survival. The data from this study support the guideline's concept of reference referral to experienced mitral surgeons to improve outcomes in patients with degenerative mitral valve disease.

17.
Blood Coagul Fibrinolysis ; 22(5): 362-8, 2011 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-21346555

RESUMO

The objective of the present study was to determine if a new procoagulant molecule, carbon monoxide releasing molecule (tricarbonyldichlororuthenium (II) dimer; CORM-2) would improve coagulation following cardiopulmonary bypass (CPB). Plasma was obtained from patients undergoing elective cardiac surgery requiring CPB. Whole blood was collected and anticoagulated with sodium citrate after induction of anesthesia and again after CPB and heparin neutralization with protamine. Blood samples were centrifuged for 15 min, with plasma collected and stored at -80°C prior to analysis. Samples were subsequently exposed to 0 or 100 µmol/l CORM-2, with coagulation activated with tissue factor. Data were collected with thrombelastography until clot strength stabilized. Patients underwent CPB for 133 ± 61 min (mean ± SD). The velocity of thrombus formation was significantly decreased (52%) by CPB, as was clot strength (53%). Addition of CORM-2 to plasma samples obtained after CPB significantly increased the velocity of clot formation (75%) and strength (52%) compared to matched unexposed samples. The lesion of plasmatic coagulation associated with CPB was significantly improved in vitro by addition of CORM-2. If preclinical assessments of efficacy and safety of CORM-2 are favorable, future clinical trials involving CORM-2 or other CORMs as a hemostatic intervention in the setting of CPB are justified.


Assuntos
Coagulação Sanguínea/efeitos dos fármacos , Ponte Cardiopulmonar/efeitos adversos , Compostos Organometálicos/uso terapêutico , Trombose/prevenção & controle , Adulto , Anestesia , Ponte Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Compostos Organometálicos/farmacologia , Protaminas , Tromboelastografia , Trombose/etiologia , Adulto Jovem
19.
Thorac Surg Clin ; 19(1): 91-105, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19288824

RESUMO

Most mediastinal masses seen on thoracic imaging are of solid tumor origin. As such, vascular lesions of the mediastinum can be mistaken for, or misinterpreted as, one of these more common mediastinal masses. This article stresses the importance of considering vascular entities in the differential diagnosis of mediastinal masses.


Assuntos
Doenças do Mediastino/diagnóstico , Mediastino/irrigação sanguínea , Doenças Vasculares/diagnóstico , Aorta Torácica/anormalidades , Humanos , Linfangioma/diagnóstico , Artéria Pulmonar/anormalidades , Veias Pulmonares/anormalidades
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