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1.
J Am Heart Assoc ; 10(20): e021406, 2021 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-34632807

RESUMO

Background Factors associated with poor prognosis following receipt of extracorporeal membrane oxygenation (ECMO) in adults with cardiac arrest remain unclear. We aimed to identify predictors of mortality in adults with cardiac arrest receiving ECMO in a nationally representative sample. Methods and Results The US Healthcare Cost and Utilization Project's National Inpatient Sample was used to identify 782 adults hospitalized with cardiac arrest who received ECMO between 2006 and 2014. The primary outcome of interest was all-cause in-hospital mortality. Factors associated with mortality were analyzed using multivariable logistic regression. The overall in-hospital mortality rate was 60.4% (n=472). Patients who died were older and more often men, of non-White race, and with lower household income than those surviving to discharge. In the risk-adjusted analysis, independent predictors of mortality included older age, male sex, lower annual income, absence of ventricular arrhythmia, absence of percutaneous coronary intervention, and presence of therapeutic hypothermia. Conclusions Demographic and therapeutic factors are independently associated with mortality in patients with cardiac arrest receiving ECMO. Identification of which patients with cardiac arrest may receive the utmost benefit from ECMO may aid with decision-making regarding its implementation. Larger-scale studies are warranted to assess the appropriate candidates for ECMO in cardiac arrest.

2.
Curr Opin Cardiol ; 36(6): 755-763, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34535004

RESUMO

PURPOSE OF REVIEW: Optimal timing of intervention for ischemic mitral regurgitation remains to be elucidated. This review summarizes the data on the management of ischemic mitral regurgitation, and their implications on current practice and future research. RECENT FINDINGS: Mechanistically, ischemic mitral regurgitation can present as Type I, Type IIIb or mixed Type I and IIIb disease. Severity of mitral regurgitation is typically quantified with echocardiography, either transthoracic or transesophageal echocardiography, but may also be assessed via cardiac MRI. In patients with moderate ischemic mitral regurgitation, revascularization can lead to left ventricular reverse remodeling in some. In patients with severe ischemic mitral regurgitation, mitral valve replacement may be associated with fewer adverse events related to heart failure and cardiovascular readmissions, compared with valve repair, although reverse remodeling may be better in patients following successful mitral repair. Transcatheter edge-to-edge repair also further complements the treatment of ischemic mitral regurgitation. SUMMARY: A tailored approach to patients should be considered for each patient presenting with ischemic mitral regurgitation.

3.
Ann Thorac Surg ; 2021 Aug 23.
Artigo em Inglês | MEDLINE | ID: mdl-34437853

RESUMO

BACKGROUND: Variation in degenerative mitral morphology may contribute to suboptimal repair rates. This study evaluates outcomes of a standardized mitral repair technique. METHODS: An institutional clinical registry was used to identify 1036 consecutive patients undergoing robotic mitral surgery between 2005-2020: 87% (n=902) had degenerative disease. Calcification, failed transcatheter repair, and endocarditis were excluded, leaving 582 (68%) patients with isolated posterior leaflet and 268 (32%) with anterior/bileaflet prolapse. Standardized repair comprised triangular resection and true-sized flexible band in posterior leaflet prolapse. Freedom from >2+ moderate mitral regurgitation stratified by prolapse location was assessed using competing risk analysis with death as a competing event. Median follow-up was 5.5 (range 0-15) years. RESULTS: Of patients with isolated posterior leaflet prolapse, 87% (n=506) had standardized repairs, and 13% (n=76) had additional or non-resectional techniques, versus 24% (n=65) and 76% (n=203) respectively for anterior/bileaflet prolapse (P<0.001). Adjunctive techniques in the isolated posterior leaflet group included chordal reconstruction (8.6%, n=50) and commissural sutures (3.4%, n=20). Overall, median clamp time was 80 (IQR 68-98) minutes, 17 patients required intra-operative re-repair, and 6 required mitral replacement. Freedom from >2+ regurgitation or reintervention at 10 years was 92% for posterior prolapse (versus 83% for anterior/bileaflet prolapse). Anterior/bileaflet prolapse was associated with late >2+ regurgitation (HR 3.0, 95% CI 1.3-7.0). CONCLUSIONS: Posterior leaflet prolapse may be repaired in > 99% of patients using triangular resection and band annuloplasty, with satisfactory long-term durability. Increased risk of complex repairs and inferior durability highlights the value of identifying anterior and bileaflet prolapse pre-operatively.

4.
J Am Coll Cardiol ; 78(9): 883-894, 2021 Aug 31.
Artigo em Inglês | MEDLINE | ID: mdl-34446160

RESUMO

BACKGROUND: Survival, functional outcomes, and quality of life after left ventricular assist device (LVAD) are ill-defined in elderly patients, and with new-generation devices. OBJECTIVES: This study sought to evaluate survival, functional outcomes, and quality of life after LVAD in contemporary practice. METHODS: Adults receiving durable LVADs between January 1, 2010, and March 1, 2020, were identified from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database. The primary outcome was adjusted survival; secondary outcomes included quality of life rated using a visual analogue scale (where 0 represents "worst health" and 100 "best health"); 6-minute walk distance; stroke; device malfunction; and rehospitalization, stratified by patient age. Median follow-up was 15 months (IQR: 6-32 months). RESULTS: The cohort comprised 68.9% (n = 16,808) patients aged <65 years, 26.3% (n = 6,418) patients aged 65-75 years, and 4.8% (n = 1,182) patients aged >75 years, who were predominantly male (n = 19,119, 78%) and on destination therapy (n = 12,425, 51%). Competing outcomes analysis demonstrated mortality (70% CIs) of 34% (33%-34%), 54% (54%-55%), and 66% (64%-68%) for patients aged <65, 65-75, and >75 years, respectively, which improved during the study in patients aged >75 years. Newer-generation devices were associated with reduced late mortality (HR: 0.35; 95% CI: 0.25-0.49). Stroke, device malfunction or thrombosis, and rehospitalizations decreased with increasing age (all P < 0.01). Median 6-minute walk distance increased from 0 feet (IQR: 0-665 feet) to 1,065 feet (IQR: 642-1,313 feet) (P < 0.001), and quality of life improved from 40 (IQR: 15-60) to 75 (IQR: 60-90) (P < 0.001) after LVAD in all age groups. CONCLUSIONS: In elderly patients, LVADs are associated with increased functional capacity, similar improvements in quality of life, and fewer complications compared with younger patients.

5.
Eur Heart J ; 2021 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-34338767

RESUMO

AIMS: Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men. METHODS AND RESULTS: The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94-1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11-1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04-1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90-1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes. CONCLUSIONS: Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.

7.
Artigo em Inglês | MEDLINE | ID: mdl-34246490
8.
Ann Thorac Surg ; 2021 Jun 28.
Artigo em Inglês | MEDLINE | ID: mdl-34197828

RESUMO

Mitral valve repair is infrequently performed in patients undergoing corrective surgery for failed mitral transcatheter edge-to-edge repair (TEER) in current US practice. This article describes surgical techniques for reconstructive surgery following failed TEER. A total of nine patients underwent robotic-assisted mitral surgery following failed TEER between 2010 and 2020 at a single center. Repair was completed in 88.9% (n=8) patients and freedom from >2+ mitral regurgitation was 87.5% (n=7) at a median follow up of 1.9 years.

9.
JAMA Netw Open ; 4(6): e2114494, 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-34190996

RESUMO

Importance: Randomized clinical trials (RCTs) provide the highest level of evidence to evaluate 2 or more surgical interventions. Surgical RCTs, however, face unique challenges in design and implementation. Objective: To evaluate the design, conduct, and reporting of contemporary surgical RCTs. Evidence Review: A literature search performed in the 2 journals with the highest impact factor in general medicine as well as 6 key surgical specialties was conducted to identify RCTs published between 2008 and 2020. All RCTs describing a surgical intervention in both experimental and control arms were included. The quality of included data was assessed by establishing an a priori protocol containing all the details to extract. Trial characteristics, fragility index, risk of bias (Cochrane Risk of Bias 2 Tool), pragmatism (Pragmatic Explanatory Continuum Indicator Summary 2 [PRECIS-2]), and reporting bias were assessed. Findings: A total of 388 trials were identified. Of them, 242 (62.4%) were registered; discrepancies with the published protocol were identified in 81 (33.5%). Most trials used superiority design (329 [84.8%]), and intention-to-treat as primary analysis (221 [56.9%]) and were designed to detect a large treatment effect (50.0%; interquartile range [IQR], 24.7%-63.3%). Only 123 trials (31.7%) used major clinical events as the primary outcome. Most trials (303 [78.1%]) did not control for surgeon experience; only 17 trials (4.4%) assessed the quality of the intervention. The median sample size was 122 patients (IQR, 70-245 patients). The median follow-up was 24 months (IQR, 12.0-32.0 months). Most trials (211 [54.4%]) had some concern of bias and 91 (23.5%) had high risk of bias. The mean (SD) PRECIS-2 score was 3.52 (0.65) and increased significantly over the study period. Most trials (212 [54.6%]) reported a neutral result; reporting bias was identified in 109 of 211 (51.7%). The median fragility index was 3.0 (IQR, 1.0-6.0). Multiplicity was detected in 175 trials (45.1%), and only 35 (20.0%) adjusted for multiple comparisons. Conclusions and Relevance: In this systematic review, the size of contemporary surgical trials was small and the focus was on minor clinical events. Trial registration remained suboptimal and discrepancies with the published protocol and reporting bias were frequent. Few trials controlled for surgeon experience or assessed the quality of the intervention.

10.
Circulation ; 144(2): e16-e35, 2021 Jul 13.
Artigo em Inglês | MEDLINE | ID: mdl-34126755

RESUMO

Over the past few decades, advances in pharmacological, catheter-based, and surgical reperfusion have improved outcomes for patients with acute myocardial infarctions. However, patients with large infarcts or those who do not receive timely revascularization remain at risk for mechanical complications of acute myocardial infarction. The most commonly encountered mechanical complications are acute mitral regurgitation secondary to papillary muscle rupture, ventricular septal defect, pseudoaneurysm, and free wall rupture; each complication is associated with a significant risk of morbidity, mortality, and hospital resource utilization. The care for patients with mechanical complications is complex and requires a multidisciplinary collaboration for prompt recognition, diagnosis, hemodynamic stabilization, and decision support to assist patients and families in the selection of definitive therapies or palliation. However, because of the relatively small number of high-quality studies that exist to guide clinical practice, there is significant variability in care that mainly depends on local expertise and available resources.

11.
12.
Ann Surg ; 2021 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-34091513

RESUMO

OBJECTIVE: To determine the gender representation among principal investigators (PIs) in US cardiac surgery clinical trials. SUMMARY BACKGROUND DATA: Being a principal investigator in a US clinical trial confers national recognition among peers. Gender representation among principal investigators (PIs) in US cardiac surgery clinical trials has not been evaluated. METHODS: We evaluated 124 US cardiac surgery trials registered on ClinicalTrials.gov from 2014 to 2019. Sixty trials included PIs (n = 266) from 128 institutions that had a combined total of 1040 adult cardiac surgeons. We examined gender representation among junior-level (instructor or assistant professor) and senior-level (associate, full, or Emeritus professor) PIs by calculating the participation-to-prevalence ratio (PPR), whereby a PPR range of 0.8-1.2 reflects equitable representation. RESULTS: The pool representation percentage was 6.1% (63/1040) for women and 93.9% (977/1040) for men. A total of 266 PI positions were assigned to adult cardiac surgeons: 6 (9.5%; PPR = 0.37) from the female pool and 260 (26.6%; PPR = 1.04) from the male pool (p = 0.004). The percentage of PIs with studies funded by industry was 9.5% of the female pool (PPR = 0.39) and 25.0% of the male pool (PPR = 1.04) (p = 0.009). No National Institutes of Health-funded or other funded trials had female PIs. An overall trend was observed towards disproportionally more men than women among PIs, especially at the senior level (p = 0.027). CONCLUSIONS: Equitable opportunities for PI positions are available for junior-level but not senior-level cardiothoracic surgeons. These results suggest a need for active engagement and promotion of equal opportunities in cardiac surgery.

13.
J Am Coll Cardiol ; 78(1): 1-9, 2021 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-33945832

RESUMO

BACKGROUND: Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined. OBJECTIVES: This study evaluated national outcomes of mitral surgery after TEER. METHODS: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality. RESULTS: In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease. CONCLUSIONS: This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.


Assuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral , Valva Mitral , Complicações Pós-Operatórias , Reoperação , Fatores Etários , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/métodos , Feminino , Doenças das Valvas Cardíacas/patologia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Mortalidade Hospitalar , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/patologia , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/cirurgia , Prognóstico , Recidiva , Reoperação/efeitos adversos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Fatores de Risco , Estados Unidos
15.
Ann Thorac Surg ; 2021 Jan 04.
Artigo em Inglês | MEDLINE | ID: mdl-33412133

RESUMO

Randomized trials in surgery face additional challenges compared with those in medicine. Some of the challenges are intrinsic to the nature of the field (eg, issues with blinding, learning curve and surgeons' experience, and difficulties in defining the appropriate timing for comparative trials). Other issues are related to the surgical culture, the attitude of surgeons toward randomized trials, and the lack of support by professional and national bodies. In this review, a group of investigators with experience in trials in congenital and adult cardiac and thoracic surgery discusses the key issues with surgical trials and suggests potential solutions.

17.
Transplant Proc ; 53(1): 329-334, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32917391

RESUMO

BACKGROUND: Indications for heart transplantation are expanding to include amyloid light chain (AL) and transthyretin-related (TTR) amyloidosis. Previously, AL amyloid had been a contraindication to heart transplantation given inferior outcomes. These patients typically have biventricular failure requiring mechanical circulatory support (MCS). We report the outcomes of patients with end-stage cardiac amyloidosis who underwent cardiac transplantation, including some who were bridged to transplantation with a durable biventricular MCS METHODS: The records for patients with cardiac amyloidosis who underwent cardiac transplant between 2010 and 2018 were reviewed. Primary endpoint was post-transplant 1-year survival. Secondary endpoints included 1-year freedom from cardiac allograft vasculopathy (as defined by stenosis ≥ 30% by angiography), nonfatal major adverse cardiac events (myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and any rejection. RESULTS: A total of 46 patients received heart transplantation with a diagnosis of either AL or TTR amyloidosis. Of these, 7 patients were bridged to transplantation with a durable biventricular MCS device (6 AL, 1 TTR) and 39 patients were transplanted without MCS bridging. The MCS group consisted of 5 total artificial hearts and 2 biventricular assist devices. The 1-year survival was 91% for the entire cohort, 83% for those with AL amyloidosis, 94% for those with TTR amyloidosis, and 86% for those who received MCS bridging. CONCLUSIONS: Cardiac transplantation can be safely performed in selected amyloidosis patients with reasonable short-term outcomes. Those bridged to transplantation with biventricular MCS appear to have short-term outcomes similar to those transplanted without MCS. Larger numbers and longer observation are required to confirm these findings.


Assuntos
Amiloidose/complicações , Cardiopatias/etiologia , Cardiopatias/cirurgia , Transplante de Coração , Resultado do Tratamento , Adulto , Idoso , Amiloidose/cirurgia , Estudos de Coortes , Feminino , Transplante de Coração/efeitos adversos , Coração Auxiliar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
19.
Transplant Proc ; 53(1): 353-357, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32650992

RESUMO

BACKGROUND: Temporary mechanical circulatory support (MCS) devices are generally used short term to maintain adequate organ perfusion in patients with advanced heart failure and cardiogenic shock. Unacceptably high waitlist mortality in this cohort motivated changes to heart allocation policy, which recognized the severity of illness by prioritization for temporary MCS and broader sharing in the new U.S. donor heart allocation policy. We evaluated the post-heart transplant outcomes for patients bridged with temporary MCS, a control population not bridged with MCS, and a cohort bridged with durable MCS. METHODS: The heart transplant research database was queried to identify patients bridged with temporary MCS and bridged with durable MCS who went directly to heart transplant in our center. Temporary MCS included Impella, intra-aortic balloon pump, and extracorporeal membrane oxygenation. Post-transplant endpoints were assessed at 30 days, 6 months, and 1 year. RESULTS: From 2010 to 2017, a total of 23 patients were bridged to heart transplant with temporary MCS and 548 were transplanted without MCS bridge. Patients bridged with temporary MCS had younger age, lower body mass index, and higher frequencies of prior blood transfusion and Status 1 (1A/1B) listing at transplant compared to patients not bridged with MCS (all P < .001). Despite the severity of illness in patients bridged with temporary MCS, post-transplant outcomes were indistinguishable from those in patients transplanted without MCS bridge, with no difference in 30-day, 6-month, or 1-year survival or 1-year freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any-treated rejection, acute cellular rejection, or antibody-mediated rejection (P = .23-.97). Similarly, compared to 157 patients bridged with durable MCS, no differences in post-transplant outcomes were identified for the temporary MCS cohort (P = .15-.94). CONCLUSION: Temporary MCS as a bridge to transplant achieves similar post-transplant outcomes at 1 year compared to no MCS and durable MCS. These encouraging findings support recent changes in the Organ Procurement and Transplantation Network | United Network Organ Sharing (OPTN|UNOS) adult heart allocation policy.


Assuntos
Transplante de Coração , Seleção de Pacientes , Políticas , Obtenção de Tecidos e Órgãos , Adulto , Estudos de Coortes , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Transplante de Coração/mortalidade , Coração Auxiliar , Humanos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Listas de Espera/mortalidade
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