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1.
Artigo em Inglês | MEDLINE | ID: mdl-34272071

RESUMO

OBJECTIVE: Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses. METHODS: All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes. RESULTS: The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52). CONCLUSIONS: Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.

2.
Ann Thorac Surg ; 2021 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-33930354

RESUMO

BACKGROUND: Percutaneous coronary intervention (PCI) is being performed more frequently for left main coronary artery disease (LMCAD). This study evaluated a real-world propensity-matched analysis of surgical vs percutaneous revascularization for LMCAD. METHODS: Adults (≥18 years of age) at a single academic institution undergoing coronary artery bypass grafting (CABG) or PCI for left main stenosis greater than or equal to 50% between 2010 and 2018 were examined. Greedy propensity-matching techniques were used to generate well-matched cohorts, and Kaplan-Meier analysis was used to compare survival. Multivariable Cox models were created for 5-year mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: A total of 1091 patients with LMCAD were identified (898 CABG, 193 PCI). Patients undergoing PCI were significantly older (77 years of age vs 68 years of age; P < .001), more likely to have heart failure (26.94% vs 13.14%; P < .001), and less likely to have 3-vessel disease (42.49% vs 65.59%; P < .001). Propensity matching yielded 215 CABG and 134 PCI well-matched patients. In the matched analysis, 1-year (77.61% vs 88.37%) and 5-year (48.77% vs 75.62%) survival were lower with PCI. Rates of MACCE at 5 years were also higher with PCI (64.93% vs 32.56%; P < .001). Rates of both myocardial infarction (19.40% vs 7.44%; P = .001) and repeat revascularization (26.12% vs 7.91%; P < .001) were higher with PCI. After risk adjustment, CABG remained associated with reduced risk of mortality (hazard ratio, 0.40; 95% confidence interval, 0.29-0.54; P < .001) and MACCE (hazard ratio, 0.37; 95% confidence interval, 0.28-0.48; P < .001) at 5 years. CONCLUSIONS: This real-world, propensity-matched analysis demonstrates substantial advantages in survival and MACCE with CABG for LMCAD, supporting surgical revascularization in this clinical setting in appropriate operative candidates.

3.
Innovations (Phila) ; 16(1): 3-16, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33491539

RESUMO

OBJECTIVE: There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons. METHODS: Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year. RESULTS: Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios. CONCLUSIONS: In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Consenso , Humanos , Medição de Risco , Fatores de Risco , Resultado do Tratamento
4.
Ann Thorac Surg ; 112(2): 582-588, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33127404

RESUMO

BACKGROUND: This study evaluated our institutional experience in forming a surgeon-based committee to discuss and provide consensus opinion on high-risk cardiac surgical cases. METHODS: The committee consisted of 4 surgeons with at least 1 senior surgeon at any given time with a rotating schedule. Patients with a Society of Thoracic Surgeons predicted risk of mortality above specified thresholds were mandated for referral to the committee in addition to patients referred at the discretion of the surgeon. Kaplan-Meier analysis was used to model survival. RESULTS: A total of 110 consecutive patients were reviewed by the committee. The most common procedure types for referral were isolated coronary artery bypass grafting (47.3%; n = 52) and coronary artery bypass grafting with concomitant aortic valve replacement (19.1%; n = 21). The overall median Society of Thoracic Surgeons predicted risk of mortality for referred patients was 5.35% (interquartile range, 4.07%-7.89%). After group discussion, a total of 62 patients were recommended to proceed with surgery (56.4%). Reasons for declining surgery included consensus that an intervention was not indicated (39.6%; n = 19), that an alternative, nonsurgical procedure was recommended (29.2%; n = 14), that there was continued medical management and reevaluation (18.8%; n = 9), and that the patient was deemed at too high a risk for surgery (12.5%; n = 6). Operative mortality in patients proceeding with surgery was 4.6% (n = 2), with an observed-to-expected mortality of 0.86. The 6-month survival after surgery was 92.2%. CONCLUSIONS: Implementation of a surgeon-based committee to discuss high-risk cases provided a unified voice to referring physicians and facilitated consensus decision-making with acceptable clinical outcomes in a challenging patient cohort.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Competência Clínica , Tomada de Decisão Clínica , Cardiopatias/cirurgia , Medição de Risco/métodos , Cirurgiões/normas , Idoso , Feminino , Cardiopatias/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Masculino , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
5.
Innovations (Phila) ; 12(5): 301-319, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29028651

RESUMO

OBJECTIVE: The purpose of this consensus conference was to develop and update evidence-informed consensus statements and recommendations on harvesting saphenous vein and radial artery via an open as compared with endoscopic technique by systematically reviewing and performing a meta-analysis of randomized and nonrandomized clinical trials. METHODS: All randomized controlled trials and nonrandomized controlled trials included in the first the International Society for Minimally Invasive Cardiothoracic Surgery Consensus Conference and Statements, in 2005 up to November 30, 2015, were included in a systematic review and meta-analysis. Based on the resultant, 76 studies (23 randomized controlled trials and 53 nonrandomized controlled trials) on 281,459 patients analyzed, consensus statements, and recommendations were generated comparing the risks and benefits of endoscopic versus open conduit harvesting for patients undergoing coronary artery bypass grafting. RESULTS: Compared with open vein harvest, it is reasonable to perform endoscopic vein harvest of saphenous vein to reduce wound-related complications, postoperative length of stay, and outpatient wound management resources and to increase patient satisfaction (class I, level A). Based on the quality of the conduit and major adverse cardiac events as well as 6-month angiographic patency, endoscopic vein harvest was noninferior to open harvest. It is reasonable to perform endoscopic radial artery harvest to reduce wound-related complication and to increase patient satisfaction (class I, level B-R and B-NR, respectively) with reduction in major adverse cardiac events and noninferior patency rate at 1 and 3 to 5 years (class III, level B-R). CONCLUSIONS: Based on the consensus statements, the consensus panel recommends (class I, level B) that endoscopic saphenous vein and radial artery harvesting should be the standard of care for patients who require these conduits for coronary revascularization.


Assuntos
Ponte de Artéria Coronária/métodos , Endoscopia/métodos , Artéria Radial/transplante , Veia Safena/transplante , Coleta de Tecidos e Órgãos/normas , Idoso , Angiografia Coronária/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Ensaios Clínicos Controlados não Aleatórios como Assunto , Satisfação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecção da Ferida Cirúrgica/prevenção & controle , Coleta de Tecidos e Órgãos/métodos , Grau de Desobstrução Vascular/fisiologia , Procedimentos Cirúrgicos Vasculares/métodos
8.
Innovations (Phila) ; 10(4): 219-29, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26371452

RESUMO

OBJECTIVE: At this consensus conference, we developed evidence-informed consensus statements and recommendations on the practice of off-pump coronary artery bypass graft (OPCAB) by systematically reviewing and performing meta-analysis of the randomized controlled trials (RCTs) comparing OPCAB and conventional coronary artery bypass (CCAB). METHODS: All RCTs of OPCAB versus CCAB through April 2013 were screened, and 102 relevant RCTs (19,101 patients) were included in a systematic review and meta-analysis (15 RCTs of 9551 high-risk patients; and 87 RCTs of 9550 low-risk patients) in accordance with the Cochrane Collaboration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Consensus statements for the risks and benefits of OPCAB surgery in mortality, morbidity, and resource use were developed based on best available evidence. RESULTS: Compared to CCAB, it is reasonable to perform OPCAB to reduce risks of stroke [class IIa, level of evidence (LOE) A], renal dysfunction/failure (class IIa, LOE A), blood transfusion (class I, LOE A), respiratory failure (class I, LOE A), atrial fibrillation (class I, LOE A), wound infection (class I, LOE A), ventilation time, and ICU and hospital length of stay (class I, LOE A). However, OPCAB may be associated with a reduced number of grafts performed (class I, LOE A) and with diminished graft patency (class IIa, LOE A, with increased coronary reintervention at 1 year and beyond (class IIa, LOE A), as well as increased mortality at a median follow-up of 5 years (class IIb, LOE A). CONCLUSIONS: OPCAB compared with CCAB may improve outcomes in the short-term (stroke, renal dysfunction, blood transfusion, respiratory failure, atrial fibrillation, wound infection, ventilation time, and length of stay). However, over the longer-term, OPCAB may be associated with reduced graft patency, and increased risk of cardiac re-intervention and death.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Ponte de Artéria Coronária sem Circulação Extracorpórea/normas , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/normas , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/normas , Ensaios Clínicos Controlados Aleatórios como Assunto
11.
Ann Thorac Surg ; 94(4): 1198-203, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22818964

RESUMO

BACKGROUND: The Mitroflow valve (Sorin Group, Milan, Italy) has been in use since 1982 and has shown long-term durability in large studies from European centers but has not been studied for long-term hemodynamics in large standardized multicenter trials. This study sought to assess the hemodynamics of the Mitroflow valve by extending the duration of follow-up in an ongoing prospective multicenter trial conducted in North America. METHODS: Six sites participated in this midterm study requiring annual follow-up and echocardiographic evaluation using a standardized transthoracic echocardiography acquisition protocol. RESULTS: There were 276 patients enrolled (age 74±8 years) and 54% were in New York Heart Association (NYHA) functional class III-IV. Follow-up from the time of valve implantation had a mean of 4.0±1.7 years with a cumulative follow-up of 1,102 patient-years. At 5 years of follow-up, 99% of patients were free of moderate or severe aortic regurgitation and 94% were in NYHA functional class I or II. Between baseline and 5 years, mean gradients increased an average of 0.4 to 4.3 mm Hg. The change in effective orifice area was appreciably small (-0.1 to -0.3 cm2) after 5 years. There were 57 deaths (4 early and 53 late) and 9 valve explants. CONCLUSIONS: The Mitroflow valve implanted in the aortic position has shown to be hemodynamically stable over a 5-year follow-up in an elderly population with a high prevalence of comorbid conditions.


Assuntos
Valva Aórtica/cirurgia , Bioprótese , Próteses Valvulares Cardíacas , Insuficiência da Valva Mitral/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Ecocardiografia , Feminino , Seguimentos , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/fisiopatologia , América do Norte , Estudos Prospectivos , Desenho de Prótese , Fatores de Tempo , Resultado do Tratamento
12.
J Cardiothorac Vasc Anesth ; 24(5): 780-4, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20650657

RESUMO

OBJECTIVE: To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery. DESIGN: A nonrandomized, observational study with propensity score-guided case-control matching of prospectively collected data. SETTING: Three interrelated, university-affiliated, community hospitals. PARTICIPANTS: Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006. INTERVENTIONS: Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A "greedy 5 to 1" propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation. CONCLUSIONS: Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cuidados Críticos/métodos , Remoção de Dispositivo/métodos , Tempo de Internação , Salas Cirúrgicas/métodos , Cuidados Pós-Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Estudos de Casos e Controles , Estudos de Coortes , Cuidados Críticos/tendências , Remoção de Dispositivo/tendências , Feminino , Humanos , Intubação Intratraqueal/métodos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Salas Cirúrgicas/tendências , Cuidados Pós-Operatórios/tendências , Estudos Prospectivos , Fatores de Tempo
15.
Innovations (Phila) ; 4(2): 49-60, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22436985

RESUMO

OBJECTIVE: : The purpose of this consensus conference was to determine whether stentless bioprosthetic valves improve clinical and resource outcomes compared with stented valves in patients undergoing aortic valve replacement, and to outline evidence-based recommendations for the use of stentless and stented bioprosthetic valves in adult aortic valve replacement. METHODS: : Before the consensus conference, the best available evidence was reviewed in that systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of validity and importance. At the consensus conference, evidence-based statements were created, and consensus processes were used to determine the ensuing recommendations. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of recommendation. RESULTS AND RECOMMENDATIONS: : Seventeen randomized studies published in 23 articles involving 1317 patients, and 14 nonrandomized trial published in 18 articles involving 2485 patients were included in the meta-analysis and consensus conference. All randomized trials inserted the stentless bioprosthetic valves in the subcoronary configuration. The consensus panel agreed upon the following statements and recommendations in patients undergoing aortic valve replacement:Because there were no randomized control trial comparing subcoronary stentless prosthetic valve and root replacement, the following recommendations are derived from expert opinion:

16.
Innovations (Phila) ; 4(2): 61-73, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22436986

RESUMO

OBJECTIVE: : This meta-analysis sought to determine whether stentless bioprosthetic valves improve clinical and resource outcomes compared with stented valves in patients undergoing aortic valve replacement. METHODS: : A comprehensive search was undertaken to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in patients undergoing aortic valve replacement available up to March 2008. The primary outcomes were clinical and resource outcomes in randomized controlled trial (RCT). Secondary outcomes clinical and resource outcomes in nonrandomized controlled trial (non-RCT). Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences and their 95% confidence intervals (CI) were analyzed as appropriate. RESULTS: : Seventeen RCTs published in 23 articles involving 1317 patients, and 14 non-RCTs published in 18 articles involving 2485 patients were included in the meta-analysis. For the primary analysis of randomized trials, mortality for stentless versus stented valve groups did not differ at 30 days (OR 1.36, 95% CI 0.68-2.72), 1 year (OR 1.01, 95% CI 0.55-1.85), or 2 to 10 years follow-up (OR 0.82, 95% CI 0.50-1.33). Aggregate event rates for all-cause mortality at 30 days were 3.7% versus 2.9%, at 1 year were 5.5% versus 5.9% and at 2 to 10 years were 17% versus 19% for stentless versus stented valve groups, respectively. Stroke or neurologic complications did not differ between stentless (3.6%) and stented (4.0%) valve groups. Risk of prosthesis-patient mismatch was numerically lower in the stentless group (11.0% vs. 31.3%, OR 0.30, 95% CI 0.05-1.66), but this parameter was reported in few trials and did not reach statistical significance. Effective orifice area index was significantly greater for stentless aortic valve compared with stented valves at 30 days (WMD 0.12 cm/m), at 2 to 6 months (WMD 0.15 cm/m), and at 1 year (WMD 0.26 cm/m). Mean gradient at 1 month was significantly lower in the stentless valve group (WMD -6 mm Hg), at 2 to 6 month follow-up (WMD -4 mm Hg,), at 1 year follow-up (WMD -3 mm Hg) and up to 3 year follow-up (WMD -3 mm Hg) compared with the stented valve group. Although the left ventricular mass index was generally lower in the stentless group versus the stented valve group, the aggregate estimates of mean difference did not reach significance during any time period of follow-up (1 month, 2-6 months, 1 year, and 8 years). CONCLUSIONS: : Evidence from randomized trials shows that subcoronary stentless aortic valves improve hemodynamic parameters of effective orifice area index, mean gradient, and peak gradient over the short and long term. These improvements have not led to proven impact on patient morbidity, mortality, and resource-related outcomes; however, few trials reported on clinical outcomes beyond 1 year and definitive conclusions are not possible until sufficient evidence addresses longer-term effects.

17.
Ann Thorac Surg ; 85(5): 1651-5, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18442558

RESUMO

BACKGROUND: We describe our experience with argatroban as a primary or secondary postoperative anticoagulant to heparin in patients receiving ventricular assist devices. METHODS: This is a retrospective review of all Abiomed (BVS5000, AB5000) and Thoratec (PVAD and IVAD) ventricular assist devices from May 2003 through May 2006 at a single institution. Postoperatively, patients received either heparin or argatroban as their anticoagulant. Patients in whom heparin-induced thrombocytopenia was suspected or confirmed were converted from heparin to argatroban. RESULTS: There were 33 Abiomed and Thoratec ventricular assist devices implanted. Thirteen patients received heparin as their primary postoperative anticoagulant; 8 of the 13 were converted to argatroban as a secondary anticoagulant (hep-arg), and 5 patients remained with heparin as their only anticoagulant. Twenty patients received argatroban as their primary and only postoperative anticoagulant. Thrombocytopenia occurred in 26 patients (79%) overall, 16 (80%) with argatroban only, 6 (75%) with hep-arg, and 4 (80%) with heparin only. Thromboembolic events occurred in 5 patients (15%) overall, 3 (15%) with argatroban only, 1 (13%) with hep-arg, and 1 (20%) with heparin only. Postoperative bleeding requiring reexploration occurred in 5 patients overall (15%), 1 with argatroban only (5%), 3 (38%) with hep-arg, and 1 (20%) with heparin only. Enzyme-linked immunosorbent assay heparin-induced thrombocytopenia tests were positive in 7 patients overall (21%), 5 (25%) with argatroban only, 2 (25%) with hep-arg, and 0 (0%) with heparin only. CONCLUSIONS: Argatroban is a comparable primary or secondary anticoagulant to heparin postoperatively in patients receiving ventricular assist devices.


Assuntos
Anticoagulantes/administração & dosagem , Coração Auxiliar , Heparina/administração & dosagem , Ácidos Pipecólicos/administração & dosagem , Complicações Pós-Operatórias/induzido quimicamente , Trombocitopenia/induzido quimicamente , Anticoagulantes/efeitos adversos , Arginina/análogos & derivados , Autoanticorpos/sangue , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Seguimentos , Transplante de Coração , Heparina/efeitos adversos , Humanos , Fatores de Transcrição Kruppel-Like/imunologia , Tempo de Tromboplastina Parcial , Ácidos Pipecólicos/efeitos adversos , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Pós-Operatórias/mortalidade , Desenho de Prótese , Proteínas Repressoras/imunologia , Estudos Retrospectivos , Sulfonamidas , Taxa de Sobrevida , Trombina/antagonistas & inibidores , Trombocitopenia/tratamento farmacológico
19.
Semin Cardiothorac Vasc Anesth ; 10(2): 171-5, 2006 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-16959745

RESUMO

Two studies assessed initiatives to improve the quality and the cost-effectiveness of cardiac surgery. The first evaluated a system for access and stabilization (SAS), with coronary stabilization, and a clinical effectiveness quality initiative (CEQI) in off-pump coronary artery bypass grafting. The SAS + CEQI cohort showed significantly lower mortality, a lower percentage of patients requiring prolonged ventilation, and a shorter mean postoperative length of hospital stay than the pre-SAS cohort who underwent on-pump coronary artery bypass grafting. The second study assessed the potential for noninvasive cerebral oximetry to reduce strokes related to all cardiac surgery by optimizing cerebral oxygen delivery. The incidence of permanent stroke was significantly lower in the cerebral oximetry group than in an earlier control group in which cerebral oximetry was not used, despite the fact that the study group had a significantly greater number of patients in New York Heart Association classes III and IV. The proportion of patients requiring prolonged ventilation was significantly lower, and the length of postoperative hospital stay was significantly shorter in the study group than in the control group. The incidence of cerebrovascular accident in the study group was 0.97%, compared with 2.03% in the controls. This translated to a potential avoidance of 12 cerebrovascular accidents and approximately $254,214 in direct costs and more than $425,000 in total costs. The results show that specific measures can improve outcomes and reduce costs in cardiac surgery. Therefore, the use of a clinical effectiveness quality initiative and cerebral oximetry in all cardiac surgery, with the SAS system for off-pump surgery, should be advocated.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Custos de Cuidados de Saúde , Oximetria/economia , Acidente Vascular Cerebral/etiologia , Ponte de Artéria Coronária sem Circulação Extracorpórea/economia , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/cirurgia , Análise Custo-Benefício , Humanos , Incidência , Tempo de Internação/economia , Morbidade , Guias de Prática Clínica como Assunto , Respiração Artificial/economia , Estudos Retrospectivos , Acidente Vascular Cerebral/economia , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento
20.
Heart Surg Forum ; 9(4): E690-2, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-16757424

RESUMO

BACKGROUND: The Thoratec Implantable Ventricular Assist Device (IVAD) is the only FDA-approved intracorporeal biventricular cardiac assist device. It is a titanium-coated version of its predecessor, the Paracorporeal Ventricular Assist Device (PVAD). The blood pump is compatible with the portable TLC-II driver, making home discharge feasible. METHODS: Nine consecutive patients were implanted with the IVAD from June 2005 through March 2006. The indications for support were acute heart failure in 6 cases and chronic heart failure in 3 cases. All patients were managed with maximal medical therapies including intravenous inotropic drugs prior to implant. RESULTS: All patients survived the surgical implant. Six patients were considered successful: 3 patients discharged to home and subsequently received transplantation, 2 are awaiting transplantation (1 at home and 1 in-house), and 1 patient was successfully explanted. Three patients expired postoperatively because of multiple organ system failure (2 patients) and pulmonary hemorrhage (1 patient). There were no device malfunctions. There was 1 localized driveline site infection and 1 thromboembolic event with partial visual loss. CONCLUSIONS: The IVAD is a unique device capable of providing uni- or bi-ventricular support for either acute or chronic heart failure conditions. Its versatility permits bridge to transplant or recovery options. Home discharge is feasible.


Assuntos
Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Implantação de Prótese/métodos , Adulto , Idoso , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Resultado do Tratamento
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