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1.
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
2.
JACC Cardiovasc Imaging ; 14(4): 797-808, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33832663

RESUMO

OBJECTIVES: This study was designed to compare the clinical and echocardiographic characteristics, management, and outcomes of severe atrial functional mitral regurgitation (AFMR) to primary mitral regurgitation (PMR). BACKGROUND: AFMR remains poorly defined clinically. METHODS: Consecutive patients who underwent transesophageal echocardiography at our institution between 2011 and 2018 for severe mitral regurgitation with preserved left ventricular function were screened. We excluded patients with endocarditis, any form of cardiomyopathy, or prior mitral intervention. The absence of leaflet pathology defined AFMR. Outcomes included death and heart failure hospitalizations. RESULTS: A total of 283 patients were included (AFMR = 14%, PMR = 86%). Compared to PMR, patients with AFMR had more comorbidities, including hypertension (94.9% vs. 76.2%; p = 0.015), diabetes mellitus (46.2% vs. 18.4%; p < 0.001), long-standing atrial fibrillation (28.2% vs. 13.1%; p = 0.015), prior nonmitral cardiac surgery (25.6% vs. 9.8%; p = 0.004), and pacemaker placement (33.3% vs. 13.5%; p = 0.002). They also had higher average E/e' (median [interquartile range]:16.04 [13.1 to 22.46] vs. 14.1 [10.89 to 19]; p = 0.036) and worse longitudinal left atrial strain peak positive value (16.86 ± 12.15% vs. 23.67 ± 14.09%; p = 0.002) compared to PMR. During follow-up (median: 22 months), patients with AFMR had worse survival (log-rank p = 0.009) and more heart failure hospitalizations (log-rank p = 0.002). They were also less likely to undergo mitral valve intervention (59.0% vs. 83.6%; p = 0.001), although surgery was associated with improved survival (log-rank p = 0.021). On multivariable regression analysis, AFMR was independently associated with mortality [adjusted odds ratio: 2.61, 95% confidence interval: 1.17 to 5.83; p = 0.02]. CONCLUSIONS: AFMR constitutes an under-recognized high-risk group, with significant comorbidities, limited therapeutic options, and poor outcomes.


Assuntos
Insuficiência da Valva Mitral , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Humanos , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/terapia , Valor Preditivo dos Testes
3.
Cardiol Clin ; 39(2): 211-220, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33894935

RESUMO

In most patients, minimally invasive approaches to mitral valve surgery are technically possible. However, in practice, patient selection is critical to mitigate safety concerns when performing the procedure. In this article, we describe our approach to preoperative assessment for minimally invasive mitral valve surgery candidacy, as well as discussing the technical aspects of procedure execution.

5.
6.
J Thorac Cardiovasc Surg ; 162(1): 83, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32111426
8.
J Thorac Cardiovasc Surg ; 161(5): 1724-1730, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-31924356

RESUMO

OBJECTIVE: Redo sternotomy in patients with arterial cardiac structures adherent to the sternum carries a risk of catastrophic bleeding. In some of those cases, particularly if they have undergone multiple previous operations, deep hypothermic circulatory arrest alone may not provide sufficient time for a controlled dissection. METHODS: We present a series of 6 cases at risk for exsanguination during sternal re-entry successfully reoperated using percutaneous cardioplegic cardiac arrest induced before completed sternal re-entry to avoid or minimize the hypothermic circulatory arrest time. RESULTS: All patients survived their complex operations. CONCLUSIONS: Percutaneous cardioplegic arrest allows safer repeat sternotomy in patients with arterial cardiac structures adherent to the sternum.

10.
J Atr Fibrillation ; 12(6): 2129, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33024483

RESUMO

Aims: Post cardiac surgery atrial fibrillation (POAF) is common, with adverse implications. However, relatively little is known regarding the time varying nature of risk factors associated with POAF. We describe variation in POAF along with its associated risk factors. Methods: Medical records of adult patients undergoing cardiac valve surgery from 2003-13, without a history of pre-operative AF were analyzed retrospectively. POAF was adjudicated using inpatient and outpatient electrocardiograms (EKG). Risk of AF over time along with time-varying risk factors were estimated using multiphase non-linear logistic mixed effects model. Results: 10,461 patients with 100,149 EKGs were analyzed [median follow-up 4 months (IQR 48 hours-2 years)]. AF prevalence changed with time since surgery and two distinct phases were identified. Prevalence peaked to 13% at 2 weeks (early phase) and 9% near 7 years post-operatively (late phase). Older age, greater severity of preoperative tricuspid valve (TV) regurgitation, mitral valve replacement and prior cardiac surgery were time-independent risk factors for POAF. TV repair was associated with a decreased risk of early phase POAF. Pre-operative blood urea nitrogen, peripheral vascular disease and hypertension were associated with a higher risk of late phase POAF. Conclusions: POAF risk shows two distinct phases with an early peak and a late gradual rise, each associated with a different set of risk factors.

11.
Echocardiography ; 37(11): 1723-1731, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32949217

RESUMO

BACKGROUND: Mitral annular calcification (MAC) is prevalent in the aging population, with recent renewed interest regarding its associations with cardiovascular risk factors, outcomes, and influence on valvular heart disease and interventions. This meta-analysis aimed to report the relationships between MAC and cardiovascular mortality and morbidity events. METHODS: Relevant studies were searched from PubMed, Cochrane, and Embase databases until November 30, 2019. Associations between MAC as a binary variable with death and cardiovascular events were pooled using random-effects models. The main outcomes of interest were all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, atrial fibrillation, and procedural outcomes. RESULTS: Among 799 article abstracts and 122 full-text articles screened, 26 (16 prospective and 10 retrospective) studies totaling 35 070 subjects were analyzed. MAC was associated with higher all-cause death, hazard ratio (95% confidence interval) 1.76 (1.43-2.22), and cardiovascular mortality 1.85 (1.45-23.5). It also positively correlated with myocardial infarction 1.48 (1.22-1.79), stroke 1.51 (1.22-2.05), incidental heart failure 1.55 (1.30-1.84), atrial fibrillation 1.75 (1.43-2.15), and their composite, major adverse cardiovascular events (MACE). Finally, conversion to mitral valve replacement at time of cardiac surgery was more in patients with MAC than without MAC, with odds ratio (95% confidence interval) 2.82 (1.28-6.18). CONCLUSION: Mitral annular calcification was overall associated with higher rates of death, and both individual and composite cardiovascular events. The presence of increasingly encountered MAC has significant clinical implications for cardiovascular risk assessment and valvular interventions.


Assuntos
Calcinose , Doenças das Valvas Cardíacas , Idoso , Humanos , Valva Mitral/diagnóstico por imagem , Estudos Prospectivos , Estudos Retrospectivos
13.
Lancet ; 396(10245): 177-185, 2020 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682483

RESUMO

BACKGROUND: Atrial fibrillation and delirium are common consequences of cardiac surgery. Dexmedetomidine has unique properties as sedative agent and might reduce the risk of each complication. This study coprimarily aimed to establish whether dexmedetomidine reduces the incidence of new-onset atrial fibrillation and the incidence of delirium. METHODS: A randomised, placebo-controlled trial was done at six academic hospitals in the USA. Patients who had had cardiac surgery with cardiopulmonary bypass were enrolled. Patients were randomly assigned 1:1, stratified by site, to dexmedetomidine or normal saline placebo. Randomisation was computer generated with random permuted block size 2 and 4, and allocation was concealed by a web-based system. Patients, caregivers, and evaluators were all masked to treatment. The study drug was prepared by the pharmacy or an otherwise uninvolved research associate so that investigators and clinicians were fully masked to allocation. Participants were given either dexmedetomidine infusion or saline placebo started before the surgical incision at a rate of 0·1 µg/kg per h then increased to 0·2 µg/kg per h at the end of bypass, and postoperatively increased to 0·4 µg/kg per h, which was maintained until 24 h. The coprimary outcomes were atrial fibrillation and delirium occurring between intensive care unit admission and the earlier of postoperative day 5 or hospital discharge. All analyses were intention-to-treat. The trial is registered with ClinicalTrials.gov, NCT02004613 and is closed. FINDINGS: 798 patients of 3357 screened were enrolled from April 17, 2013, to Dec 6, 2018. The trial was stopped per protocol after the last designated interim analysis. Among 798 patients randomly assigned, 794 were analysed, with 400 assigned to dexmedetomidine and 398 assigned to placebo. The incidence of atrial fibrillation was 121 (30%) in 397 patients given dexmedetomidine and 134 (34%) in 395 patients given placebo, a difference that was not significant: relative risk 0·90 (97·8% CI 0·72, 1·15; p=0·34). The incidence of delirium was non-significantly increased from 12% in patients given placebo to 17% in those given dexmedetomidine: 1·48 (97·8% CI 0·99-2·23). Safety outcomes were clinically important bradycardia (requiring treatment) and hypotension, myocardial infarction, stroke, surgical site infection, pulmonary embolism, deep venous thrombosis, and death. 21 (5%) of 394 patients given dexmedetomidine and 8 (2%) of 396 patients given placebo, had a serious adverse event as determined by clinicians. 1 (<1%) of 391 patients given dexmedetomidine and 1 (<1%) of 387 patients given placebo died. INTERPRETATION: Dexmedetomidine infusion, initiated at anaesthetic induction and continued for 24 h, did not decrease postoperative atrial arrhythmias or delirium in patients recovering from cardiac surgery. Dexmedetomidine should not be infused to reduce atrial fibrillation or delirium in patients having cardiac surgery. FUNDING: Hospira Pharmaceuticals.


Assuntos
Fibrilação Atrial/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Delírio/prevenção & controle , Dexmedetomidina/administração & dosagem , Hipnóticos e Sedativos/administração & dosagem , Esquema de Medicação , Feminino , Humanos , Infusões Intravenosas , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Resultado do Tratamento
14.
Artigo em Inglês | MEDLINE | ID: mdl-32089343

RESUMO

OBJECTIVE: The dissemination of mitral valve repair as the first-line treatment and the introduction of MitraClip for patients who have a prohibitive risk for surgery have changed the landscape of mitral valve intervention. The aim of this study is to provide current and generalizable data regarding the trend of mitral valve interventions and outcomes from 2000 to 2016. METHODS: Patients ≥18 years of age who underwent mitral-valve interventions were identified using the National Inpatient Sample database. National estimates were generated by means of discharge weights; comorbid conditions were identified using Elixhauser methods. All trends were analyzed with JoinPoint software. RESULTS: A total of 656,030 mitral valve interventions (298,102 mitral valve replacement, 349,053 mitral valve repair, and 8875 MitraClip) were assessed. No changes in rate of procedures (per 100,000 people in the United States) were observed over this period (annual percent change, -0.4; 95% confidence limit, -1.1 to 0.3; P = .3). From 2000 to 2010, the number of replacements decreased by 5.6% per year (P < .001), whereas repair increased by 8.4% per year from 2000 to 2006 (P < .001). MitraClip procedures increased by 84.4% annually from 2013 to 2016 (P < .001). The burden of comorbidities increased throughout the study for all groups, with the greatest score for MitraClip recipients. Overall, length of stay has decreased for all interventions, most significantly for MitraClip. In-hospital mortality decreased from 8.5% to 3.7% for all interventions, with MitraClip having the most substantial decrease from 3.6% to 1.5%. CONCLUSIONS: Over a 17-year period, mitral-valve interventions were associated with improved outcomes despite being applied to an increasingly sicker population.

20.
Cardiovasc Diagn Ther ; 9(4): 379-385, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31555543

RESUMO

Endurance athletes, particularly competitive runners, are using wrist worn devices with the heart rate (HR) feature to guide their training. However, few studies have assessed the effectiveness of these at high levels of exertion. The purpose of this study was to measure the accuracy of the HR monitor feature in four watches at six different treadmill speeds. This prospective study recruited 50 healthy, athletic adults (68% male, mean age of 29, and mean BMI of 23 kg/m2). All subjects wore a three lead ECG and Polar H7 chest strap monitor and two different randomly assigned wrist worn HR monitors. These included the Apple Watch III, Fitbit Iconic, Garmin Vivosmart HR, and Tom Tom Spark 3. Once all devices were on, they were asked to run at the following speeds on a treadmill (in mph): 4, 5, 6, 7, 8, and 9 for two min. HR was assessed on all devices and agreement among measurements determined with Lin's concordance correlation coefficient (CCC) (rc). The Polar H7 chest strap had the greatest agreement with the ECG (rc=98). This was followed by the Apple Watch III (rc=96). The Fitbit Iconic, Garmin Vivosmart HR, and Tom Tom Spark 3 all had the same level of agreement (rc=89). The Polar H7 chest strap was the most accurate, and the Apple Watch was superior among watches. For endurance athletes and their coaches, a chest strap device or Apple Watch may be the best choice for guiding workouts and performance.

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