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1.
J Gastrointest Surg ; 2019 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-30945088

RESUMO

BACKGROUND: Optimization of perioperative fluid management is a controversial issue. Weight-adjusted, fixed fluid strategies do not take into account patient hemodynamic status, so that individualized strategies guided by relevant variables may be preferable. We studied this issue in patients undergoing pancreatic surgery within our institution. METHODS: All patients who underwent a laparotomy for pancreatic cancer during a 5-month period at our hospital (AOUI of Verona, Italy) were eligible to be included in this prospective, observational study. According to the responsible anesthesiologist's free choice, patients received, during surgery, either liberal (12 ml/kg/h) or restricted (4 ml/kg/h) fixed-volume weight-guided replacement fluids or goal-directed (GD) fluid replacement using stroke volume variation (SVV) determined by the FloTrac Vigileo device. RESULTS: Eighty-six patients were included: 29 in the liberal group, 23 in the restricted group, and 34 in the GD group. The mean duration of surgery was 6 [4-7] h. Patients in the liberal group received more perioperative fluid than those in the GD and restricted groups. Nearly one third of all patients had a major complication, including delayed enteral feeding, and presented a longer duration of hospital stay. Despite the biases related to our limited cohort, there were significantly fewer postoperative complications (such as postoperative fistula, abdominal collection, and hemorrhage) in the restricted and GD groups of patients than in the liberal one. CONCLUSION: In patients undergoing pancreatic surgery, a restricted or individually guided GD strategy for management of perioperative fluids can result in fewer complications than a liberal fluid strategy. Larger and randomized investigations are warranted to confirm these data on this domain.

2.
Am J Cardiol ; 121(5): 642-648, 2018 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-29329825

RESUMO

Results of transcatheter aortic valve implantation (TAVI) for treatment of severe noncalcific isolated aortic regurgitation (AR) complicated by advanced heart failure or cardiogenic shock has been previously reported only in isolated case reports. Current self-expanding transcatheter aortic valves are designed to treat aortic valve stenosis, and have also been implanted in cases of severe AR due to degenerated bioprosthesis and in very few cases of native aortic valves. We report 13 consecutive inoperable patients with noncalcific, pure AR, and advanced heart failure treated with emergency percutaneous transfemoral implantation with self-expandable CoreValves at our institution between July 2012 and September 2017. The immediate and long-term clinical outcome was prospectively assessed according to the Valve Academic Research Consortium-2 criteria for device success and safety. All but 3 patients had previous surgery of the aortic root, including 2 implants of Heart Mate-II left ventricle assist device; none had surgical aortic bioprosthesis at the time of the TAVI. Valve implantation was successful in 12 of 13 patients (92%) and 1 patient required a second unplanned valve procedure within 18 hours. Oversizing the prosthesis by approximately 15% yielded better results with 1 valve. Two patients with left ventricle assist device died within 30 days of TAVI. All patients who survived to hospital discharge had none or just mild residual AR, improved their cardiac function, and survived at long-term without recurrence of clinical events. In conclusion, implanting self-expandable transcatheter valves in patients pure AR in this small study was safe and effective, and represented an important option for inoperable patients with noncalcific severe AR.

3.
EuroIntervention ; 13(13): 1512-1519, 2018 01 20.
Artigo em Inglês | MEDLINE | ID: mdl-28846545

RESUMO

AIMS: We sought to assess eventual changes in iFR measurements in patients with aortic stenosis (AS) before and after TAVI in coronary lesions with different degrees of angiographic severity. METHODS AND RESULTS: The functional relevance of 145 coronary lesions was assessed by online iFR and FFR measurement in 66 patients with severe AS before and after TAVI, during the same procedure. The iFR-FFR classification agreement was calculated for pre-TAVI and post-TAVI measurements. Mean iFR values remained identical before and after TAVI, irrespective of the angiographic severity of the coronary stenosis (0.89±0.12 vs. 0.89±0.12, p=0.66). However, individual iFR values varied widely after TAVI and the 0.89 iFR threshold was crossed by 15% of the investigated coronary lesions. Higher iFR variation was related to a higher transaortic gradient drop after valve intervention. The diagnostic accuracy of iFR in predicting an FFR ≤0.8 was poor (65%) in lesions with severe obstructions, and tended to increase post TAVI. CONCLUSIONS: Although overall values did not change after TAVI, iFR presented significant and mostly erratic individual variations after valve replacement. Delta iFR was influenced by the extent of the transaortic gradient drop induced by TAVI. Therefore, caution is advisable in the interpretation of iFR in the presence of AS.

4.
Cardiovasc Revasc Med ; 19(3 Pt B): 355-359, 2018 Apr - May.
Artigo em Inglês | MEDLINE | ID: mdl-29113864

RESUMO

BACKGROUND: The complexity of coronary physiology in presence of severe aortic stenosis (AS) raises concerns about the reliability of pressure-derived indexes in this clinical setting. Furthermore, neither fractional flow reserve (FFR) nor instantaneous wave-free period (iFR) has been validated in AS. Combining iFR and FFR in a tailored decision-making strategy may help to increase simplicity, accuracy and safety of physiology-guided revascularization in AS. METHODS: In this prospective observational study iFR and FFR were measured before and after TAVI during the same procedure in patients with severe AS and concomitant coronary artery disease (CAD). All decisions about revascularization were based on post-TAVI FFR assessment. The best iFR "defer" and "treatment" values were identified according to their baseline negative (NPV) and positive predictive values (PPV) respectively. A post-hoc analysis was then performed to compare the hybrid iFR-FFR approach with the FFR-only strategy. RESULTS: Sixty-two patients underwent pre- and post-TAVI pressure-wire assessment and were included in the analysis. A "defer iFR value" >0.93 yielded a NPV of 98.4% (91.7%-99.9%) to exclude FFR non-significant stenosis (>0.80), and a "treatment iFR value" <0.83 had a PPV of 91.3% (72%-98.9%) to identify FFR-significant stenosis (≤0.80). A hybrid decision-making strategy based on iFR and FFR spared 63% of patients from adenosine, while maintaining 97% overall agreement with FFR lesions classification. CONCLUSION: A hybrid iFR-FFR diagnostic strategy is feasible and safe in patients with severe AS undergoing TAVI and allows to spare the majority of patients from adenosine, while maintaining a high agreement with FFR classification of coronary lesions.

6.
Minerva Med ; 109(1): 31-40, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28730800

RESUMO

Detecting coronary artery disease at a subclinical level has always been a challenging task for cardiologists. Various non-invasive echocardiographic approaches such as measurements of left ventricular hypertrophy, diastolic function, left atrial enlargement, valve sclerosis and calcification, epicardial fat thickness, and pulse wave velocity have been proposed to integrate the available risk-charts. The present review is a collection of evidence that supports the role of the above mentioned features in cardiac risk stratification, summarizing the state of the art in non-invasive echocardiographic coronary risk assessment. Each parameter is presented with its strengths and weaknesses, aiming to trace the future directions for the development of a reliable non-invasive approach.


Assuntos
Doença da Artéria Coronariana/diagnóstico por imagem , Ecocardiografia , Doenças Assintomáticas , Doenças Cardiovasculares/diagnóstico por imagem , Humanos , Melhoria de Qualidade , Medição de Risco/métodos , Fatores de Risco
7.
Ther Hypothermia Temp Manag ; 7(2): 101-106, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28437236

RESUMO

Therapeutic hypothermia is recommended by international guidelines after cardio-circulatory arrest. However, the effects of different temperatures during the first 24 hours after deep hypothermic circulatory arrest (DHCA) for aortic arch surgery on survival and neurologic outcome are undefined. We hypothesize that temperature variation after aortic arch surgery is associated with survival and neurologic outcome. In the period 2010-2014, a total of 210 consecutive patients undergoing aortic arch surgery with DHCA were included. They were retrospectively divided into three groups by median nasopharyngeal temperature within 24 hours after rewarming: hypothermia (<36°C; n = 65), normothermia (36-37°C; n = 110), and hyperthermia (>37°C; n = 35). Multivariate stepwise logistic and linear regressions were performed to determine whether different temperature independently predicted 30-day mortality, stroke incidence, and neurologic outcome assessed by cerebral performance category (CPC) at hospital discharge. Compared with normothermia, hyperthermia was independently associated with a higher risk of 30-day mortality (28.6% vs. 10.9%; odds ratio [OR] 2.8; 95% confidence interval [CI], 1.1-8.6; p = 0.005), stroke incidence (64.3% vs. 9.1%; OR 9.1; 95% CI, 2.7-23.0; p = 0.001), and poor neurologic outcome (CPC 3-5) (68.8% vs. 39.6%; OR 4.8; 95% CI, 1.4-8.7; p = 0.01). No significant differences were demonstrated between hypothermia and normothermia. Postoperative hypothermia is not associated with a better outcome after aortic arch surgery with DHCA. However, postoperative hyperthermia (>37°C) is associated with high stroke incidence, poor neurologic outcome, and increased 30-day mortality. Target temperature management in the first 24 hours after surgery should be evaluated in prospective randomized trials.


Assuntos
Parada Circulatória Induzida por Hipotermia Profunda , Reaquecimento , Adulto , Idoso , Aorta Torácica/cirurgia , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Parada Circulatória Induzida por Hipotermia Profunda/mortalidade , Parada Circulatória Induzida por Hipotermia Profunda/estatística & dados numéricos , Disfunção Cognitiva/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Reaquecimento/efeitos adversos , Reaquecimento/métodos , Reaquecimento/mortalidade , Reaquecimento/estatística & dados numéricos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Temperatura Ambiente
8.
Microvasc Res ; 112: 109-114, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28385576

RESUMO

OBJECTIVE: The hemolytic product free-hemoglobin (fHb) reduces nitric oxide (NO) bioavailability. The present study aims to establish whether administration of different blood transfusions result in increased circulating fHb levels and NO consumption with effects on arterial NO-dependent blood flow in patients undergoing CABG surgery. METHODS: Ninety-five consecutive patients undergoing elective CABG surgery were prospectively divided in four groups based on blood transfusion requirements during surgery: stored blood cells (SBC, n. 21), intraoperative autologous salvaged blood (ASB, n. 25), SBC and ASB (n.22), no transfusion (control, n. 27). Blood samples were collected before and after intervention to analyse plasma levels of fHb and NO consumption. Endothelium-dependent relaxation was assessed in left internal mammary artery (LIMA) rings harvested before chest closure. Peripheral artery tonometry was assessed after intervention. RESULTS: Transfusions with SBC increased plasma fHb (p<0.05). Transfusions of ASB resulted in higher plasma fHb compared to SBC (p<0.01). fHb concentrations directly correlated with NO consumption (r=0.65, p<0.001). Maximal endothelium-dependent relaxation in LIMA was significantly attenuated in SBC and ASB patients compared to control (15.2±3.1% vs 21.1±2.5% vs 43±5.0% respectively; p<0.01). Significant correlations were identified between the aortic pressure wave velocity, plasma fHb concentration and NO consumption (p<0.01). CONCLUSIONS: Intraoperative blood transfusions and particularly autologous salvaged blood impair endothelium-dependent relaxation through NO scavenging by fHb. These findings obtained in vitro and in vivo provide new insights into the adverse relation between blood transfusions and patient outcome.


Assuntos
Transfusão de Sangue Autóloga/efeitos adversos , Transfusão de Sangue , Ponte de Artéria Coronária/efeitos adversos , Endotélio Vascular/fisiopatologia , Artéria Torácica Interna/fisiopatologia , Artéria Torácica Interna/cirurgia , Vasodilatação , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Endotélio Vascular/metabolismo , Feminino , Hemoglobinas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Óxido Nítrico/metabolismo , Recuperação de Sangue Operatório , Estudos Prospectivos , Análise de Onda de Pulso , Rigidez Vascular
9.
Am J Cardiol ; 120(4): 625-631, 2017 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-27964903

RESUMO

Coronary artery disease (CAD) is often present in patients with severe aortic valve stenosis candidates to transcatheter aortic valve implantation (TAVI). Mild CAD may also worsen and need treatment years after TAVI. The implantation of a transcatheter valve may interfere with the capability of reengaging the coronary arteries. We prospectively assessed the feasibility of performing coronary angiography (CA), fractional flow reserve, and, where indicated, percutaneous coronary intervention after valve implantation in a consecutive series of patients with CAD undergoing TAVI. Valve type and size were decided according to accurate computed tomography scan and angiographic measurement of the aortic root structures. We analyzed 66 consecutive patients undergoing TAVI, 41 with balloon-expandable, and 25 with self-expandable transcatheter valves. Right and left coronary catheterization (132 vessels) was successful in all cases except in 1 left coronary artery after a high implantation of a self-expandable valve (unsuccess rate, 1 in 50 vessels). In 6 of 132 vessels (4%), CA was initially nonselective, but after positioning the 0.014″ intracoronary guidewire, selective injections were obtained in all these cases. Percutaneous coronary intervention was performed successfully in 19 coronary vessels (17 patients) as indicated by fractional flow reserve measurements. In conclusion, catheterization of the coronary ostia after transfemoral TAVI with balloon or self-expandable valves is safe and feasible in almost all cases. Accurate imaging of the aortic root and procedural planning may help to avoid too high implantation of supra-annular self-expandable valves to obviate difficulties in accessing coronary ostia. Use of intracoronary guidewires facilitates selective CA in cases with difficult access.


Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco/métodos , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/cirurgia , Intervenção Coronária Percutânea , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/diagnóstico por imagem , Estudos de Viabilidade , Feminino , Seguimentos , Próteses Valvulares Cardíacas , Humanos , Masculino , Estudos Prospectivos , Reoperação , Fatores de Risco , Resultado do Tratamento
10.
Circ Cardiovasc Interv ; 9(11)2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27803040

RESUMO

BACKGROUND: Aortic valve stenosis may influence fractional flow reserve (FFR) of concomitant coronary artery disease by causing hypertrophy and reducing the vasodilatory reserve of the coronary circulation. We sought to investigate whether FFR values might change after valve replacement. METHODS AND RESULTS: The functional relevance of 133 coronary lesions was assessed by FFR in 54 patients with severe aortic valve stenosis before and after transcatheter aortic valve implantation (TAVI) during the same procedure. A linear mixed model was used to verify the interaction of TAVI effect with the FFR values. No significant overall change in FFR values was found before and after the aortic valve stenosis removal (0.89±0.10 versus 0.89±0.13; P=0.73). A different trend in FFR groups (positive if ≤0.8; negative if >0.8) was found after TAVI (P for interaction <0.001). Positive FFR values worsened after TAVI (0.71±0.11 versus 0.66±0.14). Conversely, negative FFR values improved after TAVI (0.92±0.06 versus 0.93±0.07). Similarly, FFR values in coronary arteries with lesions presenting percent diameter stenosis >50 worsened after TAVI (0.84±0.12 versus 0.82±0.16; P=0.02), whereas FFR values in arteries with mild lesions (percent diameter stenosis <50) tended toward improvement after TAVI (0.90±0.07 versus 0.91±0.09; P=0.69). Functional FFR variations after TAVI changed the indication to treat the coronary stenosis in 8 of 133 (6%) lesions. CONCLUSIONS: Coronary hemodynamics are influenced by aortic valve stenosis removal. Nevertheless, FFR variations after TAVI are minor and crossed the diagnostic cutoff of 0.8 in a small number of patients after valve replacement. Borderline coronary lesions might become functionally significant after valve replacement, although FFR-guided interventions were infrequent even in patients with angiographically significant lesions.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Doença da Artéria Coronariana/diagnóstico , Circulação Coronária , Vasos Coronários/fisiopatologia , Hemodinâmica , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/fisiopatologia , Cateterismo Cardíaco , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/fisiopatologia , Ecocardiografia , Feminino , Reserva Fracionada de Fluxo Miocárdico , Humanos , Modelos Lineares , Masculino , Estudos Prospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento , Vasodilatação
11.
Open Heart ; 3(2): e000420, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27621826

RESUMO

OBJECTIVE: The use of transcatheter aortic valve implantation (TAVI) is growing rapidly in countries with a predominantly elderly population, posing a huge challenge to healthcare systems worldwide. The increment of human and economic resource consumption imposes a careful monitoring of clinical outcomes and cost-benefit balance, and this article is aimed at analysing clinical outcomes related to the TAVI learning curve. METHODS: Outcomes of 177 consecutive transfemoral TAVI procedures performed in 5 years by a single team were analysed by the Cumulative Sum of failures method (CUSUM) according to the clinical events comprised in the Valve Academic Research Consortium (VARC-2) safety end point and the VARC-2 definition of device success. Margins for events acceptance were extrapolated from landmark trials that tested both balloon or self-expandable percutaneous valves. RESULTS: 30-day and 1-year survival rates were 97.2% and 89.9%, respectively. Achievement of the primary end point (number of cases needed to provide the acceptable margin of the composite end point of any death, stroke, myocardial infarction, life-threatening bleeding, major vascular complications, stage 2-3 acute kidney injury and valve-related dysfunction requiring a repeat procedure) required the performance of 54 cases, while the learning curve to achieve 'device success' identified 32 cases to reach the expected proficiency. In this experience, the baseline clinical risk as assessed by the Society of Thoracic Surgeons (STS) score determined the long-term survival rather than the adverse events related to the learning curve. CONCLUSIONS: A relatively large number of cases are required to achieve clinical outcomes comparable to those reported in high-volume centres and controlled trials. According to our national workload standards, this represents more than 2 years of continuous activity.

13.
Cardiovasc Pathol ; 25(4): 336-338, 2016 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26522681

RESUMO

Mitral annular caseoma is a common incidental finding involving the posterior annulus. It has an innocent nature, with the exception of its endocarditic degeneration and/or a stenotic functional effect when exophytic. We report an exceptionally rare isolated anterior mitral annular caseoma involving also the anterior mitral leaflet and affecting its physiologic systolic movement, thus resulting in a restricting anterior leaflet motion responsible for mitral insufficiency. The case was successfully treated by complex mitral valve repair.


Assuntos
Calcinose/patologia , Insuficiência da Valva Mitral/patologia , Valva Mitral/patologia , Idoso , Calcinose/complicações , Calcinose/cirurgia , Procedimentos Cirúrgicos Cardíacos , Ecocardiografia , Ecocardiografia Transesofagiana , Humanos , Masculino , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/cirurgia
14.
J Thorac Cardiovasc Surg ; 150(5): 1303-12.e4, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26277475

RESUMO

OBJECTIVES: Intraoperative assessment of the proper neochordal length during mitral plasty may be complex sometimes. Patient-specific finite element models were used to elucidate the biomechanical drawbacks underlying an apparently correct mitral repair for isolated posterior prolapse. METHODS: Preoperative patient-specific models were derived from cardiac magnetic resonance images; integrated with intraoperative surgical details to assess the location and extent of the prolapsing region, including the number and type of diseased chordae; and complemented by the biomechanical properties of mitral leaflets, chordae tendineae, and artificial neochordae. We investigated postoperative mitral valve biomechanics in a wide spectrum of different techniques (single neochorda, double neochordae, and preconfigured neochordal loop), all reestablishing adequate valvular competence, but differing in suboptimal millimetric expanded polytetrafluoroethylene suture lengths in a range of ±2 mm, compared with the corresponding "ideal repair." RESULTS: Despite the absence of residual regurgitation, alterations in chordal forces and leaflet stresses arose simulating suboptimal repairs; alterations were increasingly relevant as more complex prolapse anatomies were considered and were worst when simulating single neochorda implantation. Multiple chordae implantations were less sensitive to errors in neochordal length tuning, but associated postoperative biomechanics were hampered when asymmetric configurations were reproduced. Computational outcomes were consistent with the presence and entity of recurrent mitral regurgitation at midterm follow-up of simulated patients. CONCLUSIONS: Suboptimal suture length tuning significantly alters chordal forces and leaflet stresses, which may be key parameters in determining the long-term outcome of the repair. The comparison of the different simulated techniques suggests possible criteria for the selection and implementation of neochordae implantation techniques.


Assuntos
Cordas Tendinosas/transplante , Implante de Prótese de Valva Cardíaca/efeitos adversos , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Prolapso da Valva Mitral/cirurgia , Valva Mitral/transplante , Fenômenos Biomecânicos , Cordas Tendinosas/patologia , Cordas Tendinosas/fisiopatologia , Simulação por Computador , Análise de Elementos Finitos , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Imagem por Ressonância Magnética , Valva Mitral/patologia , Valva Mitral/fisiopatologia , Anuloplastia da Valva Mitral/instrumentação , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/fisiopatologia , Prolapso da Valva Mitral/diagnóstico , Prolapso da Valva Mitral/fisiopatologia , Modelos Cardiovasculares , Politetrafluoretileno , Valor Preditivo dos Testes , Desenho de Prótese , Recidiva , Fatores de Risco , Técnicas de Sutura , Suturas , Falha de Tratamento
15.
Microvasc Res ; 101: 8-14, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26002544

RESUMO

BACKGROUND: To investigate changes in red blood cell (RBC) rheology over time in critically ill patients with sepsis and their relationship with outcome. METHODS: In this prospective, non-interventional study, RBC rheology was assessed using the Laser-assisted Optical Rotational Cell Analyzer in a convenience sample of intensive care unit (ICU) patients with (n=64) and without (n=160) sepsis. Results were compared to measures in healthy volunteers (n=20). RBC rheology was also assessed on days 1 and 3 of the ICU stay in 32 of the non-septic and 19 of the septic patients. RBC deformability was determined by the elongation index (EI) in relation to the shear stress (0.3 to 50Pa) applied to the RBC membrane. An aggregation index (AI) was assessed simultaneously with the same device. RESULTS: The ICU mortality rate of the septic patients was 31%. RBC deformability was already reduced in septic patients at ICU admission, an effect that persisted during the study period and worsened in the non-survivors for the large majority of shear stresses studied (e.g., EI for 50Pa of shear stress was 0.527±0.064 in non-survivors vs. 0.566±0.034 in survivors, p<0.05). These changes were not observed in non-septic patients. The AI was more elevated in septic than in non-septic patients at ICU admission, but had no prognostic value. CONCLUSIONS: Alterations in RBC rheology, including reduced deformability and increased aggregation, occur early in septic patients and reductions in RBC deformability over time are associated with a poor outcome.


Assuntos
Deformação Eritrocítica , Eritrócitos/citologia , Sepse/sangue , Sepse/fisiopatologia , Adulto , Cuidados Críticos , Agregação Eritrocítica , Membrana Eritrocítica/metabolismo , Feminino , Humanos , Lasers , Masculino , Pessoa de Meia-Idade , Pressão , Prognóstico , Estudos Prospectivos , Reologia , Resistência ao Cisalhamento , Estresse Mecânico , Resultado do Tratamento
16.
Microvasc Res ; 98: 23-8, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25433297

RESUMO

The use of high concentrations of inhaled oxygen has been associated with adverse effects but recent data suggest a potential therapeutic role of normobaric hyperoxia (NH) in sepsis and cerebral ischemia. Hyperoxia may induce vasoconstriction and alter endothelial function, so we evaluated its effects on the microcirculation in 40 healthy adult volunteers using side-stream dark field (SDF) video-microscopy on the sublingual area and near-infrared spectroscopy (NIRS) on the thenar eminence. In a first group of volunteers (n=18), measurements were taken every 30 min: at baseline in air, during NH (close to 100% oxygen via a non-rebreathing mask) and during recovery in air. In a second group (n=22), NIRS measurements were taken in NH or ambient air on two separate days to prevent any potential influence of repeated NIRS measurements. NH significantly decreased the proportion of perfused vessels (PPV) from 92% to 66%, perfused vessel density (PVD) from 11.0 to 7.3 vessels/mm, perfused small vessel density (PSVD) from 9.0 to 5.8 vessels/mm and microvascular flow index (MFI) from 2.8 to 2.0, and increased PPV heterogeneity from 7.5% to 30.4%. Thirty minutes after return to air, PPV, PVD, PSVD and MFI remained partially altered. During NH, NIRS descending slope and NIRS muscle oxygen consumption (VO2) decreased from 8.5 to 7.9%/s and 127 to 103 units, respectively, in the first group and from 10.7 to 9.4%/s and 150 to 115 units in the second group. NH, therefore, alters the microcirculation in healthy subjects, decreasing capillary perfusion and VO2 and increasing the heterogeneity of the perfusion.


Assuntos
Hiperóxia/metabolismo , Microcirculação , Oxigênio/química , Adulto , Isquemia Encefálica/metabolismo , Capilares/patologia , Feminino , Voluntários Saudáveis , Hemodinâmica , Humanos , Hiperemia/metabolismo , Isquemia , Masculino , Microscopia de Vídeo , Soalho Bucal/irrigação sanguínea , Consumo de Oxigênio , Perfusão , Sepse/metabolismo , Espectroscopia de Luz Próxima ao Infravermelho
17.
Eur J Cardiothorac Surg ; 47(2): 291-8; discussion 298, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24740935

RESUMO

OBJECTIVES: To evaluate if pulsatile cardiopulmonary bypass (CPB) has any protective influence on renal function in elderly patients undergoing aortic valve replacement (AVR). METHODS: Forty-six patients (≥ 75 years old) with aortic valve stenosis underwent AVR with either pulsatile perfusion (PP) or non-pulsatile perfusion (NP) during CPB. Haemodynamic efficacy of the blood pump during either type of perfusion was described in terms of the energy equivalent pressure and the surplus haemodynamic energy. Urine samples were collected before surgery, at sternum closure, and at 2 and 18 h of intensive care unit stay to detect acute kidney injury markers. Perioperative urine levels of N-acetyl-ß-D-glucosaminidase (NAG), kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin (NGAL) were assessed together with plasma creatinine, creatinine clearance (CCr) and 24-h haemodynamic monitoring. Normally distributed continuous variables were described as mean ± standard deviation and non-normally distributed data were presented as the median [25th-75th percentiles]. RESULTS: PP was characterized by a significantly higher amount of surplus haemodynamic energy transferred to the patients (P < 0.001), with lower mean systemic vascular resistance during CPB (P = 0.020) and during 18 h postoperatively (group-P = 0.018). No difference was found between pre- and postoperative CCr in the PP group (71 ± 23 vs 60 ± 35 ml/min, P = 0.27), while its statistically significant perioperative decrement was observed in the NP group (67 ± 24 vs 45 ± 15 ml/min, P < 0.001). The PP group showed significantly lower urinary levels of NAG at 18 h postoperatively (P = 0.008), and NGAL at sternum closure (P = 0.010), 2 h (P < 0.001) and 18 h (P = 0.015) postoperatively. CONCLUSIONS: Short-term PP in elderly patients showed higher safety for renal physiology than NP, resulting in better maintenance of glomerular filtration and lower renal tissue injury.


Assuntos
Lesão Renal Aguda/epidemiologia , Valva Aórtica/cirurgia , Ponte Cardiopulmonar/efeitos adversos , Perfusão/efeitos adversos , Lesão Renal Aguda/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/métodos , Feminino , Hemodinâmica/fisiologia , Humanos , Testes de Função Renal , Masculino , Perfusão/métodos
18.
Cardiovasc Revasc Med ; 15(5): 295-7, 2014 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24445212

RESUMO

Left ventricular assistance with surgically implanted pump devices like the HeartMate may be crucial in selected patient with end-stage heart failure. However, mainly due to its high aortic output, the pump itself may induce severe aortic regurgitation that could result in paradoxycal worsening of the anterograde perfusion after the initiation of the support. Surgical or percutaneous occlusion of the aortic valve has proved useful in these kinds of patients. Here we present a successful case of bail-out CoreValve implantation after HeartMate II positioning complicated by acute severe aortic regurgitation in a patient with a failing homograft and end-stage ventricular dysfunction, ineligible for heart transplanation.


Assuntos
Aloenxertos/cirurgia , Insuficiência da Valva Aórtica/terapia , Implante de Prótese de Valva Cardíaca/instrumentação , Coração Auxiliar , Substituição da Valva Aórtica Transcateter/instrumentação , Cateterismo Cardíaco/métodos , Insuficiência Cardíaca/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Função Ventricular Esquerda
19.
J Crit Care ; 29(1): 144-9, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24120089

RESUMO

PURPOSE: The aim of this study was to assess the role of blood soluble urokinase-type plasminogen activator receptor (suPAR) levels in the diagnosis and prognostication of sepsis in critically ill patients. METHODS: Serum suPAR levels were measured prospectively in adult intensive care unit (ICU) patients on admission and then daily until ICU discharge (maximum of 14 days) using an enzyme-linked immunosorbent assay kit. Normal levels were established in 31 healthy controls. RESULTS: We included 258 patients (161 men); median admission Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were 17 (9-23) and 6 (3-9), respectively. The mortality rate was 13.6%. Sepsis was diagnosed on admission in 94 patients (36%), of whom 23 had severe sepsis and 49 had septic shock. On admission, septic patients had higher suPAR levels than did nonseptic patients (8.9 [5.9-12.7] vs 3.7 [2.7-5.4] ng/mL), but the predictive value of suPAR for diagnosing sepsis was weaker than that of C-reactive protein. During the week after ICU admission, serum suPAR concentrations correlated with Sequential Organ Failure Assessment scores over time. High suPAR levels on admission were a strong independent predictor for ICU and 28-day mortality. In the global population, a suPAR level higher than 6.15 ng/mL had 66% sensitivity and 64% specificity for prediction of ICU mortality, with a receiver operating characteristic area under the curve of 0.726 (95% confidence interval, 0.645-0.808). CONCLUSIONS: In ICU patients, serum suPAR concentrations have limited use for identifying sepsis, but their time course correlated with the degree of organ dysfunction, and they have prognostic value in septic and nonseptic populations.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva/estatística & dados numéricos , Sepse/fisiopatologia , Ativador de Plasminogênio Tipo Uroquinase/sangue , APACHE , Adulto , Idoso , Biomarcadores , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Prognóstico , Estudos Prospectivos , Curva ROC , Sepse/sangue , Sepse/mortalidade
20.
J Cardiothorac Vasc Anesth ; 27(6): 1384-98, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24103711

RESUMO

OBJECTIVE: To identify all interventions that increase or reduce mortality in patients with acute kidney injury (AKI) and to establish the agreement between stated beliefs and actual practice in this setting. DESIGN AND SETTING: Systematic literature review and international web-based survey. PARTICIPANTS: More than 300 physicians from 62 countries. INTERVENTIONS: Several databases, including MEDLINE/PubMed, were searched with no time limits (updated February 14, 2012) to identify all the drugs/techniques/strategies that fulfilled all the following criteria: (a) published in a peer-reviewed journal, (b) dealing with critically ill adult patients with or at risk for acute kidney injury, and (c) reporting a statistically significant reduction or increase in mortality. MEASUREMENTS AND MAIN RESULTS: Of the 18 identified interventions, 15 reduced mortality and 3 increased mortality. Perioperative hemodynamic optimization, albumin in cirrhotic patients, terlipressin for hepatorenal syndrome type 1, human immunoglobulin, peri-angiography hemofiltration, fenoldopam, plasma exchange in multiple-myeloma-associated AKI, increased intensity of renal replacement therapy (RRT), CVVH in severely burned patients, vasopressin in septic shock, furosemide by continuous infusion, citrate in continuous RRT, N-acetylcysteine, continuous and early RRT might reduce mortality in critically ill patients with or at risk for AKI; positive fluid balance, hydroxyethyl starch and loop diuretics might increase mortality in critically ill patients with or at risk for AKI. Web-based opinion differed from consensus opinion for 30% of interventions and self-reported practice for 3 interventions. CONCLUSION: The authors identified all interventions with at least 1 study suggesting a significant effect on mortality in patients with or at risk of AKI and found that there is discordance between participant stated beliefs and actual practice regarding these topics.


Assuntos
Lesão Renal Aguda/prevenção & controle , Lesão Renal Aguda/terapia , Lesão Renal Aguda/mortalidade , Comorbidade , Pesquisas sobre Serviços de Saúde , Hemodinâmica , Humanos , Internet , Monitorização Intraoperatória , Assistência Perioperatória
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