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1.
Ann Thorac Surg ; 2021 Aug 14.
Artigo em Inglês | MEDLINE | ID: mdl-34403692

RESUMO

BACKGROUND: Readmission after coronary artery bypass grafting (CABG) is associated with adverse outcomes and increased cost. We evaluated the impact of a high value care discharge protocol on readmission, length of stay (LOS) and discharge destination in patients undergoing isolated CABG. METHODS: In 2016, a comprehensive, patient-centered discharge protocol was implemented. A nurse practitioner was the fulcrum of this program, which focused on improving health literacy, disease management and rigorous follow-up. All patients undergoing isolated CABG between 2012-2019 were retrospectively analyzed with regard to 30-day readmission, LOS, and discharge disposition. Differences were analyzed by Mann-Whitney, chi-squared and t-tests. Analyses were repeated using propensity matching. RESULTS: A total of 910 consecutive patients undergoing isolated CABG were included in the analyses - 353 pre-protocol and 557 post-protocol. Pre-protocol patients had a readmission rate of 14.4% (n=51), compared to 6.8% (n=38) in the post-protocol patients (p<0.001). Median postoperative LOS prior to implementation was 6 days (interquartile range 5-8) compared to 5 days (interquartile range 4-6) post-implementation (p<0.001). Post-implementation, a higher proportion of patients were discharged to home compared to a skilled nursing facility (82.7% [n=461] vs 73.9% [n=261], p=0.002). Following propensity matching, 298 well-balanced patients were included for analysis and these significant reductions in LOS, readmission and discharge destination persisted. CONCLUSIONS: Implementation of a new discharge protocol was significantly associated with reduced readmission and LOS, along with higher rates of discharge to home in isolated CABG patients. Importantly, the results were sustainable and did not require additional resources, delivering high value care.

2.
Tex Heart Inst J ; 48(3)2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34383957

RESUMO

During the coronavirus disease 2019 (COVID-19) pandmic, more patients are presenting with complications late after acute myocardial infarction. We report the case of a 71-year-old man who delayed seeking medical care for 2 weeks, despite progressive shortness of breath, cough, and tactile fever, for fear of contracting COVID-19 in the hospital. Clinical and echocardiographic evaluation revealed a ventricular septal rupture secondary to acute myocardial infarction. The patient underwent urgent cardiac catheterization, followed by successful saphenous vein grafting to the left anterior descending coronary artery and open surgical repair of the ventricular septal rupture with a bovine pericardial patch. This case highlights a potential long-lasting negative effect that the COVID-19 pandemic will have on the care-seeking behavior and health of patients with acute cardiovascular disease.


Assuntos
COVID-19 , Cateterismo Cardíaco/métodos , Ponte de Artéria Coronária/métodos , Medo , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Infarto do Miocárdio com Supradesnível do Segmento ST , Ruptura do Septo Ventricular , Idoso , COVID-19/epidemiologia , COVID-19/psicologia , Angiografia Coronária/métodos , Ecocardiografia/métodos , Eletrocardiografia/métodos , Humanos , Masculino , SARS-CoV-2 , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Tempo para o Tratamento/tendências , Resultado do Tratamento , Ruptura do Septo Ventricular/diagnóstico , Ruptura do Septo Ventricular/etiologia , Ruptura do Septo Ventricular/fisiopatologia , Ruptura do Septo Ventricular/cirurgia
3.
J Card Surg ; 36(5): 1668-1671, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-32939825

RESUMO

BACKGROUND AND AIM: First reported in December of 2019, the COVID-19 pandemic caused by SARS-CoV-2 has had a profound impact on the implementation of care. Here, we describe our institutional experience with a rapid influx of patients at the epicenter of the pandemic. METHODS: We retrospectively review our experience with the departments of cardiology, cardiothoracic surgery, anesthesia, and critical care medicine and summarize protocols developed in the midst of the pandemic. RESULTS: The rapid influx of patients requiring an intensive level of care required a complete restructuring of units, including the establishment of a new COVID-19 negative unit for the care of patients requiring urgent or emergent non-COVID-19 related care including open-heart surgery. This unique unit allowed for the delivery of safe and effective care in the epicenter of the pandemic. CONCLUSIONS: Here, we demonstrate the response of a large tertiary academic medical center to the COVID-19 pandemic. Specifically, we demonstrate how rapid structural changes can allow for the continued delivery of cardiac surgical care with similar outcomes as those reported before the pandemic.


Assuntos
COVID-19 , Procedimentos Cirúrgicos Cardíacos , Humanos , New York , Pandemias , Estudos Retrospectivos , SARS-CoV-2
4.
J Cardiothorac Surg ; 10: 174, 2015 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-26611877

RESUMO

BACKGROUND: Although surgical ablation of atrial fibrillation is commonly performed during concomitant coronary or valve surgery, it is still only performed in a fraction these cases when indicated, and less often in patients undergoing aneurysm surgery. We describe our experience in patients undergoing ascending aneurysm repair and concomitant atrial fibrillation ablation. METHODS: From January 2004 until November 2011, 40 patients underwent ascending aneurysm repair and atrial fibrillation ablation at our institution and were retrospectively analyzed. RESULTS: Average age was 67.6 years (43-85). Root replacement was performed in 23 (57.5 %) and arch replacement with circulatory arrest in 18 (45 %). At an average of 41.8 months, 81 % of patients were in sinus rhythm. Operative survival was 100 %, with 1 and 5 year survival of 97.5 and 93.1 %, respectively. Kaplan-Meier analysis revealed improved overall survival in patients with rhythm success (log-rank test p = 0.037). CONCLUSIONS: Aortic aneurysm repair with concomitant atrial fibrillation ablation is safe and efficacious despite the requirement for an already extensive procedure with rhythm success rates similar to those quoted in the setting of other procedures. Successful restoration of sinus rhythm improves long term survival and should be considered in patients presenting with aortic aneurysm and atrial fibrillation.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/complicações , Fibrilação Atrial/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
5.
Am J Ther ; 16(3): 204-14, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-19454859

RESUMO

The efficacy of vein grafts used in coronary and peripheral artery bypass is limited by excessive hyperplasia and fibrosis that occur early after engraftment. In the present study, we sought to determine whether low-dose spironolactone alleviates maladaptive vein graft arterialization and alters intimal reaction to coronary artery stenting. Yorkshire pigs were randomized to treatment with oral spironolactone 25 mg daily or placebo. All animals underwent right carotid artery interposition grafting using a segment of external jugular vein and, 5 days later, underwent angiography of carotid and coronary arteries. At that time, a bare metal stent was placed in the left anterior descending artery and balloon angioplasty was performed on the circumflex coronary artery. Repeat carotid and coronary angiograms were performed before euthanasia and graft excision at 30 days. Angiography revealed that venous grafts of spironolactone-treated animals had lumen diameters twice the size of controls at 5 days, a finding that persisted at 30 days. However, neointima and total vessel wall areas also were 2- to 3-fold greater in spironolactone-treated animals, and there were no differences in vessel wall layer thicknesses or collagen and elastin densities. In the coronary circulation, there were no differences between treatment groups in any vessel wall parameters in either stented or unstented vessels. Taken together, these observations suggest that low-dose spironolactone may exert a novel protective effect on remodeling in venous arterial grafts that does not depend on the reduction of hyperplastic changes but may involve dilatation of the vessel wall.


Assuntos
Angioplastia Coronária com Balão , Artérias Carótidas/cirurgia , Veias Jugulares/transplante , Espironolactona/uso terapêutico , Bloqueadores do Receptor Tipo 1 de Angiotensina II/farmacologia , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Animais , Artérias Carótidas/diagnóstico por imagem , Angiografia Coronária , Vasos Coronários/patologia , Stents , Suínos
6.
Ann Thorac Surg ; 82(4): 1407-12, 2006 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-16996943

RESUMO

BACKGROUND: First time operations on the ascending aorta are performed with low mortality, few complications, and excellent long-term results. Reoperations for aortic pathology in patients with previous cardiac surgery carry significantly more risk. Technical issues during the procedure, as well as age, preoperative New York Heart Association class, and perioperative renal dysfunction, have been shown to contribute heavily to worse outcomes. We analyzed our results with aortic reoperations with the intent of further reducing surgical risk through alterations in surgical technique or patient selection. METHODS: From July 1997 until October 2005, 147 patients having previous cardiac surgery presented with aneurysm or dissection of the ascending aorta or root. Perioperative data were retrospectively analyzed. Morbidity, mortality, and risk factors for these events were calculated. RESULTS: Eight patients expired (5.4%) after their reoperation. Significant (p < 0.05) univariate risk factors for mortality included age greater than 75 years (< 0.001), previous coronary artery bypass grafting (CABG) (< 0.008), cardiopulmonary bypass greater than 240 minutes (< 0.01), need for intraaortic balloon pump support (< 0.001), need for new CABG (< 0.007), postoperative cerebrovascular accident (< 0.032), and tracheostomy (< 0.003). Age 75 years or older (p < 0.025) was the only significant variable for death by multivariate analysis. A majority of patients (n = 87, 60%) required circulatory arrest to complete their procedure. However, neither arch involvement nor type of aortic root procedure was predictive of perioperative mortality. CONCLUSIONS: Surgery on the ascending aorta and root in patients who have had previous cardiac surgery can be performed with low mortality. Advanced age and significant coronary disease may negatively influence surgical results.


Assuntos
Aorta/cirurgia , Aneurisma Aórtico/cirurgia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Fatores Etários , Aneurisma Aórtico/epidemiologia , Procedimentos Cirúrgicos Cardíacos/métodos , Doença das Coronárias/epidemiologia , Humanos , Seleção de Pacientes , Reoperação , Fatores de Risco
8.
J Thorac Cardiovasc Surg ; 131(2): 403-11, 2006 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-16434271

RESUMO

OBJECTIVE: Epicardial, beating heart cryoablation for the treatment of atrial fibrillation may be limited by heat from intracardiac blood flow. We therefore evaluated the ability to create cryolesions using an argon-based cryoclamp device, which temporarily occludes blood flow and facilitates transmurality. METHODS: Six mongrel dogs underwent sternotomy. A clamp employing a 10-cm argon-based linear cryoablation device was used epicardially to isolate the pulmonary veins and left atrial appendage. After clamping of lesions, the probe was removed from the cryoclamp device, and the remaining linear lesions, analogous to the Cox maze III, were performed. Pulmonary vein stenosis was evaluated with the use of magnetic resonance imaging. Left atrial function and pulmonary venous flow velocities were assessed with transesophageal echocardiography. Transmurality was confirmed both electrically and histologically. Animals were then put to death at 30 days. RESULTS: All acute and chronic cryoclamp lesions produced conduction block. There was no change in right (RPV) or left pulmonary vein (LPV) diameter on the basis of magnetic resonance imaging at baseline and at planned death (RPV-1, 19.6 +/- 2.9 mm vs 16.9 +/- 2.8 mm, P = .22; RPV-2, 13.2 +/- 2.0 mm vs 11.8 +/- 1.6 mm, P = .22; and LPV, 12.2 +/- 2.4 mm vs 11.2 +/- 1.9 mm, P = .30). Left atrial function and pulmonary venous flow velocities were unchanged. Tissue sections determined transmurality in 93% of cryoclamp lesions and 84% of linear ablations performed with the 10-cm malleable probe. CONCLUSIONS: Epicardial application of this cryoclamp device on the beating heart produced transmural lesions, which persisted 30 days. Linear epicardial cryoablation was not as effective as the cryoclamp device at producing consistent transmural lesions. This novel, versatile device may be useful in treating patients with atrial fibrillation on the beating heart without cardiopulmonary bypass.


Assuntos
Fibrilação Atrial/cirurgia , Criocirurgia/instrumentação , Animais , Fibrilação Atrial/diagnóstico por imagem , Fibrilação Atrial/patologia , Estimulação Cardíaca Artificial , Constrição , Criocirurgia/métodos , Cães , Ecocardiografia Transesofagiana , Imageamento por Ressonância Magnética , Miocárdio/patologia , Veias Pulmonares
9.
Ann Thorac Surg ; 80(5): 1688-92, 2005 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-16242439

RESUMO

BACKGROUND: Patients requiring valvular heart surgery may have circumferential calcification of the ascending aorta. A variety of creative procedures have been described for managing this "porcelain aorta." We describe a technique based on replacement of the ascending aorta and proximal arch under profound hypothermic circulatory arrest, followed by the valve procedure. METHODS: Twenty-five consecutive patients with a porcelain aorta were referred for heart valve surgery. In every case the aorta was replaced under circulatory arrest before the valve procedure. Postoperative morbidity, mortality, and univariate risk factors for death were calculated. Fisher's exact test defined significant perioperative variables with a p value less than 0.05. RESULTS: Of 25 patients, 23 (92%) survived the surgery to hospital discharge. One patient had a stroke (4%) and 2 patients (8%) required reexploration for bleeding. Risk factors for perioperative death by univariate analysis included age more than 78 years (p < 0.009), cardiopulmonary bypass time longer than 200 minutes (p < 0.0001), reexploration for bleeding (p < 0.02), need for intra-aortic balloon pump support (p < 0.001), and postoperative gastrointestinal complications (p < 0.001). CONCLUSIONS: Valve replacement or repair in the patient with a porcelain aorta can be safely accomplished with a technique based on aortic replacement under circulatory arrest. Elderly patients requiring extensive procedures and prolonged periods on bypass have a substantially increased risk for postoperative complications and death.


Assuntos
Doenças da Aorta/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Idoso , Idoso de 80 Anos ou mais , Aorta/cirurgia , Doenças da Aorta/classificação , Doenças da Aorta/complicações , Ponte Cardiopulmonar , Feminino , Doenças das Valvas Cardíacas/patologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos
10.
Circulation ; 112(9 Suppl): I1-6, 2005 Aug 30.
Artigo em Inglês | MEDLINE | ID: mdl-16159799

RESUMO

BACKGROUND: The development of ablative energy sources has simplified the surgical treatment of atrial fibrillation (AF) during concomitant cardiac procedures. We report our results using argon-based endocardial cryoablation for the treatment of AF in patients undergoing concomitant cardiac procedures. METHODS AND RESULTS: Sixty-three patients with AF who were undergoing concomitant cardiac procedures had the same left atrial endocardial lesion set using a flexible argon-based cryoablative device. Mean age was 65.1+/-1.3 years. Sixty-two percent had permanent AF, whereas 38% had paroxysmal AF. Mean duration of AF was 30.5+/-4.8 months. Mean left atrial diameter was 5.5+/-0.1 cm. Mean ejection fraction was 45+/-1.4%. All endocardial lesions were performed for 1 minute once tissue temperature reached -40 degrees C. Follow-up echocardiograms were obtained to determine freedom from AF. Kaplan-Meier analysis demonstrated an 88.5% freedom from AF rate at 12 months. Ablation time was 16.8+/-0.6 minutes. There were no in-hospital deaths and no strokes. Twelve patients (19%) required postoperative permanent pacemaker placement. CONCLUSIONS: Cryoablation using this flexible argon-based device for the treatment of AF during concomitant cardiac procedures was safe and effective, with 88.5% of patients free from AF at 12 months.


Assuntos
Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos , Criocirurgia/instrumentação , Idoso , Argônio , Fibrilação Atrial/complicações , Criocirurgia/métodos , Feminino , Seguimentos , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Humanos , Tábuas de Vida , Masculino , Pessoa de Meia-Idade , Marca-Passo Artificial , Cuidados Pós-Operatórios , Estudos Prospectivos , Veias Pulmonares/cirurgia , Resultado do Tratamento
11.
Ann Thorac Surg ; 79(6): 1879-85, 2005 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15919277

RESUMO

BACKGROUND: The clinical and financial outcomes of a change in practice from traditional tracheostomy (open) to bedside percutaneous dilatational tracheostomies (PDT) was evaluated in patients who underwent cardiothoracic surgery. METHODS: During 3 years, 86 tracheostomies were performed in more than 4,000 patients who underwent cardiac surgery, 59 open and 27 PDT. A retrospective analysis was performed comparing clinical and financial outcomes of the two groups. RESULTS: There were no significant differences in demographics, medical histories, operations, or complications between open and PDT except the open group experienced more postoperative arrhythmias (70% [41 of 59] versus 44% [12 of 27], p < 0.05). Total savings associated with 1 year of PDT was $84,000, for a projected discounted savings of $283,000 during the study period. A sensitivity analysis of critical economic variables (number of tracheostomies per year, cost of operating room per minute, cost of intensive care unit bed per day) was included to evaluate the impact on cost savings. The net present value analysis, which discounts future savings by an appropriate interest rate, yielded a range of projected savings of PDT more than 5 years of $73,000 to $541,000 with a best estimate of $304,000 using figures established from our 3-year experience with PDT. Sensitivity analysis of the net present value for each critical variable was $227,000 per day of reduced intensive care unit length of stay, $180,000 per cost of operating room avoidance, $100,000 per intensive care unit bed cost per day, and $11,000 per additional tracheostomy per year. CONCLUSIONS: There were no significant clinical differences between open and PDT in cardiac surgery patients during the 3-year study period; however, PDT offered significant cost savings.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Custos de Cuidados de Saúde/estatística & dados numéricos , Sistemas Automatizados de Assistência Junto ao Leito , Traqueostomia/economia , Traqueostomia/métodos , Redução de Custos , Dilatação/métodos , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Estudos Retrospectivos , Resultado do Tratamento
12.
Ann Thorac Surg ; 79(1): 133-7; discussion 137-8, 2005 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-15620929

RESUMO

BACKGROUND: Descending thoracic and thoracoabdominal aortic aneurysms may arise in the distal aortic arch. Repair of these aneurysms has been associated with increased morbidity and operative mortality. Complex surgical and endovascular techniques have reduced the risks for this cohort. We examined outcomes utilizing an approach based on simple cross-clamping of the arch. METHODS: From July 1997 to January 2004, 272 consecutive patients had aneurysm repair through the left chest. Twenty-nine requiring profound hypothermic circulatory arrest (PHCA) were excluded. Two hundred and forty-three were divided into two groups: group I (n = 60) had distal arch involvement and required cross-clamping proximal to the left subclavian artery. Group II (n = 183) were cross-clamped distal to the subclavian. Adjuncts for neurologic and renal protection were utilized as needed. RESULTS: In-hospital mortality for all 243 patients was 3.7%. There was no difference in mortality between groups (I, 3.3% vs II, 3.8%). Group I patients also had similar rates of paraplegia (I, 0% vs II, 2.2%), stroke (I, 1.2% vs II ,1.1%), and renal failure (I, 1.7% vs II, 5.5%). Group I patients had significantly more recurrent nerve palsies (I, 33% vs II, 4.9%) although this did not translate into a higher incidence of respiratory failure. CONCLUSIONS: Repair of thoracic aneurysms arising in the distal arch can be repaired with a technique based on simple cross-clamping without an increase in mortality or major neurologic injury. Recurrent nerve palsy is much more common with this approach but is well-tolerated without increasing the need for tracheostomy.


Assuntos
Aorta Torácica , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Constrição , Complicações Pós-Operatórias/etiologia , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Anastomose Cirúrgica , Aorta Torácica/patologia , Aorta Torácica/cirurgia , Aneurisma da Aorta Abdominal/patologia , Aneurisma da Aorta Torácica/patologia , Estudos de Coortes , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Paraplegia/epidemiologia , Paraplegia/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Reimplante , Estudos Retrospectivos , Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Artéria Subclávia/cirurgia , Resultado do Tratamento , Paralisia das Pregas Vocais/epidemiologia , Paralisia das Pregas Vocais/etiologia
13.
Ann Thorac Surg ; 77(4): 1309-14; discussion 1314, 2004 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15063257

RESUMO

BACKGROUND: End-organ malperfusion is a dreaded complication of type A aortic dissections. Different strategies have been proposed to manage this complex cohort of patients. Ideal management includes the rapid restoration of organ perfusion while avoiding catastrophic rupture and tamponade. We present our experience with primary aortic repair as the optimal method of patient management. METHODS: From July 1997 until April 2003, 101 patients underwent dissection repair and were assessed for malperfusion of the central nervous system, renal, visceral or extremity circulation. Patients with coronary artery malperfusion were analyzed separately. Aortic repair was performed expeditiously utilizing femoral bypass, circulatory arrest, and antegrade perfusion after completion of the distal anastomosis. Persistent malperfusion led to additional procedures. In-hospital morbidity, end-organ salvage, and mortality were determined. Chi-square analysis defined variables contributing significantly to outcome. RESULTS: Twenty-three patients presented with malperfusion. The operative mortality for the entire cohort with malperfusion, 4.4% (n = 1), was not greater than those without it, 5.1% (n = 4). Five patients required additional procedures following aortic repair, a majority in patients with persistent extremity ischemia. All deficits resolved except for one patient with spinal ischemia and one with visceral ischemia. Visceral malperfusion was highly lethal with a mortality of 33% (n = 1). All other patients presenting with malperfusion survived to discharge. CONCLUSIONS: Patients with malperfusion in the setting of acute type A dissection should undergo immediate aortic reconstruction as the primary means of reestablishing end-organ perfusion. Early postoperative intervention for persistent deficits leads to a gratifyingly high rate of end-organ salvage.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma Aórtico/cirurgia , Doenças Vasculares Periféricas/complicações , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Dissecante/complicações , Aneurisma Dissecante/fisiopatologia , Aneurisma Aórtico/complicações , Aneurisma Aórtico/fisiopatologia , Circulação Sanguínea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias
14.
Ann Thorac Surg ; 75(6): 1953-5, 2003 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-12822644

RESUMO

Traditionally, symptomatic pericardial cysts have been treated with thoracotomy and resection. More recently, video-assisted thoracoscopic procedures for pericardial cysts have been reported. We present the case of a 43-year-old man who was suffering from a symptomatic pericardial cyst. He underwent successful resection using a computer-enhanced robotic surgical system. This case is an example of the continued extension of robotic-assisted thoracic surgery.


Assuntos
Cisto Mediastínico/cirurgia , Robótica/instrumentação , Cirurgia Assistida por Computador/instrumentação , Cirurgia Torácica Vídeoassistida/instrumentação , Adulto , Desenho de Equipamento , Humanos , Masculino , Cisto Mediastínico/diagnóstico por imagem , Tomografia Computadorizada por Raios X
15.
Ann Thorac Surg ; 75(4): 1215-20, 2003 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-12683566

RESUMO

BACKGROUND: With an increasing awareness of health issues and greater emphasis on preventive medicine, the general population is living longer and healthier lives than ever before. Physicians are taking care of older patients, many of whom may require cardiac surgical procedures. Improving cardiopulmonary bypass technology allows for safer procedures with reduced morbidity and mortality even in older patients. METHODS: We have performed a retrospective analysis of 42 consecutive nonagenarian patients who underwent open-heart procedures over a 10-year period (1993 to 2002) at our institution. Their demographic profiles, operative data, perioperative results, and long-term outcomes were recorded and analyzed. RESULTS: Twenty-two women and 20 men with an age range of 90 to 97 years (mean, 91.4 years) had open-heart surgery over the study period. The complication rate was 67% overall, consisting of 7% respiratory (pneumonia, respiratory failure, reintubation), 7% hemorrhagic or embolic (postoperative bleeding, cerebral vascular accident), 12% infectious (wound infection, sepsis), and 31% new arrhythmia (atrial fibrillation, atrial flutter, ventricular tachycardia, ventricular fibrillation). Despite these complication rates, average hospital stay was 17.5 days (median, 11 days), with an intensive care unit stay of 12.0 days (median, 5 days). Thirty-day survival was 95% and survival to discharge was 93% (three deaths total; one cardiac arrest at hospital day 134 and two perioperative deaths; one ventricular arrhythmia, one cerebral vascular accident). The only statistically significant risk factor of mortality was emergency surgery. Currently, 81% are still alive an average of 2.53 years since surgery (range, 0.16 to 7.1 years). CONCLUSIONS: With improving techniques and greater attention to detail, the select nonagenarian can safely undergo cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar , Emergências , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento
16.
Ann Thorac Surg ; 74(4): 1066-70, 2002 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-12400746

RESUMO

BACKGROUND: Advances in end-organ protection have dramatically reduced the incidence of the life-threatening complications associated with the elective repair of thoracoabdominal and descending thoracic aortic aneurysms. However, in the setting of a ruptured thoracic aneurysm, one may not have the luxury of complex end-organ support. We analyzed our experience with ruptured thoracic aneurysms to define morbidity and mortality in the present era. METHODS: One hundred seventy-two patients with thoracoabdominal or descending thoracic aneurysms were operated on between July 1997 and October 2001. Forty presented with either a contained or free rupture. Three techniques were used for aortic reconstruction: clamp and sew, left heart bypass, and hypothermic circulatory arrest. Adjuncts for neurologic and renal support were used when circumstances and anatomy permitted. RESULTS: Seven of 40 patients died in the hospital (17.5%). Four patients died intraoperatively, all of acute myocardial infarction. Five of the seven deaths were in patients who presented in shock. Two patients (5%) experienced paraplegia, 3 (7.5%) had renal failure requiring hemodialysis, 8 (20%) required a tracheostomy, and 6 (15%) had recurrent nerve palsies. There was one stroke (2.6%). Mean diameter of ruptured aneurysms was 8.5 cm. CONCLUSIONS: Ruptured thoracic aneurysms can be repaired with a gratifying rate of salvage. Rapid diagnosis and triage for repair is necessary to avoid progressive deterioration into shock. The incidence of myocardial infarction, and the mortality associated with this event, underscores the need for aggressive cardiac evaluation in the elective thoracic aneurysm patient. The size at rupture also emphasizes the need for earlier referral for elective aneurysm repair.


Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Ruptura Aórtica/cirurgia , Sacarose/análogos & derivados , Adulto , Idoso , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Abdominal/mortalidade , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/mortalidade , Ruptura Aórtica/complicações , Ruptura Aórtica/mortalidade , Árvores de Decisões , Ácidos Graxos , Humanos , Pessoa de Meia-Idade
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