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1.
Ann Thorac Surg ; 2021 Dec 24.
Artigo em Inglês | MEDLINE | ID: mdl-34958771

RESUMO

BACKGROUND: Surgical aortic valve replacement can be performed either through a minimally invasive (MI) or full sternotomy (FS) approach. The present study compared outcomes of MI versus FS for isolated surgery among patients enrolled in the PARTNER 3 low-risk trial. METHODS: Patients with severe, symptomatic aortic stenosis at low surgical risk with anatomy suitable for transfemoral access were eligible for PARTNER 3 enrollment. The primary outcome was the composite endpoint of death, stroke, or rehospitalization (valve-, procedure-, or heart-failure-related) at 1 year. Secondary outcomes included the individual components of the primary endpoint as well as patient-reported health status at 30 days and 1 year. RESULTS: In the PARTNER 3 study, 358 patients underwent isolated surgery at 68 centers through an MI (n=107) or FS (n=251) approach (8 patients were converted from MI to FS). Mean age and Society of Thoracic Surgeons score were similar between groups. The Kaplan-Meier estimate of the primary outcome was similar in the MI versus FS groups (16.9% versus 14.9%; hazard ratio [95% CI]: 1.15 [0.66 - 2.03]; P=0.618). There were no significant differences in the 1-year rates of all-cause death (2.8% versus 2.8%), all stroke (1.9% versus 3.6%), or rehospitalization (13.3% versus 10.6%, P > 0.05 for all). Quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire score at 30 days or 1 year was comparable in both groups. CONCLUSIONS: For patients at low risk for isolated surgery, MI and FS approaches were associated with similar in-hospital and 1-year outcomes.

2.
Ann Thorac Surg ; 2021 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-34785247

RESUMO

BACKGROUND: The relationship between institutional volume and operative mortality following SAVR remains unclear. METHODS: From 1/2013 to 6/2018, 234,556 patients underwent isolated SAVR (n=144,177) or SAVR+CABG (n=90,379) within the STS ACSD. The association between annualized SAVR volume [Group 1 (1-25 SAVR), Group 2 (26-50 SAVR), Group 3 (51-100 SAVR), and Group 4 (>100 SAVR)] and operative mortality and composite major morbidity/mortality was assessed. Random effects models were used to evaluate whether historic (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes. RESULTS: The annualized median number of SAVRs per site was 35 [IQR: 22-59, isolated AVR: 20, AVR+CABG: 13]. Among isolated SAVR cases, the mean operative mortality and composite morbidity/mortality were 1.5% and 9.7%, respectively, at the highest volume sites (Group 4); with significantly higher rates among progressively lower volume groups (p-trend<0.001). After adjustment, lower volume centers experienced increased odds of operative mortality [Group 1 vs. 4 (Ref): AOR (SAVR), 2.24 (1.91-2.64); AOR (SAVR+CABG), 1.96 (1.67-2.30)] and major morbidity/mortality [AOR (SAVR), 1.53 (1.39-1.69); AOR (SAVR+CABG), 1.46 (1.32-1.61)] compared to the highest volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category and prior outcomes explained a greater proportion of hospital operative outcomes than prior volume. CONCLUSIONS: Operative outcomes following SAVR±CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive than prior volume of future outcomes. Given excellent outcomes observed at many lower volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

3.
JACC Cardiovasc Interv ; 14(18): 1995-2005, 2021 09 27.
Artigo em Inglês | MEDLINE | ID: mdl-34556273

RESUMO

OBJECTIVES: The aim of this study was to compare 5-year cardiovascular, renal, and bioprosthetic valve durability outcomes in patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). BACKGROUND: Patients with severe AS and CKD undergoing TAVR or SAVR are a challenging, understudied clinical subset. METHODS: Intermediate-risk patients with moderate to severe CKD (estimated glomerular filtration rate <60 mL/min/m2) from the PARTNER (Placement of Aortic Transcatheter Valve) 2A trial (patients randomly assigned to SAPIEN XT TAVR or SAVR) and SAPIEN 3 Intermediate Risk Registry were pooled. The composite primary outcome of death, stroke, rehospitalization, and new hemodialysis was evaluated using Cox regression analysis. Patients with and without perioperative acute kidney injury (AKI) were followed through 5 years. A core laboratory-adjudicated analysis of structural valve deterioration and bioprosthetic valve failure was also performed. RESULTS: The study population included 1,045 TAVR patients (512 SAPIEN XT, 533 SAPIEN 3) and 479 SAVR patients. At 5 years, SAVR was better than SAPIEN XT TAVR (52.8% vs 68.0%; P = 0.04) but similar to SAPIEN 3 TAVR (52.8% vs 58.7%; P = 0.89). Perioperative AKI was more common after SAVR than TAVR (26.3% vs 10.3%; P < 0.001) and was independently associated with long-term outcomes. Compared with SAVR, bioprosthetic valve failure and stage 2 or 3 structural valve deterioration were significantly greater for SAPIEN XT TAVR (P < 0.05) but not for SAPIEN 3 TAVR. CONCLUSIONS: In intermediate-risk patients with AS and CKD, SAPIEN 3 TAVR and SAVR were associated with a similar risk for the primary endpoint at 5 years. AKI was more common after SAVR than TAVR, and SAPIEN 3 valve durability was comparable with that of surgical bioprostheses.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Próteses Valvulares Cardíacas , Insuficiência Renal Crônica , Substituição da Valva Aórtica Transcateter , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Humanos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
4.
Artigo em Inglês | MEDLINE | ID: mdl-34419402

RESUMO

OBJECTIVES: The aim of this study was to evaluate the role of wall shear stress (WSS) as a predictor of ascending aorta (AAo) growth at 5 years or greater follow-up. BACKGROUND: Aortic 4-dimensional flow cardiac magnetic resonance (CMR) can quantify regions exposed to high WSS, a known stimulus for arterial wall dysfunction. However, its association with longitudinal changes in aortic dilation in patients with bicuspid aortic valve (BAV) is unknown. METHODS: This retrospective study identified 72 patients with BAV (45 ± 12 years) who underwent CMR for surveillance of aortic dilation at baseline and ≥5 years of follow-up. Four-dimensional flow CMR analysis included the calculation of WSS heat maps to compare regional WSS in individual patients with population averages of healthy age- and sex-matched subjects (database of 136 controls). The relative areas of the AAo and aorta (in %) exposed to elevated WSS (outside the 95% CI of healthy population averages) were quantified. RESULTS: At a median follow-up duration of 6.0 years, the mean AAo growth rate was 0.24 ± 0.20 mm/y. The fraction of the AAo exposed to elevated WSS at baseline was increased for patients with higher growth rates (>0.24 mm/y, n = 32) compared with those with growth rates <0.24 mm/y (19.9% [interquartile range (IQR): 10.2-25.5] vs 5.7% [IQR: 1.5-21.3]; P = 0.008). Larger areas of elevated WSS in the AAo and entire aorta were associated with higher rates of AAo dilation >0.24 mm/y (odds ratio: 1.51; 95% CI: 1.05-2.17; P = 0.026 and odds ratio: 1.70; 95% CI: 1.01-3.15; P = 0.046, respectively). CONCLUSIONS: The area of elevated AAo WSS as assessed by 4-dimensional flow CMR identified BAV patients with higher rates of aortic dilation and thus might determine which patients require closer follow-up.

5.
JACC Cardiovasc Interv ; 14(14): 1565-1574, 2021 07 26.
Artigo em Inglês | MEDLINE | ID: mdl-34294398

RESUMO

OBJECTIVES: The aim of this study was to assess the incidence and prognostic impact of early and late postoperative atrial fibrillation or flutter (POAF) in patients with severe aortic stenosis (AS) treated with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). BACKGROUND: There is an ongoing controversy regarding the incidence, recurrence rate, and prognostic impact of early (in-hospital) POAF and late (postdischarge) POAF in patients with AS undergoing TAVR or SAVR. METHODS: In the PARTNER (Placement of Aortic Transcatheter Valve) 3 trial, patients with severe AS at low surgical risk were randomized to TAVR or SAVR. Analyses were performed in the as-treated population excluding patients with preexistent atrial fibrillation or flutter. RESULTS: Among 781 patients included in the analysis, early POAF occurred in 152 (19.5%) (18 of 415 [4.3%] and 134 of 366 [36.6%] following TAVR and SAVR, respectively). Following discharge, 58 new or recurrent late POAF events occurred within 1 year following the index procedure in 55 of 781 patients (7.0%). Early POAF was not an independent predictor of late POAF following discharge (odds ratio: 1.04; 95% CI: 0.52-2.08; P = 0.90). Following adjustment, early POAF was not an independent predictor of the composite outcome of death, stroke, or rehospitalization (hazard ratio: 1.10; 95% CI: 0.64-1.92; P = 0.72), whereas late POAF was associated with an increased adjusted risk for the composite outcome (hazard ratio: 8.90; 95% CI: 5.02-15.74; P < 0.0001), irrespective of treatment modality. CONCLUSIONS: In the PARTNER 3 trial, early POAF was more frequent following SAVR compared with TAVR. Late POAF, but not early POAF, was significantly associated with worse outcomes at 2 years, irrespective of treatment modality.


Assuntos
Estenose da Valva Aórtica , Fibrilação Atrial , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Assistência ao Convalescente , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/cirurgia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Alta do Paciente , Fatores de Risco , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
7.
Radiol Cardiothorac Imaging ; 3(3): e200456, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34235440

RESUMO

Stanford type B aortic dissection (TBAD) is associated with relatively high rates of morbidity and mortality, and appropriate treatment selection is important for optimizing patient outcomes. Depending on individualized risk factors, clinical presentation, and imaging findings, patients are generally stratified to optimal medical therapy anchored by antihypertensives or thoracic endovascular aortic repair (TEVAR). Using standard anatomic imaging with CT or MRI, several high-risk features including aortic diameter, false lumen (FL) features, size of entry tears, involvement of major aortic branch vessels, or evidence of visceral malperfusion have been used to select patients likely to benefit from TEVAR. However, even with these measures, the number needed to treat for TEVAR remains, and improved risk stratification is needed. Increasingly, the relationship between FL hemodynamics and adverse aortic remodeling in TBAD has been studied, and evolving noninvasive techniques can measure numerous FL hemodynamic parameters that may improve risk stratification. In addition to summarizing the current clinical state of the art for morphologic TBAD evaluation, this review provides a detailed overview of noninvasive methods for TBAD hemodynamics characterization, including computational fluid dynamics and four-dimensional flow MRI. Keywords: CT, Image Postprocessing, MRI, Cardiac, Vascular, Aorta, Dissection © RSNA, 2021.

10.
Interact Cardiovasc Thorac Surg ; 33(3): 325-332, 2021 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-33893493

RESUMO

OBJECTIVES: This study was conducted to determine if gender bias explains the worse outcomes in women than in men who undergo mitral valve surgery for degenerative mitral regurgitation. METHODS: Patients who underwent mitral valve surgery for degenerative mitral regurgitation with or without concomitant ablation surgery for atrial fibrillation were identified from the Cardiovascular Research Database of the Clinical Trial Unit of the Bluhm Cardiovascular Institute at Northwestern Memorial Hospital and were defined according to the Society of Thoracic Surgery National Adult Cardiac Surgery Database. Of the 1004 patients (33% female, mean age 62.1 ± 12.4 years; 67% male, mean age 60.1 ± 12.4 years) who met this criteria, propensity score matching was utilized to compare sex-related differences. RESULTS: Propensity score matching of 540 patients (270 females, mean age 61.0 ± 12.2; 270 males, mean age 60.9 ± 12.3) demonstrated that 98% of mitral valve surgery performed in both groups was mitral valve repair and 2% was mitral valve replacement. Preoperative CHA2DS2-VASc scores were higher in women and fewer women were discharged directly to their homes. Before surgery, women had smaller left heart chambers, lower cardiac outputs, higher diastolic filling pressures and higher volume responsiveness than men. However, preoperative left ventricular and right ventricular strain values, which are normally higher in women, were similar in the 2 groups, indicating worse global strain in women prior to surgery. CONCLUSIONS: The worse outcomes reported in women compared to men undergoing surgery for degenerative mitral regurgitation are misleading and not based on gender bias except in terms of referral patterns. Men and women who present with the same type and degree of mitral valve disease and similar comorbidities receive the same types of surgical procedures and experience similar postoperative outcomes. Speckle-tracking echocardiography to assess global longitudinal strain of the left and right ventricles should be utilized to monitor for myocardial dysfunction related to chronic mitral regurgitation.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Doenças das Valvas Cardíacas , Insuficiência da Valva Mitral , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/diagnóstico por imagem , Valva Mitral/cirurgia , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/cirurgia , Estudos Retrospectivos , Sexismo , Resultado do Tratamento
12.
J Am Heart Assoc ; 10(7): e019584, 2021 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-33754803

RESUMO

Background The impact of atrial fibrillation (AF) in intermediate surgical risk patients with severe aortic stenosis who undergo either transcatheter or surgical aortic valve replacement (AVR) is not well established. Methods and Results Data were assessed in 2663 patients from the PARTNER (Placement of Aortic Transcatheter Valve) 2A or S3i trials. Analyses grouped patients into 3 categories according to their baseline and discharge rhythms (ie, sinus rhythm [SR]/SR, SR/AF, or AF/AF). Among patients with transcatheter AVR (n=1867), 79.2% had SR/SR, 17.6% had AF/AF, and 3.2% had SR/AF. Among patients with surgical AVR (n=796), 71.7% had SR/SR, 14.1% had AF/AF, and 14.2% had SR/AF. Patients with transcatheter AVR in AF at discharge had increased 2-year mortality (SR/AF versus SR/SR; hazard ratio [HR], 2.73; 95% CI, 1.68-4.44; P<0.0001; AF/AF versus SR/SR; HR, 1.56; 95% CI, 1.16-2.09; P=0.003); patients with SR/AF also experienced increased 2-year mortality relative to patients with AF/AF (HR, 1.77; 95% CI, 1.04-3.00; P=0.03). For patients with surgicalAVR, the presence of AF at discharge was also associated with increased 2-year mortality (SR/AF versus SR/SR; HR, 1.93; 95% CI, 1.25-2.96; P=0.002; and AF/AF versus SR/SR; HR, 1.67; 95% CI, 1.06-2.63; P=0.027). Rehospitalization and persistent advanced heart failure symptoms were also more common among patients with transcatheter AVR and surgical AVR discharged in AF, and major bleeding was more common in the transcatheter AVR cohort. Conclusions The presence of AF at discharge in patients with intermediate surgical risk aortic stenosis was associated with worse outcomes-especially in patients with baseline SR-including increased all-cause mortality at 2-year follow-up. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01314313 and NCT03222128.


Assuntos
Estenose da Valva Aórtica/cirurgia , Fibrilação Atrial/complicações , Frequência Cardíaca/fisiologia , Complicações Pós-Operatórias/epidemiologia , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Fibrilação Atrial/fisiopatologia , Eletrocardiografia , Feminino , Humanos , Incidência , Masculino , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
13.
J Am Coll Cardiol ; 77(9): 1149-1161, 2021 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-33663731

RESUMO

BACKGROUND: In low surgical risk patients with symptomatic severe aortic stenosis, the PARTNER 3 (Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis) trial demonstrated superiority of transcatheter aortic valve replacement (TAVR) versus surgery for the primary endpoint of death, stroke, or re-hospitalization at 1 year. OBJECTIVES: This study determined both clinical and echocardiographic outcomes between 1 and 2 years in the PARTNER 3 trial. METHODS: This study randomly assigned 1,000 patients (1:1) to transfemoral TAVR with the SAPIEN 3 valve versus surgery (mean Society of Thoracic Surgeons score: 1.9%; mean age: 73 years) with clinical and echocardiography follow-up at 30 days and at 1 and 2 years. This study assessed 2-year rates of the primary endpoint and several secondary endpoints (clinical, echocardiography, and quality-of-life measures) in this as-treated analysis. RESULTS: Primary endpoint follow-up at 2 years was available in 96.5% of patients. The 2-year primary endpoint was significantly reduced after TAVR versus surgery (11.5% vs. 17.4%; hazard ratio: 0.63; 95% confidence interval: 0.45 to 0.88; p = 0.007). Differences in death and stroke favoring TAVR at 1 year were not statistically significant at 2 years (death: TAVR 2.4% vs. surgery 3.2%; p = 0.47; stroke: TAVR 2.4% vs. surgery 3.6%; p = 0.28). Valve thrombosis at 2 years was increased after TAVR (2.6%; 13 events) compared with surgery (0.7%; 3 events; p = 0.02). Disease-specific health status continued to be better after TAVR versus surgery through 2 years. Echocardiographic findings, including hemodynamic valve deterioration and bioprosthetic valve failure, were similar for TAVR and surgery at 2 years. CONCLUSIONS: At 2 years, the primary endpoint remained significantly lower with TAVR versus surgery, but initial differences in death and stroke favoring TAVR were diminished and patients who underwent TAVR had increased valve thrombosis. (Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients With Aortic Stenosis [PARTNER 3]; NCT02675114).


Assuntos
Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/cirurgia , Complicações Pós-Operatórias/mortalidade , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/tendências , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico por imagem , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento
15.
Am J Cardiol ; 148: 116-123, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33691183

RESUMO

The prognostic impact of preexisting atrial fibrillation or flutter (AF) in low-risk patients with severe aortic stenosis treated with transcatheter (TAVR) or surgical aortic valve replacement (SAVR) remains unknown. In this sub-analysis of the PARTNER 3 trial of patients with severe aortic stenosis at low surgical risk randomized 1:1 to TAVR versus SAVR, clinical outcomes were analyzed at 2 years according to AF status. Among 948 patients included in the analysis (452 [47.7%] in the SAVR vs 496 [52.3%] in the TAVR arm), 168 (17.6%) patients had AF [88/452 (19.5%) and 80/496 (16.1%) treated with SAVR and TAVR, respectively]. At 2 years, patients with AF had higher unadjusted rates of the composite outcome of death, stroke or rehospitalization (21.2% vs 12.9%, p = 0.007) and rehospitalization alone (15.3% vs 9.4%, p = 0.03) but not all cause death (3.8% vs 2.6%, p = 0.45) or stroke (4.8% vs 2.6%, p = 0.12). In adjusted analyses, patients with AF had a higher risk for the composite outcome of death, stroke or rehospitalization (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.20-2.71, p = 0.0046) and rehospitalization alone (HR 1.8, 95% CI 0.12-2.9, p = 0.015), but not death or stroke. There was no interaction between treatment modality and AF on the composite outcome (Pinter = 0.83). In conclusion, preexisting AF in patients with severe AS at low surgical risk was associated with increased risk of the composite outcome of death, stroke or rehospitalization at 2 years, irrespective of treatment modality.


Assuntos
Estenose da Valva Aórtica/cirurgia , Fibrilação Atrial/epidemiologia , Mortalidade , Readmissão do Paciente/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia , Substituição da Valva Aórtica Transcateter , Idoso , Estenose da Valva Aórtica/epidemiologia , Comorbidade , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Prognóstico , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Resultado do Tratamento
16.
Artigo em Inglês | MEDLINE | ID: mdl-33610367

RESUMO

OBJECTIVE: To determine the prevalence of concomitant aortic regurgitation (AR) in cardiac surgery and the outcomes of treatment options. METHODS: Between April 2004 and June 2018, 3289 patients underwent coronary artery bypass, mitral valve, or aortic aneurysm surgery without aortic stenosis. AR was graded none/trivial (score = 0), mild (score = 1+), or moderate (score = 2+). Patients with untreated 2+ AR were compared with those with 0 or 1+ AR, and to those with 2+ AR who had aortic valve surgery. Thirty-day and late survival, echocardiography, and clinical outcomes were compared using propensity score matching. RESULTS: One hundred thirty-eight patients (4.2%) had 2+ AR; and 45 (33%) received aortic valve repair (n = 9) or replacement (n = 36) in the treated group and were compared with 2765 untreated patients with 0 AR and 386 patients with 1+ AR. Valve surgery was more common with anatomic leaflet abnormalities: bicuspid aortic valve (9% vs 0%; P < .01), rheumatic valve disease (16% vs 3%; P < .01), and calcification (47% vs 27%; P = .021). In unadjusted analysis, lower preoperative AR grade was associated with increased 10-year survival (P < .001). At year 10, progression to more-than-moderate AR among moderate AR patients was 2.6% and late intervention rate was 3.1%. In the untreated 2+ AR group, on last follow-up echocardiogram, 58% had improvement in AR, 41% remained 2+, and only 1% progressed to severe AR. CONCLUSIONS: Aortic valve surgery in select patients with concomitant moderate AR can be added with minimal added risk, but untreated AR does not influence long-term survival after cardiac surgery and rarely required late intervention.

17.
J Card Surg ; 36(4): 1543-1545, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33586231

RESUMO

Four-dimensional (4D) flow magnetic resonance imaging (MRI) has not been used to describe flow through a Thoraflex Hybrid graft. We present the first 4D flow MRI depiction of Thoraflex Hybrid graft after use as a frozen elephant trunk to repair a DeBakey Type I aortic dissection.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Imageamento por Ressonância Magnética
18.
Ann Thorac Surg ; 111(3): 809-817, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32791060

RESUMO

BACKGROUND: Surgical ablation of atrial fibrillation (AF) concomitant with cardiac surgery is a Society of Thoracic Surgeons (STS) class I recommendation, although the AF is frequently ignored. Analysis of the STS Database 30-day outcomes of isolated surgical aortic valve replacement (AVR) with and without AF ablation is presented. METHODS: Data on 87,426 surgical aortic valve replacement patients were extracted from the STS database (version 2.81, 2014-2017) and patients were divided into 3 groups: (1) No preoperative AF, (2) Preoperative AF with concomitant ablation, and (3) Preoperative AF without ablation. The latter 2 groups were propensity score-matched in 1-(up)-to-2 ratio to alleviate covariate imbalances and reduce bias. Thirty-day outcomes were evaluated and compared. RESULTS: Preoperative AF was present in 17.8% (15,596 of 87,426 patients). Ablation was performed in 33.1% (5,167 of 15,596), and 57.7% (2,983) had left atrial appendage closure. Propensity score matching (AF ablated n = 3692; AF non-ablated n = 5724), revealed that there was no difference between the AF ablated and AF non-ablated groups in mortality (2.8% vs 3.0%, respectively; P = .65) or for stroke (1.6% vs 1.7%, respectively; P = .82), but postoperative pacemaker implantation was higher in the AF ablated patients (6.8% AF ablated vs 5.0% AF non-ablated, P < .001). CONCLUSIONS: Despite being a class I recommendation, AF ablation concomitantly with other cardiac surgical procedures remains lower than current guideline recommendation in surgical aortic valve replacement patients. Ablation for AF does not increase the 30-day operative mortality or perioperative morbidity compared with non-ablated patients, although new pacemaker requirements were higher in the AF ablated group.


Assuntos
Valva Aórtica/cirurgia , Fibrilação Atrial/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Idoso , Fibrilação Atrial/complicações , Ablação por Cateter/métodos , Feminino , Doenças das Valvas Cardíacas/complicações , Mortalidade Hospitalar/tendências , Humanos , Illinois/epidemiologia , Masculino , Fatores de Risco
19.
Ann Thorac Surg ; 112(2): 354-362, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33279545

RESUMO

BACKGROUND: Although cryosurgery has been used to treat cardiac arrhythmias for nearly 5 decades, the mechanism of action and the surgical technique that produces optimal cryolesions for the treatment of atrial fibrillation are still poorly understood. This has resulted in surgical outcomes that can be improved by a better understanding the mechanisms of cryothermia ablation and the proper surgical techniques that take advantage of those mechanisms. METHODS: The cryobiology underlying cryosurgical ablation is described, as are the nuances of cryosurgical techniques that ensure the reliable creation of contiguous, uniformly transmural atrial cryolesions. The oft-misunderstood "2-minute rule" for the application of cryothermia is clarified in detail, along with its variations that depend on target myocardial temperature. RESULTS: The creation of optimal cryolesions depends on cryoprobe temperature, the temperature of the target myocardium, the duration of cryothermia application, and the presence or absence of a "heat sink" or "cooling sink" created by intracavitary blood circulation. Cryothermia kills myocardial cells during both the freezing and thawing phases of cryoablation cycle. The critical lethal temperature for myocardium is -30°C. The slower the target tissue thaws, the higher the percentage of cell death. CONCLUSIONS: The availability of cryosurgical techniques has revolutionized the surgical treatment of atrial fibrillation. By utilizing modern cryosurgical devices and adhering to the technical principles described, surgeons can now perform surgical procedures for atrial fibrillation that are quicker, safer, and as effective as the standard Maze-III/IV procedure.


Assuntos
Criocirurgia/métodos , Miocárdio/patologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Temperatura Corporal , Morte Celular , Humanos
20.
Ann Thorac Surg ; 111(6): 1884-1891, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-32987022

RESUMO

BACKGROUND: Sutureless/rapid-deployment (SRD) valves for aortic valve replacement (AVR) are new surgical bioprosthetic valves that allow for expedited implantation and facilitate minimally invasive approaches. Although clinical trial data are available for SRDs in the United States, how their clinical outcomes compare with traditional stented bioprosthetic (SBP) valves is unknown in a post-approval, commercial setting. METHODS: The Society of Thoracic Surgery Adult Cardiac Surgery Database was queried for patients who underwent an AVR. Transcatheter AVR cases were excluded. Thirty-day outcomes were compared between SRD valves (Perceval S [LivaNova, Houston, TX] and Intuity Elite [Edwards Lifesciences, Irvine CA]) and SBP valve patients. The SRD and SBP patients were propensity score-matched in a 1:(up to) 3 ratio. Primary outcome was 30-day mortality and secondary outcomes were major comorbidities, paravalvular regurgitation, and predischarge pacemaker implant. RESULTS: Propensity score matching resulted in 4486 SRD patients and 13,215 SBP patients. The SRD recipients had more permanent pacemakers (11.4% vs 4.9%, P < .001) shorter cross-clamp times (median: 68 vs 86 minutes, P < .001), and fewer full sternotomies (75% vs 77% , P < .024) than SBP but similar 30-day mortality (3.1% vs 3.1%, P = .98) and moderate or greater paravalvular regurgitation (0.2% vs 0.1%, P = .21). CONCLUSIONS: SRD implantation was associated with reduced operative times and smaller incisions. Rates of 30-day mortality, major comorbidities, and perivalvular regurgitation were similar between SRD and SBP patients. Longer follow-up is needed to determine the implications of increased permanent pacemaker implantation rates in SRD patients.


Assuntos
Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Desenho de Prótese , Fatores de Tempo , Resultado do Tratamento
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