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1.
Heart ; 106(4): 280-286, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31439661

RESUMO

OBJECTIVES: To examine the prognostic significance of atrial fibrillation (AF) versus sinus rhythm (SR) on the management and outcomes of patients with severe aortic stenosis (AS). METHODS: 1847 consecutive patients with severe AS (aortic valve area ≤1.0 cm2 and aortic valve systolic mean Doppler gradient ≥40 mm Hg or peak velocity ≥4 m/s) and left ventricular ejection fraction ≥50% were identified. The independent association of AF and all-cause mortality was assessed. RESULTS: Age was 76±11 years and 46% were female; 293 (16%) patients had AF and 1554 (84%) had SR. In AF, 72% were symptomatic versus 71% in SR. Survival rate at 5 years for AF (41%) was lower than SR (65%) (age- and sex-adjusted HR=1.66 (1.40-1.98), p<0.0001). In multivariable analysis, factors associated with mortality included age (HR per 10 years=1.55 (1.42-1.69), p<0.0001), dyspnoea (HR=1.58 (1.33-1.87), p<0.0001), ≥ moderate mitral regurgitation (HR=1.63 (1.22-2.18), p=0.001), right ventricular systolic dysfunction (HR=1.88 (1.52-2.33), p<0.0001), left atrial volume index (HR per 10 mL/m2=1.13 (1.07-1.19), p<0.0001) and aortic valve replacement (AVR) (HR=0.44 (0.38-0.52), p<0.0001). AF was not a predictor of mortality independent of variables strongly correlated HR=1.02 (0.84-1.25), p=0.81). The 1-year probability of AVR following diagnosis of severe AS was lower in AF (49.8%) than SR (62.5%) (HR=0.73 (0.62-0.86), p<0.001); among patients with AF not referred for AVR, symptoms were frequently attributed to AF instead of AS. CONCLUSION: AF was associated with poor prognosis in patients with severe AS, but apparent differences in outcomes compared with SR were explained by factors other than AF including concomitant cardiac abnormalities and deferral of AVR due to attribution of cardiac symptoms to AF.

2.
Echocardiography ; 36(7): 1397-1400, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31209920

RESUMO

We describe a case of a mass-like echocardiographic density on a mechanical prosthetic aortic valve. We initially suspected a thrombus vs vegetation on transthoracic echocardiography, but after transesophageal echocardiography, the density was subsequently determined to be cavitation by reviewing the initial images in slow motion.

3.
J Am Coll Cardiol ; 73(5): 589-597, 2019 02 12.
Artigo em Inglês | MEDLINE | ID: mdl-30732713

RESUMO

BACKGROUND: Arrhythmias, conduction abnormalities, and intracardiac thrombus are common in patients with cardiac amyloidosis (CA). Outcomes of direct-current cardioversion (DCCV) for atrial arrhythmias in patients with CA are unknown. OBJECTIVES: This study sought to examine DCCV procedural outcomes in patients with CA. METHODS: Patients with CA scheduled for DCCV for atrial arrhythmias from January 2000 through December 2012 were identified and matched 2:1 with control patients by age, sex, type of atrial arrhythmia, and date of DCCV. RESULTS: CA patients (n = 58, mean age 69 ± 9 years, 81% male) were included. CA patients had a significantly higher cardioversion cancellation rate (28% vs. 7%; p < 0.001) compared with control patients, mainly due to intracardiac thrombus identified on transesophageal echocardiogram (13 of 16 [81%] vs. 2 of 8 [25%]; p = 0.02); 4 of 13 of the CA patients (31%) with intracardiac thrombus on transesophageal echocardiogram received adequate anticoagulation ≥3 weeks and another 2 of 13 (15%) had arrhythmia duration <48 h. DCCV success rate (90% vs. 94%; p = 0.4) was not different. Procedural complications were more frequent in CA versus control patients (6 of 42 [14%] vs. 2 of 106 [2%]; p = 0.007); complications in CA included ventricular arrhythmias in 2 and severe bradyarrhythmias requiring pacemaker implantation in 2. The only complication in the control group was self-limited bradyarrhythmias. CONCLUSIONS: Patients with CA undergoing DCCV had a significantly high cancellation rate mainly due to a high incidence of intracardiac thrombus even among patients who received adequate anticoagulation. Although the success rate of restoring sinus rhythm was high, tachyarrhythmias and bradyarrhythmias complicating DCCV were significantly more frequent in CA patients compared with control patients.


Assuntos
Amiloidose , Fibrilação Atrial , Cardioversão Elétrica , Cardiopatias , Trombose , Idoso , Amiloidose/complicações , Amiloidose/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/terapia , Contraindicações de Procedimentos , Ecocardiografia Transesofagiana/métodos , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/métodos , Feminino , Cardiopatias/complicações , Cardiopatias/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Estudos Retrospectivos , Risco Ajustado , Trombose/diagnóstico por imagem , Trombose/etiologia
4.
Clin Cardiol ; 41(12): 1578-1582, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30144129

RESUMO

BACKGROUND: Surgical exclusion of the left atrial appendage (LAA) can be performed at the time of cardiac operation as a potential modality to decrease cardioembolic risk attributable to atrial fibrillation (AF), but it remains unclear if this decreases stroke incidence. Furthermore, it is not known whether LAA exclusion impacts the decision to discontinue anticoagulation impacting subsequent stroke risk. HYPOTHESIS: LAA exclusion does not significantly alter subsequent anticoagulation use or stroke incidence. METHODS: We studied 124 patients from Olmsted County with prior history of AF who underwent cardiac surgery at our institution between 1993 and 2015. Patients were divided into two groups on the basis of LAA exclusion and matched (1:1) according to 16 pretreatment variables using propensity scores obtained from a logistic regression model. Outcome data collected through chart review for survival, stroke, and the presence and duration of anticoagulation were compared between groups. RESULTS: The proportion of patients receiving anticoagulation at discharge and at 5 years was not significantly different between patients who underwent LAA exclusion and those who did not; 90% vs 81%, P = 0.156, 48% vs 49%, P = 0.722, respectively. On Kaplan-Meier analysis there were no significant differences in time free from stroke between cases and controls. Patients discharged on oral anticoagulation (OAC) had significantly lower risk of stroke (HR = 0.19, 95% confidence interval [CI] = 0.06-0.59, P = 0.004), independent of whether LAA closure was used. CONCLUSION: LAA exclusion did not appear to reduce early or late stroke. Only OAC was associated with a reduction in stroke risk, underscoring the need for continued anticoagulation in high-risk patients.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Cuidados Pós-Operatórios/métodos , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Estudos de Casos e Controles , Feminino , Humanos , Incidência , Masculino , Minnesota/epidemiologia , Prevalência , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Resultado do Tratamento
5.
JAMA ; 319(20): 2116-2126, 2018 05 22.
Artigo em Inglês | MEDLINE | ID: mdl-29800182

RESUMO

Importance: Surgical occlusion of the left atrial appendage (LAAO) may be performed during concurrent cardiac surgery. However, few data exist on the association of LAAO with long-term risk of stroke, and some evidence suggests that this procedure may be associated with subsequent development of atrial fibrillation (AF). Objective: To evaluate the association of surgical LAAO performed during cardiac surgery with risk of stroke, mortality, and development of subsequent AF. Design, Setting, and Participants: Retrospective cohort study using a large US administrative database that contains data from adult patients (≥18 years) with private insurance or Medicare Advantage who underwent coronary artery bypass graft (CABG) or valve surgery between January 1, 2009, and March 30, 2017, with final follow-up on March 31, 2017. One-to-one propensity score matching was used to balance patients on 76 dimensions to compare those with vs without LAAO, stratified by history of prior AF at the time of surgery. Exposures: Surgical LAAO vs no surgical LAAO during cardiac surgery. Main Outcomes and Measures: The primary outcomes were stroke (ie, ischemic stroke or systemic embolism) and all-cause mortality. The secondary outcomes were postoperative AF (AF within 30 days after surgery among patients without prior AF) and long-term AF-related health utilization (event rates of outpatient visits and hospitalizations). Results: Among 75 782 patients who underwent cardiac surgery (mean age, 66.0 [SD, 11.2] years; 2 2091 [29.2%] women, 25 721 [33.9%] with preexisting AF), 4374 (5.8%) underwent concurrent LAAO, and mean follow-up was 2.1 (SD, 1.9) years. In the 8590 propensity score-matched patients, LAAO was associated with a reduced risk of stroke (1.14 vs 1.59 events per 100 person-years; hazard ratio [HR], 0.73 [95% CI, 0.56-0.96]; P = .03) and mortality (3.01 vs 4.30 events per 100 person-years; HR, 0.71 [95% CI, 0.60-0.84]; P < .001). LAAO was associated with higher rates of AF-related outpatient visits (11.96 vs 10.26 events per person-year; absolute difference, 1.70 [95% CI, 1.60-1.80] events per person-year; rate ratio, 1.17 [95% CI, 1.10-1.24]; P < .001) and hospitalizations (0.36 vs 0.32 event per person-year; absolute difference, 0.04 [95% CI, 0.02-0.06] event per person-year; rate ratio, 1.13 [95% CI, 1.05-1.21]; P = .002). In patients with prior AF (6438/8590 [74.9%]) with vs without LAAO, risk of stroke was 1.11 vs 1.71 events per 100 person-years (HR, 0.68 [95% CI, 0.50-0.92]; P = .01) and risk of mortality was 3.22 vs 4.93 events per 100 person-years (HR, 0.67 [95% CI, 0.56-0.80]; P < .001), respectively. In patients without prior AF (2152/8590 [25.1%]) with vs without LAAO, risk of stroke was 1.23 vs 1.26 events per 100 person-years (HR, 0.95 [95% CI, 0.54-1.68]), risk of mortality was 2.30 vs 2.49 events per 100 person-years (HR, 0.92 [95% CI, 0.61-1.37]), and risk of postoperative AF was 27.7% vs 20.2% events per 100 person-years (HR, 1.46 [95% CI, 1.22-1.73]; P < .001). The interaction term between prior AF and LAAO was not significant (P = .29 for stroke and P = .16 for mortality). Conclusions and Relevance: Among patients undergoing cardiac surgery, concurrent surgical LAAO, compared with no surgical LAAO, was associated with reduced risk of subsequent stroke and all-cause mortality. Further research, including from randomized clinical trials, is needed to more definitively determine the role of surgical LAAO.


Assuntos
Apêndice Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Cardiopatias/mortalidade , Cardiopatias/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , Acidente Vascular Cerebral/etiologia
6.
Am J Cardiol ; 121(12): 1540-1547, 2018 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-29609898

RESUMO

Although current guidelines advocate using the CHA2DS2-VASc score to assess the risk of stroke in patients with atrial fibrillation (AF), compared with transesophageal echocardiography (TEE), its ability to predict left atrial appendage thrombus (LAAT) is limited. We studied 3,324 consecutive patients with sustained AF from our prospective registry of patients who underwent first-time TEE-guided electrical cardioversion (ECV) from May 2000 through March 2012. The association of CHA2DS2-VASc score or TEE risk factors with the occurrence of LAAT was analyzed. The mean (SD) age was 69 (12.5) years and 67% were men. LAAT was identified in 49 (1.5%) during pre-ECV TEE. Compared with patients without LAAT, those with LAAT had lower peak left atrial appendage emptying velocity (LAAEV) (17.2 ± 8.5 vs 36.6 ± 20.8; p <0.001) and left ventricular ejection fraction (LVEF) (39.9 ± 17.6 vs 51.4 ± 13.7; p <0.001); their CHA2DS2-VASc score also was higher, but the difference was not statistically significant (3.6 ± 1.4 vs 3.2 ± 1.6; p = 0.06). Multivariate logistic regression analysis identified an LVEF ≤40% (adjusted odds ratio 2.48, 95% confidence interval 1.38 to 4.46), LAAEV 20.3 to 33.9 cm/s (odds ratio 12.19, 95% confidence interval 1.53 to 96.86), and LAAEV ≤20.2 cm/s as independent predictors of LAAT. An LAAEV cut-point of 20 cm/s and an LVEF ≤40% were optimal for detecting LAAT (sensitivity 75% and 62%; specificity 77% and 75%; area under the curve 0.822 and 0.776, respectively). On follow-up, LAAT was an independent risk factor of subsequent ischemic stroke but did not influence survival. In conclusion, reduced LVEF and reduced LAAEV are important pathophysiologic correlates of left atrial appendage thrombogenesis and subsequent ischemic stroke in patients who underwent TEE-guided ECV for AF.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/terapia , Função do Átrio Esquerdo , Ecocardiografia Transesofagiana , Cardioversão Elétrica , Átrios do Coração/diagnóstico por imagem , Cardiopatias/diagnóstico por imagem , Trombose/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Feminino , Cardiopatias/epidemiologia , Hemodinâmica , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Volume Sistólico , Trombose/epidemiologia
8.
JACC Cardiovasc Imaging ; 11(4): 534-541, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-28917680

RESUMO

OBJECTIVES: This study sought to investigate the incidence, associated findings, and natural history of effusive-constrictive pericarditis (ECP) after pericardiocentesis. BACKGROUND: ECP is characterized by the coexistence of tense pericardial effusion and constriction of the heart by the visceral pericardium. Echocardiography is currently the main diagnostic tool in the assessment of pericardial disease, but limited data have been published on the incidence and prognosis of ECP diagnosed by echo-Doppler. METHODS: A total of 205 consecutive patients undergoing pericardiocentesis at Mayo Clinic, Rochester, Minnesota, were divided into 2 groups (ECP and non-ECP) based on the presence or absence of post-centesis echocardiographic findings of constrictive pericarditis. Clinical, laboratory, and imaging characteristics were compared. RESULTS: ECP was subsequently diagnosed in 33 patients (16%) after pericardiocentesis. Overt clinical cardiac tamponade was present in 52% of ECP patients and 36% of non-ECP patients (p = 0.08). Post-procedure hemopericardium was more frequent in the ECP group (33% vs. 13%; p = 0.003), and a higher percentage of neutrophils and lower percentage of monocytes were noted on pericardial fluid analysis in those patients. Clinical and laboratory findings were otherwise similar. Baseline early diastolic mitral septal annular velocity was significantly higher in the ECP group. Before pericardiocentesis, respiratory variation of mitral inflow velocity, expiratory diastolic flow reversal of hepatic vein, and respirophasic septal shift were significantly more frequent in the ECP group. Fibrinous or loculated effusions were also more frequently observed in the ECP group. Four deaths occurred in the ECP group; all 4 patients had known malignancies. During median follow-up of 3.8 years (interquartile range: 0.5 to 8.3 years), only 2 patients required pericardiectomy for persistent constrictive features and symptoms. CONCLUSIONS: In a large cohort of unselected patients undergoing pericardiocentesis, 16% were found to have ECP. Pre-centesis echocardiographic findings might identify such patients. Long-term prognosis in those patients remains good, and pericardiectomy was rarely required.


Assuntos
Derrame Pericárdico/epidemiologia , Pericardiocentese/efeitos adversos , Pericardite Constritiva/epidemiologia , Idoso , Anti-Inflamatórios/uso terapêutico , Ecocardiografia Doppler , Feminino , Hemodinâmica , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Derrame Pericárdico/diagnóstico por imagem , Derrame Pericárdico/fisiopatologia , Derrame Pericárdico/terapia , Pericardiectomia , Pericardite Constritiva/diagnóstico por imagem , Pericardite Constritiva/fisiopatologia , Pericardite Constritiva/terapia , Prognóstico , Estudos Retrospectivos , Fatores de Tempo , Função Ventricular Esquerda
9.
Eur J Haematol ; 99(6): 569-576, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28952167

RESUMO

AIMS: von Willebrand factor (VWF) is an independent risk factor for adverse events in patients with non-valvular atrial fibrillation (NVAF). However, it is unclear if VWF level remains elevated and predictive of stroke during entire course of NVAF. METHODS AND RESULTS: In order to determine if VWF is a time-dependent blood variable, VWF antigen measured by latex immunoassay in 425 NVAF patients and 100 controls with normal sinus rhythm (NSR) was analyzed according to NVAF duration (<1 month: n = 76, 1-12 months: n = 98, and >12 months: n = 251). The mean VWF antigen level in NVAF patients with <1-month duration (167 ± 59%) was not different compared to those with 1-12 months (157 ± 50%, P = .24) and >12 months duration (156 ± 54%, P = .11) but higher compared to NSR controls (143 ± 48%, P = .003). Higher VWF level correlated with higher CHADS2 scores and with progressing intensity of blood stasis in the left atrium and thrombus formation in all three time periods of atrial fibrillation duration. Patients not treated with warfarin had VWF 30% higher in the first month compared to following months. CONCLUSIONS: von Willebrand Factor is steadily elevated throughout the course of dysrhythmia in NVAF patients treated with warfarin and in those with higher intensity of left atrium blood stasis.


Assuntos
Fibrilação Atrial/sangue , Biomarcadores/sangue , Fator de von Willebrand , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/etiologia , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
10.
Echocardiography ; 34(11): 1708-1711, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28942610

RESUMO

Among patients undergoing cardioversion for atrial fibrillation, the presence of left ventricular thrombus is a relatively uncommon and challenging clinical dilemma. While left atrial appendage thrombus is a contraindication to cardioversion, there is paucity of data regarding the safety of cardioversion in with the presence of left ventricular apical thrombus. Also, thrombus characteristics such as protrusion and mobility on echocardiography are known risk factors for systemic embolism. In this article, we present a case highlighting the management of atrial fibrillation in the setting of left ventricular dysfunction, acute heart failure, and echocardiographic evidence of acute left ventricular apical thrombus.


Assuntos
Fibrilação Atrial/terapia , Trombose Coronária/diagnóstico por imagem , Ecocardiografia Transesofagiana/métodos , Cardioversão Elétrica/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Doença Aguda , Idoso , Fibrilação Atrial/complicações , Trombose Coronária/complicações , Trombose Coronária/fisiopatologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Fatores de Risco , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/fisiopatologia
11.
Am J Cardiol ; 119(9): 1468-1472, 2017 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-28262200

RESUMO

Few data exist on direct current cardioversion (DCCV) in adult patients with congenital heart disease (CHD). This is a retrospective case-control study of 279 adults with CHD and 279 adults without CHD (control group) who had elective DCCV for atrial arrhythmias at Mayo Clinic, 2001 to 2013. Control patients were matched by gender and arrhythmia type. The objective was to compare DCCV procedural failure (failure to terminate the presenting arrhythmia) and arrhythmia recurrence (AR). In the CHD group (mean age 55 ± 20 years; men 166 [59%]), the most common diagnosis was Fontan palliation (61; 22%). Transesophageal echocardiography was performed before DCCV in 216 patients (77%); 162 (58%) had atrial flutter, and 117 (42%) had atrial fibrillation. Procedural failure and AR between the case and the control groups were more common in the CHD group (14% vs 7%, p = 0.01) and (83% vs 66% at 60 months, p = 0.001) respectively. There were no deaths or thromboembolic complications. The multivariable risk factors for procedural failure were Fontan palliation and spontaneous echocardiographic contrast; the risk factors for AR were Fontan palliation and atrial fibrillation. When patients with Fontan palliation were excluded from the analysis, the outcome of DCCV (failure and recurrence rates) was similar for the CHD and non-CHD groups despite the age difference between the cohorts. In conclusion, the present study showed that DCCV outcomes were similar for CHD and non-CHD patients, with the exception of patients with Fontan palliation.


Assuntos
Fibrilação Atrial/terapia , Flutter Atrial/terapia , Cardioversão Elétrica , Cardiopatias Congênitas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Flutter Atrial/complicações , Estudos de Casos e Controles , Ecocardiografia Transesofagiana , Feminino , Técnica de Fontan , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Recidiva , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento
12.
Circulation ; 135(4): 366-378, 2017 01 24.
Artigo em Inglês | MEDLINE | ID: mdl-27903589

RESUMO

BACKGROUND: Prophylactic exclusion of the left atrial appendage (LAA) is often performed during cardiac surgery ostensibly to reduce the risk of stroke. However, the clinical impact of LAA closure in humans remains inconclusive. METHODS: Of 10 633 adults who underwent coronary artery bypass grafting and valve surgery between January 2000 and December 2005, 9792 patients with complete baseline characteristics, surgery procedure, and follow-up data were included in this analysis. A propensity score-matching analysis based on 28 pretreatment covariates was performed and 461 matching pairs were derived and analyzed to estimate the association of LAA closure with early postoperative atrial fibrillation (POAF) (atrial fibrillation ≤30 days of surgery), ischemic stroke, and mortality. RESULTS: In the propensity-matched cohort, the overall incidence of POAF was 53.9%. In this group, the rate of early POAF among the patients who underwent LAA closure was 68.6% versus 31.9% for those who did not undergo the procedure (P<0.001). LAA closure was independently associated with an increased risk of early POAF (adjusted odds ratio, 3.88; 95% confidence interval, 2.89-5.20), but did not significantly influence the risk of stroke (adjusted hazard ratio, 1.07; 95% confidence interval, 0.72-1.58) or mortality (adjusted hazard ratio, 0.92; 95% confidence interval, 0.75-1.13). CONCLUSIONS: After adjustment for treatment allocation bias, LAA closure during routine cardiac surgery was significantly associated with an increased risk of early POAF, but it did not influence the risk of stroke or mortality. It remains uncertain whether prophylactic exclusion of the LAA is warranted for stroke prevention during non-atrial fibrillation-related cardiac surgery.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Acidente Vascular Cerebral/etiologia , Idoso , Fibrilação Atrial/fisiopatologia , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Estudos de Coortes , Feminino , Humanos , Masculino , Acidente Vascular Cerebral/fisiopatologia , Análise de Sobrevida
14.
Am J Ther ; 23(1): e118-38, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-23689090

RESUMO

Atrial fibrillation (AF) is a highly prevalent cardiac arrhythmia that leads to hospitalizations for complications and adverse events each year. Despite significant improvement in our therapeutic approaches in the past decade, management of AF remains a difficult task. Novel therapies have failed to terminate AF and prevent its recurrence, and patients with AF continue to have thromboembolic complications. With the increasingly aging population and associated conditions, the prevalence of AF is expected to progressively increase, becoming a public health problem. Most patients with AF have multiple comorbidities and are of advanced age, making long-term anticoagulation challenging. This article provides an overview of the current pharmacological therapies for the management of AF, with particular emphasis on the emerging agents.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Antiarrítmicos/classificação , Antiarrítmicos/uso terapêutico , Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Fibrilação Atrial/complicações , Humanos , Inibidores da Agregação de Plaquetas/uso terapêutico
15.
Am Heart J ; 170(5): 914-22, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26542499

RESUMO

BACKGROUND: Left atrial appendage emptying flow velocity (LAAEV) depends largely on left atrioventricular compliance and may play a role in mediating the perpetuation of atrial fibrillation (AF) and AF-related outcomes. METHODS: We identified 3,251 consecutive patients with sustained AF undergoing first-time successful transesophageal echocardiography (TEE)-guided electrical cardioversion who were enrolled in a prospective registry between May 2000 and March 2012. Left atrial appendage emptying flow velocity was stratified into quartiles: ≤20.2, 20.3-33.9, 34-49.9, and ≥50 cm/s. Multivariate Cox regression models were used to identify independent predictors of AF recurrence, ischemic stroke, and all-cause mortality. RESULTS: The mean (SD) age was 69 (12.6) years and 67% were men. Compared with the fourth quartile, patients in the first-third quartiles were significantly older, had higher CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack [TIA], vascular disease, age 65-74 years, sex category) scores, greater frequency of atrial spontaneous echo contrast, and AF of longer duration. Kaplan-Meier analysis showed a decreased probability of event-free survival with decreasing quartiles of LAAEV. Five-year cumulative event rates across first-fourth quartiles were 83%, 80%, 73%, and 73% (P < .001) for first AF recurrence; 7.5%, 7.0%, 4.1%, and 4.0%, for stroke (P = .01); and 31.3%, 26.1%, 24.1%, and 19.4%, for mortality (P < .001), respectively. Multivariate Cox regression analysis revealed an independent association of the first and second quartiles with AF recurrence (P < .001 and P < .001, respectively) and stroke (P = .03, and P = .04, respectively), and of the first quartile with mortality (P = .003). CONCLUSIONS: Patients with decreased LAAEV have an increased risk of AF recurrence, stroke, and mortality after successful electrical cardioversion. Real-time measurement of LAAEV by TEE may be a useful physiologic biomarker for individualizing treatment decisions in patients with AF.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/fisiopatologia , Velocidade do Fluxo Sanguíneo/fisiologia , Cardioversão Elétrica , Monitorização Fisiológica/métodos , Acidente Vascular Cerebral/epidemiologia , Idoso , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/complicações , Fibrilação Atrial/terapia , Intervalo Livre de Doença , Ecocardiografia Transesofagiana , Feminino , Seguimentos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Estudos Prospectivos , Recidiva , Acidente Vascular Cerebral/etiologia , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
16.
Am Heart J ; 170(4): 659-68, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26386789

RESUMO

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. Data are lacking on the long-term prognostic implications of POAF. We hypothesized that POAF, which reflects underlying cardiovascular pathophysiologic substrate, is a predictive marker of late AF and long-term mortality. METHODS: We identified 603 Olmsted County, Minnesota, residents without prior documented history of AF who underwent coronary artery bypass graft and/or valve surgery from 2000 to 2005. Patients were monitored for first documentation of late AF or death at >30 days postoperatively. Multivariate Cox regression models were used to assess the independent association of POAF with late AF and long-term mortality. RESULTS: After a mean follow-up of 8.3 ± 4.2 years, freedom from late AF was less with POAF than no POAF (57.4% vs 88.9%, P < .001). The risk of late AF was highest within the first year at 18%. Univariate analysis demonstrated that POAF was associated with significantly increased risk of late AF [hazard ratio (HR), 5.09; 95% CI, 3.65-7.22] and long-term mortality (HR, 1.79; 95% CI, 1.38-2.22). After adjustment for age, sex, and clinical and surgical risk factors, POAF remained independently associated with development of late AF (HR, 3.52; 95% CI, 2.42-5.13) but not long-term mortality (HR, 1.16; 95% CI, 0.87-1.55). Conversely, late AF was independently predictive of long-term mortality (HR, 3.25; 95% CI, 2.42-4.35). Diastolic dysfunction independently influenced the risk of late AF and long-term mortality. CONCLUSIONS: Postoperative atrial fibrillation was an independent predictive marker of late AF, whereas late AF, but not POAF, was independently associated with long-term mortality. Patients who develop new-onset POAF should be considered for continuous anticoagulation at least during the first year following cardiac surgery.


Assuntos
Fibrilação Atrial/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Vigilância da População , Complicações Pós-Operatórias , Medição de Risco , Idoso , Fibrilação Atrial/etiologia , Feminino , Seguimentos , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo
18.
J Med Cases ; 5(6): 376-379, 2014 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-25197328

RESUMO

Cholesterol embolization syndrome (CES) is a complication sometimes occurring after invasive endovascular procedures. CES is characterized by release of cholesterol crystals and particles from atheromatous plaques, which can occlude distal vessels and induce an inflammatory response, resulting in end-organ damage. We report the case of a 66-year-old man who presented with an acute ST-elevation myocardial infarction. An intra-aortic balloon pump was placed due to hemodynamic instability following percutaneous coronary intervention. Ten weeks after discharge, he presented with signs and symptoms of CES (e.g., livedo reticularis, acrocyanosis, acute renal failure), and a new left ventricular apical thrombus. Withdrawal of anticoagulation is often recommended in the setting of CES, on the presumption that anticoagulants favor plaque hemorrhage and subsequent cholesterol micro-embolization. Because of the potential disastrous consequences of an embolus, the patient was anticoagulated with warfarin concurrently with corticosteroids to suppress the inflammatory response to cholesterol crystals. His renal function continued to improve and was discharged without the need for dialysis. This case illustrates that anticoagulation therapy in CES is feasible and appears to be safe in patients with a coexisting urgent indication for anticoagulation.

19.
Am J Cardiol ; 114(10): 1562-7, 2014 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-25260946

RESUMO

Baseline pulmonary hypertension (PH) is a predictor of poor outcomes in patients with severe aortic stenosis (AS). Surgical aortic valve replacement is thought to alleviate PH. The aim of this study was to determine the prognostic impact of PH in patients who underwent transcatheter aortic valve replacement (TAVR). An observational cohort study was conducted using prospectively collected data on 277 consecutive patients with severe AS who underwent TAVR at the Mayo Clinic (Rochester, Minnesota) from November 1, 2008, to June 31, 2013. Clinical and echocardiographic data, pulmonary function characteristics, and outcomes stratified by tertiles of pulmonary artery systolic pressure (PASP) were analyzed. From 277 patients who underwent TAVR, 251 patients had PASP assessment at baseline. Those in the highest PASP tertile (PASP ≥49 mm Hg) had more severe chronic lung disease and worse diastolic dysfunction. Being in the highest PASP tertile was an independent predictor of long-term mortality (hazard ratio 2.88, 95% confidence interval 1.15 to 7.23). Patients in the highest PASP tertile had longer lengths of hospital stay, while other short-term outcomes (30-day mortality and readmission, stroke, prolonged ventilation, and reoperation for bleeding) were similar across PASP tertiles. TAVR was associated with a decrease in PASP in the highest PASP tertile at 1 week after the procedure (-8 ± 14 mm Hg) and at 3 months (-7 ± 15 mm Hg) compared with baseline. In conclusion, among patients with severe AS who underwent TAVR, higher baseline PASP was strongly associated with diastolic dysfunction and chronic lung disease. Patients with higher baseline PASP tolerated TAVR relatively well in the early postprocedural phase, with diminished long-term survival. PH should not disqualify patients with severe AS from consideration for TAVR.


Assuntos
Estenose da Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas , Hipertensão Pulmonar/fisiopatologia , Pressão Propulsora Pulmonar/fisiologia , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/fisiopatologia , Ecocardiografia , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/epidemiologia , Hipertensão Pulmonar/etiologia , Incidência , Estimativa de Kaplan-Meier , Masculino , Minnesota/epidemiologia , Prognóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências
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