Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 92
Filtrar
1.
Anesth Analg ; 2020 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-31922998

RESUMO

BACKGROUND: The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend a bundle of different measures for patients at increased risk of acute kidney injury (AKI). Prospective, single-center, randomized controlled trials (RCTs) have shown that management in accordance with the KDIGO recommendations was associated with a significant reduction in the incidence of postoperative AKI in high-risk patients. However, compliance with the KDIGO bundle in routine clinical practice is unknown. METHODS: This observational prevalence study was performed in conjunction with a prospective RCT investigating the role of the KDIGO bundle in high-risk patients undergoing cardiac surgery. A 2-day observational prevalence study was performed in all participating centers before the RCT to explore routine clinical practice. The participating hospitals provided the following data: demographics and surgical characteristics, AKI rates, and compliance rates with the individual components of the bundle. RESULTS: Ninety-five patients were enrolled in 12 participating hospitals. The incidence of AKI within 72 hours after cardiac surgery was 24.2%. In 5.3% of all patients, clinical management was fully compliant with all 6 components of the bundle. Nephrotoxic drugs were discontinued in 52.6% of patients, volume optimization was performed in 70.5%, 52.6% of the patients underwent functional hemodynamic monitoring, close monitoring of serum creatinine and urine output was undertaken in 24.2% of patients, hyperglycemia was avoided in 41.1% of patients, and no patient received radiocontrast agents. The patients received on average 3.4 (standard deviation [SD] ±1.1) of 6 supportive measures as recommended by the KDIGO guidelines. There was no significant difference in the number of applied measures between AKI and non-AKI patients (3.2 [SD ±1.1] vs 3.5 [SD ±1.1]; P = .347). CONCLUSIONS: In patients after cardiac surgery, compliance with the KDIGO recommendations was low in routine clinical practice.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31668634

RESUMO

BACKGROUND: Delirium after cardiac surgery is associated with adverse outcomes, including prolonged hospital stay, prolonged intensive care unit stay, and increased mortality. Effective preventive interventions and treatments still are largely unknown. AIM: This systematic review aimed to gather and summarize the existing evidence from randomized trials concerning interventions studied in the prevention or treatment of delirium in adult patients undergoing cardiac surgery. METHODS: A systematic review of the literature using a key word strategy and Boolean operators was performed. PubMed and the Cochrane and Scopus databases were searched for pertinent studies until July 2018 (no inception limit). RESULTS: Of 2,556 articles identified, 56 studies met the inclusion criteria and were included in the review-39 addressed pharmacologic strategies and 17 nonpharmacologic interventions. Interestingly, 51 (91%) trials focused on delirium prevention and only 5 (9%) on delirium treatment. Most of the analyzed studies were recent double-blind, single-center trials conducted in Europe or North America, with a low risk of bias. Overall, 38 different interventions were identified: 15 (26%) interventions were performed before surgery, 20 (36%) in the operating room, and 21 (38%) after surgery. The most frequently analyzed strategies were the administration of dexmedetomidine, ketamine, antipsychotics, glucocorticoids, propofol, opioids, volatile anesthetics, local anesthetics, and remote ischemic preconditioning. The analyzed strategies were extremely heterogenous, and dexmedetomidine was the most promising measure able to prevent the development of postoperative delirium. CONCLUSIONS: In the present systematic review of 56 randomized controlled trials that examined 38 interventions, the authors found that dexmedetomidine was the most frequently studied agent and that it might reduce the occurrence of delirium after cardiac surgery.

3.
Ann Card Anaesth ; 22(4): 400-406, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31621676

RESUMO

Background: Percutaneous left atrial appendage occlusion (LAAO) is indicated in subjects with atrial fibrillation who cannot receive oral anticoagulants. This procedure requires transesophageal echocardiography guidance and is usually performed under general anesthesia. The Janus Mask is a new device designed to allow upper endoscopic procedures during noninvasive ventilation (NIV). Aims: This study aims to assess the possibility of performing LAAO under sedation and NIV. Setting: Cardiac electrophysiology laboratory. Design: Case-control study. Materials and Methods: Data from 11 subjects undergoing LAAO under sedation and NIV with the Janus Mask were retrospectively collected. Procedure duration, outcomes, and physicians' satisfaction were compared with those of 11 subjects who underwent LAAO under general anesthesia in the same period. Statistical Analysis: Univariate analysis and analysis of variance for between-groups comparison. Results: The 11 subjects treated with sedation experienced a good outcome, with a high degree of satisfaction from the medical team. An increase in arterial partial pressure of carbon dioxide in the Janus group (45 [43-62] mmHg vs. 33 [30-35] mmHg in the general anesthesia group, P < 0.001) led to a transient pH decrease 45 min after the beginning of the procedure (7.30 [7.18-7.36] vs. 7.40 [7.39-7.46], P = 0.014). No differences in arterial partial pressure of oxygen, FiO2, and hemodynamic parameters were observed. The subjects' conditions at discharge from the recovery room were comparable. No difference in procedure duration was registered. Conclusions: LAAO procedure under sedation and NIV through the Janus Mask is safe and feasible. This strategy might represent a valuable alternative to manage such a compromised and fragile population.

4.
Br J Anaesth ; 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31607387

RESUMO

BACKGROUND: Bleeding and transfusions affect mortality in aortic surgery. Although tranexamic acid significantly reduced bleeding in multiple settings, its role in major vascular surgery was never studied. The aim of this study was to determine if tranexamic acid reduces blood loss in open abdominal aortic aneurysm (AAA) surgery. METHODS: A total of 100 patients undergoing elective open AAA repair were randomised to receive tranexamic acid (a loading dose of 500 mg and a continuous infusion of 250 mg h-1) or placebo. The primary outcome was intraoperative blood loss, and the secondary outcomes were the number of patients receiving red blood cells, occurrence of thromboembolic events, and mortality. Data were analysed using the intention-to-treat principle. RESULTS: Fifty patients were randomised into each group. Median (inter-quartile range) intraoperative blood loss was 400 (300-1050) ml in the tranexamic acid group vs 500 (360-1000) ml in the placebo group (P=0.44). Transfusion rate was seven/50 (14%) in the tranexamic group vs 12/50 (24%) in the placebo group (P=0.20). No thrombosis was recorded. In a post hoc analysis, postoperative blood loss was reduced in the tranexamic group both at 4 h (60 [40-80] ml vs 100 [60-140] ml, P<0.001) and 24 h (180 [120-275] vs 275 [190-395] ml, P=0.003) after surgery. At 1 yr, three patients were dead, all in the placebo group (P=0.24) and all after 28 days. CONCLUSIONS: Tranexamic acid did not reduce intraoperative blood loss or blood transfusions in open AAA repair, although it may reduce postoperative blood loss without increasing adverse effects. CLINICAL TRIAL REGISTRATION: NCT02335359.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31473115

RESUMO

OBJECTIVE: To find out if there are any differences in biomarkers between severe isolated right ventricular (RV) dysfunction and severe isolated left ventricular (LV) dysfunction after cardiac surgery using cardiopulmonary bypass. DESIGN: Observational study. SETTING: Teaching hospital. PARTICIPANTS: A total of 46 patients who had severe isolated RV or LV dysfunction after cardiac surgery. INTERVENTION: The authors collected perioperative clinical and biomarker data. MEASUREMENTS AND MAIN RESULTS: Severe isolated RV dysfunction patients (n = 20) had higher postoperative direct bilirubin (p = 0.030), total bilirubin (p = 0.044), glucose (p = 0.011), and international normalized ratio (INR) (p = 0.050) by repeated measure analysis of variance when compared with patients with severe isolated LV dysfunction (n = 26). The RV group also showed lower preoperative alanine transferase (19.3 ± 1.5 v 32.7 ± 4.2, p = 0.001), higher 4-hour INR (1.5 ± 0.3 v 1.4 ± 0.2, p = 0.008), and higher 48-hour INR (1.8 ± 0.4 v 1.4 ± 0.1, p < 0.001). None in the LV group died, whereas 4 patients in the RV group died (all of them had preoperative atrial fibrillation and underwent double valve replacement surgery). CONCLUSION: The authors observed biomarkers differences between severe isolated RV dysfunction and severe isolated RV dysfunction.

6.
Eur J Vasc Endovasc Surg ; 58(1): 13-22, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31186133

RESUMO

OBJECTIVE: Open repair of thoraco-abdominal aortic aneurysm (TAAA) is a challenging procedure, associated with high rates of peri-operative bleeding and blood product transfusions. A large intra-operative volume transfusion has been associated with higher in hospital mortality and prolonged mechanical ventilation. A propensity score matched study was carried out to assess whether the introduction of a rotational thromboelastometry (ROTEM) based transfusion strategy reduces allogenic blood transfusion and affects morbidity in patients undergoing open TAAA repair. METHODS: All patients undergoing open TAAA repair at the San Raffaele Scientific Institute between 2009 and 2017 were included. Until 2016, a protocol based on estimated blood loss and conventional coagulation tests was used. After March 2016 a ROTEM guided transfusion protocol was developed and adopted. To account for selection bias, propensity score matching was performed. RESULTS: Five hundred and forty-seven consecutive patients were included. After propensity score matching, 77 patients in the ROTEM algorithm group were successfully matched with 77 patients in the standard algorithm group. Patients managed with ROTEM received fewer red blood cells units (3.5 [range 0-11] vs. 4 [range 0-17]; p = .026) and a lower volume of fresh frozen plasma (286 ± 496 vs. 2,050 ± 1,120; p < .001). In addition, fewer patients received fresh frozen plasma (35% vs. 97%; p < .001). Patients in the ROTEM group showed a significant decrease in the occurrence of pulmonary complications (44% vs. 83%; p = .01). Cost analysis showed a relevant reduction of per-patient expense after the introduction of ROTEM (€834 ± €577 vs. €1,285 ± €851; p < .001) CONCLUSION: A ROTEM guided transfusion strategy significantly limited the quantity of transfused blood products during open TAAA repair, improving clinical outcomes while reducing costs, allowing for better resource distribution in a setting where blood loss is relevant.

7.
J Cardiothorac Vasc Anesth ; 33(10): 2685-2694, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31064730

RESUMO

OBJECTIVE: Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN: A systematic review of the literature followed by a consensus-based voting process. SETTING: A web-based international consensus conference. PARTICIPANTS: Two hundred fifty-one physicians from 46 countries. INTERVENTIONS: The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS: The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION: The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.

8.
N Engl J Med ; 380(13): 1214-1225, 2019 03 28.
Artigo em Inglês | MEDLINE | ID: mdl-30888743

RESUMO

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.).


Assuntos
Anestesia Intravenosa , Anestésicos Gerais/farmacologia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Administração por Inalação , Idoso , Anestesia Geral , Anestésicos Intravenosos , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Método Simples-Cego , Volume Sistólico
9.
J Cardiothorac Vasc Anesth ; 33(7): 1845-1851, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30898421

RESUMO

OBJECTIVE: To identify reliable predictors of periprocedural intensive care unit (ICU) admission after transvenous lead extraction (LE) in a high-volume center. DESIGN: Retrospective observational study. SETTING: University tertiary-care hospital. PARTICIPANTS: All patients undergoing LE at San Raffaele Scientific Institute, Milan, Italy, from 2005 to 2015. INTERVENTIONS: LE procedures were performed in the electrophysiology laboratories with a cardiac operating room on standby between the end of the morning surgical case and before the start of the afternoon surgical case. Most procedures were conducted with the patient under procedural sedation and analgesia. After LE, patients were admitted either to the ward or to the ICU. Medical history and intraprocedural data were recorded. MEASUREMENTS AND MAIN RESULTS: Of the 389 procedures performed during the study period, 50 patients (13%) were admitted to the ICU owing to persistent hemodynamic instability or intraoperative complications requiring endotracheal intubation. Complete procedural success was achieved in 370 patients (95%), and the clinical success rate was 98.4%. No deaths were recorded. Five complications requiring emergency surgery (1.3%) were reported. Preprocedural right ventricular dysfunction (odds ratio (OR) 7.41; confidence interval 1.85-29.7; p < 0.01) and the need for general anesthesia (OR 12; confidence interval 1.49-97.06; p = 0.019) were independent predictors of ICU admission. CONCLUSIONS: Preoperative identification of patients who need ICU admission after LE is crucial to increase patient safety and decrease hospital costs. Severe right ventricular dysfunction and need for general anesthesia identify patients with low cardiac reserve who are at increased risk for ICU admission after the procedure.

10.
N. Engl. j. med ; 380(13): 1214-1225, Mar. 2019. gráfico, tabela
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1024163

RESUMO

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.). (AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Ponte de Artéria Coronária , Anestésicos Inalatórios , Anestesia Geral , Anestesia Intravenosa
11.
Catheter Cardiovasc Interv ; 93(3): 522-529, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-30286515

RESUMO

OBJECTIVES: This study aimed to predict the displacement of self-expanding transcatheter heart valves (THV) during final deployment. BACKGROUND: Accurate device positioning during transcatheter aortic valve implantation (TAVI) is crucial for optimal results. METHODS: At our institution, 103 patients who underwent transfemoral TAVI with Evolut R were retrospectively identified. Multiple linear regression models were created, and a predictor equation was built to quantify the factors that may affect THV behavior. RESULTS: Multiple linear regression analysis for THV displacement on the left coronary cusp (LCC) identified the angle between the THV and the ascending aorta (ATA), predilation, and less operator experience as independent predictors of upward displacement, whereas estimated glomerular filtration rate (eGFR) was inversely related with THV behavior (95% confidence interval: 0.219 to 0.340, 0.447 to 2.092, 0.165 to 1.757, and -0.053 to -0.011, respectively). Predictors of THV displacement on the noncoronary cusp side could not be identified using this model. CONCLUSIONS: The ATA at the point of recapture, predilation, and less operator experience were independent predictors of upward displacement of THV on the LCC side. eGFR was an independent predictor of THV downward displacement on the LCC side. Of them, the ATA was the strongest predictor. Physicians may need to adjust this angle adequately before deployment to achieve the appropriate position.

12.
J Cardiothorac Vasc Anesth ; 33(6): 1639-1645, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30502311

RESUMO

OBJECTIVE: To assess the beneficial effects of noninvasive ventilation in treating postoperative pulmonary complications in patients undergoing thoracoabdominal aortic aneurysm (TAAA) open repair surgery. DESIGN: Randomized controlled trial. SETTING: University tertiary-care hospital. PARTICIPANTS: Forty patients who underwent elective TAAA open repair. INTERVENTIONS: Patients were randomized to the "noninvasive ventilation" group, receiving 2-hour cycles of noninvasive ventilation every 8 hours for at least 3 days in addition to the best available postoperative treatment currently in use at the authors' institution versus the "standard" group, not receiving noninvasive ventilation treatment MEASUREMENTS AND MAIN RESULTS: The primary outcome of clinical worsening, described as a composite outcome of need for therapeutic noninvasive ventilation, need for mechanical ventilation owing to respiratory causes, need for intensive care unit admission owing to respiratory causes, and in-hospital mortality, occurred in 2 (11%) patients in the noninvasive ventilation group versus 12 (57%) in the standard group (p = 0.002; relative risk 0.18; 95% confidence interval 0.047-0.72). CONCLUSION: Noninvasive ventilation is a promising, affordable, and easy-to-use tool to prevent postoperative respiratory complications after TAAA open surgical repair.

13.
J Cardiothorac Vasc Anesth ; 33(7): 1883-1889, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30581110

RESUMO

OBJECTIVE: Patients undergoing transapical cardiac procedure are a minority of cardiac surgery patients but represent a challenge for cardiac anesthesiologists because they generally are older and have more comorbidities than do open heart cardiac surgery patients. The aims of this study were to describe the anesthetic experience with transapical procedures in a single high-volume center and to analyze the most critical aspects for anesthetic management. DESIGN: Retrospective study. SETTING: IRCCS San Raffaele Scientific Institute, Milan, Italy. PARTICIPANTS: All patients undergoing a cardiac transapical procedure from January 2009 to April 2018 were included in this case series. INTERVENTIONS: Patients were managed by a multidisciplinary heart team. The perioperative anesthetic approach and hemodynamic management were consistent and performed by a group of trained cardiac anesthesiologists. MEASUREMENTS AND MAIN RESULTS: The study population comprised 143 patients: 81 (57%) underwent an aortic valve procedure, 60 (42%) a mitral valve intervention, 1 patient underwent a procedure involving both the aortic and mitral valves, and 1 patient underwent correction of a congenital heart defect. A major intraoperative complication occurred in 5 (3.5%) patients, the procedure was not technically feasible because of unsuitable anatomy in 3 patients, and conversion to open heart surgery was needed in 2 patients. All patients were admitted to the intensive care unit. Intensive care unit stay was 1 (1-3) days, and hospital stay was 6 (5-8) days. Hospital survival was 94%. CONCLUSIONS: Patients undergoing transapical cardiac procedures are a minority of cardiac surgery patients, but represent a high-risk population. A patient-tailored anesthetic approach, in the context of the therapeutic strategy shared by the heart team, is crucial to improve outcomes.

14.
Eur J Vasc Endovasc Surg ; 57(3): 360-367, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30385186

RESUMO

OBJECTIVE: Epidural analgesia improves pain control and outcomes of abdominal aortic aneurysm procedures, while the effect of thoracic epidural analgesia on thoraco-abdominal aortic aneurysm (TAAA) repair is unknown. The aim of the study was to evaluate thoracic epidural analgesia effects in patients undergoing open TAAA repair in terms of pain control and clinically relevant outcomes. METHODS: This was a retrospective study of a prospectively collected database. Patients undergoing open TAAA repair between January 2009 and December 2016. RESULTS: Four hundred and fifty-nine consecutive patients were included. Thoracic epidural analgesia was used in 409 (89%) of cases. On multivariable analysis, patients who received thoracic epidural analgesia experienced reduced post-operative pain (odds ratio [OR] 0.003, 95% confidence interval [CI] 0.0007-0.009; p < .001), a lower rate of acute kidney injury (AKI; OR 0.39, 95% CI 0.21-0.71 [p = .002]), atrial fibrillation (OR 0.47, 95% CI 0.23-0.95; p = .04), acute myocardial infarction (AMI; OR 0.189, 95% CI 0.05-0.64; p = .008), and paraplegia (OR 0.31, 95% CI 0.157-0.615; p = .001) compared with the conventional analgesia (CA) group. After propensity score matching, 43 patients in the CA group were compared with 43 in thoracic epidural analgesia group. On case match analysis thoracic epidural analgesia showed a significant reduction in post-operative pain (p < .001) and no differences in the incidence of AKI, atrial fibrillation, AMI, and paraplegia. In the thoracic epidural analgesia group there were no epidural haematomas. CONCLUSION: Thoracic epidural analgesia was effective in reducing post-operative pain with no effect on major post-operative complications. The use of thoracic epidural analgesia, if not contraindicated, might be considered in clinical practice, even in patients undergoing open TAAA repair. Whether a better post-operative management enhances patient's recovery in this setting remains to be tested.


Assuntos
Analgesia Epidural/métodos , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Idoso , Analgesia Epidural/efeitos adversos , Analgesia Epidural/mortalidade , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/mortalidade , Implante de Prótese Vascular/mortalidade , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
JACC Cardiovasc Interv ; 11(15): 1519-1526, 2018 08 13.
Artigo em Inglês | MEDLINE | ID: mdl-30093056

RESUMO

OBJECTIVES: This study sought to determine predictors of advanced conduction disturbances requiring late (≥48 h) permanent pacemaker replacement (PPM) after transcatheter aortic valve replacement (TAVR). METHODS: Data of consecutive patients were identified by retrospective review of a TAVR database of a single center in Milan, Italy, between October 2007 and July 2015. We defined delta PR (ΔPR) and delta QRS (ΔQRS) interval as the difference between the last PR and QRS length available 48 h after TAVR and the baseline PR and QRS length. RESULTS: Overall population included 740 patients. We excluded 78 patients who already had a PPM and 51 patients who received a PPM <48 h after TAVR. The final analysis included 611 patients. Fifty-four patients (8.8%) developed an advanced conduction disturbance requiring PPM ≥48 h following TAVR. Patients who required a late PPM implant had a wider QRS width (113 ± 25 ms vs. 105 ± 23 ms; p = 0.009) and a higher prevalence of baseline right bundle branch block (12.9% vs. 5.3%; p = 0.026) and were more likely to have a self-expandable valve implanted (51.8% vs. 31.9%; p = 0.003). The ΔPR was 40 ± 51 ms (p = 0.0001) and the ΔQRS was 22 ± 61 ms (p = 0.001). Multivariable analysis revealed that baseline right bundle branch block (odds ratio: 3.56; 95% confidence interval: 1.07 to 11.77; p = 0.037) and ΔPR (odds ratio for each 10-ms increase: 1.31; 95% confidence interval: 1.18 to 1.45; p = 0.0001) are independent predictors of delayed advanced conduction disturbances. CONCLUSIONS: This analysis showed that baseline right bundle branch block and the amount of increase of PR length after TAVR are independent predictors of late (≥48 h) advanced conduction disturbances requiring PPM replacement after TAVR in this cohort. A simple ECG analysis could help in detecting potentially lethal advanced conduction disturbances that could occur more than 48 h after TAVR.


Assuntos
Arritmias Cardíacas/terapia , Estimulação Cardíaca Artificial , Sistema de Condução Cardíaco/fisiopatologia , Marca-Passo Artificial , Substituição da Valva Aórtica Transcateter/efeitos adversos , Potenciais de Ação , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/fisiopatologia , Bases de Dados Factuais , Eletrocardiografia , Feminino , Frequência Cardíaca , Humanos , Itália/epidemiologia , Masculino , Prevalência , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
16.
Can J Cardiol ; 34(8): 1088.e1-1088.e2, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30056846

RESUMO

Surgical treatment of functional mitral regurgitation (MR) is usually based on the correction of both annular dilation and leaflet disease to minimize the risk of recurrence of MR at follow-up. This combined approach may also represent an interesting strategy during transcatheter mitral valve repair systems. We report a successful case of combined Cardioband (Edwards Lifesciences, Irvine, California) and MitraClip (Abbott, Santa Clara, California) implantation for the treatment of functional MR, with good acute and medium-term clinical and echocardiographic outcomes.


Assuntos
Cateterismo Cardíaco/métodos , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Cirurgia Assistida por Computador/métodos , Idoso , Ecocardiografia Tridimensional , Ecocardiografia Transesofagiana , Fluoroscopia , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/diagnóstico
18.
J Cardiothorac Vasc Anesth ; 32(4): 1955-1970, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29709436

RESUMO

Extracorporeal membrane oxygenation (ECMO) is used with increasing frequency to treat severe cardiac or respiratory failure as it can provide respiratory only or combined circulatory and respiratory support. Despite efforts aimed at increasing its diffusion however, ECMO is currently reserved, usually as last resort, in very severe cases, which are managed almost exclusively in the intensive care unit (ICU). Recent improvements in both technology and patients' management is leading to constant improvement in patients' outcome, especially in centers with a high caseload volume and after ensuring careful patients' selection. Moreover, since short ECMO runs are associated with limited complications, there are now several potential situations outside the ICU and outside the cardiac surgery setting where ECMO is being (or could be) successfully employed to provide cardio-respiratory support, including: high-risk structural heart interventions, ventricular tachycardia ablation, cesarean section, trauma, and, most interestingly, non-cardiac elective procedures in patients at high risk for perioperative cardiac or respiratory complications. Given the increased availability and the good outcomes of ECMO, when carefully employed, we are thus moving towards a future in which no patient should be denied diagnostic or therapeutic procedure exclusively due to high cardiorespiratory risk.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Oxigenação por Membrana Extracorpórea/métodos , Unidades de Terapia Intensiva , Cuidados Pré-Operatórios/métodos , Procedimentos Cirúrgicos Cardíacos/tendências , Doenças Cardiovasculares/fisiopatologia , Doenças Cardiovasculares/terapia , Oxigenação por Membrana Extracorpórea/tendências , Previsões , Humanos , Unidades de Terapia Intensiva/tendências , Cuidados Pré-Operatórios/tendências
19.
J Vasc Surg ; 68(4): 966-975, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29606568

RESUMO

OBJECTIVE: The aim of this study was to evaluate the perioperative and short-term results in a cohort of patients treated during the last year at our institution with the stent-assisted balloon-induced intimal disruption and relamination in aortic dissection repair (STABILISE) technique for acute complicated aortic dissection. METHODS: Between June 2016 and June 2017, 10 patients (all male; mean age, 62.6 ± 7.4 years) received treatment for acute complicated aortic dissection with the STABILISE technique. After a standard provisional extension to induce complete attachment procedure using the commercially available endovascular dissection system (Cook Medical, Bloomington, Ind), the distal stent graft area and the bare stent area were ballooned to completely exclude the thoracic false lumen (FL) and to obtain a single-channeled abdominal aorta. Computed tomography was routinely performed within the first postoperative week before discharge and then at 3 months, at 6 months, and yearly thereafter. The technical and clinical success rates were analyzed. RESULTS: The 30-day technical and clinical success rates were 100%, with complete thrombosis of the thoracic FL and no type I endoleak. Malperfusion was resolved in all cases. No aortic ruptures were recorded, and no open conversion was required. One case of delayed spinal cord ischemia fully resolved within the discharge period. Predischarge computed tomography showed complete thrombosis of the thoracic FL in all cases. In two cases, some degree of patency of the abdominal FL was observed. At short-term follow-up, the overall aortic diameters remained stable with no further dilation. CONCLUSIONS: The STABILISE technique was safe and feasible in this cohort of patients, with complete thrombosis of the thoracic FL and creation of a single-channeled aorta in most cases. Further studies are needed to ascertain the long-term behavior of the treated aorta.


Assuntos
Aneurisma Dissecante/cirurgia , Angioplastia com Balão/métodos , Aneurisma Aórtico/cirurgia , Implante de Prótese Vascular/métodos , Doença Aguda , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/fisiopatologia , Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Aneurisma Aórtico/diagnóstico por imagem , Aneurisma Aórtico/fisiopatologia , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Angiografia por Tomografia Computadorizada , Ecocardiografia Transesofagiana , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Fatores de Tempo , Resultado do Tratamento
20.
Minerva Cardioangiol ; 66(6): 691-699, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29642696

RESUMO

Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, ß1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.


Assuntos
Implante de Prótese de Valva Cardíaca/métodos , Insuficiência da Valva Tricúspide/cirurgia , Valva Tricúspide/cirurgia , Débito Cardíaco/fisiologia , Ecocardiografia Transesofagiana/métodos , Hemodinâmica/fisiologia , Humanos , Assistência Perioperatória/métodos , Respiração Artificial/métodos , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/fisiopatologia , Disfunção Ventricular Direita/fisiopatologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA