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1.
Artigo em Inglês | MEDLINE | ID: mdl-32362544

RESUMO

OBJECTIVE: To evaluate current results of surgical aortic valve replacement (SAVR) ± coronary artery bypass grafting surgery. DESIGN: Independent, multicenter, prospective registry. SETTING: Tertiary university hospitals. PARTICIPANTS: The study comprised 1,192 consecutive patients, stratified as low-, intermediate-, and high-risk according to EuroSCORE II (<4, 4-9, >9, respectively). INTERVENTIONS: SAVR ± coronary artery bypass grafting surgery. MEASUREMENTS AND MAIN RESULTS: Thirty-day mortality and major morbidity, 2-year actuarial survival and freedom from stroke, and independent predictors of mortality in each risk category were assessed. These data were considered in light of published randomized controlled trials. Thirty-day mortality was 1.0%, 3.0% and 2.1% in the low-, intermediate-, and high-risk patients, with a 2-year actuarial survival of 98.6%, 93.8%, and 94.0%, respectively. Preoperative atrial fibrillation (odds ratio [OR] 8.3), minithoracotomy access (OR 5.8), postoperative dialysis (OR 3.4), type V acute myocardial infarction (OR 20.4), and moderate aortic regurgitation (OR 28.8) predicted 30-day mortality in the low-risk group. Preoperative dialysis (OR 18.3), critical state (OR 36.7), postoperative transfusions of plasma (OR 1.9 per unit transfused), and de-novo dialysis (OR 6.2) predicted 30-day mortality in the intermediate-risk group. Prior cardiac surgery (OR 18.1), postoperative extracorporeal membrane oxygenation (OR 9.8), and gastrointestinal complications (OR 17.2) predicted 30-day mortality in the high-risk group. Although baseline differences existed, low-risk patients demonstrated low 30-day mortality and 30-day to 12-month stroke in light of the PARTNER 3 and EVOLUT Low Risk trial results. Intermediate-risk patients demonstrated low 30-day to 2-year mortality, when the PARTNER 2 trial was considered, and low 30-day to 2-year stroke, when the PARTNER 2 and SURTAVI trials were considered. High-risk patients showed low 30-day to 2-year mortality in light of the results of the PARTNER 1 and CoreValve US trials. CONCLUSIONS: SAVR is still a safe and effective surgery for aortic stenosis regardless of risk category.

3.
Infect Control Hosp Epidemiol ; : 1-8, 2020 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-31957634

RESUMO

OBJECTIVE: To develop a risk score for deep sternal wound infection (DSWI) after isolated coronary artery bypass grafting (CABG). DESIGN: Multicenter, prospective study. SETTING: Tertiary-care referral hospitals. PARTICIPANTS: The study included 7,352 patients from the European multicenter coronary artery bypass grafting (E-CABG) registry. INTERVENTION: Isolated CABG. METHODS: An additive risk score (the E-CABG DSWI score) was estimated from the derivation data set (66.7% of patients), and its performance was assessed in the validation data set (33.3% of patients). RESULTS: DSWI occurred in 181 (2.5%) patients and increased 1-year mortality (adjusted hazard ratio, 4.275; 95% confidence interval [CI], 2.804-6.517). Female gender (odds ratio [OR], 1.804; 95% CI, 1.161-2.802), body mass index ≥30 kg/m2 (OR, 1.729; 95% CI, 1.166-2.562), glomerular filtration rate <45 mL/min/1.73 m2 (OR, 2.410; 95% CI, 1.413-4.111), diabetes (OR, 1.741; 95% CI, 1.178-2.573), pulmonary disease (OR, 1.935; 95% CI, 1.178-3.180), atrial fibrillation (OR, 1.854; 95% CI, 1.096-3.138), critical preoperative state (OR, 2.196; 95% CI, 1.209-3.891), and bilateral internal mammary artery grafting (OR, 2.088; 95% CI, 1.422-3.066) were predictors of DSWI (derivation data set). An additive risk score was calculated by assigning 1 point to each of these independent risk factors for DSWI. In the validation data set, the rate of DSWI increased along with the E-CABG DSWI scores (score of 0, 1.0%; score of 1, 1.8%; score of 2, 2.2%; score of 3, 6.9%; score ≥4: 12.1%; P < .0001). Net reclassification improvement, integrated discrimination improvement, and decision curve analysis showed that the E-CABG DSWI score performed better than other risk scores. CONCLUSIONS: DSWI is associated with poor outcome after CABG, and its risk can be stratified using the E-CABG DSWI score. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT02319083.

4.
Ann Thorac Surg ; 109(1): 294-301, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31421104

RESUMO

BACKGROUND: Epiaortic ultrasonography (EAU) is a valid imaging method to detect atherosclerotic changes of the ascending aorta and to guide surgical strategies for the prevention of cerebral embolism in patients undergoing isolated coronary artery bypass grafting (CABG). However, its use is not widespread. METHODS: The impact of EAU on the outcome after isolated CABG was investigated in patients from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry. A systematic review and meta-analysis of the literature was performed to substantiate the findings of this observational study. RESULTS: EAU was performed intraoperatively in 673 of 7241 patients (9.3%) from the E-CABG registry. In the overall series, the rates of stroke without and with aortic manipulation were 0.3% and 1.3%, respectively (P = .003). In 660 propensity score-matched pairs, EAU was associated with significantly lower risk of stroke (0.6% vs 2.6%, P = .007). A literature search yielded 5 studies fulfilling the inclusion criteria. These studies, along with the present one, included 11,496 patients, of whom 3026 (25.7%) underwent intraoperative EAU. Their rate of postoperative stroke was significantly lower than in patients not investigated with EAU (pooled rate, 0.6% vs 1.9%; risk ratio, 0.40; 95% confidence interval, 0.24-0.66; I2 = 0%). On the basis of these pooled rates, the number needed to treat to prevent 1 stroke is 76.9. CONCLUSIONS: Avoiding aortic manipulation is associated with the lowest risk of stroke in patients undergoing CABG. When manipulation of the ascending aorta is planned, EAU is effective in guiding the surgical strategy to reduce the risk for embolic stroke in these patients.

5.
J Am Heart Assoc ; 8(24): e013650, 2019 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-31830873

RESUMO

Background The impact of the coronary artery bypass grafting (CABG) technique (on- versus off-pump, single versus multiple aortic clamping) on postoperative neurological outcome remains a matter of controversy. The aim of this study was to assess the association between the incidence of postoperative stroke and the degree of aortic manipulation in one of the largest contemporary CABG series. Methods and Results A retrospective, multicenter, international study was conducted in 25 388 patients undergoing isolated CABG procedures with on-pump CABG (ONCAB) or off-pump CABG (OPCAB) technique including single or multiple aortic clamping. Postoperative stroke was defined as a postoperative neurological deficit lasting more than 24 hours and associated with evidence of a brain lesion on computed tomography. The degree of aortic manipulation was assumed to be higher for on-pump versus off-pump surgery and for multiple versus single or no aortic clamping. Logistic regression and propensity matching were used. ONCAB procedures were performed in 17 231 cases and OPCAB in 8157. The incidence of postoperative stroke was significantly lower in the OPCAB group even after propensity matching (0.4% OPCAB versus 1.2% ONCAB, P=0.02). In the ONCAB group (but not in the OPCAB arm) the use of single aortic clamping was associated with significantly reduced postoperative stroke rate (odds ratio, 0.05; 95% CI, 0.008 to 0.07 [P<0.001]). Conclusions OPCAB and the use of single aortic clamping in the ONCAB arm were associated with a reduced incidence of postoperative stroke. Our data confirm a strong association between aortic manipulation and neurological outcome after CABG surgery.

6.
Aorta (Stamford) ; 7(2): 63-66, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31529431

RESUMO

Treatment of aortic arch aneurysm with standard open surgery is technically demanding, and associated morbidity and mortality are not insignificant. In high-risk patients, hybrid procedures with debranching and reimplantation or bypass of the aortic arch vessel followed by thoracic endovascular aortic repair (TEVAR) in the aortic arch represent a valid alternative to open surgery. However, when the ascending aorta is mildly dilated, the risk of retrograde dissection increases sharply. Here, we report a case of thoracic aortic aneurysm, with normal ascending aorta diameter, treated with Type I debranching and anterograde TEVAR complicated by anastomotic pseudoaneurysm and acute endocarditis, treated ultimately with ascending aortic repair and aortic valve replacement.

8.
Int J Cardiol ; 292: 62-67, 2019 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-31130281

RESUMO

BACKGROUND: To assess early and late mortality in patients with isolated acute tricuspid valve infective endocarditis (TVIE) using data from a multicenter registry. METHODS: From 1983 to 2018, isolated acute TVIE was surgically treated in 157 (3.8%) patients [mean age 47 ±â€¯16 years (range 15-86 years), 25% females]. Of these, 142 (90%) had native tricuspid regurgitation, 7 (5%) native tricuspid valve (TV) steno-regurgitation, and 8 (5%) prosthetic TVIE. Intravenous drug use (IVDU) was recorded in 38% of patients, infection involved cardiac implantable electronic device leads in 21%, and vascular catheters for dialysis in 1%; in the remaining cases, the cause was unknown. The primary endpoint was in-hospital outcome, long-term freedom from recurrence and overall survival. RESULTS: Overall, 77 (49%) patients underwent TV repair, 72 (46%) TV replacement, and 8 (5%) prosthetic TV replacement. Early mortality was 11% (n = 17). Expected early mortality according to EndoSCORE was 12%, with age (odds ratio 1.06) and redo (odds ratio 6.64) as risk factors. Late deaths occurred in 31 patients and TVIE recurrences in 4. Survival rates at 10, 20, and 25 years were 66%, 60%, and 44%, respectively. Risk factors were age [hazard ratio (HR) 1.06], mycotic TVIE (HR 4.2), IVDU (HR 4.90), infected prosthesis replacement (HR 4.4), and presence of cardiac implantable electronic device leads (HR 3.0). No significant difference was found in valve repair vs. replacement and in IVDUs vs. non-IVDUs. CONCLUSIONS: Patients with isolated acute TVIE undergoing surgical treatment show acceptable early and late outcomes. TVIE recurrence was low, and repair of the affected valve does not seem to confer any advantage either at early or long term up to 25 years.

9.
Ann Thorac Surg ; 107(6): 1690-1698, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30898561

RESUMO

BACKGROUND: We evaluated perioperative bleeding after coronary artery bypass grafting (CABG) in patients preoperatively treated with ticagrelor or clopidogrel, stratified by discontinuation of these P2Y12 inhibitors. METHODS: All patients from the prospective, European Multicenter Registry on Coronary Artery Bypass Grafting (E-CABG) treated with ticagrelor or clopidogrel undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding, stratified by P2Y12 inhibitor discontinuation. Secondary outcome measures included four additional definitions of major bleeding. Propensity score matching was performed to adjust for differences in preoperative and perioperative covariates. RESULTS: Of 2,311 patients who were included, 1,293 (55.9%) received clopidogrel and 1,018 (44.1%) ticagrelor preoperatively. Mean time between discontinuation and the operation was 4.5 ± 3.2 days for clopidogrel and 4.9 ± 3.0 days for ticagrelor. In the propensity score-matched cohort, ticagrelor-treated patients had a higher incidence of major bleeding according to Universal Definition of Perioperative Bleeding when ticagrelor was discontinued 0 to 2 days compared with 3 days before the operation (16.0% vs 2.7%, p = 0.003). Clopidogrel-treated patients had a higher incidence of major bleeding according to the Universal Definition of Perioperative Bleeding when clopidogrel was discontinued 0 to 3 days compared with 4 to 5 days before the operation (15.6% vs 8.3%, p = 0.031). CONCLUSIONS: In patients receiving ticagrelor 2 days before CABG and in those receiving clopidogrel 3 days before CABG, there was an increased rate of severe bleeding. Postponing nonemergent CABG for at least 3 days after discontinuation of ticagrelor and 4 days after clopidogrel should be considered.


Assuntos
Clopidogrel/efeitos adversos , Ponte de Artéria Coronária , Inibidores da Agregação de Plaquetas/efeitos adversos , Hemorragia Pós-Operatória/induzido quimicamente , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Ticagrelor/efeitos adversos , Idoso , Clopidogrel/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/administração & dosagem , Hemorragia Pós-Operatória/epidemiologia , Período Pré-Operatório , Estudos Prospectivos , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Ticagrelor/administração & dosagem
10.
Eur J Prev Cardiol ; 26(7): 743-745, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30861700
11.
Heart Lung Circ ; 28(12): 1881-1887, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30709591

RESUMO

BACKGROUND: Recent studies suggested that prothrombin complex concentrate (PCC) might be more effective than fresh frozen plasma (FFP) to reduce red blood cell (RBC) transfusion requirement after cardiac surgery. METHODS: This is a comparative analysis of 416 patients who received FFP postoperatively and 119 patients who received PCC with or without FFP after isolated coronary artery bypass grafting (CABG). RESULTS: Mixed-effects regression analyses adjusted for multiple covariates and participating centres showed that PCC significantly decreased RBC transfusion (67.2% vs. 87.5%, adjusted OR 0.319, 95%CI 0.136-0.752) and platelet transfusion requirements (11.8% vs. 45.2%, adjusted OR 0.238, 95%CI 0.097-0.566) compared with FFP. The PCC cohort received a mean of 2.7±3.7 (median, 2.0, IQR 4) units of RBC and the FFP cohort received a mean of 4.9±6.3 (median, 3.0, IQR 4) units of RBC (adjusted coefficient, -1.926, 95%CI -3.357-0.494). The use of PCC increased the risk of KDIGO (Kidney Disease: Improving Global Outcomes) acute kidney injury (41.4% vs. 28.2%, adjusted OR 2.300, 1.203-4.400), but not of KDIGO acute kidney injury stage 3 (6.0% vs. 8.0%, OR 0.850, 95%CI 0.258-2.796) when compared with the FFP cohort. CONCLUSIONS: These results suggest that the use of PCC compared with FFP may reduce the need of blood transfusion after CABG.

12.
Am J Cardiol ; 123(4): 565-570, 2019 02 15.
Artigo em Inglês | MEDLINE | ID: mdl-30527774

RESUMO

The perioperative bleeding risk in patients receiving fondaparinux versus low-molecular weight heparin before coronary artery bypass grafting has not been reported. We evaluated perioperative coronary artery bypass grafting-related bleeding in patients with acute coronary syndrome preoperatively treated with fondaparinux or low-molecular weight heparin. All patients with acute coronary syndrome from the prospective, European multicenter registry on coronary artery bypass grafting preoperatively treated with fondaparinux or low-molecular weight heparin undergoing isolated primary CABG were eligible. The primary outcome measure was severe or massive bleeding defined according to the Universal Definition of Perioperative Bleeding stratified by P2Y12 inhibitor discontinuation. Secondary outcome measures included 3 additional definitions of major bleeding used in cardiac surgery trials. Propensity score matching was performed to adjust for differences in pre- and perioperative covariates. 1,525 patients were included, of whom 276 (18.1%) received fondaparinux and 1,249 (81.9%) low-molecular weight heparin preoperatively. In the propensity score-matched cohort (245 pairs), the risk of major bleeding according to the universal definition of perioperative bleeding severe or massive bleeding (11.8 vs 9.0%, p = 0.285) and the 3 other major bleeding definitions was similar between the fondaparinux and low-molecular weight heparin cohorts. In conclusion, preoperative treatment with fondaparinux compared with low-molecular weight heparin was associated with similar incidence of perioperative bleeding in patients with acute coronary syndrome who underwent coronary artery bypass grafting.


Assuntos
Síndrome Coronariana Aguda/cirurgia , Perda Sanguínea Cirúrgica , Ponte de Artéria Coronária/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Fondaparinux/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Hemorragia Pós-Operatória/epidemiologia , Idoso , Estudos de Coortes , Europa (Continente) , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Sistema de Registros
13.
Eur J Cardiothorac Surg ; 55(4): 653-659, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30325419

RESUMO

OBJECTIVES: Non-A non-B aortic dissections are rare, and little is known about their natural history, indications for surgery and operative results. We aim to examine the literature to summarize what is known of the natural history of non-A non-B dissections and evaluate the outcomes of the therapeutic options available. METHODS: An extensive literature search was performed using MEDLINE to find all published studies that report data on the natural history and outcomes of patients with non-A non-B aortic dissection. Data on patients treated with medical therapy were extracted to characterize the natural history. Primary end points included 30-day mortality, stroke and retrograde type A dissection. RESULTS: Of the 423 studies found, 14 articles (433 patients) fulfilled the inclusion criteria for quantitative analysis. The proportion of medically treated patients ranged from 5 to 54% with a pooled rate of 36% (50/138). The 30-day mortality of patients treated with medical therapy was 14% (7/50). The overall estimated proportion of 30-day mortality for patients who underwent intervention was 3.6% [95% confidence interval (CI) 1.7-5.6%], retrograde type A dissection was 2.6% (95% CI 0.8-4.4%) and stroke was 2.8% (95% CI 1.0-4.5%). CONCLUSIONS: Despite the likelihood of reporting and selection bias, patients with non-A non-B dissection often have a complicated course requiring some form of intervention. The 30-day mortality of patients treated with medical therapy seems higher than surgical or endovascular therapy. Ideally, further large prospective studies are necessary to confirm our suggestion that early intervention may be indicated in non-A non-B dissections.

14.
Platelets ; 30(4): 480-486, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29676943

RESUMO

The impact of thrombocytopenia on postoperative bleeding and other major adverse events after cardiac surgery is unclear. This issue was investigated in a series of patients who underwent isolated coronary artery bypass grafting (CABG) from the prospective, multicenter E-CABG registry. Preoperative thrombocytopenia was defined as preoperative platelet count <150 × 109/L and it was considered moderate-severe when preoperative platelet count was <100 × 109/L. Multilevel mixed-effects regression analysis was performed to adjust the effect of thrombocytopenia on outcomes for baseline and operative covariates as well as for interinstitutional differences in patient-blood management. Among 7189 patients included in this analysis, 599 (8.3%) had preoperative thrombocytopenia. Patient with preoperative thrombocytopenia had an increased chest drainage output at 12 h (mean, 519 vs. 456 mL, adjusted coeff. 39, 95%CI 18-60) and rates of severe-massive bleeding (Universal Definition of Perioperative Bleeding (UDPB) severity grades 3-4: 12.7% vs. 8.1%, adjusted OR 1.47, 95%CI 1.11-1.93; E-CABG bleeding severity grades 2-3: 10.4% vs. 6.1%, adjusted OR 1.78, 95%CI 1.30-2.43). Thrombocytopenia was associated with an increased risk of hospital/30-day death (3.2% vs. 1.9%, adjusted OR 2.02, 95%CI 1.20-3.42), 1-year death (5.7% vs. 3.4%, adjusted HR 1.68, 95%CI 1.16-2.44), deep sternal wound infection (3.5% vs. 2.4%, adjusted OR 1.65, 95%CI 1.02-2.66), acute kidney injury (28.1% vs. 22.2%, OR 1.45, 1.18-1.78), and prolonged stay in the intensive care unit (mean, 3.6 vs 2.8 days, adjusted coeff. 0.74, 95%CI 0.40-1.09). Similar results were observed in a subset of patients with moderate-severe thrombocytopenia (51 patients, 0.7%). In particular, these patients had a markedly higher rate of acute kidney injury (40%, adjusted OR, 1.94, 95%CI 1.05-3.57), resternotomy for bleeding (7.8%, adjusted OR 3.49, 95%CI 1.20-10.21), and severe-massive bleeding (UDPB severity grades 3-4: 23.5%, adjusted OR 3.08, 95%CI 1.52-6.22; E-CABG bleeding severity grades 2-3: 23.5%, adjusted OR 4.43, 95%CI 2.15-9.15) compared to patients with normal preoperative platelet count. Mild preoperative thrombocytopenia is associated with increased risk of severe-massive bleeding, mortality, and other major adverse events after CABG. Such risks are markedly increased in patients with moderate-severe preoperative thrombocytopenia.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Trombocitopenia/etiologia , Idoso , Feminino , Humanos , Masculino , Período Pré-Operatório , Estudos Prospectivos , Trombocitopenia/patologia
15.
Eur J Cardiothorac Surg ; 56(2): 424, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30561572
16.
Interact Cardiovasc Thorac Surg ; 28(1): 17-22, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30007311

RESUMO

OBJECTIVES: Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS: We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS: Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS: Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.


Assuntos
Aorta Torácica/lesões , Procedimentos Endovasculares/métodos , Previsões , Stents , Traumatismos Torácicos/cirurgia , Lesões do Sistema Vascular/cirurgia , Ferimentos não Penetrantes/cirurgia , Adulto , Idoso , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Traumatismos Torácicos/complicações , Traumatismos Torácicos/diagnóstico , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Ferimentos não Penetrantes/diagnóstico , Adulto Jovem
17.
Innovations (Phila) ; 13(6): 448-450, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30540589

RESUMO

Different case series have been published demonstrating the feasibility of endovascular repair of the ascending aorta in selected patients deemed unfit for open surgery. However, the use of commercially available stent graft in the ascending aorta remains off-label, and their excessive length often prevents their deployment in the ascending aorta. Here we report a case of successful primary endovascular repair of the ascending aorta using a physician modified off-the-shelf device.


Assuntos
Aorta/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Procedimentos Endovasculares , Idoso de 80 Anos ou mais , Aorta/diagnóstico por imagem , Insuficiência da Valva Aórtica/diagnóstico por imagem , Prótese Vascular , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/métodos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Feminino , Fluoroscopia , Humanos , Stents , Tomografia Computadorizada por Raios X
18.
J Am Heart Assoc ; 7(20): e010089, 2018 10 16.
Artigo em Inglês | MEDLINE | ID: mdl-30371287

RESUMO

Background Multiple percutaneous coronary interventions ( PCIs ) are considered determinant of poor outcome in patients undergoing coronary artery bypass grafting ( CABG ), but scarce data exist to substantiate this. Methods and Results Patients who underwent CABG without history of prior PCI or with PCI performed >30 days before surgery were selected for the present analysis from the prospective, multicenter E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) registry. Out of 6563 patients with data on preoperative SYNTAX (Synergy between PCI With Taxus and Cardiac Surgery) score, 1181 patients (18.0%) had undergone PCI >30 days before CABG . Of these, 11.6% underwent a single PCI , 4.4% 2 PCI s, and 2.1% ≥3 PCI s. PCI of a single main coronary vessel was performed in 11.3%, of 2 main vessels in 4.9%, and of 3 main vessels in 1.6% of patients. Multivariable analysis showed that differences in early mortality and other outcomes were not significantly different in the study cohorts. The adjusted hospital/30-day mortality rate was 1.8% in patients without history of prior PCI , 1.9% in those with a history of 1 PCI , 1.4% after 2 PCI s, and 2.5% after ≥3 PCI s (adjusted P=0.8). The adjusted hospital/30-day mortality rate was 2.0% in those who had undergone PCI of 1 main coronary vessel, 1.3% after PCI of 2 main vessels, and 3.1% after PCI of 3 main coronary vessels (adjusted P=0.6). Conclusions Multiple prior PCI s are not associated with increased risk of early adverse events in patients undergoing isolated CABG . The present results are conditional to survival after PCI and should not be viewed as a support for a policy of multiple PCI as opposed to earlier CABG . Clinical Trial Registration URL : http://www.Clinicaltrials.gov . Unique identifier: NCT 02319083.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Idoso , Ponte de Artéria Coronária/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Intervenção Coronária Percutânea/mortalidade , Prognóstico , Estudos Prospectivos , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Reoperação/estatística & dados numéricos , Fatores de Risco , Stents
19.
Eur J Vasc Endovasc Surg ; 56(5): 741-748, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30197287

RESUMO

OBJECTIVES: The aim of this study was to evaluate the prognostic impact of untreated asymptomatic carotid artery stenosis (CS) in patients undergoing isolated coronary artery bypass grafting (CABG). METHODS: This was a post hoc analysis of data from a prospective multicentre observational study. Patients without history of stroke or transient ischaemic attack from the multicentre E-CABG registry who were screened for CS before isolated CABG were included. RESULTS: Among 2813 patients screened by duplex ultrasound and who did not undergo carotid intervention for asymptomatic CS, 11.1% had a stenosis of 50-59%, 6.0% of 60-69%, 3.1% of 70-79%, 1.4% of 80-89%, 0.5% of 90-99%, and 1.1% had carotid occlusion. In the screened population post-operative stroke occurred in 25 patients (0.9%), with an incidence of 1.5% among patients with CS ≥ 50% (n = 649). Pre-operative screening had not found a relevant CS in 15 of 25 patients suffering stroke after CABG. Brain imaging identified cerebral ischaemic injury in 20 patients, which was bilateral in five patients (25%), ipsilateral to a CS ≥ 50% in six (30%), and ipsilateral to a CS ≥ 70% in three (15%). In univariable analysis, the severity of CS was associated with a significantly increased risk of stroke (CS < 50%, 0.7%; 50-59%, 1.0%; 60-69%, 0.6%; 70-79%, 1.2%; 80-89%, 5.1%; 90-99%, 7.7%; occluded, 6.7%, p < .001). In multivariable analysis, a CS of 90-99% (OR 12.03, 95% CI 1.34-108.23) and the presence of an occluded internal carotid artery (OR 8.783, 95% CI 1.820-42.40) were independent predictors of stroke along with urgency of the procedure, severe massive bleeding according to the E-CABG classification, and the presence of a porcelain ascending aorta. CONCLUSIONS: Among screened patients with untreated asymptomatic patients, CS ≥ 90% was an independent predictor of post-operative stroke. As this condition has a low prevalence and when left untreated is associated with a relatively low rate of stroke, pre-operative screening of asymptomatic CS before CABG may not be justified. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov. Unique identifier: NCT02319083.


Assuntos
Estenose das Carótidas/cirurgia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Endarterectomia das Carótidas , Adulto , Idoso , Estenose das Carótidas/diagnóstico , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/complicações , Endarterectomia das Carótidas/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
20.
J Cardiovasc Med (Hagerstown) ; 19(7): 382-388, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29877976

RESUMO

AIMS: Triple valve surgery (TVS) may still be considered a challenge in cardiac surgery, and is still associated with a not negligible mortality and morbidity. This study analyzed retrospectively patients' data from RERIC (Registro Regionale degli Interventi Cardiochirurgici) registry, to evaluate early and mid-term results of TVS. METHODS: From April 2002 to December 2013, data from n = 44 211 cardiac surgical procedures were collected from six Cardiac Surgery Departments (RERIC). Two hundred and eighty patients undergoing TVS were identified, including aortic and mitral replacement with tricuspid repair in 211 patients (75.3%), aortic replacement with mitral and tricuspid repair in 64 (22.9%) and triple valve replacement in 5 (1.8%). Univariate and multivariate analyses were performed to identify predictors of overall mortality or adverse outcomes. RESULTS: The mean age of the patients was 67.5 ±â€Š12.2. Overall in-hospital mortality rate was 7.9%: in-hospital mortality was 10.9% in mitral valve repair and 6.6% in mitral valve replacement, respectively. Tricuspid valve replacement was associated with the highest mortality rate (40%). Independent predictors of in-hospital mortality were serum creatinine greater than 2 mg/dl [odds ratio (OR) 4.5; P = 0.03], concomitant coronary artery bypass graft (CABG) (OR 3.8; P = 0.01) and previous cardiac surgery (OR 5.1; P = 0.04). Overall cumulative mortality rate at 1, 3 and 5 years was 14.7, 24.1 and 28.9%, respectively. Mitral valve replacement associated with tricuspid valve repair showed better survival rate (hazard ratio 0.1; P = 0.007). CONCLUSION: TVS has demonstrated satisfactory results in terms of in-hospital and mid-term mortality rate. Renal failure, reoperations and concomitant CABG resulted as risk factors for mortality; moreover, we could not demonstrate a mid-term better survival rate of mitral valve repair compared with the replacement.


Assuntos
Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/mortalidade , Valva Mitral/cirurgia , Valva Tricúspide/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/efeitos adversos , Feminino , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Mortalidade Hospitalar , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Sistema de Registros , Reoperação , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento , Adulto Jovem
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