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1.
CMAJ ; 191(9): E247-E256, 2019 Mar 04.
Artigo em Inglês | MEDLINE | ID: mdl-30833491

RESUMO

BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 µmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.

2.
JACC Basic Transl Sci ; 3(5): 591-600, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30456331

RESUMO

Leukocyte telomere shortening reflects stress burdens and has been associated with cardiac events. However, the patient-specific clinical value of telomere assessment remains unknown. Moreover, telomere shortening cannot be inferred from a single telomere length assessment. The authors investigated and developed a novel strategy for gauging leukocyte telomere shortening using autologous cardiac atrial referencing. Using multitissue assessments from 163 patients who underwent cardiovascular surgery, we determined that the cardiac atrium-leukocyte telomere length difference predicted post-operative complexity. This constituted the first evidence that a single-time assessment of telomere dynamics might be salient to acute cardiac care.

3.
J Pediatr Surg ; 53(5): 937-941, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29506814

RESUMO

BACKGROUND: Hypertrophic pyloric stenosis (HPS) is a common neonatal condition treated with open or laparoscopic pyloromyotomy. 3D-printed organs offer realistic simulations to practice surgical techniques. The purpose of this study was to validate a 3D HPS stomach model and assess model reliability and surgical realism. METHODS: Medical students, general surgery residents, and adult and pediatric general surgeons were recruited from a single center. Participants were videotaped three times performing a laparoscopic pyloromyotomy using box trainers and 3D-printed stomachs. Attempts were graded independently by three reviewers using GOALS and Task Specific Assessments (TSA). Participants were surveyed using the Index of Agreement of Assertions on Model Accuracy (IAAMA). RESULTS: Participants reported their experience levels as novice (22%), inexperienced (26%), intermediate (19%), and experienced (33%). Interrater reliability was similar for overall average GOALS and TSA scores. There was a significant improvement in GOALS (p<0.0001) and TSA scores (p=0.03) between attempts and overall. Participants felt the model accurately simulated a laparoscopic pyloromyotomy (82%) and would be a useful tool for beginners (100%). CONCLUSION: A 3D-printed stomach model for simulated laparoscopic pyloromyotomy is a useful training tool for learners to improve laparoscopic skills. The GOALS and TSA provide reliable technical skills assessments. LEVEL OF EVIDENCE: II.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Laparoscopia/educação , Impressão Tridimensional/estatística & dados numéricos , Estenose Pilórica Hipertrófica/cirurgia , Piloromiotomia/educação , Treinamento por Simulação , Feminino , Humanos , Internato e Residência , Masculino , Pediatria , Piloromiotomia/métodos , Reprodutibilidade dos Testes , Inquéritos e Questionários
4.
Urology ; 111: 110-115, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29054720

RESUMO

OBJECTIVE: To determine, via a randomized comparison study, whether robotic simulator-acquired skills transfer to performance of a urethrovesical anastomosis (UVA) on a 3-dimensional-printed bladder model using the da Vinci Robot. MATERIALS AND METHODS: Medical students, surgical residents, and fellows were recruited and divided into 2 groups: Group 1 (G1) (junior trainees) and Group 2 (G2) (senior trainees). Participants were randomized to identical simulator training curricula on the dV-Trainer (dV-T) or da Vinci Surgical Skills Simulator (dVSSS). Participants then completed a UVA task on a 3-dimensional-printed bladder model using the da Vinci robot. Three blinded expert robotic surgeons rated videotaped performances of the UVA task using validated assessment tools, namely, the Global Evaluative Assessment of Robotic Skills (GEARS; overall procedure) and Robotic Anastomosis Competence Evaluation (RACE; specific to UVA). RESULTS: Thirty-nine participants (G1 = 23 and G2 = 16) completed the study. Participants in G2 had significantly more simulation and surgical experience compared with G1 (P <.05). UVA scores of the dVSSS group were higher compared with dV-T (GEARS: P = .09; RACE: P = .01). In the G1 cohort, dVSSS scores were significantly higher than dV-T (GEARS: P = .01; RACE: P <.01). In the G2 cohort, scores were statistically similar (GEARS: P = .32; RACE: P = .91). CONCLUSION: Compared with the dV-T, the dVSSS training led to superior GEARS and RACE scores for performance of the UVA task in junior trainees, but not in senior trainees. The dVSSS can be used to improve surgical skills acquisition in less experienced trainees in a safe and effective manner.

5.
Innovations (Phila) ; 12(4): 231-238, 2017 Jul/Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28763350

RESUMO

OBJECTIVE: The aims of the study were to determine whether endoscopic harvesting of the radial artery (RA) reduces morbidity due to pain, infection, and disability with improvement in satisfaction and cosmesis compared to the conventional technique and (2) to compare the 6-month angiographic patency of the RA harvested conventionally and endoscopically. METHODS: In a prospective randomized study, 119 patients undergoing coronary artery bypass grafting using the RA were randomized to have RA harvested either conventionally (n = 59) or endoscopically (n = 60). RESULTS: Radial artery harvest time (open wound time) was significantly reduced in the endoscopic group (36.5 ± 9.4 vs 57.7 ± 9.4 minutes, P < 0.001). Only one patient developed wound infection (1.6%) in the endoscopic group compared with six patients (10.2%), P = 0.061, in the conventional group. Although this was not statistically significant, clinically this was relevant in terms of reduction in postoperative morbidity. Postoperative pain in the arm incision was significantly lower in the endoscopic group at postoperative day 2 (P < 0.001) and at discharge (P < 0.001) and similar to the conventional open group at 6 weeks' follow-up (P = 0.103). Overall patient satisfaction and cosmesis were significantly better in the endoscopic group at postoperative day 2 (P < 0.001), at discharge (P < 0.001), and at 6 weeks' follow-up (P < 0.001). There was no difference in the arm disability postoperatively (P = 0.505) between the two groups. Six-month angiographic assessment of 23 patients (12 endoscopic and 11 open) revealed no difference in the patency rate (10/12 in endoscopic and 9/11 in open group). CONCLUSIONS: Endoscopic RA harvesting reduced the incidence of postoperative wound infection and wound pain and improved patient satisfaction and cosmesis compared with conventional harvesting technique. There was no difference in the 6-month angiographic patency of the RA harvested conventionally and endoscopically.


Assuntos
Ponte de Artéria Coronária/métodos , Endoscopia/métodos , Artéria Radial/transplante , Coleta de Tecidos e Órgãos/métodos , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Artéria Radial/cirurgia , Coleta de Tecidos e Órgãos/efeitos adversos , Coleta de Tecidos e Órgãos/estatística & dados numéricos
6.
J Cardiothorac Vasc Anesth ; 31(4): 1174-1182, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28159523

RESUMO

OBJECTIVE: Peripheral nerve injury (PNI) is a common and potentially devastating complication in cardiac surgery. Somatosensory evoked potential (SSEP) monitoring is one of the modalities for PNI; however, its application is limited by complicated logistics. This study aimed to assess the feasibility of using a novel, automated SSEP device (EPAD; SafeOp Surgical, Hunt Valley, MD) for detection of intraoperative PNI during cardiac surgery. DESIGN: Prospective, observational study. SETTING: Single university hospital. PARTICIPANTS: Cardiac surgical patients. INTERVENTIONS: After Ethics Board approval and written consent, study participants were monitored using the EPAD automated SSEP device during cardiac surgery. All patients with prolonged and abnormal SSEP changes were evaluated postoperatively, and if they were symptomatic, they were referred for further nerve conduction and electromyographic assessment. MEASUREMENTS AND MAIN RESULTS: Of the 43 patients who consented to study inclusion, 33 were monitored successfully. With increasing clinical experience the authors encountered minimal technical issues, and satisfactory signals were obtained in most patients. Abnormal SSEP signal changes, which were encountered in 5 (15.2%) patients, were interpreted as impending PNI; 3 patients experienced prolonged signal changes (>1 h), and 2 (6.1%) of these developed symptomatic peripheral neuropathy that was confirmed with nerve conduction studies. CONCLUSIONS: The EPAD automated SSEP device is a viable option for detecting PNI during cardiac surgery. A high incidence of intraoperative peripheral nerve compromise and a 6.1% incidence of postoperative peripheral neuropathy were observed. This study reports the clinical feasibility of using the EPAD automated SSEP device; additional studies are required to evaluate the diagnostic test accuracy and the outcome benefit of routine SSEP monitoring in cardiac surgical patients.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Potenciais Somatossensoriais Evocados/fisiologia , Monitorização Neurofisiológica Intraoperatória/métodos , Traumatismos dos Nervos Periféricos/diagnóstico , Traumatismos dos Nervos Periféricos/fisiopatologia , Idoso , Estudos de Viabilidade , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/instrumentação , Masculino , Pessoa de Meia-Idade , Traumatismos dos Nervos Periféricos/etiologia , Estudos Prospectivos
7.
Can J Cardiol ; 33(4): 535-539, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28011107

RESUMO

Management of cardiac surgery health human resources (HHR) has been challenging, with recent graduates struggling to secure employment and a shortage of cardiac surgeons predicted as early as 2020. The length of cardiac surgery training prevents HHR supply from adapting in a timely fashion to changes in demand, resulting in a critical need for active workforce management. This study details the results of the 2015 Canadian Society of Cardiac Surgeons (CSCS) workforce survey undertaken as part of the CSCS strategy for active workforce management. The 38-question survey was administered electronically to all 96 trainees identified as being registered in a Canadian cardiac surgery residency program for the 2015-2016 academic year. Eighty-four of 96 (88%) trainees responded. The majority of participants were satisfied with their training experience. However, 29% stated that their clinical and operative exposure needed improvement, and 57% of graduating trainees did not believe that they would be competent to practice independently at the conclusion of their training. Although 51% of participants believe the job market is improving, 94% of senior trainees found it competitive or extremely difficult to secure an attending staff position. Participants highlighted a need for improved career counselling and formal mentorship. Although the job market is perceived to be improving, a mismatch in the cardiac surgery workforce supply and demand remains because current trainees continue to experience difficulty securing employment after the completion of residency training. Trainees have identified improved career counselling and mentorship as potential strategies to aid graduates in securing employment.


Assuntos
Procedimentos Cirúrgicos Cardíacos/educação , Escolha da Profissão , Educação de Pós-Graduação em Medicina/métodos , Internato e Residência , Cirurgiões/educação , Inquéritos e Questionários , Cirurgia Torácica , Atitude do Pessoal de Saúde , Canadá , Humanos , Satisfação no Emprego , Recursos Humanos
8.
Stroke Vasc Neurol ; 2(4): 198-203, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29507780

RESUMO

Objectives: Microembolic signals (MES) on transcranial Doppler (TCD) predict stroke and cognitive decline. Plasma levels of total homocysteine (tHcy), a prothrombotic factor, are higher in patients with microemboli in carotid stenosis and in patients with paradoxical embolism. In this study we assessed the association between the level of tHcy and the number of MES in patients with mechanical heart valves (MHVs). Methods: TCD monitoring was performed to detect MES before and after breathing 100% oxygen and repeated every 2-4 weeks up to six times. Results: Twenty-five patients with MHVs (mean age: 63.60±10.15 years) participated in this study; 15 were men (66.47±7.25 years) and 10 were women (59.30±12.60 years). In total, there were 126 study visits. In multiple regression, higher tHcy was associated with more MES in both preoxygenation (OR 1.34 (95% CI 1.07 to 1.68, P=0.009)) and postoxygenation (OR 1.40 (95% CI 1.07 to 1.83, P=0.01)) phases. Current smoking and the length of time between the operation and monitoring also correlated with a higher number of MES before and after breathing oxygen, particularly in women. Conclusions: Higher tHcy and smoking were associated with a higher MES count in both preoxygenation and postoxygenation phases. Because smoking can be stopped and hyperhomocysteinaemia is treatable, these are clinically important findings.

9.
Lancet ; 386(10000): 1243-1253, 2015 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-26460660

RESUMO

BACKGROUND: Cardiopulmonary bypass initiates a systemic inflammatory response syndrome that is associated with postoperative morbidity and mortality. Steroids suppress inflammatory responses and might improve outcomes in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. We aimed to assess the effects of steroids in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. METHODS: The Steroids In caRdiac Surgery (SIRS) study is a double-blind, randomised, controlled trial. We used a central computerised phone or interactive web system to randomly assign (1:1) patients at high risk of morbidity and mortality from 80 hospital or cardiac surgery centres in 18 countries undergoing cardiac surgery with the use of cardiopulmonary bypass to receive either methylprednisolone (250 mg at anaesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients were assigned with block randomisation with random block sizes of 2, 4, or 6 and stratified by centre. Patients aged 18 years or older were eligible if they had a European System for Cardiac Operative Risk Evaluation of at least 6. Patients were excluded if they were taking or expected to receive systemic steroids in the immediate postoperative period or had a history of bacterial or fungal infection in the preceding 30 days. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcomes were 30-day mortality and a composite of death and major morbidity (ie, myocardial injury, stroke, renal failure, or respiratory failure) within 30 days, both analysed by intention to treat. Safety outcomes were also analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00427388. FINDINGS: Patients were recruited between June 21, 2007, and Dec 19, 2013. Complete 30-day data was available for all 7507 patients randomly assigned to methylprednisolone (n=3755) and to placebo (n=3752). Methylprednisolone, compared with placebo, did not reduce the risk of death at 30 days (154 [4%] vs 177 [5%] patients; relative risk [RR] 0·87, 95% CI 0·70-1·07, p=0·19) or the risk of death or major morbidity (909 [24%] vs 885 [24%]; RR 1·03, 95% CI 0·95-1·11, p=0·52). The most common safety outcomes in the methylprednisolone and placebo group were infection (465 [12%] vs 493 [13%]), surgical site infection (151 [4%] vs 151 [4%]), and delirium (295 [8%] vs 289 [8%]). INTERPRETATION: Methylprednisolone did not have a significant effect on mortality or major morbidity after cardiac surgery with cardiopulmonary bypass. The SIRS trial does not support the routine use of methylprednisolone for patients undergoing cardiopulmonary bypass. FUNDING: Canadian Institutes of Health Research.


Assuntos
Anti-Inflamatórios/uso terapêutico , Ponte Cardiopulmonar/métodos , Metilprednisolona/uso terapêutico , Síndrome de Resposta Inflamatória Sistêmica/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/mortalidade , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Resposta Inflamatória Sistêmica/etiologia
10.
Anesthesiology ; 123(6): 1404-10, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26501386

RESUMO

BACKGROUND: Persistent incisional pain is common after cardiac surgery and is believed to be in part related to inflammation and poorly controlled acute pain. Methylprednisolone is a corticosteroid with substantial antiinflammatory and analgesic properties and is thus likely to ameliorate persistent surgical pain. Therefore, the authors tested the primary hypothesis that patients randomized to methylprednisolone have less persistent incisional pain than those given placebo. METHODS: One thousand forty-three patients having cardiopulmonary bypass for cardiac surgery via a median sternotomy were included in this substudy of Steroids in Cardiac Surgery (SIRS) trial. Patients were randomized to 500 mg intraoperative methylprednisolone or placebo. Incisional pain was assessed at 30 days and 6 months after surgery, and the potential risk factors were also evaluated. RESULTS: Methylprednisolone administration did not reduce pain at 30 days or persistent incisional pain at 6 months, which occurred in 78 of 520 patients (15.7%) in the methylprednisolone group and in 88 of 523 patients (17.8%) in the placebo group. The odds ratio for methylprednisolone was 0.93 (95% CI, 0.79 to 1.09, P = 0.37). Furthermore, there was no difference in worst pain and average pain in the last 24 h, pain interference with daily life, or use of pain medicine at 6 months. Younger age, female sex, and surgical infections were associated with the development of persistent incisional pain. CONCLUSIONS: Intraoperative methylprednisolone administration does not reduce persistent incisional pain at 6 months in patients recovering from cardiac surgery.


Assuntos
Anti-Inflamatórios/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Metilprednisolona/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Fatores Etários , Idoso , Ponte Cardiopulmonar , Feminino , Seguimentos , Humanos , Masculino , Fatores de Risco , Fatores Sexuais , Resultado do Tratamento
11.
Innovations (Phila) ; 10(4): 279-81, 2015 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26368033

RESUMO

We present a case of a 48-year-old female patient successfully bridged to recovery with the Impella 5.0 microaxial pump (Abiomed, Danvers, MA USA) after presenting with cardiogenic shock secondary to acute fulminant viral myocarditis. After 1 week of flu-like symptoms, the patient presented to her community emergency department with chest pain and hypotension. A diagnosis of inferior ST elevation myocardial infarction was made; subsequent angiography demonstrated normal coronary arteries and a left ventricular ejection fraction of 10%. A provisional diagnosis of viral myocarditis was made. As her condition deteriorated further, she underwent insertion of an Impella 5.0 after failure of supportive medical therapy. Myocardial recovery occurred, and the Impella was removed after 1 week. After a prolonged cardiac intensive care unit stay requiring temporary hemodialysis, the patient recovered sufficiently to tolerate device explant, transfer to the recovery ward, and ultimate discharge home. This case report highlights the benefit of mechanical circulatory support in a patient with cardiogenic shock from viral myocarditis as well as some of the complications that can occur in this critically ill subset of patients.


Assuntos
Coração Auxiliar , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Miocardite/terapia , Miocardite/virologia , Choque Cardiogênico/terapia , Choque Cardiogênico/virologia , Doença Aguda , Lesão Renal Aguda/diagnóstico por imagem , Lesão Renal Aguda/terapia , Lesão Renal Aguda/virologia , Angiografia Coronária/métodos , Ecocardiografia , Serviço Hospitalar de Emergência , Feminino , Humanos , Unidades de Terapia Intensiva , Pessoa de Meia-Idade , Miocardite/diagnóstico por imagem , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/diagnóstico por imagem , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/virologia
12.
Innovations (Phila) ; 10(2): 77-84, 2015 Mar-Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25807170

RESUMO

OBJECTIVE: From 2005 to 2007, 119 patients were enrolled in a prospective randomized controlled trial comparing open and endoscopically harvested radial arteries for coronary artery bypass grafting. The objective of the current study was to compare graft patency between intervention groups at more than 5 years from the initial trial. We hypothesized that endoscopically harvested radial arteries would show equivalent patency to those conventionally harvested. METHODS: At 5 years or greater from their operation, all consenting patients underwent a single-day anatomic and functional cardiac assessment with coronary computed tomography angiography and sestamibi myocardial perfusion scanning. Medical Outcomes Study 36-Item Short-Form Health Surveys and Seattle Angina Questionnaires were completed to assess the overall quality of life. All patients had received calcium channel blocker therapy for at least 6 months postoperatively. RESULTS: The mean (SD) duration of follow-up was 79.2 (8.6) months for all patients. One death occurred within 30 days of coronary artery bypass grafting in each treatment group, and eight additional noncardiac deaths occurred during the study time frame. Of 119 patients, 66 consented to follow-up. Thirty-two had open radial artery harvest, and 34 had endoscopic radial artery harvest. At more than 5 years, there were 28 patent conventionally harvested radial arteries (87.5%) and 31 patent endoscopically harvested radial arteries (91.2%) (P = 0.705). Measured quality of life was comparable between groups. CONCLUSIONS: Endoscopic radial artery harvest is safe and effective when compared with open radial artery harvest, with excellent graft patency demonstrated at more than 5 years. Patency results are noninferior in endoscopic radial artery harvest.


Assuntos
Ponte de Artéria Coronária/métodos , Endoscopia/métodos , Artéria Radial/transplante , Coleta de Tecidos e Órgãos/métodos , Grau de Desobstrução Vascular , Bloqueadores dos Canais de Cálcio/uso terapêutico , Angiografia Coronária/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Prospectivos , Qualidade de Vida , Veia Safena/transplante , Resultado do Tratamento
13.
Heart Rhythm ; 12(4): 699-705, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25595923

RESUMO

BACKGROUND: Although often short-lived and self-limiting, postoperative atrial fibrillation (POAF) is a well-recognized postoperative complication of cardiac surgery and is associated with a 2-fold increase in cardiovascular mortality and morbidity. OBJECTIVE: Our aim was to determine whether intraoperative bilateral pulmonary vein radiofrequency ablation decreases the incidence of POAF in patients undergoing coronary artery bypass grafting (CABG). METHODS: A total of 175 patients undergoing CABG was prospectively randomized to undergo adjuvant bilateral radiofrequency pulmonary vein ablation in addition to CABG (group A; n = 89) or CABG alone (group B; n = 86). Intraoperative pulmonary vein isolation was confirmed by the inability to pace the heart via the pulmonary veins after ablation. All patients received postoperative ß-blocker. RESULTS: There was no difference in the incidence of POAF in the treatment group who underwent adjuvant pulmonary vein ablation (group A; 37.1%) compared with the control group who did not (group B; 36.1%) (P = .887). There were no differences in postoperative inotropic support, antiarrhythmic drug use, need for oral anticoagulation, and complication rates. The mean length of postoperative hospital stay was 8.2 ± 6.5 days in the ablation group and 6.7 ± 4.6 days in the control group (P < .001). CONCLUSION: Adjuvant pulmonary vein isolation does not decrease the incidence of POAF or its clinical impact but increases the mean length of stay in the hospital. The mechanism of POAF does not appear to depend on the pulmonary veins.


Assuntos
Fibrilação Atrial , Ablação por Cateter/métodos , Ponte de Artéria Coronária/efeitos adversos , Complicações Pós-Operatórias , Veias Pulmonares/cirurgia , Idoso , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/etiologia , Fibrilação Atrial/cirurgia , Canadá , Ponte de Artéria Coronária/métodos , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados (Cuidados de Saúde) , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia
14.
The Lancet ; 386(10000): 1243-1253, 2015.
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: ses-32878

RESUMO

BACKGROUND:Cardiopulmonary bypass initiates a systemic inflammatory response syndrome that is associated with postoperative morbidity and mortality. Steroids suppress inflammatory responses and might improve outcomes in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. We aimed to assess the effects of steroids in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass.METHODS:The Steroids In caRdiac Surgery (SIRS) study is a double-blind, randomised, controlled trial. We used a central computerised phone or interactive web system to randomly assign (1:1) patients at high risk of morbidity and mortality from 80 hospital or cardiac surgery centres in 18 countries undergoing cardiac surgery with the use of cardiopulmonary bypass to receive either methylprednisolone (250 mg at anaesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients were assigned with block randomisation with random block sizes of 2, 4, or 6 and stratified by centre. Patients aged 18 years or older were eligible if they had a European System for Cardiac Operative Risk Evaluation of at least 6. Patients were excluded if they were taking or expected to receive systemic steroids in the immediate postoperative period or had a history of bacterial or fungal infection in the preceding 30 days. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcomes were 30-day mortality and a composite of death and major morbidity (ie, myocardial injury, stroke, renal failure, or respiratory failure) within 30 days, both analysed by intention to treat. Safety outcomes were also analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00427388... (AU)


Assuntos
Metilprednisolona , Circulação Extracorpórea
15.
Can J Cardiol ; 30(12): 1725-31, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25475475

RESUMO

Current guideline-based recommendations for oral dual-antiplatelet therapy in an acute coronary syndrome (ACS) include the use of newer adenosine diphosphate receptor inhibitor (ADPri) regimens and agents. The Canadian ACS Reflective Program is a multicenter observational quality-enhancement project that compared the use of ADPri therapy in 2 phases (November 2011-March 2013 and April 2013-November 2013) and also compared ADPri use with previous national data from the Canadian Global Registry of Acute Coronary Events (2000-2008). Of 3099 patients with ACS, 30.6% had ST-segment elevation myocardial infarction (STEMI), 52.3% had non-STEMI, and 17% had unstable angina. There was high use of dual-antiplatelet therapy for ≤ 24 hours, with important increases noted when compared with previous national experience (P for trend, < 0.0001). Clopidogrel was the most commonly used ADPri (82.2%), with lower use of the newer agents ticagrelor (9.0%) and prasugrel (3.1%). Ticagrelor and prasugrel use was most frequent in patients with STEMI undergoing percutaneous coronary intervention PCI (34.3%). There was relatively lower use of ADPri therapy at discharge; it was given mainly to patients who did not undergo PCI (68.2%) and to those with non-ST-elevation ACS (82%). When comparing the 2 consecutive phases of data collection in the ACS Reflective, there was an approximate 3- and 2-fold increase in the early and discharge use of the newer ADPri agents, respectively. In conclusion, there has been a temporal increase in ADPri use compared with previous national experience and an increased uptake of newer ADPri agents. Additional work is needed to identify and address barriers limiting optimal implementation of these newer guideline-recommended agents into routine Canadian practice.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Fidelidade a Diretrizes , Inibidores da Agregação de Plaquetas/uso terapêutico , Sistema de Registros , Idoso , Canadá , Esquema de Medicação , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Estudos Prospectivos , Resultado do Tratamento
16.
J Thorac Cardiovasc Surg ; 148(2): 726-32, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24820190

RESUMO

OBJECTIVE: Cardiac surgery is a major cause of acute kidney injury. In this setting, receipt of blood transfusions seems to be associated with a higher risk of acute kidney injury, as measured using serum creatinine values. We examined this association further by using urinary biomarkers of kidney injury. METHODS: A total of 1210 adults underwent cardiac surgery and were divided into 3 groups on the basis of the receipt of intraoperative packed red blood cell units: no blood (n = 894), 2 or less packed red blood cell units (n = 206), and more than 2 packed red blood cell units (n = 110). Acute kidney injury was defined as (1) doubling of serum creatinine from the preoperative value; (2) first postoperative urinary interleukin-18 in the fifth quintile; and (3) first postoperative urinary neutrophil gelatinase-associated lipocalin in the fifth quintile. We determined the relative risk for acute kidney injury outcome according to packed red blood cell units group after adjusting for 12 preoperative and surgical variables. By using the Sobel test for mediation analysis, we also evaluated the role of biomarkers in causing acute kidney injury through alternative pathways. RESULTS: Acute kidney injury was more common in those who received more than 2 packed red blood cell units. In patients receiving more than 2 packed red blood cell units, the adjusted relative risks were 2.3 (95% confidence interval, 1.2-4.4, P .01), 1.36 (95% confidence interval, 1.0-1.9, P .05), and 1.34 (95% confidence interval, 1.0-1.8, P .06) for doubling of serum creatinine, urinary interleukin-18 in the fifth quintile (>60 pg/mL), and urinary neutrophil gelatinase-associated lipocalin in the fifth quintile (>102 ng/mL), respectively. Furthermore, the effect of packed red blood cell units transfusion on acute kidney injury was partially mediated by interleukin-18. CONCLUSIONS: Receipt of 2 or more packed red blood cell units during cardiac surgery is associated with a greater risk of acute kidney injury defined by serum creatinine and kidney injury biomarkers.


Assuntos
Lesão Renal Aguda/etiologia , Lesão Renal Aguda/urina , Proteínas da Fase Aguda/urina , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Transfusão de Eritrócitos/efeitos adversos , Interleucina-18/urina , Lipocalinas/urina , Proteínas Proto-Oncogênicas/urina , Lesão Renal Aguda/sangue , Lesão Renal Aguda/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Biomarcadores/urina , Creatinina/sangue , Feminino , Humanos , Lipocalina-2 , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Regulação para Cima
17.
Am Heart J ; 167(5): 660-5, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24766975

RESUMO

BACKGROUND: Steroids may improve outcomes in high-risk patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CBP). There is a need\ for a large randomized controlled trial to clarify the effect of steroids in such patients. METHODS: We plan to randomize 7,500 patients with elevated European System for Cardiac Operative Risk Evaluation who are undergoing cardiac surgery with the use of CBP to methylprednisolone or placebo. The first coprimary outcome is 30-day all-cause mortality, and the most second coprimary outcome is a composite of death, MI, stroke, renal failure, or respiratory failure within 30 days. Other outcomes include a composite of MI or mortality at 30 days, new onset atrial fibrillation, bleeding and transfusion requirements, length of intensive care unit stay and hospital stay, infection, stroke, wound complications, gastrointestinal complications, delirium, postoperative insulin use and peak blood glucose, and all-cause mortality at 6 months. RESULTS: As of October 22, 2013, 7,034 patients have been recruited into SIRS in 82 centers from 18 countries. Patient's mean age is 67.3 years, and 60.4% are male. The average European System for Cardiac Operative Risk Evaluation is 7.0 with 22.1% having an isolated coronary artery bypass graft procedure, and 66.1% having a valve procedure. CONCLUSIONS: SIRS will lead to a better understanding of the safety and efficacy of prophylactic steroids for cardiac surgery requiring CBP.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiopatias/cirurgia , Metilprednisolona/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Saúde Global , Glucocorticoides/administração & dosagem , Humanos , Incidência , Injeções Intravenosas , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento
18.
BMJ Open ; 4(3): e004842, 2014 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-24598306

RESUMO

INTRODUCTION: Steroids In caRdiac Surgery trial (SIRS) is a large international randomised controlled trial of methylprednisolone or placebo in patients undergoing cardiac surgery with the use of a cardiopulmonary bypass pump. At the time of surgery, compared with placebo, methylprednisolone divided into two intravenous doses of 250 mg each may reduce the risk of postoperative acute kidney injury (AKI). METHODS AND ANALYSIS: With respect to the study schedule, over 7000 substudy eligible patients from 81 centres in 18 countries were randomised in December 2013. The authors will use a logistic regression to estimate the adjusted OR of methylprednisolone versus placebo on the primary outcome of AKI in the 14 days following surgery (a postoperative increase in serum creatinine of ≥50%, or ≥26.5 µmol/L, from the preoperative value). The stage of AKI will also be considered, as will the outcome of AKI in those with and without preoperative chronic kidney disease. After receipt of grant funding, the authors began to record additional perioperative serum creatinine measurements in consecutive patients enrolled at substudy participating centres, and patients were invited to enroll in a 6-month serum creatinine collection. In these trial subpopulations, the authors will consider the outcome of AKI defined in alternate ways, and the outcome of a 6-month change in kidney function from the preoperative value. ETHICS AND DISSEMINATION: The authors were competitively awarded a grant from the Canadian Institutes of Health Research for this SIRS AKI substudy. Ethics approval was obtained for additional serum creatinine recordings in consecutive patients enrolled at participating centres. The additional kidney data collection first began for patients enrolled after 1 March 2012. In patients who provided consent, the last 6-month kidney outcome data will be collected in 2014. The results will be reported no later than 2015. CLINICAL TRIAL REGISTRATION: Number NCT00427388.


Assuntos
Lesão Renal Aguda/prevenção & controle , Anti-Inflamatórios/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Metilprednisolona/uso terapêutico , Biomarcadores/sangue , Canadá , Procedimentos Cirúrgicos Cardíacos/métodos , Protocolos Clínicos , Creatinina/sangue , Humanos , Projetos de Pesquisa , Fatores de Risco
19.
Can J Surg ; 56(1): 21-6, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23187039

RESUMO

BACKGROUND: Cardiac retransplantation remains the most viable option for patients with allograft heart failure; however, careful patient selection is paramount considering limited allograft resources. We analyzed clinical outcomes following retransplantation in an academic, tertiary care institution. METHODS: Between 1981 and 2011, 593 heart transplantations, including 22 retransplantations were performed at our institution. We analyzed the preoperative demographic characteristics, cause of allograft loss, short- and long-term surgical outcomes and cause of death among patients who had cardiac retransplantations. RESULTS: Twenty-two patients underwent retransplantation: 10 for graft vascular disease, 7 for acute rejection and 5 for primary graft failure. Mean age at retransplantation was 43 (standard deviation [SD] 15) years; 6 patients were women. Thirteen patients were critically ill preoperatively, requiring inotropes and/or mechanical support. The median interval between primary and retransplantation was 2.2 (range 0-16) years. Thirty-day mortality was 31.8%, and conditional (> 30 d) 1-, 5- and 10-year survival after retransplantation were 93%, 79% and 59%, respectively. A diagnosis of allograft vasculopathy (p = 0.008) and an interval between primary and retransplantation greater than 1 year (p = 0.016) had a significantly favourable impact on 30-day mortality. The median and mean survival after retransplantation were 3.3 and 5 (SD 6, range 0-18) years, respectively; graft vascular disease and multiorgan failure were the most common causes of death. CONCLUSION: Long-term outcomes for primary and retransplantation are similar if patients survive the 30-day postoperative period. Retransplantation within 1 year of the primary transplantation resulted in a high perioperative mortality and thus may be a contraindication to retransplantation.


Assuntos
Rejeição de Enxerto/cirurgia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Adulto , Feminino , Rejeição de Enxerto/etiologia , Transplante de Coração/mortalidade , Transplante de Coração/normas , Humanos , Imunossupressores/administração & dosagem , Estimativa de Kaplan-Meier , Masculino , Registros Médicos , Pessoa de Meia-Idade , Ontário , Seleção de Pacientes , Período Perioperatório , Reoperação/mortalidade , Reoperação/normas , Estudos Retrospectivos , Fatores de Risco , Atenção Terciária à Saúde , Fatores de Tempo , Transplante Homólogo , Resultado do Tratamento
20.
J Cardiothorac Vasc Anesth ; 26(1): 32-8, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21889364

RESUMO

OBJECTIVE: To compare measurements obtained by transesophageal echocardiography (TEE) and epicardial echocardiography (EE) for evaluation of the tricuspid valve (TV) and pulmonary valve (PV). DESIGN: Prospective observational. SETTING: University hospital. PARTICIPANTS: Patients undergoing elective coronary artery bypass grafting with or without aortic valve replacement. INTERVENTIONS: After routine intraoperative TEE, EE was performed to compare measurements obtained by the 2 methods. MEASUREMENTS AND MAIN RESULTS: After institutional review board approval, 25 patients >18 years old were recruited. Biases with EE versus TEE for E and A waves were 11.9 cm/second (95% confidence interval [CI], 48.2 to -24.4) and 6.8 cm/second (95% CI, 28 to -15), respectively, and for E/A ratio was 0.08 (95% CI, 1.2 to -1). Pulmonary velocity bias was 57.94 cm/second (95% CI, 192.9 to -76.98), with higher values using EE. Bias for pulmonary trunk diameter was -0.31 cm (95% CI, 1.5 to -2.1). For quality of images, means were 2.4 (standard deviation [SD], 1.0) for EE and 2.3 (SD, 0.57) with TEE for TV and 2.4 (SD, 1.0) with EE and 2.5 (SD, 1.0) with TEE for PV. For the number of leaflets visualized, means were 2.2 (SD, 1.0) with EE and 2.5 (SD, 0.5) with TEE for TV and 2.5 (SD, 0.5) for EE and 1.3 (SD, 1.1) with TEE for PV. CONCLUSIONS: There was good agreement for Doppler measurements across TVs; however, measurements across PVs were significantly higher with EE versus TEE. TV Doppler measurements were difficult to acquire even for surgeons experienced in epiaortic scanning.


Assuntos
Ecocardiografia Transesofagiana/instrumentação , Ecocardiografia Transesofagiana/normas , Pericárdio/diagnóstico por imagem , Valva Pulmonar/diagnóstico por imagem , Valva Tricúspide/diagnóstico por imagem , Idoso , Ponte de Artéria Coronária/instrumentação , Ponte de Artéria Coronária/normas , Humanos , Pericárdio/cirurgia , Estudos Prospectivos , Valva Pulmonar/cirurgia , Valva Tricúspide/cirurgia
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