Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 41
Filtrar
1.
N Engl J Med ; 379(13): 1224-1233, 2018 09 27.
Artigo em Inglês | MEDLINE | ID: mdl-30146969

RESUMO

BACKGROUND: We reported previously that, in patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive transfusion strategy was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or 28 days after surgery, whichever came first. We now report the clinical outcomes at 6 months after surgery. METHODS: We randomly assigned 5243 adults undergoing cardiac surgery to a restrictive red-cell transfusion strategy (transfusion if the hemoglobin concentration was <7.5 g per deciliter intraoperatively or postoperatively) or a liberal red-cell transfusion strategy (transfusion if the hemoglobin concentration was <9.5 g per deciliter intraoperatively or postoperatively when the patient was in the intensive care unit [ICU] or was <8.5 g per deciliter when the patient was in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis occurring within 6 months after the initial surgery. An expanded secondary composite outcome included all the components of the primary outcome as well as emergency department visit, hospital readmission, or coronary revascularization occurring within 6 months after the index surgery. The secondary outcomes included the individual components of the two composite outcomes. RESULTS: At 6 months after surgery, the primary composite outcome had occurred in 402 of 2317 patients (17.4%) in the restrictive-threshold group and in 402 of 2347 patients (17.1%) in the liberal-threshold group (absolute risk difference before rounding, 0.22 percentage points; 95% confidence interval [CI], -1.95 to 2.39; odds ratio, 1.02; 95% CI, 0.87 to 1.18; P=0.006 for noninferiority). Mortality was 6.2% in the restrictive-threshold group and 6.4% in the liberal-threshold group (odds ratio, 0.95; 95% CI, 0.75 to 1.21). There were no significant between-group differences in the secondary outcomes. CONCLUSIONS: In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy for red-cell transfusion was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis at 6 months after surgery. (Funded by the Canadian Institutes of Health Research and others; TRICS III ClinicalTrials.gov number, NCT02042898 .).


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Transfusão de Eritrócitos/métodos , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar , Causas de Morte , Feminino , Seguimentos , Hemoglobinas/análise , Humanos , Estimativa de Kaplan-Meier , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Insuficiência Renal/etiologia , Acidente Vascular Cerebral/etiologia
2.
Anesthesiology ; 128(2): 317-327, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29189290

RESUMO

BACKGROUND: The relative contributions of intraoperative and postoperative hypotension to perioperative morbidity remain unclear. We determined the association between hypotension and a composite of 30-day myocardial infarction and death over three periods: (1) intraoperative, (2) remaining day of surgery, and (3) during the initial four postoperative days. METHODS: This was a substudy of POISE-2, a 10,010-patient factorial-randomized trial of aspirin and clonidine for prevention of myocardial infarction. Clinically important hypotension was defined as systolic blood pressure less than 90 mmHg requiring treatment. Minutes of hypotension was the exposure variable intraoperatively and for the remaining day of surgery, whereas hypotension status was treated as binary variable for postoperative days 1 to 4. We estimated the average relative effect of hypotension across components of the composite using a distinct effect generalized estimating model, adjusting for hypotension during earlier periods. RESULTS: Among 9,765 patients, 42% experienced hypotension, 590 (6.0%) had an infarction, and 116 (1.2%) died within 30 days of surgery. Intraoperatively, the estimated average relative effect across myocardial infarction and mortality was 1.08 (98.3% CI, 1.03, 1.12; P < 0.001) per 10-min increase in hypotension duration. For the remaining day of surgery, the odds ratio was 1.03 (98.3% CI, 1.01, 1.05; P < 0.001) per 10-min increase in hypotension duration. The average relative effect odds ratio was 2.83 (98.3% CI, 1.26, 6.35; P = 0.002) in patients with hypotension during the subsequent four days of hospitalization. CONCLUSIONS: Clinically important hypotension-a potentially modifiable exposure-was significantly associated with a composite of myocardial infarction and death during each of three perioperative periods, even after adjustment for previous hypotension.


Assuntos
Hipotensão/epidemiologia , Complicações Intraoperatórias/mortalidade , Infarto do Miocárdio/epidemiologia , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Comorbidade , Feminino , Humanos , Masculino
3.
N Engl J Med ; 377(22): 2133-2144, 2017 11 30.
Artigo em Inglês | MEDLINE | ID: mdl-29130845

RESUMO

BACKGROUND: The effect of a restrictive versus liberal red-cell transfusion strategy on clinical outcomes in patients undergoing cardiac surgery remains unclear. METHODS: In this multicenter, open-label, noninferiority trial, we randomly assigned 5243 adults undergoing cardiac surgery who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) I of 6 or more (on a scale from 0 to 47, with higher scores indicating a higher risk of death after cardiac surgery) to a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was <7.5 g per deciliter, starting from induction of anesthesia) or a liberal red-cell transfusion threshold (transfuse if hemoglobin level was <9.5 g per deciliter in the operating room or intensive care unit [ICU] or was <8.5 g per deciliter in the non-ICU ward). The primary composite outcome was death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis by hospital discharge or by day 28, whichever came first. Secondary outcomes included red-cell transfusion and other clinical outcomes. RESULTS: The primary outcome occurred in 11.4% of the patients in the restrictive-threshold group, as compared with 12.5% of those in the liberal-threshold group (absolute risk difference, -1.11 percentage points; 95% confidence interval [CI], -2.93 to 0.72; odds ratio, 0.90; 95% CI, 0.76 to 1.07; P<0.001 for noninferiority). Mortality was 3.0% in the restrictive-threshold group and 3.6% in the liberal-threshold group (odds ratio, 0.85; 95% CI, 0.62 to 1.16). Red-cell transfusion occurred in 52.3% of the patients in the restrictive-threshold group, as compared with 72.6% of those in the liberal-threshold group (odds ratio, 0.41; 95% CI, 0.37 to 0.47). There were no significant between-group differences with regard to the other secondary outcomes. CONCLUSIONS: In patients undergoing cardiac surgery who were at moderate-to-high risk for death, a restrictive strategy regarding red-cell transfusion was noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis, with less blood transfused. (Funded by the Canadian Institutes of Health Research and others; TRICS III ClinicalTrials.gov number, NCT02042898 .).


Assuntos
Procedimentos Cirúrgicos Cardíacos , Transfusão de Eritrócitos/métodos , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar , Feminino , Hemoglobinas/análise , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Análise de Intenção de Tratamento , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Assistência Perioperatória , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Insuficiência Renal/etiologia , Acidente Vascular Cerebral/etiologia
5.
Ann Thorac Surg ; 104(4): 1289-1297, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28935302

RESUMO

BACKGROUND: Elevated, single-measure, postoperative troponin is associated with adverse events after cardiac surgery. We hypothesized that increases in troponin from the first to the second postoperative day are also associated with all-cause, 12-month mortality and major adverse cardiac events (MACE). METHODS: This observational study included consecutive adults undergoing on-pump cardiac surgery with cardiac arrest. Troponin T was measured on the first and second postoperative day and was classified as "increasing" (>10%), "unchanged" (10% to -10%), or "decreasing" (<-10%). The primary endpoint was all-cause, 12-month mortality. Secondary endpoints were all-cause 12-month mortality or MACE and both outcomes at 30 days. The main analysis was by multivariable Cox regression. RESULTS: Of 1,417 included patients, 99 (7.0%) died and 162 (11.4%) died or suffered MACE at 12 months. A significant interaction (p < 0.001) between first postoperative day troponin and the troponin trend from the first to the second postoperative day on 12-month, all-cause mortality precluded an analysis independent of first postoperative day troponin. Consequently, we stratified patients by their first postoperative day troponin (cutoff, 0.8 µg/L). Increasing troponin was associated with higher mortality in patients with first postoperative day troponin T ≥ 0.8 µg/L (hazard ratio, 1.98; 95% CI, 1.09 to 3.59; p = 0.025). CONCLUSIONS: Troponin changes from the first to the second postoperative day should not be interpreted without consideration of the first postoperative day troponin concentration. For patients with a first postoperative day troponin ≥ 0.8 µg/L, an increase by more than 10% from the first to the second postoperative day was significantly associated with all-cause, 12-month mortality and other adverse events.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Complicações Pós-Operatórias/mortalidade , Troponina T/sangue , Idoso , Biomarcadores/sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Cardiopatias/epidemiologia , Cardiopatias/etiologia , Cardiopatias/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Modelos de Riscos Proporcionais , Estudos Prospectivos
6.
J Cardiothorac Vasc Anesth ; 31(6): 2072-2079, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28803769

RESUMO

OBJECTIVE: To evaluate the perioperative course of urine levels of the renal damage biomarkers tissue inhibitor of metalloproteinase 2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) and to evaluate the predictive value of elevated TIMP-2 × IGFBP7 concentrations to predict acute kidney injury (AKI) early after cardiac on-pump surgery. DESIGN: Prospective, observational cohort study. SETTING: University hospital. PARTICIPANTS: The study comprised 110 consecutive patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB) between January and March 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Urinary TIMP-2 × IGFBP7 levels were quantified using a commercially available kit at the following measurement points: before surgery, 1 hour after starting CPB, 4 hours after weaning from CPB, and 24 hours after weaning from CPB (time points 1-4). Postoperative AKI was defined according to Kidney Disease Improving Global Outcomes criteria. AKI after cardiac surgery was diagnosed in 9 patients (8%). The perioperative course of TIMP-2 × IGFBP7 was significantly different in patients with and without postoperative AKI (p < 0.001). TIMP-2 × IGFBP7 levels were significantly higher in patients with AKI 1 hour after CPB start and 24 hours after weaning from CPB (p < 0.05). TIMP-2 × IGFBP7 levels >0.40 (ng/mL)2/1,000 measured at 1 hour after starting CPB were found to be the optimal cut-off, with a sensitivity of 0.778 and a specificity of 0.641. The negative predictive value was 0.972. CONCLUSIONS: Urine levels of TIMP-2 × IGFBP7 are predictive for AKI at an early time point (1 hour after starting CPB). Renal damage biomarkers such as TIMP-2 and IGFBP7 might be recommended as a supplement to traditionally used criteria of AKI prediction.


Assuntos
Lesão Renal Aguda/urina , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Proteínas de Ligação a Fator de Crescimento Semelhante a Insulina/urina , Complicações Pós-Operatórias/urina , Inibidor Tecidual de Metaloproteinase-2/urina , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/urina , Procedimentos Cirúrgicos Cardíacos/tendências , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos Prospectivos
7.
Anesth Analg ; 125(3): 753-761, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28753169

RESUMO

BACKGROUND: B-type natriuretic peptide (BNP) is a predictor of mortality after on-pump cardiac surgery. However, previous limited and heterogeneous studies have focused on peak concentrations at 3 to 5 days after surgery and may not offer clinicians much help in early decision-making. After confirming the predictive value of first-postoperative-day BNP in a preliminary analysis, we explored the association between isolated second-postoperative-day BNP concentrations, second-day BNP concentrations in conjunction with first-day BNP concentrations, and the change in BNP (ie, ΔBNP) from the first to the second postoperative day and 12-month, all-cause mortality. METHODS: We included consecutive patients undergoing on-pump cardiac surgery in this observational, secondary analysis of prospectively collected data. We analyzed biomarkers on the first and second postoperative day. ΔBNP was defined as BNP on the second postoperative day minus BNP on the first postoperative day. The primary end point was 12-month, all-cause mortality. The secondary end point was a composite of major adverse cardiac events (MACEs) at 12 months and/or all-cause mortality at 12 months. MACE was defined as nonfatal cardiac arrest, myocardial infarction, and congestive heart failure. The association between BNP and outcomes was examined by receiver operating characteristic curves, as well as univariate and multivariable logistic regression, adjusting for the EuroSCORE II, cross-clamp time, and first-postoperative-day troponin T. RESULTS: We included 1199 patients in the preliminary analysis focused on BNP on postoperative day 1. In the analyses examining BNP variables requiring second-postoperative-day BNP measurement (n = 708), we observed 66 (9.3%) deaths, 48 (6.8%) MACE, and 104 (14.7%) deaths and/or MACE. Both first- and second-postoperative-day BNP were significant independent predictors of all-cause, 12-month mortality per 100 ng/L increase (adjusted odds ratio [aOR], 1.040 [95% confidence interval (CI), 1.019-1.065] and 1.064 [95% CI, 1.031-1.105], respectively). When used in conjunction with one another, first-day BNP was not significant (aOR, 1.021 [95% CI, 0.995-1.048]), while second-day BNP remained significant (aOR, 1.046 [95% CI, 1.008-1.091]). The ΔBNP per 100 ng/L increase was not associated with 12-month, all-cause mortality in the univariable (OR, 0.977 [95% CI, 0.951-1.007]) or multivariable analysis (aOR, 0.989 [95% CI, 0.962-1.021]). CONCLUSIONS: Both absolute concentrations of first- and second-postoperative-day BNP are independent predictors of 12-month, all-cause mortality. When modeled together, second-postoperative-day BNP is more predictive of 12-month, all-cause mortality. Although intuitively appealing, the change in BNP from the first to the second postoperative day is a complex variable and should not routinely be used for prognostication.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/tendências , Peptídeo Natriurético Encefálico/sangue , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos de Coortes , Feminino , Cardiopatias/sangue , Cardiopatias/mortalidade , Cardiopatias/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Estudos Prospectivos , Fatores de Tempo
8.
J Cardiothorac Vasc Anesth ; 31(6): 1966-1973, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28711314

RESUMO

OBJECTIVE: Postoperative delirium (POD) is a common complication after cardiac surgery and is associated with increased patient morbidity and mortality. The objective of this study was to identify risk factors for long duration and overall burden of POD after cardiac surgery. DESIGN: One-year, single-center, retrospective, observational cohort study. SETTING: University hospital. PARTICIPANTS: Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 2013. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were screened for POD using the Intensive Care Delirium Screening Checklist. The primary outcome measure was the incidence of POD. Secondary outcome measures were the duration of POD and the area under the curve determined using the Intensive Care Delirium Screening Checklist score over time. Independent predictors of POD were estimated in multivariable logistic regression models. Hospital length of stay, medications, and outcome data also were analyzed. Among the 656 patients included in the cohort, 618 were analyzed. The overall incidence of POD was 39%. Older patient age (odds ratio [95% confidence interval]) 1.06 [1.04-1.09] for an increase of 1 year, p < 0.001); low preoperative serum albumin (1.08 [1.03-1.13] for a decrease of 1 g/L, p < 0.001); a history of atrial fibrillation (2.30 [1.30-4.09], p = 0.004); perioperative stroke (6.27 [1.54-43.64], p = 0.008); ascending aortic replacement surgery (2.99 [1.50-6.05], p = 0.002); longer duration of procedure (1.37 [1.16-1.63] for an increase of 1 hour, p < 0.001); and increased postoperative C-reactive protein concentration (2.16 [1.49-3.16] for a 2-fold increase, p < 0.001) were associated with higher odds of POD. Among patients affected by POD, older age, perioperative stroke, longer procedure time, and increased postoperative C-reactive protein were consistently predictive of longer duration of POD and greater area under the curve. CONCLUSIONS: Known risk factors for the development of POD after cardiac surgery also are predictive of prolonged duration and high overall burden of POD.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Efeitos Psicossociais da Doença , Delírio/diagnóstico , Delírio/etiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Adulto , Fatores Etários , Idoso , Proteína C-Reativa/metabolismo , Procedimentos Cirúrgicos Cardíacos/tendências , Estudos de Coortes , Delírio/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/sangue , Valor Preditivo dos Testes , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
9.
Anesth Analg ; 125(4): 1110-1117, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28537984

RESUMO

BACKGROUND: Troponin T is a predictor of cardiac morbidity and mortality after cardiac surgery with most data examining fourth generational troponin T assays. We hypothesize that postoperative high-sensitivity troponin T (hsTnT) measured in increments of the upper limit of the norm independently predicts 30-day all-cause mortality. METHODS: We included consecutive patients undergoing on-pump cardiac surgery from February 2010 to March 2012 in a prospective cohort that measured hsTnT at 0600 of the first and second postoperative day. Our primary end point was 30-day, all-cause mortality. The secondary end point was 12-month, all-cause mortality in patients surviving the first 30 days. We divided hsTnT into 5 predetermined categorizes based on the upper limit of the norm (ULN). We used Cox regression to examine an association of hsTnT independent of the EuroSCORE II at both 30 days as well as at 12 months in patients surviving the first 30 days. We assessed the area under the receiver operating characteristics curve and the net reassignment improvement for examining the benefit of adding of hsTnT to the EuroSCORE II for prognostication and restratification of 30-day, all-cause mortality. RESULTS: We included 1122 of 1155 eligible patients (75% male; mean age 66 ± 11 years). We observed 58 (5.2%) deaths at 30 days and another 35 (3.4%) deaths at 12 months in patients surviving 30 days. HsTnT categorized by ULN exhibited a graded response for the mortality. Furthermore, hsTnT remained an independent predictor of all-cause mortality at 30 days (adjusted hazard ratio 1.019 [1.014-1.024] per 10-fold increase in ULN) as well as at 12 months (adjusted hazard ratio 1.019 [1.007-1.032]) in patients surviving the first 30 days. The addition of hsTnT to the EuroSCORE II significantly increased the area under the receiver operating characteristics curve (area under curve: 0.816 [95% confidence interval, 0.754-0.878] versus area under curve: 0.870 [95% confidence interval, 0.822-0.917], respectively; P = .012). Finally, adding hsTnT to the EuroSCORE II improved restratification by the net reassignment improvement, primarily by improving rule-out of events. CONCLUSIONS: This analysis suggests that, similar to previous assays, higher postoperative concentrations of hsTnT are independently associated with all-cause mortality in patients undergoing on-pump cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/mortalidade , Troponina T/sangue , Idoso , Biomarcadores/sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/tendências , Estudos de Coortes , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária/tendências , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Complicações Pós-Operatórias/diagnóstico , Estudos Prospectivos , Fatores de Tempo
10.
Eur J Anaesthesiol ; 34(5): 271-279, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28221206

RESUMO

BACKGROUND: The clinical significance of new pathological Q waves after on-pump cardiac surgery is uncertain. OBJECTIVES: To determine whether or not either the occurrence per se or the location of new pathological Q waves after on-pump cardiac surgery is associated with 12-month, all-cause mortality and/or major adverse cardiac events (MACEs). DESIGN: Observational cohort study. SETTING: Single university hospital from January 2007 to October 2010. PATIENTS: Consecutive adult patients undergoing elective on-pump cardiac surgery with MACE-free survival until at least the 7th postoperative day and available ECGs both preoperatively and on the 7th postoperative day (n = 1464). We conducted a subgroup analysis in patients undergoing isolated coronary artery bypass grafting (n = 740). MAIN OUTCOME MEASURE: Our primary endpoint was 12-month, all-cause mortality and/or MACE, defined as acute coronary syndrome, cardiac arrest, congestive heart failure or re-vascularisation at 12 months. Using logistic regression, we examined the prognostic value of new pathological Q waves according to the Minnesota ECG Code, adjusting for the EuroSCORE II, cardiopulmonary bypass time and peak postoperative troponin T concentrations. RESULTS: We included 1464 patients (74% men; mean ±â€ŠSD age 66 ±â€Š10 years) and observed 103 (7.0%) all-cause deaths and/or MACEs at 12 months. A total of 236 patients (16.1%) had definite or probable new pathological Q waves according to the Minnesota ECG Code. The occurrence of new pathological Q waves per se was not associated with our primary endpoint [adjusted odds ratio, 0.970 (95% confidence interval, 0.540 to 1.648)]. However, the occurrence of a new pathological Q wave in V1 to V5 (anterior) was a strong independent predictor for poor outcome [adjusted odds ratio, 3.461 (95% confidence interval, 1.501 to 7.242)]. CONCLUSION: The current analysis suggests that for patients undergoing elective on-pump cardiac surgery, only new pathological Q waves in V1 to V5 (anterior) in the 7th postoperative day ECG are associated with 12-month, all-cause mortality and/or MACE. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT00468598.


Assuntos
Procedimentos Cirúrgicos Cardíacos/tendências , Procedimentos Cirúrgicos Eletivos/tendências , Eletrocardiografia/tendências , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Eletrocardiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
11.
Turk J Anaesthesiol Reanim ; 45(6): 367-373, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29359077

RESUMO

Objective: Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery. Methods: A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model. Results: LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD. Conclusion: LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions.

13.
Platelets ; 27(3): 254-61, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26367099

RESUMO

Reduced aspirin responsiveness (i.e. persistent high platelet reactivity in platelet function testing) might be associated with increased risk of myocardial ischemia and cardiac mortality in patients with coronary disease. However, the impact in patients undergoing coronary artery bypass grafting (CABG) is unclear. The aim of this prospective cohort study was to evaluate the predictive value of reduced aspirin responsiveness on cardiac and thromboembolic events in patients undergoing elective isolated CABG surgery with aspirin intake until at least two days before surgery. We included 304 patients in this prospective single-center cohort study. Impedance platelet aggregometry (Multiplate®) was performed directly before and on the first day after surgery. Reduced aspirin responsiveness was defined as area under the curve in ASPItest (AUCASPI) ≥300 U. The primary outcome was a composite of all-cause mortality and/or major adverse cardiac or thromboembolic events within 1 year. Reduced aspirin responsiveness was found in 13 and 24% of patients pre and postoperatively, respectively. There was no difference in the outcomes between patients with normal and reduced aspirin responsiveness in the preoperative measurement (log-rank test, p = 0.540). Multivariate analysis including logistic EuroSCORE I and postoperative troponin T levels did not show any association of reduced aspirin responsiveness with adverse outcome (hazard ratio, 0.576; (95% CI 0.128-2.585; p = 0.471). Similarly, postoperative reduced aspirin responsiveness was not associated with adverse events. To conclude, reduced aspirin responsiveness as evaluated by Multiplate® platelet function analyzer was not associated with increased incidence of major adverse cardiac and thromboembolic events and mortality after CABG surgery.


Assuntos
Aspirina/farmacologia , Plaquetas/efeitos dos fármacos , Plaquetas/metabolismo , Resistência a Medicamentos , Impedância Elétrica , Inibidores da Agregação de Plaquetas/farmacologia , Agregação Plaquetária/efeitos dos fármacos , Idoso , Área Sob a Curva , Aspirina/uso terapêutico , Biomarcadores , Procedimentos Cirúrgicos Cardíacos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Contagem de Plaquetas , Testes de Função Plaquetária , Período Pós-Operatório , Estudos Prospectivos , Análise de Sobrevida , Resultado do Tratamento
14.
Circulation ; 130(12): 948-57, 2014 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-25098242

RESUMO

BACKGROUND: The independent predictive value of troponin T (TNT) after on-pump cardiac surgery was established in several studies. However, adjustment was limited to preoperative risk factors without considering perioperative complications. Data on the prognostic value of postoperative B-type natriuretic peptide (BNP) are scarce. Our aim was to assess the independent value of TNT and BNP to predict 12-month outcome after cardiac surgery with adjustment for preoperative risk estimates and postoperative complications and to report risk stratification gains when considering the European System for Cardiac Operative Risk Evaluation (EuroSCORE) combined with postoperative biomarkers. METHODS AND RESULTS: This prospective cohort study included consecutive patients undergoing on-pump cardiac surgery between 2007 and 2010. We evaluated postoperative TNT and BNP, the EuroSCORE, and postoperative complications as predictors of adverse events using Cox regression. The primary end point was death or major adverse cardiac events within 1 year after surgery. We calculated the net reclassification index of TNT and BNP in addition to the EuroSCORE. We enrolled 1559 patients, of whom 176 (11.3%) experienced an event. The adjusted hazard ratio of TNT >0.8 µg/L was 2.13 (95% confidence interval, 1.47-3.15) and of BNP >790 ng/L was 2.44 (95% confidence interval, 1.65-3.62). The net reclassification index of the addition of TNT and BNP to the EuroSCORE was 0.276 (95% confidence interval, 0.195-0.348). CONCLUSIONS: Postoperative TNT and BNP are strong predictors of 1-year events after on-pump cardiac surgery independent of preoperative risk factors and postoperative complications. Updating the preoperative EuroSCORE risk with postoperative TNT and BNP after surgery allows for improved prediction of 1-year death or major adverse cardiac events.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Peptídeo Natriurético Encefálico/sangue , Troponina T/sangue , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos
16.
J Cardiothorac Vasc Anesth ; 27(6): 1181-8, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23962459

RESUMO

OBJECTIVES: Proximal aortic surgery with hypothermic circulatory arrest (HCA) commonly involves perioperative transfusion of allogeneic blood products, including red blood cells, plasma, and platelets. The authors hypothesized that surgery with HCA could be performed without allogeneic blood products and that a thromboelastometry-guided algorithm would reduce the transfusion of allogeneic blood products. DESIGN: A retrospective analysis of prospectively collected data. Patients with and without thromboelastometry guidance were compared by case-control analysis (n = 62 matched patients) and multivariate regression (n = 194 patients). SETTING: Single-center university hospital. PARTICIPANTS: This study included 194 patients undergoing elective and emergent procedures with HCA involving the proximal aorta. INTERVENTIONS: A thromboelastometry-guided treatment algorithm during surgery was used in 153 patients (79%), and conventional coagulation management was used in 41 patients (21%). MEASUREMENTS AND MAIN RESULTS: During surgery and the following 24 hours, allogeneic blood products were transfused in 106 patients (55%). Median (interquartile range) number of allogeneic blood products transfused was 1 unit (0-6 units). Case-control analysis showed lower transfusion rates of red blood cells, plasma, and any allogeneic blood product (all p<0.050) in patients with thromboelastometry guidance. In the multivariate analysis, thromboelastometry guidance was associated with an odds ratio of 0.26 (95% confidence interval, 0.08-0.84; p = 0.025) for the transfusion of any allogeneic blood product. The use of thromboelastometry was not associated with adverse events (odds ratio 0.72; 95% confidence interval, 0.27-1.90; p = 0.507). CONCLUSIONS: Allogeneic blood products were avoided in a proportion of patients. The findings further suggest that thromboelastometry-guided coagulation management promoting the use of coagulation factor concentrates decreased the use of allogeneic blood products during complex cardiac surgery.


Assuntos
Transfusão de Sangue/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Idoso , Algoritmos , Anticoagulantes/uso terapêutico , Aorta/cirurgia , Fatores de Coagulação Sanguínea/análise , Estudos de Casos e Controles , Intervalos de Confiança , Cuidados Críticos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Análise de Regressão , Estudos Retrospectivos , Tromboelastografia , Reação Transfusional
17.
Circulation ; 126(23): 2696-704, 2012 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-23136158

RESUMO

BACKGROUND: Volatile anesthetics provide myocardial preconditioning in coronary surgery patients. We hypothesized that sevoflurane compared with propofol reduces the incidence of myocardial ischemia in patients undergoing major noncardiac surgery. METHODS AND RESULTS: We enrolled 385 patients at cardiovascular risk in 3 centers. Patients were randomized to maintenance of anesthesia with sevoflurane or propofol. We recorded continuous ECG for 48 hours perioperatively, measured troponin T and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) on postoperative days 1 and 2, and evaluated postoperative delirium by the Confusion Assessment Method. At 6 and 12 months, we contacted patients by telephone to assess major adverse cardiac events. The primary end point was a composite of myocardial ischemia detected by continuous ECG and/or troponin elevation. Additional end points were postoperative NT-proBNP concentrations, major adverse cardiac events, and delirium. Patients and outcome assessors were blinded. We tested dichotomous end points by χ(2) test and NT-proBNP by Mann-Whitney test on an intention-to-treat basis. Myocardial ischemia occurred in 75 patients (40.8%) in the sevoflurane and 81 (40.3%) in the propofol group (relative risk, 1.01; 95% confidence interval, 0.78-1.30). NT-proBNP release did not differ across allocation on postoperative day 1 or 2. Within 12 months, 14 patients (7.6%) suffered a major adverse cardiac event after sevoflurane and 17 (8.5%) after propofol (relative risk, 0.90; 95% confidence interval, 0.44-1.83). The incidence of delirium did not differ (11.4% versus 14.4%; P=0.379). CONCLUSIONS: Compared with propofol, sevoflurane did not reduce the incidence of myocardial ischemia in high-risk patients undergoing major noncardiac surgery. The sevoflurane and propofol groups did not differ in postoperative NT-proBNP release, major adverse cardiac events at 1 year, or delirium.


Assuntos
Complicações Intraoperatórias/prevenção & controle , Éteres Metílicos/uso terapêutico , Isquemia Miocárdica/prevenção & controle , Assistência Perioperatória/métodos , Propofol/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Anestésicos/uso terapêutico , Feminino , Seguimentos , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/etiologia , Fatores de Risco , Sevoflurano , Método Simples-Cego
18.
Transfus Med Rev ; 26(1): 1-13, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21872428

RESUMO

In the recent years, thromboelastography has become a popular monitoring device for hemostasis and transfusion management in major surgery, trauma, and hemophilia. Thromboelastography is performed in whole blood and assesses the viscoelastic property of clot formation under low shear condition. Thromboelastography can be performed with a variety of activator and inhibitors at different concentrations representing the most important factors for different intervals and clot formation variables reported in multiple studies and algorithms. Furthermore, fibrinogen levels and platelet counts have a major influence on thromboelastographic variables. In addition, differences in patient populations, devices, and preanalytical conditions contribute to some conflicting findings in different studies.


Assuntos
Coagulação Sanguínea , Hematologia/métodos , Tromboelastografia/métodos , Algoritmos , Testes de Coagulação Sanguínea , Plaquetas/metabolismo , Fibrinogênio/metabolismo , Hematócrito , Hemostasia , Humanos , Tempo de Tromboplastina Parcial , Fatores de Tempo
19.
Anesth Analg ; 112(5): 1019-33, 2011 May.
Artigo em Inglês | MEDLINE | ID: mdl-21372274

RESUMO

BACKGROUND: Several studies have evaluated preoperative B-type natriuretic peptides (NPs) for predicting mortality after surgery; however, the number of deaths in each study was small, limiting the power of these studies. We conducted a systematic review and meta-analysis of studies addressing preoperative NP levels to predict mortality after cardiac and noncardiac surgery. METHODS: We searched MEDLINE and EMBASE using the terms "natriuretic peptides," "surgery or surgical procedures," and a validated combination of prognostic and diagnostic terms. Two investigators independently assessed studies for eligibility and extracted data. The end points were all-cause mortality at ≥6 months and at ≤90 days. We used a bivariate model to derive measures of prognostic accuracy and their heterogeneity. We calculated the pooled positive predictive value (PPV) and negative predictive value (NPV) by Bayesian Markov chain Monte Carlo methods. RESULTS: Of the 1558 retrieved articles, 23 studies satisfied the predefined eligibility criteria. After cardiac surgery, the diagnostic odds ratio of NP was 4.11 (95% confidence interval, 2.22-7.60) for ≥6-month mortality, the PPV 0.17 (95% Bayesian confidence interval, 0.07-0.36), and the NPV 0.96 (0.90-0.98). After noncardiac surgery, the diagnostic odds ratio of NP was 4.97 (3.06-8.07) for ≥6-month mortality. The corresponding PPV was 0.24 (0.14-0.38) and the NPV 0.94 (0.88-0.97). Results were similar for ≤90-day mortality. CONCLUSIONS: Preoperative NP concentrations were associated with mortality after cardiac and noncardiac surgery. NP had high NPVs for both types of surgery suggesting that preoperative NP concentrations may be helpful in preoperative risk stratification.


Assuntos
Biomarcadores/sangue , Peptídeos Natriuréticos/sangue , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Idoso de 80 Anos ou mais , Teorema de Bayes , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Método de Monte Carlo , Razão de Chances , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Período Pré-Operatório , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima
20.
J Thorac Cardiovasc Surg ; 141(2): 361-7, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20381082

RESUMO

OBJECTIVES: Right ventricular dysfunction occurs very soon after conventional coronary bypass surgery with cardiopulmonary bypass and might not recover within 1 year after the operation. It has been postulated that performing coronary surgery without cardiopulmonary bypass might preserve right ventricular function. We hypothesized that right ventricular global and overall systolic functions are better preserved 3 months after off-pump surgery than after conventional coronary bypass surgery. METHODS: Fifty patients scheduled for elective coronary bypass surgery were randomly assigned to conventional or off-pump surgery. Right ventricular function was assessed by means of transthoracic echocardiographic analysis the day before the operation and 3 months later. Right ventricular myocardial performance index was used as a marker of global right ventricular function, and right ventricular fractional area change was used as a marker of overall right ventricular systolic function. Peak systolic velocities of the lateral tricuspid annulus were studied to assess regional systolic function of the right ventricular free wall. RESULTS: Surgical intervention was completed according to randomization in 48 of 50 patients. Demographic and perioperative characteristics were similar in the 2 groups. Over the study period, right ventricular myocardial performance index and right ventricular fractional area change did not change in comparison with the baseline values in both groups. Peak systolic velocity of the lateral tricuspid annulus was decreased significantly in both groups 3 months after the operation. There were no significant intergroup differences in any echocardiographic marker of right ventricular function. CONCLUSIONS: Global right ventricular function was not better preserved 3 months after off-pump surgery than after conventional coronary bypass surgery.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária , Estenose Coronária/cirurgia , Disfunção Ventricular Direita/prevenção & controle , Função Ventricular Direita , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Estenose Coronária/fisiopatologia , Ecocardiografia Doppler de Pulso , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração Miocárdica , Estudos Prospectivos , Índice de Gravidade de Doença , Suíça , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/etiologia , Disfunção Ventricular Direita/fisiopatologia , Função Ventricular Esquerda
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA