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1.
Artigo em Inglês | MEDLINE | ID: mdl-34520838

RESUMO

To determine the impact of aortic root replacement (ARR) with a stentless bioprosthetic valve on midterm outcomes compared to a stented bioprosthetic valve-graft conduit. This was an observational study of aortic root operations from 2010 to 2018. All patients with a complete ARR for nonendocarditis reasons were included, while patients undergoing valve-sparing root replacements or primary aortic valve replacement or repair were excluded. Of the patients with a complete ARR, bioprosthetic valve implants were included, while mechanical valve implants were excluded. Patients were dichotomized into the stented ARR group and the stentless ARR group. A total of 1:1 nearest neighbor propensity matching was employed to assess the association of stentless valves with short-term and midterm outcomes. A total of 455 patients underwent a complete ARR with a bioprosthetic valve implant for nonendocarditis reasons, of which 212 (46.6%) received a stented valve, while 243 (53.4%) received a stentless valve. After matching, postoperative outcomes were similar across each group (P > 0.05), including operative mortality and adverse neurologic events. Median follow-up for the entire cohort was 4.41 years (95% CI: 4.01, 4.95). At 1 year follow-up, aortic regurgitation ≥ 2+ and ejection fraction were similar across each group (P > 0.05); however, the stentless valve group had lower aortic valve velocity and transvalvular pressure gradient. Finally, reoperations and survival were similar for each group over the study's follow-up (P > 0.05). Stentless valves may provide hemodynamic benefits after ARR; however, the clinical impact of those benefits for survival and reoperation may not yet be evident in the midterm.

2.
J Card Surg ; 36(10): 3599-3606, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34363420

RESUMO

BACKGROUND: Time of day for surgical procedures has been a topic of considerable controversy, with some suggesting that later operating times are associated with worse outcomes. METHODS: All patients who underwent open cardiac surgery from 2011 to 2018 were included. Patients that had ventricular assist devices, heart transplant, transcatheter aortic valves, aortic dissections, and emergent operations were excluded. Primary outcomes included postoperative mortality and survival; secondary outcomes included postoperative complications and readmission. RESULTS: The initial patient population consisted of 7883 patients who underwent index cardiac surgery. Following propensity matching (3:1), there were 2569 patients in the a.m. cohort (7-11 a.m.) and 860 patients in the p.m. cohort (3-11 p.m.). All baseline characteristics were matched to equivalent proportions. Total intensive care unit time following surgery was longer for the a.m. cohort (46.5 vs. 40.0 h; p<.001). Otherwise, there was no significant difference between cohorts including operative mortality (1.83% vs 2.21%; p= .48). On multivariable analysis, p.m. surgery was not significantly associated with 30 days mortality (hazard ratio [HR]: 0.96 [0.60, 1.53]; p= .86] or mortality over the study follow-up (HR: 0.87 [0.73, 1.03]; p= .10]. For propensity-matched cohorts, Kaplan-Meier survival at 30 days (97.9% vs. 97.4%; p= .44), 1 (93.4% vs 93.9%; p= .51), and 5 years (80.9% vs. 80.2%; p= .84) was not significantly different between cohorts. CONCLUSION: Short- and long-term mortality, hospital readmission, and postoperative complications were not significantly different between patients that underwent cardiac surgery starting in the a.m. versus patients who had cases that started in the afternoon.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Mortalidade Hospitalar , Humanos , Morbidade , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
3.
J Card Surg ; 36(11): 4292-4300, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34405439

RESUMO

BACKGROUND: Open total arch replacement remains the gold standard treatment for aneurysms and dissections involving the aortic arch. However, high-risk surgical candidates may benefit from endovascular techniques to reduce the risk of perioperative mortality and morbidity, especially neurologic complications. Numerous endografts are available for investigational use in the aortic arch as part of investigational device exemption (IDE) programs. Some devices are fenestrated or scalloped, while others are branched, ranging from single branch to triple branch stent-grafts. Furthermore, chimney techniques and in situ fenestration may be utilized in bailout or emergent situations. RESULTS: Initial results describing outcomes of complete endovascular repair of the aortic arch are encouraging, with current data estimating that technical success ranges from 84.2% to 100%. Moreover, operative mortality may be as high as 13.2%, while neurologic complications also remain common, with stroke rates being as high as 20% and spinal cord ischemia being as high as 3.1%. However, more data are necessary to determine the comparative treatment effect of endovascular stent-grafting of the aortic arch, compared with conventional open and hybrid repairs. Longitudinal follow-up is also lacking, which will determine the long-term durability of endografts in the aortic arch. Nevertheless, endovascular repair represents an important opportunity for improving outcomes in patients with complex and potentially devastating pathologies of the aortic arch.


Assuntos
Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular , Humanos , Complicações Pós-Operatórias/epidemiologia , Desenho de Prótese , Fatores de Risco , Stents , Resultado do Tratamento
4.
Artigo em Inglês | MEDLINE | ID: mdl-34420792

RESUMO

OBJECTIVE: This study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease. METHODS: This was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement. RESULTS: A total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790). CONCLUSIONS: Morbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.

5.
Artigo em Inglês | MEDLINE | ID: mdl-34384591

RESUMO

OBJECTIVE: To evaluate the ability of intraoperative neurophysiologic monitoring (IONM) during aortic arch reconstruction with hypothermic circulatory arrest (HCA) to predict early (<48 hours) adverse neurologic events (ANE; stroke or transient ischemic attack) and operative mortality. METHODS: This was an observational study of aortic arch surgeries requiring HCA from 2010 to 2018. Patients were monitored with electroencephalogram (EEG) and somatosensory evoked potentials (SSEP). Baseline characteristics and postoperative outcomes were compared according to presence or absence of IONM changes, which were defined as any acute variation in SSEP or EEG, compared with baseline. Multivariable logistic regression analysis was used to assess the association of IONM changes with operative mortality and early ANE. RESULTS: A total of 563 patients underwent aortic arch reconstruction with HCA and IONM. Of these, 119 (21.1%) patients had an IONM change, whereas 444 (78.9%) did not. Patients with IONM changes had increased operative mortality (22.7% vs 4.3%) and increased early ANE (10.9% vs 2.9%). In multivariable analysis, SSEP changes were correlated with early ANE (odds ratio [OR], 4.68; 95% confidence interval [CI], 1.51-14.56; P = .008), whereas EEG changes were not (P = .532). Permanent SSEP changes were correlated with early ANE (OR, 4.56; 95% CI, 1.51-13.77; P = .007), whereas temperature-related SSEP changes were not (P = .997). Finally, any IONM change (either SSEP or EEG) was correlated with operative mortality (OR, 5.82; 95% CI, 2.72-12.49; P < .001). CONCLUSIONS: Abnormal IONM events during aortic arch reconstruction with HCA portend worse neurologic outcomes and operative mortality and have a negative predictive value of 97.1%. SSEP might be more sensitive than EEG for predicting early ANE, especially when SSEP changes are permanent.

6.
J Card Surg ; 36(10): 3631-3638, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34242433

RESUMO

INTRODUCTION: Coronary artery bypass grafting (CABG) continues to be the most commonly performed cardiac surgical procedure in the world. The use of multiarterial grafting may confer a long-term survival benefit over the use of vein grafts. However, there is a paucity of data comparing the use of in situ versus free right internal mammary artery (RIMA) in isolated CABG. METHODS: Patients that underwent isolated CABG between 2010 and 2018 where RIMA was used in addition to a left internal mammary artery graft. Patients with prior cardiac surgery or percutaneous coronary intervention were excluded. Propensity matching was used for subanalysis. Mortality and major adverse cardiac and cerebrovascular events (MACCE) were analyzed with Kaplan-Meier survival curves and Cox multivariable regression. Heart failure-specific readmissions were assessed with cumulative incidence curves with Fine and Gray competing risk regression. RESULTS: A total of 667 patients underwent isolated CABG. Of those, 422 had free RIMA and 245 had in situ RIMA utilized. Mortality was similar between cohorts (p = 0.199) with 5-year mortality rates of 6.6% (free) and 4.1% (in situ). MACCE was similar between cohorts, with 5-year event rates of 33.6% and 33.9% (p = 0.99). RIMA style was not a significant predictor of any outcome. CONCLUSION: There was no difference in long-term mortality, complications, MACCE, or heart failure readmissions when comparing a contemporary cohort of patients undergoing isolated CABG utilizing RIMA as a conduit. These data may allow surgeons to consider using RIMA either as an in situ or a free conduit.


Assuntos
Doença da Artéria Coronariana , Artéria Torácica Interna , Intervenção Coronária Percutânea , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Humanos , Anastomose de Artéria Torácica Interna-Coronária , Estudos Retrospectivos , Resultado do Tratamento
7.
Artigo em Inglês | MEDLINE | ID: mdl-34272071

RESUMO

OBJECTIVE: Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses. METHODS: All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes. RESULTS: The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52). CONCLUSIONS: Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.

8.
Heart Surg Forum ; 24(2): E336-E344, 2021 03 31.
Artigo em Inglês | MEDLINE | ID: mdl-33798040

RESUMO

BACKGROUND: This study examined changes in aortic dissection (AD) mortality from 2006 to 2017 and assessed the impact of weekday versus weekend presentation upon mortality. METHODS: This observational study analyzed all records in the Nationwide Emergency Department Sample (NEDS) database. NEDS aggregates discharge data from 984 hospitals in 36 states and the District of Columbia in the United States of America. All patients with thoracic and thoracoabdominal AD recorded as their principal diagnosis were identified via ICD codes. RESULTS: Patient characteristics (weekday|weekend) count: 26,759|9,640, P = 0.016; age (years): 65.2 ± 15.8|64.7 ± 16.2, P = 0.016; women: 11,318 (42.3%)|4,086 (42.4), P = 0.883; Charlson comorbidity index: 2.3 ± 1.7|2.3 ± 1.6, P = 0.025. There were 36,399 ED visits with diagnosed AD. Annual AD diagnoses increased by 70% from 2006 to 2017. From 2012-2017, patients had lower in-hospital mortality (9.9% versus 11.9%, P < 0.001) compared with 2006-2011. Patients reporting during the weekend had higher in-hospital mortality (11.8% versus 10.4%, P < 0.001) compared with weekdays. On multivariable analysis, year of presentation remained independently associated with in-hospital mortality, with 2012-2017 being associated with reduced mortality (odds ratio (OR) 0.90, 95% CI: 0.82, 0.99, P = 0.031), as compared with 2006-2011. Weekend presentation remained independently associated with worse in-hospital mortality (OR 1.17, 95% CI: 1.05, 1.29, P = 0.003) compared with weekday presentation. CONCLUSION: Although AD mortality is decreasing, the patients presenting on the weekend were 13% more likely to die in the hospital compared with patients presenting during the week.


Assuntos
Aneurisma Dissecante/mortalidade , Aneurisma da Aorta Torácica/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Previsões , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
9.
Ann Thorac Surg ; 2021 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-33882294

RESUMO

BACKGROUND: Combining clinical and research excellence has become an increasingly difficult endeavor for thoracic surgeons, with typical success rates for the NHLBI and NCI being 25.1% and 11.3% respectively. The Thoracic Surgery Foundation (TSF), which is an arm of the Society of Thoracic Surgeons, provides research awards and grants aimed at early career faculty to assist in securing federal peer reviewed funding. The aim of this study was to assess the impact of these awards. METHODS: Faculty awardees of the TSF research awards from 1995 to 2019 were included in the study. The scholarly work of awardees was assessed using SCOPUS , MEDLINE, and google scholar for publications, citations and h-index. NIH RePorter and federal RePorter was used to search for any grants awarded to these individuals. For publications and citations associated with a TSF grant, a four-year window from the time of the research award was utilized. RESULTS: Fifty-two research awards were given to early career faculty during this study period, 8 (15%) were awarded to MD PhDs. Six (12%) of awardees were female. Cardiac faculty were awarded 27 (52%) of awards and general thoracic faculty were awarded 25 (48%); of the cardiac faculty, 4 (17.4%) were congenital cardiac faculty. In the 4-year period following the TSF grant award, the mean number of published articles per awardee was 23 (interquartile range (IQR) 12-36) with a median citation count of 147 (IQR 32-327). The current median h-index was 26 (IQR 15-36) with 2,323 (IQR 1,173-4,568) median citations. Forty-eight percent of all awardees received at least 1 subsequent grant grant, with 40.4% being awarded from the NIH and25% having two or more NIH grants. Comparing academic position at the time of the award to current position, 54% of awardees had an advancement in their professional rank. On analyzing leadership positions, 42% of awardees were division chiefs, 21% were associate clinical directors, and 28% were clinical directors. CONCLUSIONS: Being a recipient of the TSF award may position an individual to excel in academic medicine, with a large portion of awardees improving their academic standing with time. The rate of successful NIH grant funding after being a TSF awardee is higher than typical institutional success rates.

10.
Artigo em Inglês | MEDLINE | ID: mdl-33838909

RESUMO

OBJECTIVE: To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products. METHODS: All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival. RESULTS: A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001). CONCLUSIONS: In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.

11.
Artigo em Inglês | MEDLINE | ID: mdl-33642109

RESUMO

OBJECTIVE: Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring. METHODS: This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups. RESULTS: Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05). CONCLUSIONS: These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.

12.
Artigo em Inglês | MEDLINE | ID: mdl-33609669

RESUMO

Prior thoracic radiation has been associated with worse outcomes after cardiac surgery. This study sought to report long-term outcomes in patients undergoing surgery for radiation-associated heart disease. This was an observational study of open cardiac surgeries from 2011 and 2018. Patients with a history of malignancy that required thoracic radiation were identified, and this cohort was matched against a non-irradiated comparison group via Mahalanobis distance matching. Kaplan-Meier survival estimation and multivariable Cox regression analysis was performed to assess the long-term impact of thoracic radiation in patients undergoing cardiac surgery. Of the 15,284 patients receiving cardiac surgery in this time-frame, 269 were identified with a history of thoracic radiation for prior malignancy. Patients with prior radiation had increased 1-year and 5-year mortality (P < 0.001), despite no difference for 30-day mortality (P = 0.719), compared to non-irradiated patients. Mahalanobis distance matching yielded 269 equitably matched pairs. On multivariable analysis, patients with prior radiation demonstrated significantly increased hazard of death, as compared to the non-irradiated group (hazard ratio 1.40, 95% confidence interval: 1.02, 1.94, P = 0.038). Patients with radiation for breast cancer demonstrated a non-significant trend toward reduced hazard of death, as compared to patients with more extensive radiation exposure. There was an increase in long-term mortality in patients with prior radiation undergoing cardiac surgery, however open cardiac surgery can safely be performed in these patients with similar operative mortality. These findings may serve as a useful adjunct in shared decision-making for patients and surgeons alike.

14.
J Card Surg ; 36(1): 206-215, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33225474

RESUMO

BACKGROUND: The wide availability of transcatheter aortic valve replacement (TAVR) and broadening of its indications to most patients with aortic stenosis may increase its utilization in the urgent setting. However, a comparison of long-term outcomes of patients undergoing urgent TAVR when compared to elective TAVR have not been well studied. METHODS: All patients that underwent TAVR from 2011 to 2018 were included. Primary outcomes included operative (30-day), 1-, and 5-year survival and readmissions. RESULTS: The total patient population undergoing TAVR was divided into urgent (n = 247) and elective (n = 946) cohorts. Thirty days mortality (6.5% vs. 2.3%; p = .001), acute kidney injury (2.8% vs. 0.6%; p = .003), and length of stay (12 vs. 3 days; p < .001) were higher for the urgent cohort. There was no significant difference between cohorts for 30-day all-cause (14.6% vs. 10.8%; p = .097) readmissions. Freedom from readmission for heart failure at 1-year (73.6% vs. 83.4%; p < .001) was lower for the urgent cohort. One- (79.0% vs. 87.1%; p < .001) and five-year (39.6% vs. 43.5%; p = .005) survival was lower for the urgent cohort. This difference was eliminated after risk adjustment (hazard ratio [HR]: 1.3; p = .158 and HR: 1.1; p = .639, respectively). CONCLUSION: Unadjusted survival was significantly worse for the urgent cohort up to 1 year. This trend continued for 5-year survival, however, after risk adjustment there was no significant difference in survival between cohorts. Although urgent TAVR is associated with increased periprocedural risk due to more comorbid disease, outcomes and long-term survival are encouraging and support the consideration of urgent TAVR as a viable alternative for this patient population.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Eletivos , Humanos , Fatores de Risco , Resultado do Tratamento
15.
Ann Thorac Surg ; 2020 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-33307073

RESUMO

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an immune-mediated reaction to heparin that provokes a prothrombotic state and causes a decline in platelet count. Data describing outcomes of HIT after cardiac surgery are limited. This study sought to determine the impact of HIT on short-term outcomes after cardiac surgery. METHODS: This was an observational study of cardiac surgeries from 2010 to 2018. Patients with HIT were matched against patients without HIT via 2:1 nearest neighbor propensity matching. Matching was performed to assess the impact of HIT on operative mortality (STS definition) and thromboembolic events (including deep vein thrombosis, pulmonary embolism, stroke, and/or acute limb ischemia) - the primary outcomes of interest. RESULTS: Of 11,820 patients undergoing an (STS indexed) cardiac surgery, 131 (1.1%) developed HIT after their index operation. After matching, operative mortality was 21.8% in HIT patients, as compared to 5.3% in non-HIT patients. Thromboembolic events occurred in 29.1% of HIT patients, as compared to 2.9% in non-HIT patients. On sub-analysis, operative mortality was significantly higher for the HIT group without thromboembolic events (16.7%) and the HIT group with thromboembolic events (34.4%), compared to the non-HIT group (5.3%). However, operative mortality was not significantly higher in the HIT group with thromboembolic events, as compared to the HIT group without thromboembolic events, after Bonferroni correction. CONCLUSIONS: Although uncommon, HIT is a highly morbid and potentially lethal complication, which should reinforce the importance of timely recognition and treatment of this adverse outcome.

16.
Ann Thorac Surg ; 2020 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-33345780

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia observed with concomitant cardiac surgery. Surgical options include a cut-and-sew technique Maze (CAS) and a cryoablation/bipolar technique Maze (CB). There are limited data comparing the long-term outcomes of these 2 techniques. METHODS: All patients who underwent either CAS or CB Maze between 2011 and 2018 were included in the study. Chi-square test and Fisher's exact test or Student's t test were used to compare differences between baseline characteristics. Kaplan-Meier survival curves were generated for each group. Cumulative incidence functions were generated for AF recurrence and Fine-Gray competing-risk regression was used to determine predictors for AF recurrence. RESULTS: A total of 482 patients underwent open surgical ablation. Of those, 287 had CAS and 198 had CB. All procedures were concomitant with cardiac surgery. There was similar long-term mortality between the CAS and CB cohorts (22.3% vs 17.4%; log-rank P = .91). There was no difference in pacemaker implantation (11.1% vs 11.3%; P = .813) or long-term freedom from AF recurrence (73.3% vs 78.2%; P = .294). On Fine-Gray competing-risk regression, New York Heart Association functional class IV (hazard ratio [HR], 2.07; P = .03), concomitant aortic valve replacement (HR, 3.02; P = .01), and concomitant CABG + valve (HR, 2.36; P = .02) were significant independent predictors for AF recurrence; Maze type was not a predictor. CONCLUSIONS: These data indicate no difference between the CAS vs CB with respect to freedom from long-term AF. Both techniques may be appropriate based on surgeon experience and patient characteristics.

17.
Artigo em Inglês | MEDLINE | ID: mdl-33186737

RESUMO

Re-exploration for excessive bleeding after cardiac surgery is a postoperative complication that has been associated with operative mortality and short-term morbidity. However, there is dearth of literature examining its long-term impact. Thus, this study sought to determine the impact of reexploration on long-term mortality in a large, contemporaneous cohort of patients. This was an observational study of open cardiac surgeries between 2010 and 2018, at a single large institution. Patients undergoing first time coronary or valvular surgery (Society of Thoracic Surgeons indexed operations) were identified. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of re-exploration on survival. To isolate long-term survival, patients with operative mortality were excluded and survival time was counted from the date of discharge until the date of death. Of the 10,824 patients undergoing first time coronary or valvular surgery, 292 (2.7%) were reexplored for bleeding. After excluding patients with operative mortality and after multivariable risk-adjustment, the reexploration group remained at significantly increased risk of death, as compared to the group not requiring re-exploration (hazards ratio 1.59, 95% confidence interval 1.21, 2.09, P = 0.001). Moreover, re-exploration was associated with longer intensive care unit stay, longer total length of hospital stay, as well as increased postoperative complications, such as prolonged ventilation, sepsis, new dialysis requirement, and new onset atrial fibrillation. The morbidity associated with re-exploration for bleeding after cardiac surgery extends into the long-term. This cohort's worse long-term survival is a provocative finding that highlights the long-term impact of excessive bleeding after cardiac surgery.

19.
J Card Surg ; 35(8): 1920-1926, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32652793

RESUMO

BACKGROUND: Redo cardiac surgery carries an inherent risk for adverse short-term outcomes and worse long-term survival. Strategies to mitigate these risks have been numerous, including initiation of cardiopulmonary bypass via peripheral cannulation before resternotomy. This study evaluated the impact of central versus peripheral cannulation on long-term survival after redo cardiac surgery. METHODS: This was an observational study of open cardiac surgeries between 2010 and 2018. Patients undergoing open cardiac surgery that utilized cardiopulmonary bypass, who also had more than equal to 1 prior cardiac surgery, were identified. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of peripheral cannulation on survival. To isolate long-term survival, patients with operative mortality were excluded and survival time was counted from the date of discharge until the date of death. RESULTS: Of the 1660 patients with more than equal to 1 prior cardiac surgery, 91 (5.5%) received peripheral cannulation. After excluding patients with operative mortality and after multivariable risk-adjustment, the peripheral cannulation group had significantly increased hazard of death, as compared to the central cannulation group (HR 1.53, 95% CI: 1.01, 2.30, P = .044). Yet, there were no relevant differences for other postoperative outcomes, including blood product requirement, prolonged ventilation (>24 hours), pneumonia, reoperation for bleeding, stroke, sepsis, and new dialysis requirement. CONCLUSIONS: This is the first study reporting the long-term impact of peripheral cannulation for redo cardiac surgery after excluding patients with operative mortality. These data suggest that central cannulation may to be the preferred approach to redo cardiac surgery whenever safe and possible.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/métodos , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/mortalidade , Reoperação/efeitos adversos , Reoperação/mortalidade , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Risco , Segurança , Taxa de Sobrevida , Fatores de Tempo
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