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1.
J Thorac Dis ; 13(9): 5458-5466, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34659812

RESUMO

Background: Left ventricular dimension has the potential to impact clinical outcomes following implantation of left ventricular assist devices (LVAD). We investigated the effect of pre-implant left ventricular end-diastolic diameter (LVEDD) on outcomes following LVAD implantation. Methods: Patients implanted with a continuous-flow LVAD between 2004 and 2018 at a single institution were included. The primary outcome was death while on LVAD support. Secondary outcomes included adverse event rates such as renal failure requiring dialysis, device thrombosis, and right ventricular failure. The LVEDD measurements were dichotomized using restricted cubic splines and threshold regression. Survival was determined using Kaplan-Meier estimates. Multivariable logistic regression was used to determine risk-adjusted mortality based on LVEDD. Results: A total of 344 patients underwent implantation of a continuous flow LVAD during the study period. The optimal cut point for LVEDD was 65 mm, with 126 (36.6%) subjects in the <65 mm group and 165 (48.0%) in the >65 mm group. The LVEDD <65 mm group was older, had more females, higher incidence of diabetes, more pre-implant mechanical ventilation, and more admissions for acute myocardial infarctions (all, P<0.05). Importantly, post-implant adverse events were similar between the groups (all, P>0.05). Risk-adjusted survival at 1-year (OR 1.3, 95% CI: 0.6-2.5, P=0.53) was also comparable between the groups. Furthermore, incremental increases in LVEDD when modeled as a continuous variable did not impact overall mortality (OR 0.98, 95% CI: 0.9-1.0, P=0.09). Conclusions: Preoperative LVEDD was not associated with rates of major morbidities or mortality following LVAD implantation.

2.
Cardiovasc Diagn Ther ; 11(4): 1002-1012, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34527523

RESUMO

Background: Readmissions following transcatheter aortic valve replacement (TAVR) are common but detailed analysis of cardiac and non-cardiac inpatient readmissions beyond thirty days to different levels of care are limited. Methods: Our study population was 1,037 consecutive patients who underwent TAVR between 2011-2017 within a multi-hospital quaternary health system. A retrospective chart review was performed and readmissions were adjudicated and classified based on primary readmission diagnosis (cardiac versus noncardiac) and level of care [intensive care unit (ICU) admission vs. non-ICU admission]. Incidence, causes, and outcomes of readmissions to up to three years post procedure were evaluated. Results: Of the 1,017 patients who survived their index hospitalization, there were readmissions due to noncardiac causes in 350 (34.4%) and cardiac causes in 208 (20.5%) during a mean 1.96 years of follow-up. The most common non-cardiac causes of readmission were sepsis/infection (14.3%), gastrointestinal (8.3%), and respiratory (4.8%), whereas heart failure (14.0%) and arrhythmias (4.6%) were the most common cardiac causes of readmission. A total of 191 (18.8%) patients were readmitted to the ICU and 372 patients (36.6%) were non-ICU readmissions. The risk of a noncardiac readmission was highest in the period immediately following TAVR (~4.5% per month) with an early high hazard phase that gradually declined over months. However, the risk of cardiac readmission remained stable at ~1% per month throughout. TAVR patients that were readmitted for any cause had markedly increased mortality; this was especially true for patients readmitted to an ICU. Conclusions: In TAVR patients who survived their index hospitalization, non-cardiac readmissions were more prevalent than cardiac. The risk of readmission and subsequent mortality was highest immediately post-procedure and declined thereafter. Readmission to ICU portends the highest risk of subsequent death in this cohort. Patient baseline co-morbidities are an important consideration for TAVR patients and play a significant role in readmissions and outcomes.

3.
J Card Surg ; 2021 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-34532900

RESUMO

Mitral regurgitation (MR) is one of the most prevalent valvular pathologies in the developed world. There continues to be a growing population of aging patients with MR who may be too high risk for surgical management. The rapid adoption and remarkable success of transcatheter aortic valve replacement (TAVR) generated enthusiasm for transcatheter mitral valve therapies; however, the complex anatomy and pathophysiology of the mitral valve confers several unique challenges for a fully percutaneous approach. Nevertheless, several devices are under development and in various phases of preclinical or clinical testing, both for transcatheter mitral valve replacement and repair. MitraClip (Abbott Vascular), which has received FDA approval, is the most established percutaneous repair strategy and has been performed in over 80,000 patients as of 2019. The following article serves as a review of the available and upcoming devices for the various etiologies of mitral valvular disease, as well as the unique challenges and potential complications of transcatheter mitral valve intervention.

4.
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.

5.
J Card Surg ; 36(11): 4015-4023, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34368992

RESUMO

BACKGROUND: This study investigated the impact of transplanting center donor acceptance patterns on usage of extended-criteria donors (ECDs) and posttransplant outcomes following orthotopic heart transplantation (OHT). METHODS: The Scientific Registry of Transplant Recipients was queried to identify heart donor offers and adult, isolated OHT recipients in the United States from January 1, 2013 to October 17, 2018. Centers were stratified into three equal-size terciles based on donor heart acceptance rates (<13.7%, 13.7%-20.2%, >20.2%). Overall survival was compared between recipients of ECDs (≥40 years, left ventricular ejection fraction [LVEF] <60%, distance ≥500 miles, hepatitis B virus [HBV], hepatitis C virus [HCV], or human immunodeficiency virus [HIV], or ≥50 refusals) and recipients of traditional-criteria donors, and among transplanting terciles. RESULTS: A total of 85,505 donor heart offers were made to 133 centers with 15,264 (17.9%) accepted for OHT. High-acceptance programs (>20.2%) more frequently accepted donors with LVEF <60%, HIV, HCV, and/or HBV, ≥50 offers, or distance >500 miles from the transplanting center (each p < .001). Posttransplant survival was comparable across all three terciles (p = .11). One- and five-year survival were also similar across terciles when examining recipients of all five ECD factors. Acceptance tier and increasing acceptance rate were not found to have any impact on mortality in multivariable modeling. Of ECD factors, only age ≥40 years was found to have increased hazards for mortality (hazard ratio, 1.33; 95% confidence interval [CI], 1.22-1.46; p < .001). CONCLUSIONS: Of recipients of ECD hearts, outcomes are similar across center-acceptance terciles. Educating less aggressive programs to increase donor acceptance and ECD utilization may yield higher national rates of OHT without major impact on outcomes.


Assuntos
Transplante de Coração , Adulto , Humanos , Estudos Retrospectivos , Volume Sistólico , Doadores de Tecidos , Transplantados , Estados Unidos , Função Ventricular Esquerda
6.
Clin Transplant ; : e14459, 2021 Aug 16.
Artigo em Inglês | MEDLINE | ID: mdl-34398485

RESUMO

BACKGROUND: This study evaluated the impact of the 2018 heart allocation policy change on geographic disparities in United States orthotopic heart transplantation (OHT). METHODS: The United Network for Organ Sharing registry was queried to measure geographic disparity in OHT rates between pre-policy and post-policy change eras. We performed multilevel Poisson regression to measure region-level OHT rates. We derived an allocation priority-adjusted median incidence rate ratio (MIRR) for each policy era, a measure of median change in OHT rates between regions. RESULTS: 5958.78 waitlist person-years were analyzed, comprising 6596 OHT procedures (3890 pre-policy and 2706 post-policy). Median region-level OHT rate was .94 transplants/person-years before and 1.51 transplants/person-years after the policy change (P < .001). The unadjusted OHT MIRR across regions was 1.29 (95% CI 1.00-1.50) pre-policy change and 1.17 (95% CI 1.00-1.43) post-policy change, suggesting that the region-related variance in OHT rates decreased under the new allocation. After adjustment for allocation priority risk factors, the MIRR pre-policy change was 1.13 (95% CI 1.01-1.32) and post-policy change was 1.15 (95% CI 1.00-1.35). CONCLUSIONS: Geography accounts for ∼10% of the disparity among United States OHT rates. Despite broader heart sharing, the updated allocation policy did not substantially alter the existing geographic disparities among OHT recipients.

7.
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
8.
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
9.
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.

10.
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.

11.
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
12.
J Card Surg ; 36(9): 3242-3249, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34231256

RESUMO

BACKGROUND: This study evaluated the impact of various sizing metrics on outcomes of female donor to male recipient orthotopic heart transplantation (OHT). METHODS: We queried the United Network of Organ Sharing database to analyze all isolated, primary adult OHTs from January 1, 2010 to January 20, 020. Patients were stratified by donor-recipient sex pairing. Logistic regression was used to investigate risk-adjusted effects of current size matching criteria (weight ratio, body mass index [BMI] ratio, predicted heart mass [pHM] ratio) on 1-year posttransplant mortality. Kaplan-Meier analysis was used to compare posttransplant survival among cohorts. RESULTS: A total of 22,450 patients were analyzed, of which 3019 (13.4%) underwent female-to-male transplantation. Of sex-matched pairs, female-to-male donation had the lowest proportion of undersized hearts using weight and BMI ratio metrics (10.5% and 5.2%) but had the highest proportion of undersizing using pHM metrics (48.1%) (all p < 0.001). Female-to-male recipients had the lowest rate of unadjusted 1-year survival (90.0%, p = 0.0169), and increased hazards of mortality after risk adjustment (odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.01-1.36, p = 0.034). Undersizing using pHM (donor-recipient ratio <0.85) was the only metric found to be associated in increased mortality after risk adjustment (OR: 1.32, 95% CI: 1.02-1.71, p = 0.035). CONCLUSION: Female-to-male heart transplantation has the worst survival of all sex-matching combinations. Although female donors in this cohort are appropriately sized using traditional metrics, half are under-sized using pHM. This, combined with its strong association with mortality, underscores the importance of routine pHM assessment when evaluating female donors for male recipients.


Assuntos
Benchmarking , Transplante de Coração , Adulto , Feminino , Humanos , Masculino , Tamanho do Órgão , Estudos Retrospectivos , Doadores de Tecidos
13.
Artigo em Inglês | MEDLINE | ID: mdl-34303777
16.
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.

17.
Clin Case Rep ; 9(7): e04186, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34295473

RESUMO

A novel method of transaxillary Impella 5.0 implantation utilizing a vascular sheath can overcome difficult arterial anatomy and provide mechanical support for patients in critical cardiogenic shock.

19.
J Thorac Dis ; 13(5): 2874-2884, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34164179

RESUMO

Background: This study evaluates anticoagulation management and its impact on longitudinal clinical outcomes in patients undergoing mechanical valve replacement. Methods: Patients undergoing mechanical mitral valve replacement (MVR) or aortic valve replacement (AVR) from 2010-2018 at a single center were included. Patients were stratified into therapeutic and non-therapeutic anticoagulation groups based on the median percentage of international normalized ratio (INR) values within the reference range (2.0-3.0 for AVR, 2.5-3.5 for MVR) during the first post-operative year. Using Cox regression analysis, comorbidity-adjusted survival and freedom from adverse events were compared. Results: Six hundred and fifty-one patients underwent mechanical valve replacement (166 MVR, 485 AVR). Comorbidity-adjusted survival was similar in the MVR and AVR cohorts (P=0.23). There was a median of 27 [interquartile range (IQR): 14-42] INRs drawn per patient in the first post-operative year. The median percentage of INRs within the reference values during the first post-operative year was 42.85% (IQR: 30.77-53.95%), with the majority of non-therapeutic INRs being subtherapeutic (34.51%; n=6,864). There were no significant differences in adjusted survival between the therapeutic and non-therapeutic groups [hazard ratio (HR): 1.12, P=0.73]. Within the first post-operative year, there were no significant differences in stroke, major bleeding, peripheral non-stroke arterial thromboembolism, and readmission for intravenous heparin in the therapeutic and non-therapeutic groups. Conclusions: Taking into account relevant comorbidities and valve type, patients with a larger proportion of non-therapeutic INRs during the first post-operative year demonstrated no difference in longitudinal clinical outcomes. Further research into more standardized INR monitoring and potentially expanded INR target ranges for patients undergoing mechanical valve replacement is warranted.

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