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1.
J Cardiothorac Surg ; 14(1): 192, 2019 Nov 08.
Artigo em Inglês | MEDLINE | ID: mdl-31703606

RESUMO

BACKGROUND: Chest tubes are routinely used to evacuate shed mediastinal blood in the critical care setting in the early hours after heart surgery. Inadequate evacuation of shed mediastinal blood due to chest tube clogging may result in retained blood around the heart and lungs after cardiac surgery. The objective of this study was to compare if active chest tube clearance reduces the incidence of retained blood complications and associated hospital resource utilization after cardiac surgery. METHODS: Propensity matched analysis of 697 consecutive patients who underwent cardiac surgery at a single center. 302 patients served as a baseline control (Phase 0), 58 patients in a training and compliance verification period (Phase 1) and 337 were treated prospectively using active tube clearance (Phase 2). The need to drain retained blood, pleural effusions, postoperative atrial fibrillation, ICU resource utilization and hospital costs were assessed. RESULTS: Propensity matched patients in Phase 2 had a reduced need for drainage procedures for pleural effusions (22% vs. 8.1%, p < 0.001) and reduced postoperative atrial fibrillation (37 to 25%, P = 0.011). This corresponded with fewer hours in the ICU (43.5 [24-79] vs 30 [24-49], p = < 0.001), reduced median postoperative length of stay (6 [4-8] vs 5 [4-6.25], p < 0.001) median costs reduced by $1831.45 (- 3580.52;82.38, p = 0.04) and the mean costs reduced by an average of $2696 (- 6027.59;880.93, 0.116). CONCLUSIONS: This evidence supports the concept that efforts to actively maintain chest tube patency in early recovery is useful in improving outcomes and reducing resource utilization and costs after cardiac surgery. TRIAL REGISTRATION: Clinicaltrial.gov, NCT02145858, Registered: May 23, 2014.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Tubos Torácicos , Drenagem/métodos , Custos Hospitalares/estatística & dados numéricos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Drenagem/economia , Drenagem/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New Hampshire , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
2.
Ann Thorac Surg ; 2019 Nov 23.
Artigo em Inglês | MEDLINE | ID: mdl-31770501

RESUMO

BACKGROUND: The Northern New England Cardiovascular Disease Study Group (NNECDSG) was founded in 1987 as a regional consortium to improve cardiovascular quality in Maine, New Hampshire, and Vermont. We sought to assess the longitudinal impact of the NNECDSG on quality and cost of coronary artery bypass grafting (CABG) during the past 30 years. METHODS: Patients undergoing isolated CABG at 5 medical centers from 1987-2017 were retrospectively reviewed (n = 67,942). They were divided into 4 time periods: 1987-1999 (n = 36,885), 2000-2005 (n = 14,606), 2006-2011(n = 8470), and 2012-2017 (n = 7981). The first period was the time the NNECDSG initiated a series of quality improvement initiatives including data feedback, quality improvement training, process mapping, and site visits. RESULTS: Throughout the 4 time intervals, there was a consistent decline in in-hospital mortality, from 3.4% to 1.8% despite an increase in predicted risk of mortality (P < .001), and a significant decline in in-hospital morbidity, including return to the operating room for bleeding, acute kidney injury, mediastinitis, and low output failure (P < .001). Median length of stay decreased from 7 to 5 days (P < .001), which translated into potential savings of $82,722,023. There was a decrease in use of red blood cells from 3.1 units to 2.6 units per patient in the most current time, which translated into potential savings of $1,985,456. CONCLUSIONS: By using collaborative quality improvement initiatives, the NNECDSG has succeeded in significant, sustained improvements in quality and cost for CABG during the past 30 years. These data support the utility of a regional consortium in improving quality.

3.
J Card Surg ; 34(8): 655-662, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31212387

RESUMO

BACKGROUND: Readmissions after cardiac surgery are common and associated with increased morbidity, mortality and cost of care. Policymakers have targeted coronary artery bypass grafting to achieve value-oriented health care milestones. We explored the causes of readmission following cardiac surgery among a regional consortium of hospitals. METHODS: Using administrative data, we identified patients readmitted to the same institution within 30 days of cardiac surgery. We performed standardized review of readmitted patients' medical records to identify primary and secondary causes of readmission. We evaluated causes of readmission by procedure and tested for univariate associations between characteristics of readmitted patients and nonreadmitted patients in our clinical registry. RESULTS: Of 2218 cardiac surgery patients, 272 were readmitted to the index hospital within 30 days for a readmission rate of 12.3%. Median time to readmission was 9 days (interquartile range 4-16 days) and only 13% of patients were evaluated in-office before readmission. Readmitted patients were more likely to have had valve surgery (31.3% vs 22.7%) than patients not readmitted. Readmitted patients were also more likely to have preoperative creatinine more than or equal to 2 mg/dL (P = .015) or congestive heart failure (CHF) (P = .034), require multiple blood transfusions or sustained inotropic support (P < .001), and experience postoperative atrial fibrillation (P = .022) or renal insufficiency (P < .001). Infection (26%), pleural or pericardial effusion (19%), arrhythmia (16%), and CHF (11%) were the most common primary etiologies leading to readmission. CONCLUSIONS: Ensuring early follow-up for high-risk patient groups while improving early detection and management of the principal drivers of readmission represent promising targets for decreasing readmission rates.


Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Arritmias Cardíacas , Fibrilação Atrial , Ponte de Artéria Coronária/estatística & dados numéricos , Feminino , Insuficiência Cardíaca , Valvas Cardíacas/cirurgia , Humanos , Masculino , New England/epidemiologia , Complicações Pós-Operatórias , Risco , Fatores de Tempo
4.
Ann Thorac Surg ; 107(1): 135-142, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30300644

RESUMO

BACKGROUND: The Society of Thoracic Surgeons guidelines recommend surgical ablation (SA) at the time of concomitant mitral operations, aortic valve replacement, coronary artery bypass grafting (CABG), and aortic valve replacement plus CABG for patients in atrial fibrillation (AF). The goal of this analysis was to assess the influence of SA on long-term survival. METHODS: A retrospective analysis of 20,407 consecutive CABG or valve procedures from 2008 to 2015 among seven centers reporting to a prospectively maintained clinical registry was conducted. Patients undergoing operation with documented preoperative AF were included (n = 2,740). Patients receiving SA were compared with patients receiving no SA. The primary end point was all-cause mortality. Secondary end points included in-hospital morbidity and mortality. RESULTS: The frequency of SA was 23.1% (n = 634), and an increase was seen in the rate of SA over the study period (p < 0.001). Concomitant SA was performed in 16.2% of CABG, 30.6% of valve, and 24.3% of valve plus CABG procedures. A substantial improvement was found in unadjusted survival among patients undergoing SA (hazard ratio 0.54, 95% confidence interval: 0.42 to 0.70). Moreover, no differences were found in postoperative complications. SA did have longer bypass times (p < 0.001) but a shorter overall length of stay (p < 0.001). After risk adjustment, SA patients had an improved 5-year survival (hazard ratio 0.69, 95% confidence interval: 0.51 to 0.92), and the effect was observed across all operations. CONCLUSIONS: In a multicenter cohort of patients with AF, concomitant SA resulted in substantially improved long-term survival across patients who underwent CABG, valve, and valve plus CABG. These findings support current guidelines from The Society of Thoracic Surgeons that recommend broader application of concomitant SA.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
5.
Ann Thorac Surg ; 105(3): 709-714, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29223418

RESUMO

BACKGROUND: This study evaluates the influence of bilateral internal mammary artery (BIMA) versus single internal mammary artery (SIMA) grafting on postoperative morbidity and long-term survival among diabetic patients undergoing coronary artery bypass grafting (CABG). METHODS: A multicenter, retrospective analysis of 47,984 consecutive CABGs performed from 1992 to 2014 at 7 medical centers was conducted. Among the study population, 1,482 CABGs with BIMA were identified, and 1,297 BIMA patients were propensity-matched to 1,297 SIMA patients. The study cohort for this analysis, drawn from matched data, included 430 diabetic patients: 217 SIMA and 213 BIMA. The primary endpoint was long-term survival. Secondary endpoints included postoperative morbidity, length of stay, and in-hospital mortality. RESULTS: The median duration of follow-up was 9.3 (range, 4.3 to 13.9) years. Among propensity-matched diabetic patients, there was no significant difference in age, body mass index, or major baseline comorbidities. The groups were also well matched on the number of diseased coronary arteries and number of distal anastomoses performed. There was no difference in the rate of mediastinitis or sternal dehiscence (p = 0.503) or in-hospital mortality (p = 0.758) between groups. Both groups had a similar median length of stay of 5 (range, 4 to 7) days. Diabetic patients who received a BIMA had significantly improved long-term survival when compared with SIMA patients (hazard ratio 0.75 [95% confidence interval 0.57 to 0.98], p = 0.034). CONCLUSIONS: Among diabetics undergoing CABG, use of BIMA grafting does not result in increased in-hospital morbidity or mortality and confers a long-term survival advantage when compared with SIMA grafting. Thus, diabetic patients should be considered for BIMA grafting more frequently.


Assuntos
Doença da Artéria Coronariana/cirurgia , Complicações do Diabetes/mortalidade , Anastomose de Artéria Torácica Interna-Coronária/efeitos adversos , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Contraindicações de Procedimentos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Complicações do Diabetes/complicações , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos
6.
Circulation ; 136(18): 1676-1685, 2017 Oct 31.
Artigo em Inglês | MEDLINE | ID: mdl-29084776

RESUMO

BACKGROUND: Although previous studies have demonstrated that patients receiving bilateral internal mammary artery (BIMA) conduits during coronary artery bypass grafting have better long-term survival than those receiving a single internal mammary artery (SIMA), data on risk of repeat revascularization are more limited. In this analysis, we compare the timing, frequency, and type of repeat coronary revascularization among patients receiving BIMA and SIMA. METHODS: We conducted a multicenter, retrospective analysis of 47 984 consecutive coronary artery bypass grafting surgeries performed from 1992 to 2014 among 7 medical centers reporting to a prospectively maintained clinical registry. Among the study population, 1482 coronary artery bypass grafting surgeries with BIMA were identified, and 1297 patients receiving BIMA were propensity-matched to 1297 patients receiving SIMA. The primary end point was freedom from repeat coronary revascularization. RESULTS: The median duration of follow-up was 13.2 (IQR, 7.4-17.7) years. Patients were well matched by age, body mass index, major comorbidities, and cardiac function. There was a higher freedom from repeat revascularization among patients receiving BIMA than among patients receiving SIMA (hazard ratio [HR], 0.78 [95% CI, 0.65-0.94]; P=0.009). Among the matched cohort, 19.4% (n=252) of patients receiving SIMA underwent repeat revascularization, whereas this frequency was 15.1% (n=196) among patients receiving BIMA (P=0.004). The majority of repeat revascularization procedures were percutaneous coronary interventions (94.2%), and this did not differ between groups (P=0.274). Groups also did not differ in the ratio of native versus graft vessel percutaneous coronary intervention (P=0.899), or regarding percutaneous coronary intervention target vessels; the most common targets in both groups were the right coronary (P=0.133) and circumflex arteries (P=0.093). In comparison with SIMA, BIMA grafting was associated with a reduction in all-cause mortality at 12 years of follow-up (HR, 0.79 [95% CI, 0.69-0.91]; P=0.001), and there was no difference in in-hospital morbidity. CONCLUSIONS: BIMA grafting was associated with a reduced risk of repeat revascularization and an improvement in long-term survival and should be considered more frequently during coronary artery bypass grafting.


Assuntos
Ponte de Artéria Coronária , Artéria Torácica Interna , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Taxa de Sobrevida
7.
Ann Thorac Surg ; 103(1): 162-171, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27570160

RESUMO

BACKGROUND: Whether delaying coronary artery bypass grafting (CABG) after myocardial infarction (MI) is associated with better outcomes or is an unnecessary use of health care resources is unclear. This study investigated the relationship between MI-to-CABG timing on in-hospital death. METHODS: From the Northern New England Cardiovascular Disease Study Group (NNE) Cardiac Surgery Registry we identified 3,060 isolated CABG patients with prior MI from 2008 to 2014. We compared in-hospital death by MI-to-CABG timing of less than 1 day, 1 to 2 days, 3 to 7 days, and 8 to 21 days. We adjusted for patient characteristics using logistic regression. RESULTS: Among patients with prior MI, CABG was performed within 1 day for 99 (3.2%), 1 to 2 days for 369 (12.1%), 3 to 7 days for 1,966 (64.3%), and 8 to 21 days for 626 (20.5%) patients. NNE-predicted mortality was similar for patients operated on within 1 day (1.8%), 1 to 2 days (1.8%), and 3 to 7 days (1.9%), but was higher for 8 to 21 days (2.4%) of MI. Crude in-hospital mortality was higher for those with MI-to-CABG time of less than 1 day (5.1%) compared with 1 to 2 days (1.6%), 3 to 7 days (1.6%), and 8 to 21 days (2.7%, p = 0.044). Adjusted in-hospital mortality remained high for less than 1 day (5.4%; 95% CI, 1.5% to 9.4%), and similar for 1 to 2 days (1.8%; 95% CI, 0.4% to 3.1%), 3 to 7 days (1.7%; 95% CI, 1.1% to 2.3%), and 8 to 21 days (2.3%; 95% CI, 1.2% to 3.3%) between MI and CABG. CONCLUSIONS: Patients operated on 1 to 2 days and 3 to 7 days after MI had a similar mortality rate, suggesting it may be possible to reduce the MI-to-CABG interval for some patients without sacrificing outcomes. Patients operated on within 1 day after MI had a higher mortality rate.


Assuntos
Ponte de Artéria Coronária/métodos , Infarto do Miocárdio/cirurgia , Sistema de Registros , Medição de Risco/métodos , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Estados Unidos/epidemiologia
8.
Otol Neurotol ; 37(5): 533-8, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26954349

RESUMO

OBJECTIVE: Demonstrate that an endoscopic keyhole approach to the middle cranial fossa is technically feasible for repair of semicircular canal dehiscence. STUDY DESIGN: Cadaveric technical feasibility/methods development study. SETTING: Tertiary care military medical center. PATIENTS: Three fresh cadaveric heads (six sides). INTERVENTION(S): Endoscopic minimally invasive approach to the middle cranial fossa using the Medtronic Fusion Guidance system. MAIN OUTCOME MEASURE(S): Ability to identify the surgical landmarks of the middle cranial fossa and successfully identify and instrument the superior semicircular canal. RESULTS: In every attempt, the arcuate eminence was successfully identified under endoscopic visualization and with the assistance of surgical navigation. The superior semicircular canal was unroofed, and its location confirmed visually and with the navigation system. The opened canal was then plugged with bone wax, bone pate, and covered with fascia. The 15-mm burr hole craniotomy provided ample room for one working instrument and a 4-mm 0-degree endoscope. CONCLUSION: The endoscopic keyhole approach to superior semicircular canal dehiscence is technically feasible in a human cadaveric model. Further studies will determine 1) if this approach is possible and safe in vivo, 2) is associated with improved surgical outcomes, and 3) if surgical navigation aids in this approach.


Assuntos
Fossa Craniana Média/cirurgia , Craniotomia/métodos , Procedimentos Cirúrgicos Otológicos/métodos , Canais Semicirculares/cirurgia , Endoscopia , Humanos
9.
Heart Surg Forum ; 18(1): E20-2, 2015 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-25881218

RESUMO

There are only a few cases of prosthetic valve endocarditis (PVE) following transcatheter aortic valve implantation (TAVI) reported in the literature. Though not very frequent, this is a serious concern because patients are high risk for surgical aortic valve replacement (SAVR) by definition, and explanting the endocarditic prosthetic valve followed by SAVR increases risk even higher.


Assuntos
Estenose da Valva Aórtica/cirurgia , Endocardite Bacteriana/etiologia , Endocardite Bacteriana/terapia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Idoso , Estenose da Valva Aórtica/complicações , Comorbidade , Endocardite Bacteriana/diagnóstico , Feminino , Humanos , Estudos Longitudinais , Prevalência , Infecções Relacionadas à Prótese/diagnóstico , Reoperação , Fatores de Risco , Resultado do Tratamento
10.
Ann Thorac Surg ; 97(1): 111-7, 2014 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-24119985

RESUMO

BACKGROUND: Of patients undergoing cardiac surgery in the United States, 15% to 20% are re-hospitalized within 30 days. Current models to predict readmission have not evaluated the association between severity of postoperative acute kidney injury (AKI) and 30-day readmissions. METHODS: We collected data from 2,209 consecutive patients who underwent either coronary artery bypass or valve surgery at 7 member hospitals of the Northern New England Cardiovascular Disease Study Group Cardiac Surgery Registry between July 2008 and December 2010. Administrative data at each hospital were searched to identify all patients readmitted to the index hospital within 30 days of discharge. We defined AKI stages by the AKI Network definition of 0.3 or 50% increase (stage 1), twofold increase (stage 2), and a threefold or 0.5 increase if the baseline serum creatinine was at least 4.0 (mg/dL) or new dialysis (stage 3). We evaluate the association between stages of AKI and 30-day readmission using multivariate logistic regression. RESULTS: There were 260 patients readmitted within 30 days (12.1%). The median time to readmission was 9 (interquartile range, 4 to 16) days. Patients not developing AKI after cardiac surgery had a 30-day readmission rate of 9.3% compared with patients developing AKI stage 1 (16.1%), AKI stage 2 (21.8%), and AKI stage 3 (28.6%, p < 0.001). Adjusted odds ratios for AKI stage 1 (1.81; 1.35, 2.44), stage 2 (2.39; 1.38, 4.14), and stage 3 (3.47; 1.85 to 6.50). Models to predict readmission were significantly improved with the addition of AKI stage (c-statistic 0.65, p = 0.001) and net reclassification rate of 14.6% (95% confidence interval: 5.05% to 24.14%, p = 0.003). CONCLUSIONS: In addition to more traditional patient characteristics, the severity of postoperative AKI should be used when assessing a patient's risk for readmission.


Assuntos
Lesão Renal Aguda/diagnóstico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Readmissão do Paciente/estatística & dados numéricos , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Lesão Renal Aguda/terapia , Idoso , Procedimentos Cirúrgicos Cardíacos/mortalidade , Intervalos de Confiança , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Assistência Perioperatória , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Reino Unido
11.
Int J Inflam ; 2013: 781024, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23970996

RESUMO

Approximately 1 in 5 patients undergoing cardiac surgery are readmitted within 30 days of discharge. Among the primary causes of readmission are infection and disease states susceptible to the inflammatory cascade, such as diabetes, chronic obstructive pulmonary disease, and gastrointestinal complications. Currently, it is not known if a patient's baseline inflammatory state measured by crude white blood cell (WBC) counts could predict 30-day readmission. We collected data from 2,176 consecutive patients who underwent cardiac surgery at seven hospitals. Patient readmission data was abstracted from each hospital. The independent association with preoperative WBC count was determined using logistic regression. There were 259 patients readmitted within 30 days, with a median time of readmission of 9 days (IQR 4-16). Patients with elevated WBC count at baseline (10,000-12,000 and >12,000 mm(3)) had higher 30-day readmission than those with lower levels of WBC count prior to surgery (15% and 18% compared to 10%-12%, P = 0.037). Adjusted odds ratios were 1.42 (0.86, 2.34) for WBC counts 10,000-12,000 and 1.81 (1.03, 3.17) for WBC count > 12,000. We conclude that WBC count measured prior to cardiac surgery as a measure of the patient's inflammatory state could aid clinicians and continuity of care management teams in identifying patients at heightened risk of 30-day readmission after discharge from cardiac surgery.

12.
Head Neck ; 35(3): E65-8, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-22076658

RESUMO

BACKGROUND: Carotid body tumors are uncommon neoplasms with unique epidemiology and management demands. Cervical embryology is complex. Developmental abnormalities can result in ectopic displacement of native tissues. METHODS: We present the case of a 21-year-old female with bilateral carotid body paragangliomas who presented to our clinic seeking excision of the symptomatic right-sided tumor. RESULTS: The patient was successfully treated with surgical excision. Two rare anatomic variants were identified in her surgical specimen: a carotid sheath parathyroid gland and ectopic thymus tissue. CONCLUSIONS: This patient represents an unreported combination of pathologic and anatomic phenomena. The paraganglioma resulted from a familial genetic mutation that is well studied in this patient's ethnic population (Dutch), and the literature on this topic is reviewed herein. The 2 anatomic variants likely represent a single, embryologic glitch that will carry no physiologic sequelae. The clinical application of this ectopic anatomy and the common embryologic origins are discussed.


Assuntos
Tumor do Corpo Carotídeo/patologia , Paraganglioma/patologia , Glândulas Paratireoides/patologia , Timo/patologia , Adulto , Tumor do Corpo Carotídeo/cirurgia , Feminino , Humanos , Paraganglioma/cirurgia , Glândulas Paratireoides/cirurgia , Timo/cirurgia
13.
J Vasc Surg ; 56(3): 668-76, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22560308

RESUMO

INTRODUCTION: Although carotid artery stenosis and coronary artery disease often coexist, many debate which patients are best served by combined concurrent revascularization (carotid endarterectomy [CEA]/coronary artery bypass graft [CABG]). We studied the use of CEA/CABG in New England and compared indications and outcomes, including stratification by risk, symptoms, and performing center. METHODS: Using data from the Vascular Study Group of New England from 2003 to 2009, we studied all patients who underwent combined CEA/CABG across six centers in New England. Our main outcome measure was in-hospital stroke or death. We compared outcomes between all patients undergoing combined CEA/CABG to a baseline CEA risk group comprised of patients undergoing isolated CEA at non-CEA/CABG centers. Further, we compared in-hospital stroke and death rates between high and low neurologic risk patients, defining high neurologic risk patients as those who had at least one of the following clinical or anatomic features: (1) symptomatic carotid disease, (2) bilateral carotid stenosis >70%, (3) ipsilateral stenosis >70% and contralateral occlusion, or (4) ipsilateral or bilateral occlusion. RESULTS: Overall, compared to patients undergoing isolated CEA at non-CEA/CABG centers (n = 1563), patients undergoing CEA/CABG (n = 109) were more likely to have diabetes (44% vs 29%; P = .001), creatinine >1.8 mg/dL (11% vs 5%; P = .007), and congestive heart failure (23% vs 10%; P < .001). Patients undergoing CEA/CABG were also more likely to take preoperative beta-blockers (94% vs 75%; P < .001) and less likely to take preoperative clopidogrel (7% vs 25%; P < .001). Patients undergoing CEA/CABG had higher rates of contralateral carotid occlusion (13% vs 5%; P = .001) and were more likely to undergo an urgent/emergent procedure (30% vs 15%; P < .001). The risk of complications was higher in CEA/CABG compared to isolated CEA, including increased risk of stroke (5.5% vs 1.2%; P < .001), death (5.5% vs 0.3%; P < .001), and return to the operating room for any reason (7.6% vs 1.2%; P < .001). Of 109 patients undergoing CEA/CABG, 61 (56%) were low neurologic risk and 48 (44%) were high neurologic risk but showed no demonstrable difference in stroke (4.9% vs 6.3%; P = .76), death, (4.9 vs 6.3%; P = .76), or return to the operating room (10.2% vs 4.3%; P = .25). CONCLUSIONS: Although practice patterns in the use of CEA/CABG vary across our region, the risk of complications with CEA/CABG remains significantly higher than in isolated CEA. Future work to improve patient selection in CEA/CABG is needed to improve perioperative results with combined coronary and carotid revascularization.


Assuntos
Estenose das Carótidas/cirurgia , Ponte de Artéria Coronária/estatística & dados numéricos , Estenose Coronária/cirurgia , Endarterectomia das Carótidas/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/complicações , Estenose das Carótidas/mortalidade , Distribuição de Qui-Quadrado , Comorbidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Estenose Coronária/complicações , Estenose Coronária/mortalidade , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Fidelidade a Diretrizes , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , New England , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Características de Residência , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Fatores de Tempo , Resultado do Tratamento
14.
Ann Otol Rhinol Laryngol ; 121(1): 13-5, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-22312922

RESUMO

OBJECTIVES: We sought to describe the novel use of a suction-irrigation device to remove a large blood clot that was causing critical obstruction of the trachea and main stem bronchi in our patient. METHODS: A large-bore suction-irrigation device designed for use in gynecologic cases was adapted for use in removal of an obstructing blood clot in the face of patient decompensation after several unsuccessful attempts at removal with standard otolaryngological instruments. RESULTS: The tracheal obstruction and the significant bronchial obstructions were successfully removed with the suction-irrigation device. The patient's ventilatory status quickly stabilized. He was extubated the following day and discharged home. CONCLUSIONS: The suction-irrigation device proved highly successful in removing a large blood clot from the airway. A similarly designed device made specifically for the airway could prove useful in similar cases in the future.


Assuntos
Sucção/instrumentação , Irrigação Terapêutica/instrumentação , Trombose , Traqueia , Idoso de 80 Anos ou mais , Desenho de Equipamento , Humanos , Masculino
15.
J Extra Corpor Technol ; 42(4): 293-300, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21313927

RESUMO

The current risk prediction models for mortality following coronary artery bypass graft (CABG) surgery have been developed on patient and disease characteristics alone. Improvements to these models potentially may be made through the analysis of biomarkers of unmeasured risk. We hypothesize that preoperative biomarkers reflecting myocardial damage, inflammation, and metabolic dysfunction are associated with an increased risk of mortality following CABG surgery and the use of biomarkers associated with these injuries will improve the Northern New England (NNE) CABG mortality risk prediction model. We prospectively followed 1731 isolated CABG patients with preoperative blood collection at eight medical centers in Northern New England for a nested case-control study from 2003-2007. Preoperative blood samples were drawn at the center and then stored at a central facility. Frozen serum was analyzed at a central laboratory on an Elecsys 2010, at the same time for Cardiac Troponin T, N-Terminal pro-Brain Natriuretic Peptide, high sensitivity C-Reactive Protein, and blood glucose. We compared the strength of the prediction model for mortality using multivariable logistic regression, goodness of fit and tested the equality of the receiving operating characteristic curve (ROC) area. There were 33 cases (dead at discharge) and 66 randomly matched controls (alive at discharge).The ROC for the preoperative mortality model was improved from .83 (95% confidence interval: .74-.92) to .87 (95% confidence interval: .80-.94) with biomarkers (p-value for equality of ROC areas .09). The addition of biomarkers to the NNE preoperative risk prediction model did not significantly improve the prediction of mortality over patient and disease characteristics alone. The added measurement of multiple biomarkers outside of preoperative risk factors may be an unnecessary use of health care resources with little added benefit for predicting in-hospital mortality.


Assuntos
Biomarcadores/sangue , Ponte de Artéria Coronária/mortalidade , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/estatística & dados numéricos , Modelos de Riscos Proporcionais , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New England/epidemiologia , Prevalência , Prognóstico , Reprodutibilidade dos Testes , Medição de Risco/métodos , Fatores de Risco , Sensibilidade e Especificidade , Análise de Sobrevida , Taxa de Sobrevida
16.
Circulation ; 116(11 Suppl): I139-43, 2007 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-17846294

RESUMO

BACKGROUND: Renal insufficiency after coronary artery bypass graft (CABG) surgery is associated with increased short-term and long-term mortality. We hypothesized that preoperative patient characteristics could be used to predict the patient-specific risk of developing postoperative renal insufficiency. METHODS AND RESULTS: Data were prospectively collected on 11,301 patients in northern New England who underwent isolated CABG surgery between 2001 and 2005. Based on National Kidney Foundation definitions, moderate renal insufficiency was defined as a GFR <60 mL/min/1.73 m2 and severe renal insufficiency as a GFR <30. Patients with at least moderate renal insufficiency at baseline were eliminated from the analysis, leaving 8363 patients who became our study cohort. A prediction model was developed to identify variables that best predicted the risk of developing severe renal insufficiency using multiple logistic regression, and the predictive ability of the model quantified using a bootstrap validated C-Index (Area Under ROC) and Hosmer-Lemeshow statistic. Three percent of the patients with normal renal function before CABG surgery developed severe renal insufficiency (229/8363). In a multivariable model the preoperative patient characteristics most strongly associated with postoperative severe renal insufficiency included: age, gender, white blood cell count >12,000, prior CABG, congestive heart failure, peripheral vascular disease, diabetes, hypertension, and preoperative intraaortic balloon pump. The predictive model was significant with chi2 150.8, probability value <0.0001. The model discriminated well, ROC 0.72 (95%CI: 0.68 to 0.75). The model was well calibrated according to the Hosmer-Lemeshow test. CONCLUSIONS: We developed a robust prediction rule to assist clinicians in identifying patients with normal, or near normal, preoperative renal function who are at high risk of developing severe renal insufficiency. Physicians may be able to take steps to limit this adverse outcome and its associated increase in morbidity and mortality.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Insuficiência Renal/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Insuficiência Renal/etiologia , Fatores de Risco
17.
Am J Otolaryngol ; 27(6): 409-12, 2006.
Artigo em Inglês | MEDLINE | ID: mdl-17084226

RESUMO

Wegener's granulomatosis (WG) is a rare, idiopathic, systemic vasculitis of small vessels that manifests in multiple organ systems. Otorhinolaryngic manifestations of this disease include recurrent sinusitis and relapsing polychondritis. Periocular involvement is also a well-documented location of Wegener's disease. We present the case of a 13-year-old girl with severe WG who developed multiple recurrent orbital infections. She underwent multiple incision and drainage surgeries of each orbit and multiple courses of intravenous antibiotics. The patient persistently reaccumulated purulence in her nasolacrimal duct system and was referred to an oculoplastic surgeon for evaluation of these recurrent infections. The diagnosis of dacryocystitis as a complication of WG was made. This unique case represents a patient with severe WG developing bilateral dacryocystitis requiring bilateral dacryocystorhinostomies.


Assuntos
Dacriocistite/diagnóstico por imagem , Granulomatose com Poliangiite/complicações , Doenças Orbitárias/diagnóstico por imagem , Adolescente , Dacriocistite/microbiologia , Dacriocistite/cirurgia , Feminino , Humanos , Doenças Orbitárias/microbiologia , Doenças Orbitárias/cirurgia , Recidiva , Tomografia Computadorizada por Raios X , Resultado do Tratamento
18.
Circulation ; 114(1 Suppl): I43-8, 2006 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-16820613

RESUMO

BACKGROUND: Hemodilutional anemia during cardiopulmonary bypass (CPB) is associated with increased mortality during coronary artery bypass graft (CABG) surgery. The impact of intraoperative red blood cell (RBC) transfusion to treat anemia during surgery is less understood. We examined the relationship between anemia during CPB, RBC transfusion, and risk of low-output heart failure (LOF). METHODS AND RESULTS: Data were collected on 8004 isolated CABG patients in northern New England between 1996 and 2004. Patients were excluded if they experienced postoperative bleeding or received > or = 3 units of transfused RBCs. LOF was defined as need for intraoperative or postoperative intra-aortic balloon pump, return to CPB, or > or = 2 inotropes at 48 hours. Having a lower nadir HCT was also associated with an increased risk of developing LOF (adjusted odds ratio, 0.90; 95% CI, 0.82 to 0.92; P=0.016), and that risk was further increased when patients received RBC transfusion. When adjusted for nadir hematocrit, exposure to RBC transfusion was a significant, independent predictor of LOF (adjusted odds ratio, 1.27; 95% CI, 1.00 to 1.61; P=0.047). CONCLUSIONS: In this study, we observed that exposure to both hemodilutional anemia and RBC transfusion during surgery are associated with increased risk of LOF, defined as placement of an intraoperative or postoperative intra-aortic balloon pump, return to CPB after initial separation, or treatment with > or = 2 inotropes at 48 hours postoperatively, after CABG. The risk of LOF is greater among patients exposed to intraoperative RBCs versus anemia alone.


Assuntos
Anemia/terapia , Baixo Débito Cardíaco/epidemiologia , Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária , Insuficiência Cardíaca/epidemiologia , Complicações Intraoperatórias/terapia , Complicações Pós-Operatórias/epidemiologia , Reação Transfusional , Idoso , Idoso de 80 Anos ou mais , Anemia/etiologia , Perda Sanguínea Cirúrgica , Transfusão de Sangue/normas , Transfusão de Sangue/estatística & dados numéricos , Baixo Débito Cardíaco/tratamento farmacológico , Baixo Débito Cardíaco/etiologia , Baixo Débito Cardíaco/cirurgia , Cardiotônicos/uso terapêutico , Estudos de Coortes , Feminino , Fidelidade a Diretrizes , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/cirurgia , Hematócrito , Humanos , Hipóxia-Isquemia Encefálica/etiologia , Hipóxia-Isquemia Encefálica/prevenção & controle , Balão Intra-Aórtico , Complicações Intraoperatórias/etiologia , Maine/epidemiologia , Masculino , Pessoa de Meia-Idade , New Hampshire/epidemiologia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/estatística & dados numéricos , Estudos Prospectivos , Risco , Vermont/epidemiologia
19.
Ann Thorac Surg ; 76(3): 760-4, 2003 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-12963194

RESUMO

BACKGROUND: Arteriosclerosis is increasingly viewed as an inflammatory disease. The purpose of these analyses was to examine the preoperative white blood cell (WBC) count, a generalized marker of inflammation, and to assess its association with in-hospital mortality and other adverse outcomes after coronary artery bypass grafting. METHODS: Information was collected prospectively on 11,270 consecutive patients who had isolated coronary artery bypass grafting in northern New England from 1996 through 2000. Patients were divided into five categories based on their preoperative WBC count. Crude and adjusted in-hospital mortality rates and adverse event rates were calculated using logistic regression. RESULTS: Increasing WBC count across its entire range was associated with a linear increase in the mortality rate. This finding was highly significant (p [trend] < 0.001) and persisted after adjustment for patient and disease characteristics. Patients with preoperative WBC of at least 12.0 x 10(9)/L had an adjusted mortality rate 2.8 times higher than those with a WBC less than 6.0 x 10(9)/L (4.8% versus 1.7%). An increasing preoperative WBC count was also significantly associated with increasing rates of perioperative strokes and the need for an intraaortic balloon pump but was not associated with mediastinitis. CONCLUSIONS: The preoperative WBC count across its entire observed range is a statistically significant independent predictor of in-hospital death and other adverse outcomes after coronary artery bypass grafting. Although the cause of the association between increased WBC count and increased morbidity and mortality is unknown, the preoperative WBC count, which is objectively measured, inexpensive, and always available, can serve as a useful marker to help predict risk before coronary artery bypass grafting.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Contagem de Leucócitos , Cuidados Pré-Operatórios , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos
20.
Circulation ; 106(12 Suppl 1): I11-3, 2002 Sep 24.
Artigo em Inglês | MEDLINE | ID: mdl-12354701

RESUMO

BACKGROUND: Review of the clinical and therapeutic implications of difference in arm blood pressure detected preoperatively in patients having heart surgery. METHODS AND RESULTS: Prospective study of 53 patients (Group 1) with gradient and comparison with a group of 175 patients without gradient (Group 2). All patients had preoperative carotid duplex interrogation and operative epiaortic scanning. There was no statistical difference regarding age, sex, status, redo, diabetes, ejection fraction, prior myocardial infarct, hyperlipidemia, or creatinine level. Risks factors for Group 1 included peripheral vascular disease (P<0.0001) and cerebrovascular symptoms (P=0.0196). Severe carotid disease (>80% stenosis) was seen in 41.5% of Group 1 and 13.7% of Group 2 (P<0.0001) patients. Severe atherosclerotic proximal aortic disease was found in 39.6% of Group 1 and 10.8% of Group 2 (P<0.0001) patients. There were 7 patients with strokes in Group 1 (13.20%) and 9 in Group 2 (5.14%; P=0.06). Four patients died in Group 1 (7.54%) and 10 died in Group 2 (5.71%; P=0.74). CONCLUSION: Brachial gradient is a marker for increased carotid and proximal atherosclerotic aortic disease. Preoperative arch study at the time of catheterization is strongly recommended, as well as preoperative carotid Doppler and operative epiaortic ultrasound.


Assuntos
Determinação da Pressão Arterial , Pressão Sanguínea , Artéria Braquial/fisiopatologia , Doença das Coronárias/diagnóstico , Doença das Coronárias/cirurgia , Idoso , Braço/irrigação sanguínea , Arteriosclerose/epidemiologia , Doença das Coronárias/diagnóstico por imagem , Feminino , Humanos , Masculino , Acidente Vascular Cerebral/epidemiologia , Ultrassonografia
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