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1.
Int Heart J ; 62(1): 175-177, 2021 Jan 30.
Artigo em Inglês | MEDLINE | ID: mdl-33455991

RESUMO

Off-pump coronary artery bypass grafting (OPCABG) may be performed on patients with high surgical risk who are poor candidates for traditional mechanical circulatory support. Hemodynamic support with micro-axial mechanical circulatory devices has been performed with limited but promising results.We report a case of a 66-year-old male with multiple comorbidities and low cardiac output undergoing OPCABG. Impella CP device was deployed for "in-pump" support during surgical coronary revascularization resulting in intraoperative stability and uncomplicated post-operative recovery.Previous reports have described the use of the Impella Recover LP 5.0 device for use during OPCABG. We describe the successful and safe perioperative use of the Impella CP device. Despite lower flow rates, adequate support was achieved and the transfemoral cannulation and smaller outer diameter than the Impella 5.0 device may decrease the risk of complications and expedite recovery. Further research will be necessary to determine the optimal perioperative hemodynamic support strategy to offer hemodynamically unstable, high, and prohibitive risk patients.


Assuntos
Baixo Débito Cardíaco/cirurgia , Ponte de Artéria Coronária sem Circulação Extracorpórea/instrumentação , Coração Auxiliar/efeitos adversos , Idoso , Cateterismo Cardíaco/métodos , Baixo Débito Cardíaco/diagnóstico , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Hemodinâmica/fisiologia , Humanos , Masculino , Assistência Perioperatória/estatística & dados numéricos , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Segurança , Resultado do Tratamento
2.
Ann Pharmacother ; 55(1): 59-64, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32590908

RESUMO

BACKGROUND: Although heparin has previously been the anticoagulant of choice during mechanical circulatory support (MCS), there is a lack of consistency in dose-response in pediatric patients. Bivalirudin offers more consistent dose-response in adults; however, there are limited data for pediatrics use. OBJECTIVE: The purpose was to characterize the usage, dosage, and safety profile of bivalirudin when used for pediatric MCS in a tertiary care pediatric hospital. METHODS: A retrospective review of pediatric patients receiving bivalirudin for extracorporeal membrane oxygenation/ventricular assist device (ECMO/VAD) anticoagulation was conducted. The primary outcome was the average dose of bivalirudin. Additional outcomes included initial and maximum bivalirudin dose, time to first therapeutic activated partial thromboplastin time (aPTT), time within goal aPTT range, bleeding and clotting complications, and cost. Data were compared between ECMO and VAD patients. RESULTS: Thirty-four patients were included. The median dose of bivalirudin was 0.37 mg/kg/h (interquartile range [IQR] = 0.21-0.56), with a maximum dose of 0.62 mg/kg/h (IQR = 0.33-0.91). VAD patients had a higher median and maximum dose as compared with ECMO patients. Patients achieved their therapeutic goal in a median of 6.1 hours and averaged 61.9% time within therapeutic aPTT. One patient had significant hemorrhage, whereas 3 patients had clotting requiring a circuit change. Bivalirudin acquisition cost was higher than heparin. CONCLUSION AND RELEVANCE: Bivalirudin dosing in ECMO and VAD patients is consistent with dosing seen in previous reports but may be higher in VAD patients. Comparative studies between heparin and bivalirudin are necessary to compare cost-effective outcomes for pediatric patients.


Assuntos
Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Fragmentos de Peptídeos/uso terapêutico , Adulto , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Criança , Pré-Escolar , Análise Custo-Benefício , Relação Dose-Resposta a Droga , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Coração Auxiliar/efeitos adversos , Hirudinas/administração & dosagem , Hirudinas/efeitos adversos , Humanos , Masculino , Tempo de Tromboplastina Parcial , Fragmentos de Peptídeos/administração & dosagem , Fragmentos de Peptídeos/efeitos adversos , Proteínas Recombinantes/administração & dosagem , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Estudos Retrospectivos , Trombose/etiologia , Trombose/prevenção & controle
3.
PLoS One ; 15(8): e0238046, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32833995

RESUMO

BACKGROUND: There are limited data on the complications with a percutaneous left ventricular assist device (pLVAD) vs. intra-aortic balloon pump (IABP) in acute myocardial infarction-cardiogenic shock (AMI-CS). OBJECTIVE: To assess the trends, rates and predictors of complications. METHODS: Using a 17-year AMI-CS population from the National Inpatient Sample, AMI-CS admissions receiving pLVAD and IABP support were evaluated for vascular, lower limb amputation, hematologic, neurologic and acute kidney injury (AKI) complications. In-hospital mortality, hospitalization costs and length of stay in pLVAD and IABP cohorts with complications was studied. RESULTS: Of 168,645 admissions, 7,855 (4.7%) receiving pLVAD support. The pLVAD cohort had higher comorbidity, cardiac arrest (36.1% vs. 29.7%) and non-cardiac organ failure (74.7% vs. 56.9%) rates. Complications were higher in pLVAD compared to IABP cohort-overall 69.0% vs. 54.7%; vascular 3.8% vs. 2.1%; lower limb amputation 0.3% vs. 0.3%; hematologic 36.0% vs. 27.7%; neurologic 4.9% vs. 3.5% and AKI 55.4% vs. 39.1% (all p<0.001 except for amputation). Non-White race, higher comorbidity, organ failure, and extracorporeal membrane oxygen use were predictors of complications for both cohorts. The pLVAD cohort with complications had higher in-hospital mortality (45.5% vs. 33.1%; adjusted odds ratio 1.65 [95% confidence interval 1.55-1.75]), shorter duration of hospital stay, and higher hospitalization costs compared to the IABP cohort with complications (all p<0.001). These results were consistent in propensity-matched pairs. CONCLUSIONS: AMI-CS admissions receiving pLVAD had higher rates of complications compared to the IABP, with worse in-hospital outcomes in the cohort with complications.


Assuntos
Coração Auxiliar/efeitos adversos , Balão Intra-Aórtico/efeitos adversos , Infarto do Miocárdio/complicações , Complicações Pós-Operatórias/etiologia , Choque Cardiogênico/complicações , Choque Cardiogênico/cirurgia , Doença Aguda , Idoso , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Choque Cardiogênico/terapia
4.
J Card Surg ; 35(10): 2825-2828, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32789877

RESUMO

Infectious complications following left ventricular assist device implantation can carry significant morbidity and mortality. The main tenet of treatment is source control which entails local wound care, intravenous antimicrobial therapy, surgical debridement, and at times, soft tissue flap coverage. The mode of therapy depends on the severity, etiology, and location of infection as well as the clinical status of the patient. We describe a case of a 46-year-old male who underwent left ventricular assist device placement complicated by pump thrombosis, recurrent infection, and hardware exposure who was successfully treated with a novel method of staged, soft tissue reconstruction.


Assuntos
Antibacterianos/administração & dosagem , Coração Auxiliar/efeitos adversos , Desenho de Prótese , Implantação de Prótese/efeitos adversos , Infecções Relacionadas à Prótese/terapia , Retalhos Cirúrgicos , Tecido Conjuntivo/cirurgia , Desbridamento , Formas de Dosagem , Ventrículos do Coração , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Relacionadas à Prótese/etiologia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Recidiva , Resultado do Tratamento
5.
F1000Res ; 92020.
Artigo em Inglês | MEDLINE | ID: mdl-32765837

RESUMO

Acute mechanical circulatory support (MCS) devices are widely used in cardiogenic shock (CS) despite a lack of high-quality clinical evidence to guide their use. Multiple devices exist across a spectrum from modest to complete support, and each is associated with unique risks. In this review, we summarize existing data on complications associated with the three most widely used acute MCS platforms: the intra-aortic balloon pump (IABP), Impella systems, and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We review evidence from available randomized trials and highlight challenges comparing complication rates from case series and comparative observational studies where a lack of granular data precludes appropriate matching of patients by CS severity. We further offer a series of best practices to help shock practitioners minimize the risk of MCS-associated complications and ensure the best possible outcomes for patients.


Assuntos
Choque Cardiogênico , Coração Auxiliar/efeitos adversos , Humanos , Balão Intra-Aórtico/efeitos adversos , Choque Cardiogênico/terapia , Fatores de Tempo , Resultado do Tratamento
6.
J Card Surg ; 35(10): 2529-2538, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32741013

RESUMO

OBJECTIVES: Renal function may improve after left ventricular assist device (LVAD) implant, however, some patients develop postoperative acute kidney injury (AKI). Randomized trials showed benefit for early renal replacement therapy (RRT) in critically ill patients with AKI, but this practice has not been studied in LVAD patients. METHODS: We performed a single-center, retrospective cohort study of all adults (>18 years) who underwent LVAD placement from 1/2010 to 12/2018. We collected preoperative, hemodynamic, echocardiographic, intraoperative, and postoperative data. AKI was defined according to Kidney Disease: Improving Global Outcomes definition. Early (E) RRT was considered treatment at AKI stage II or below. Standard (S) RRT was considered treatment at AKI stage III. Outcomes and Kaplan-Meier analysis were compared between groups. RESULTS: A total of 184 patients were included (mean age 56.10 years, 81% males, 30.4% African-American race). A total of 71 (38.6%) developed AKI and 17 (9.24%) needed RRT (11 E vs 6 S). A total of 11 remained hemodialysis-dependent at discharge (5 [45.5%] in E vs 6 [100%] in S, P = .043). There was a trend toward shorter intensive care unit stay and ventilation time in E group, and overall hospital stay was significantly less in the E group (48.18 ± 25.95 vs 94.00 ± 53.07 days, P = .028). Thirty-day mortality was similar between groups (E 18% vs S 16%, P = .9), but there was a trend toward improved overall survival in the E group. CONCLUSION: This is the first study to examine early initiation of RRT after LVAD implant. Early RRT was associated with shorter hospital stay, lower need for permanent RRT, and a trend toward improved survival. This practice may provide significant cost savings and should be examined further.


Assuntos
Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Coração Auxiliar/efeitos adversos , Terapia de Substituição Renal/métodos , Lesão Renal Aguda/economia , Lesão Renal Aguda/mortalidade , Estudos de Coortes , Redução de Custos , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Terapia de Substituição Renal/economia , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
7.
Circ Heart Fail ; 13(7): e006840, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32660322

RESUMO

Biomarkers have a well-defined role in the diagnosis and management of chronic heart failure, but their role in patients with left ventricular assist devices and cardiac transplant is uncertain. In this review, we summarize the available literature in this patient population, with a focus on clinical application. Some ubiquitous biomarkers, for example, natriuretic peptides and cardiac troponin, may assist in the diagnosis of left ventricular assist device complications and transplant rejection. Novel biomarkers focused on specific pathological processes, such as left ventricular assist device thrombosis and profiling of leukocyte activation, continue to be developed and show promise in altering the management of the advanced heart failure patient. Few biomarkers at this time have been assessed with sufficient scrutiny to warrant broad, universal application, but encouraging limited data and large potential for impact should prompt ongoing investigation.


Assuntos
Biomarcadores/sangue , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/terapia , Doença Crônica , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Implantação de Prótese/efeitos adversos
8.
PLoS One ; 15(7): e0235604, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32645079

RESUMO

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response (SIRS) and affects the organ vascular bed. Experimentally, the lack of pulsatility alters myogenic tone of resistance arteries and increases the parietal inflammatory response. The purpose of this study was to compare the vascular reactivity of the internal thoracic arteries (ITAs) due to the inflammatory response between patients undergoing coronary artery bypass grafting (CABG) under CPB with a roller pump or with a centrifugal pump. METHODS: Eighty elective male patients undergoing CABG were selected using one or two internal thoracic arteries under CPB with a roller pump (RP group) or centrifugal pump (CFP group). ITA samples were collected before starting CPB (Time 1) and before the last coronary anastomosis during aortic cross clamping (Time 2). The primary endpoint was the endothelium-dependent relaxation of ITAs investigated using wire-myography. The secondary endpoint was the parietal inflammatory response of arteries defined by the measurements of superoxide levels, leukocytes and lymphocytes rate and gene expression of inflammatory proteins using. Terminal complement complex activation (SC5b-9) and neutrophil activation (elastase) analysis were performed on arterial blood at the same times. RESULTS: Exposure time of ITAs to the pump flow was respectively 43.3 minutes in the RP group and 45.7 minutes in the CFP group. Acetylcholine-dependent relaxation was conserved in the two groups whatever the time. Gene expression of C3 and C4a in the artery wall decreased from Time 1 to Time 2. No oxidative stress was observed in the graft. There was no difference between the groups concerning the leukocytes and lymphocytes rate. SC5b-9 and elastase increased between Time 1 and Time 2. CONCLUSION: Endothelium-dependent relaxation of the internal thoracic arteries was preserved during CPB whatever the type of pump used. The inflammatory response observed in the blood was not found in the graft wall within this time frame. TRIAL REGISTRATION: Name of trial study protocol: IPITA Registration number (ClinicalTrials.gov): NCT04168853.


Assuntos
Ponte Cardiopulmonar/instrumentação , Ponte de Artéria Coronária/métodos , Coração Auxiliar/efeitos adversos , Artéria Torácica Interna/cirurgia , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/instrumentação , Endotélio Vascular/metabolismo , Endotélio Vascular/fisiologia , Feminino , Humanos , Elastase de Leucócito/metabolismo , Masculino , Pessoa de Meia-Idade , Estresse Oxidativo , Complicações Pós-Operatórias/epidemiologia , Transplantes/fisiologia , Transplantes/cirurgia , Vasoconstrição , Vasodilatação
9.
PLoS One ; 15(7): e0235684, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32645710

RESUMO

AIMS: Although patients supported with a Continuous-Flow Left Ventricular Assist Device (CF-LVAD) are hemodynamically stable, their exercise capacity is limited. Hence, the aim of this work was to investigate the underlying factors that lead to peak and submaximal exercise intolerance of CF-LVAD supported patients. METHODS: Seven months after CF-LVAD implantation, eighty three patients performed a maximal cardiopulmonary exercise test and a six minute walk test. Peak oxygen uptake and the distance walked were measured and expressed as a percentage of the predicted value (%VO2p and %6MWD, respectively). Preoperative conditions, echocardiography, laboratory results and pharmacological therapy data were collected and a correlation analysis against %VO2p and %6MWD was performed. RESULTS: CF-LVAD patients showed a relatively higher submaximal exercise capacity (%6MWD = 64±16%) compared to their peak exertion (%VO2p = 51±14%). The variables that correlated with %VO2p were CF-LVAD parameters, chronotropic response, opening of the aortic valve at rest, tricuspid insufficiency, NT-proBNP and the presence of a cardiac implantable electronic device. On the other hand, the variables that correlated with %6MWD were diabetes, creatinine, urea, ventilation efficiency and CF-LVAD pulsatility index. Additionally, both %6MWD and %VO2p were influenced by the CF-LVAD implantation timing, calculated from the occurrence of the cardiac disease. CONCLUSION: Overall, both %6MWD and %VO2p depend on the duration of heart failure prior to CF-LVAD implantation. %6MWD is primarily determined by parameters underlying the patient's general condition, while %VO2p mostly relies on the residual function and chronotropic response of the heart. Moreover, since %VO2p was relatively lower compared to %6MWD, we might infer that CF-LVAD can support submaximal exercise but is not sufficient during peak exertion. Hence concluding that the contribution of the ventricle is crucial in sustaining hemodynamics at peak exercise.


Assuntos
Tolerância ao Exercício/fisiologia , Insuficiência Cardíaca/fisiopatologia , Coração Auxiliar/efeitos adversos , Adulto , Idoso , Ecocardiografia , Exercício Físico/fisiologia , Teste de Esforço , Feminino , Insuficiência Cardíaca/cirurgia , Ventrículos do Coração/fisiopatologia , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Função Ventricular Esquerda/fisiologia
10.
J Card Surg ; 35(8): 2073-2076, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32652630

RESUMO

BACKGROUND: Ventricular assist devices driveline infections are common, recalcitrant, and carry high morbidity and mortality. Herein, we reported a patient with driveline infection that was successfully treated with a combination of systemic antibiotics, surgical debridement, and instillation of absorbable antibiotic beads to the wound bed. METHODS AND RESULTS: A 39-year-old man with nonischemic cardiomyopathy underwent insertion of a continuous flow left ventricular assist device. Four years postoperatively, the patient presented with clinical, laboratory, and radiologic signs of driveline tract infection. He underwent extensive surgical debridement, installation of absorbable antibiotic beads that consisted of calcium sulfate, vancomycin, and tobramycin, into the wound bed, and systemic antibiotics. The patient was free of infection 9 month postoperatively. CONCLUSION: Absorbable calcium sulfate antibiotic beads may serve as a beneficial adjunct to surgical debridement and systemic antibiotics for the treatment of ventricular assist device driveline infection, and merit further investigation.


Assuntos
Antibacterianos/administração & dosagem , Cardiomiopatias/terapia , Quimioterapia Adjuvante/métodos , Coração Auxiliar/efeitos adversos , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Relacionadas à Prótese/etiologia , Adulto , Sulfato de Cálcio/administração & dosagem , Cefadroxila/administração & dosagem , Cefazolina/administração & dosagem , Desbridamento , Formas de Dosagem , Quimioterapia Combinada , Humanos , Masculino , Infecções Relacionadas à Prótese/microbiologia , Staphylococcus aureus , Tobramicina/administração & dosagem , Resultado do Tratamento , Vancomicina/administração & dosagem
11.
J Card Surg ; 35(7): 1477-1483, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32652785

RESUMO

BACKGROUND: Continuous-flow left ventricular assist devices (LVADs) produces supraphysiologic shear stress that causes von Willebrand factor (VWF) degradation and a bleeding diathesis. Reduction of revolutions per minute (RPM) with axial-flow LVADs does not decrease shear stress enough to reduce VWF degradation and bleeding. However, it is unknown if RPM reduction with centrifugal flow LVADs may minimize VWF degradation. We tested the hypothesis that RPM reduction preserves VWF multimers in the centrifugal-flow EVAHEART left ventricular assist system (LVAS), which is designed to minimize shear stress and blood trauma. METHODS: Whole blood samples were collected from humans (n = 28). Blood was circulated in ex vivo mock circulatory loops for 6 hours with an EVAHEART LVAS at 2300 (n = 12), 2100 (n = 8), or 1800 RPM (n = 8). Immunoblotting was used to resolve and quantify VWF multimers and degradation fragments. RESULTS: RPM reduction from 2300 to 2100 to 1800 RPM significantly decreased EVAHEART blood flow from 5.8 ± 0.4 to 4.3 ± 0.6 to 4.1 ± 0.5 L/min (analysis of variance [ANOVA], P = .03). RPM reduction protected VWF from pathologic degradation. At lower RPMs, significantly greater levels of VWF multimers were observed (ANOVA, P = .001). Similarly, at lower RPMs, significantly fewer VWF fragments, a product of VWF degradation, were observed (ANOVA, P = .007). CONCLUSIONS: RPM reduction significantly reduced VWF degradation with the centrifugal-flow EVAHEART LVAS, an LVAD specifically designed with low shear stress. Different LVADs have unique hematologic footprints and should be managed with device-specific protocols. Adjustment of RPM to minimize blood trauma while still maintaining physiologic hemodynamics has the potential to decrease complications related to LVAD-associated von Willebrand's disease, such as gastrointestinal bleeding and hemorrhagic stroke.


Assuntos
Velocidade do Fluxo Sanguíneo , Coração Auxiliar/efeitos adversos , Desenho de Prótese , Proteólise , Doenças de von Willebrand/etiologia , Fator de von Willebrand/metabolismo , Adulto , Idoso , Hemorragia Cerebral/etiologia , Feminino , Hemorragia Gastrointestinal/etiologia , Hemodinâmica , Transtornos Hemorrágicos/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Multimerização Proteica , Resistência ao Cisalhamento , Estresse Mecânico , Adulto Jovem , Doenças de von Willebrand/fisiopatologia
13.
Lancet ; 396(10245): 199-212, 2020 07 18.
Artigo em Inglês | MEDLINE | ID: mdl-32682486

RESUMO

Cardiogenic shock can occur due to acute ischaemic or non-ischaemic cardiac events, or from progression of long-standing underlying heart disease. When addressing the cause of underlying disease, the management of cardiogenic shock consists of vasopressors and inotropes; however, these agents can increase myocardial oxygen consumption, impair tissue perfusion, and are frequently ineffective. An alternative approach is to temporarily augment cardiac output using mechanical devices. The use of these devices-known as temporary circulatory support systems-has increased substantially in recent years, despite being expensive, resource intensive, associated with major complications, and lacking high-quality evidence to support their use. This Review summarises the physiological basis underlying the use of temporary circulatory support for cardiogenic shock, reviews the evidence informing indications and contraindications, addresses ethical considerations, and highlights the need for further research.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Balão Intra-Aórtico/métodos , Choque Cardiogênico/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar/efeitos adversos , Humanos , Balão Intra-Aórtico/efeitos adversos
14.
J Card Surg ; 35(10): 2853-2856, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32683721

RESUMO

BACKGROUND: Outflow graft (OG) obstruction is a dangerous complication that may occur for various reasons after left ventricular assist device (LVAD) implantation. CASE SUMMARY: We describe the case of a 51-year-old patient on LVAD support who developed significant OG kinking and external OG obstruction due to a fibrin mass causing severe stenosis. Both the OG kinking and external obstruction were eliminated via a left lateral thoracotomy.


Assuntos
Fibrina , Oclusão de Enxerto Vascular/etiologia , Oclusão de Enxerto Vascular/cirurgia , Coração Auxiliar/efeitos adversos , Implantação de Prótese/efeitos adversos , Toracotomia/métodos , Trombose/etiologia , Oclusão de Enxerto Vascular/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
15.
J Card Surg ; 35(10): 2847-2852, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32683723

RESUMO

BACKGROUND: With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including the implantation of total artificial hearts (TAHs) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. CASE PRESENTATION: A 65-year-old man with a history of nonischemic cardiomyopathy had received a left ventricular assist device, and then 2 years later, underwent orthotopic heart transplantation using the bicaval anastomosis technique. The postprocedural course was complicated by primary graft failure, resulting in the need for implantation of a TAH. About 5 months after TAH implantation, he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal, and liver function. CONCLUSION: Potential fatal complications caused by catheter or wire entrapment in the right-sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.


Assuntos
Transplante de Coração/efeitos adversos , Transplante de Coração/métodos , Coração Artificial/efeitos adversos , Coração Auxiliar/efeitos adversos , Disfunção Primária do Enxerto/etiologia , Síndrome da Veia Cava Superior/etiologia , Síndrome da Veia Cava Superior/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos , Veia Cava Superior/cirurgia , Idoso , Constrição Patológica/cirurgia , Humanos , Masculino , Radiografia Intervencionista , Cirurgia Assistida por Computador/métodos , Resultado do Tratamento , Veia Cava Superior/patologia
16.
J Card Surg ; 35(10): 2672-2678, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32678965

RESUMO

BACKGROUND: Short duration, antimicrobial prophylaxis that includes antistaphylococcal activity is recommended at the time of left ventricular assist device (LVAD) implantation to reduce infection-related complications. There continues to be wide variability in surgical infection prophylaxis (SIP) regimens among implantation centers. The aim of this study is to characterize current SIP regimens at different LVAD centers. METHODS: A survey study was conducted from 26 September 2017 to 25 October 2017. Surveys were distributed electronically to LVAD coordinators and infectious diseases specialists at 75 US medical centers identified as having an LVAD program. Data collection included information about antimicrobial selection, duration, Staphylococcus aureus screening, and decolonization procedures. RESULTS: We received 29 survey responses. The majority of surveys were completed by infectious diseases physicians (72.4% [21 out of 29]). Most responding centers reported LVAD programs established for greater than 10 years (20 out of 29 [69%]). Cardiac transplantation was performed in 28 out of 29 (96%) centers. Of centers reporting a defined SIP regimen for non-penicillin allergic patients (96% [28 out of 29]), 17.9% (5 out of 28) reported a four-drug regimen, 35.7% (10 out of 28) reported a three-drug regimen, and 46.4% (13 out of 28) reported a two-drug regimen, while no centers reported a single-drug regimen. Empiric fluconazole was common (50% [14 out of 28]) and 96.4% (27 out of 28) of regimens included vancomycin. Duration of antimicrobial prophylaxis (24 hours to 5 days), S. aureus screening, decolonization procedures, and alterations due to drug allergies varied across participating centers. CONCLUSIONS: Our survey results indicate wide variation in SIP regimens among participating LVAD centers. These results highlight the need for studies evaluating the implications of SIP regimens, and whether clinical factors that prolong antimicrobial duration impact postoperative infection rates.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia , Coração Auxiliar/efeitos adversos , Implantação de Prótese/efeitos adversos , Infecções Relacionadas à Prótese/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Inquéritos e Questionários , Aztreonam/administração & dosagem , Cefalosporinas/administração & dosagem , Estudos Transversais , Quimioterapia Combinada , Fluconazol/administração & dosagem , Humanos , Levofloxacino/administração & dosagem , Infecções Relacionadas à Prótese/etiologia , Rifampina/administração & dosagem , Infecção da Ferida Cirúrgica/etiologia , Vancomicina/administração & dosagem
18.
Cochrane Database Syst Rev ; 6: CD013002, 2020 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-32496607

RESUMO

BACKGROUND: Cardiogenic shock (CS) is a state of critical end-organ hypoperfusion due to a primary cardiac disorder. For people with refractory CS despite maximal vasopressors, inotropic support and intra-aortic balloon pump, mortality approaches 100%. Mechanical assist devices provide mechanical circulatory support (MCS) which has the ability to maintain vital organ perfusion, to unload the failing ventricle thus reduce intracardiac filling pressures which reduces pulmonary congestion, myocardial wall stress and myocardial oxygen consumption. This has been hypothesised to allow time for myocardial recovery (bridge to recovery) or allow time to come to a decision as to whether the person is a candidate for a longer-term ventricular assist device (VAD) either as a bridge to heart transplantation or as a destination therapy with a long-term VAD. OBJECTIVES: To assess whether mechanical assist devices improve survival in people with acute cardiogenic shock. SEARCH METHODS: We searched CENTRAL, MEDLINE (Ovid), Embase (Ovid) and Web of Science Core Collection in November 2019. In addition, we searched three trials registers in August 2019. We scanned reference lists and contacted experts in the field to obtain further information. There were no language restrictions. SELECTION CRITERIA: Randomised controlled trials on people with acute CS comparing mechanical assist devices with best current intensive care management, including intra-aortic balloon pump and inotropic support. DATA COLLECTION AND ANALYSIS: We performed data collection and analysis according to the published protocol. Primary outcomes were survival to discharge, 30 days, 1 year and secondary outcomes included, quality of life, major adverse cardiovascular events (30 days/end of follow-up), dialysis-dependent (30 days/end of follow-up), length of hospital stay and length of intensive care unit stay and major adverse events. We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to the studies which contribute data to the meta-analyses for the prespecified outcomes Summary statistics for the primary endpoints were risk ratios (RR), hazard ratios (HRs) and odds ratios (ORs) with 95% confidence intervals (CIs). MAIN RESULTS: The search identified five studies from 4534 original citations reviewed. Two studies included acute CS of all causes randomised to treatment using TandemHeart percutaneous VAD and three studies included people with CS secondary to acute myocardial infarction who were randomised to Impella CP or best medical management. Meta-analysis was performed only to assess the 30-day survival as there were insufficient data to perform any further meta-analyses. The results from the five studies with 162 participants showed mechanical assist devices may have little or no effect on 30-day survival (RR of 1.01 95% CI 0.76 to 1.35) but the evidence is very uncertain. Complications such as sepsis, thromboembolic phenomena, bleeding and major adverse cardiovascular events were not infrequent in both the MAD and control group across the studies, but these could not be pooled due to inconsistencies in adverse event definitions and reporting. We identified four randomised control trials assessing mechanical assist devices in acute CS that are currently ongoing. AUTHORS' CONCLUSIONS: There is no evidence from this review of a benefit from MCS in improving survival for people with acute CS. Further use of the technology, risk stratification and optimising the use protocols have been highlighted as potential reasons for lack of benefit and are being addressed in the current ongoing clinical trials.


Assuntos
Coração Auxiliar , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Doença Aguda , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Coração Auxiliar/efeitos adversos , Humanos , Tempo de Internação , Qualidade de Vida , Diálise Renal/estatística & dados numéricos
20.
J Oral Maxillofac Surg ; 78(11): 1921.e1-1921.e9, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32574607

RESUMO

PURPOSE: Individuals with implantable ventricular assist devices (VADs) are at extremely high risk of bleeding, thromboembolism, and infection after undergoing invasive dental procedures. This study aimed to investigate the systemic and local complications of tooth extraction before and after VAD implantation. PATIENTS AND METHODS: This retrospective cohort study was conducted at a single center. Oral surgical procedures were performed in patients before and/or after left VAD implantation for bridge-to-heart transplantation between April 2013 and December 2017. In this study, the medical charts of the patients were retrospectively reviewed. Data about pre-extraction complete blood count, coagulation profile, biochemical profile, and incidence of local and systemic complications were compared in patients undergoing tooth extraction before VAD implantation (b-VAD group) versus after VAD implantation (a-VAD group). RESULTS: In total, 28 inpatients underwent 36 oral surgical procedures before and/or after VAD implantation. Moreover, 24 tooth extractions were performed in the b-VAD group, and 12 were performed in the a-VAD group. The incidence of post-extraction bleeding was higher in the a-VAD group (P = .001, Mann-Whitney U test), and a significant difference was observed in terms of activated partial thromboplastin time (P = .010, Mann-Whitney U test). Systemic complications associated with VADs included cerebral infarction (n = 2) and driveline infection (n = 1). Post-extraction bleeding was observed within 90 days after VAD implantation in all patients who underwent tooth extraction. CONCLUSIONS: The risk of bleeding after tooth extraction was higher in the a-VAD group (67%) than in the b-VAD group (13%). In 3 cases, VAD-related systemic complications developed within a short period after tooth extraction. The extraction management in the b-VAD group could be controlled without causing any problem. Hence, the opportune time of tooth extraction is before VAD implantation.


Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Insuficiência Cardíaca/cirurgia , Coração Auxiliar/efeitos adversos , Humanos , Estudos Retrospectivos , Extração Dentária , Resultado do Tratamento
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