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1.
Khirurgiia (Mosk) ; (12): 46-51, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33301253

RESUMO

Blakemore probe-obturator was previously preferable for primary hemostasis in patients with bleeding from esophageal varices. Currently, Danis self-expanding nitinol stent became an effective alternative. According to some manufacturers, Danis stent has some advantages over balloon tamponade. We report implantation of nitinol stent for hemostasis in a patient with multiple recurrent bleeding and ineffective endoscopic manipulations. A method of stent fixation for prevention of distal migration as the most common complication is described.


Assuntos
Varizes Esofágicas e Gástricas , Hemorragia Gastrointestinal , Hipertensão Portal , Ligas , Materiais Biocompatíveis , Varizes Esofágicas e Gástricas/diagnóstico , Varizes Esofágicas e Gástricas/etiologia , Varizes Esofágicas e Gástricas/cirurgia , Esofagoscopia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/cirurgia , Hemostasia Cirúrgica/instrumentação , Humanos , Hipertensão Portal/complicações , Hipertensão Portal/diagnóstico , Falha de Prótese , Implantação de Prótese/métodos , Stents
2.
Khirurgiia (Mosk) ; (12): 93-98, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33301261

RESUMO

Perforation of the esophagus is a serious and dangerous condition due to progressive development of mediastinitis and sepsis. This disease is often fatal. In the last decade, endoscopic stenting of the esophagus became more common in these patients as an alternative to traditional surgery. We report successful minimally invasive endoscopic treatment of esophageal perforation with post-burn necrosis of its wall.


Assuntos
Perfuração Esofágica , Esofagoscopia , Mediastinite , Implantação de Prótese/métodos , Drenagem , Perfuração Esofágica/diagnóstico , Perfuração Esofágica/etiologia , Perfuração Esofágica/cirurgia , Humanos , Mediastinite/diagnóstico , Mediastinite/etiologia , Mediastinite/cirurgia , Sepse/etiologia , Stents
3.
Plast Reconstr Surg ; 146(6): 1394-1403, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33234978

RESUMO

Interest in amputation surgery has increased in conjunction with rising public awareness about amputee care. To date, plastic surgeons have impacted the quality of life and functional potential of amputees through novel strategies for sensory feedback and prosthesis control and various techniques for neuroma treatment and prevention. Osseointegration, which involves the direct skeletal attachment of a prosthesis to bone, has the ability to further maximize amputee function. There exists a critical role for plastic surgeons to help optimize techniques for extremity osseointegration through improved wound care and soft-tissue management. An overview of current osseointegrated prostheses and their associated limitations, and potential avenues through which plastic surgeons can help mitigate these challenges, are discussed in this article.


Assuntos
Amputação/efeitos adversos , Membros Artificiais , Osseointegração , Implantação de Prótese/métodos , Qualidade de Vida , Amputados/psicologia , Humanos , Papel Profissional , Cirurgiões , Resultado do Tratamento
4.
J Fr Ophtalmol ; 43(10): 1020-1024, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33127181

RESUMO

PURPOSE: To evaluate the progression of keratoconus in 932 eyes of 659 patients through visual, refractive and topographic data after intracorneal ring segment (ICRS) implantation. METHODS: Retrospective review of 659 patients who underwent ICRS (Intacs®) implantation for keratoconus between September 1997 and November 2017. Demographics, preoperative and postoperative uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA) in LogMAR, corneal topography parameters (thinnest pachymetry, Kmax), central corneal pachymetry and total follow-up time were evaluated. Statistical analysis was performed using IBM SPSS Statistics 24.0 for windows. RESULTS: Nine hundred and thirty-two eyes of 659 patients, with a mean age of 30.41 years (range 11-76 years), were evaluated. Mean total follow up time was 3.02 years. Forty-one eyes had a total follow up of over 10 years. Both UCVA and BCVA improved significantly after ICRS implantation (P<0.01). Only 18 eyes (2.66% of eyes of patients under 35 years of age) were found to have progression of keratoconus based on postoperative topographic data (Mean age 23.00 years, 55.6% female, total follow-up 2 to 10 years) CONCLUSION: ICRS implantation showed long-term improvement and stability in visual and topographic results in a large case series of patients with keratoconus. Only a minimal rate of progression was detected in young patients. However, further prospective studies need to be conducted to better define predictability of postoperative visual outcomes and progression.


Assuntos
Substância Própria/cirurgia , Ceratocone/cirurgia , Procedimentos Cirúrgicos Oftalmológicos , Implantação de Prótese , Adolescente , Adulto , Idoso , Criança , Paquimetria Corneana , Substância Própria/patologia , Topografia da Córnea , Progressão da Doença , Feminino , Seguimentos , Humanos , Ceratocone/diagnóstico , Ceratocone/epidemiologia , Ceratocone/patologia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Oftalmológicos/efeitos adversos , Procedimentos Cirúrgicos Oftalmológicos/instrumentação , Procedimentos Cirúrgicos Oftalmológicos/métodos , Procedimentos Cirúrgicos Oftalmológicos/estatística & dados numéricos , Próteses e Implantes/efeitos adversos , Implantação de Prótese/efeitos adversos , Implantação de Prótese/métodos , Implantação de Prótese/estatística & dados numéricos , Refração Ocular , Estudos Retrospectivos , Resultado do Tratamento , Acuidade Visual , Adulto Jovem
5.
Sci Rep ; 10(1): 18507, 2020 10 28.
Artigo em Inglês | MEDLINE | ID: mdl-33116246

RESUMO

We sought to describe the surgical techniques required in the ab-interno method to implant subretinal prostheses in mini-pigs and suggest tips to facilitate optimal outcomes. During vitrectomy, the use of valved trocar cannulas was essential to stabilize the detached retina and implanted chip. As a first step in retinal detachment, a 23-gauge cannula with very small amount of viscoelastic material was used to establish the retinal hole and promote retinal detachment. Then, balanced salt solution was applied to increase the retinal detachment and diathermy was used to make opening for subretinal prosthesis. For easy positioning of the subretinal prosthesis, a curved laser probe was adopted when handling the subretinal prosthesis under the retina. After surgery, the sclerotomy sites were tightly sutured to prevent silicone oil leakage. Without special equipment, such as a 41-gauge tip, retinal detachment could be induced easily, while the prosthesis was also successfully inserted and manipulated under the retina without an iatrogenic retinal tear. Two weeks after the operation, the oil fully occupied the intraocular volume without leakage. The subretinal prosthesis remained stable without complication. Understanding the principle of the ab-interno method and considering several tips for improving surgical access may help to enhance surgical success rates of subretinal prostheses implantation.


Assuntos
Implantação de Prótese/métodos , Próteses Visuais/efeitos adversos , Vitrectomia/métodos , Animais , Próteses e Implantes , Retina/cirurgia , Descolamento Retiniano/cirurgia , Perfurações Retinianas/cirurgia , Suínos , Porco Miniatura , Acuidade Visual
6.
J Otolaryngol Head Neck Surg ; 49(1): 59, 2020 Aug 10.
Artigo em Inglês | MEDLINE | ID: mdl-32778168

RESUMO

With the COVID-19 pandemic, there has been significant changes and challenges in the management of oncology patients. One of the major strategies to reduce transmission of the virus between patients and healthcare workers is deferral of follow-up visits. However, deferral may not be possible in total laryngectomy patients. Urgent procedures may be necessary to prevent complications related to ill-fitting tracheoesophageal puncture (TEP) voice prostheses, such as aspiration or loss of voicing. In this paper, we describe the Princess Margaret Cancer Center's approach to managing this unique patient population.


Assuntos
Infecções por Coronavirus/prevenção & controle , Controle de Infecções/organização & administração , Neoplasias Laríngeas/cirurgia , Laringectomia/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Infecções por Coronavirus/epidemiologia , Infecção Hospitalar/prevenção & controle , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Humanos , Neoplasias Laríngeas/diagnóstico , Laringectomia/métodos , Laringe Artificial , Masculino , Ontário , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Implantação de Prótese/métodos , Implantação de Prótese/estatística & dados numéricos , Medição de Risco
7.
J Card Surg ; 35(8): 2067-2069, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32652695

RESUMO

A 43-year-old gentleman was transferred for management of acute on chronic cardiogenic shock (left ventricular ejection fraction < 10%). Upon arrival, we inserted a left axillary intra-aortic balloon pump for hemodynamic support. He underwent an emergent left and right-heart catheterization which showed patent stents and coronaries, in the setting of severely elevated pulmonary artery and pulmonary capillary wedge pressure. On hospital day 35, we escalated support to Centrimag in conjunction with a 31 French Protek Duo Rapid Deployment cannula. A centrimag cannula apical sewing cuff was sewn in continuous fashion along the left ventricular apex. Via modified seldinger technique, we tunneled the Protek Duo Rapid Deployment cannula through the silastic sewing cuff and the ventricular apex, traversing the aortic valve. On hospital day 50, he underwent left anterior thoracotomy and mini-sternotomy for implantation of durable Heartware left ventricular assist device. He was discharged home off inotropes and had resumed his normal activities. He is currently listed as status four for heart transplantation.


Assuntos
Cateterismo Cardíaco/métodos , Coração Auxiliar , Implantação de Prótese/métodos , Choque Cardiogênico/terapia , Doença Aguda , Adulto , Doença Crônica , Transplante de Coração , Hemodinâmica , Humanos , Balão Intra-Aórtico , Masculino , Pressão Propulsora Pulmonar , Choque Cardiogênico/fisiopatologia , Esternotomia/métodos , Toracotomia/métodos , Listas de Espera
8.
Am Heart J ; 226: 222-231, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32629295

RESUMO

BACKGROUND: A randomized, sham-controlled trial in patients with heart failure (HF) and left ventricular ejection fraction (LVEF) ≥40% demonstrated reductions in pulmonary capillary wedge pressure (PCWP) with a novel transcatheter InterAtrial Shunt Device (IASD). Whether this hemodynamic effect will translate to an improvement in cardiovascular outcomes and symptoms requires additional study. STUDY DESIGN AND OBJECTIVES: REDUCE Elevated Left Atrial Pressure in Patients with Heart Failure II (REDUCE LAP HF-II) is a multicenter, prospective, randomized, sham-controlled, blinded trial designed to evaluate the clinical efficacy of the IASD in symptomatic HF and elevated left atrial pressures. Up to 608 HF patients age ≥ 40 years with LVEF ≥40%, PCWP ≥25 mm Hg during supine ergometer exercise, and PCWP ≥5 mm Hg higher than right atrial pressure will be randomized 1:1 to the IASD versus sham control. Key exclusion criteria include hemodynamically significant valvular disease, evidence of pulmonary arterial hypertension, and right heart dysfunction. The primary endpoint is a hierarchical composite, analyzed by the Finkelstein-Schoenfeld methodology, that includes (1) cardiovascular mortality or first nonfatal ischemic stroke through 12 months; (2) total (first plus recurrent) HF hospitalizations or healthcare facility visits for intravenous diuretics up to 24 months, analyzed when the last randomized patient completes 12 months of follow-up; and (3) change in Kansas City Cardiomyopathy Questionnaire overall summary score from baseline to 12 months. Follow-up echocardiography will be performed at 6, 12, and 24 months to evaluate shunt flow and cardiac chamber size/function. Patients will be followed for a total of 5 years after the index procedure. CONCLUSIONS: REDUCE LAP-HF II is designed to evaluate the clinical efficacy of the IASD device in patients with symptomatic HF with elevated left atrial pressure and LVEF ≥40%.


Assuntos
Insuficiência Cardíaca/cirurgia , Próteses e Implantes , Implantação de Prótese/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Cateterismo Cardíaco , Método Duplo-Cego , Insuficiência Cardíaca/fisiopatologia , Humanos , Estudos Multicêntricos como Assunto , Estudos Prospectivos , Função Ventricular Esquerda
9.
J Glaucoma ; 29(9): e106-e107, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32657820

RESUMO

To prevent corneal endothelial cell loss, ciliary sulcus tube insertion is preferred for the pseudophakic eye. However, we sometimes encounter technical difficulties when inserting the tube through the sulcus. Even in cases in which we are able to insert a 23-G needle through the sulcus into the space between the iris and intraocular lens, the tube of Ahmed valve may stray into the vitreous cavity or under Elschnig pearls. To remedy such conditions, we developed a new tube insertion method using a 4-0 proline stent as a guide to insert the tube in the appropriate position.


Assuntos
Implantes para Drenagem de Glaucoma , Glaucoma/cirurgia , Prolina , Implantação de Prótese/métodos , Suturas , Perda de Células Endoteliais da Córnea/prevenção & controle , Humanos , Pressão Intraocular , Stents , Técnicas de Sutura
10.
Sci Rep ; 10(1): 11159, 2020 07 07.
Artigo em Inglês | MEDLINE | ID: mdl-32636437

RESUMO

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.


Assuntos
Drenagem/métodos , Endossonografia/métodos , Vesícula Biliar/cirurgia , Implantação de Prótese/métodos , Stents Metálicos Autoexpansíveis , Ultrassonografia de Intervenção/métodos , Animais , Modelos Animais de Doenças , Drenagem/instrumentação , Vesícula Biliar/diagnóstico por imagem , Doenças da Vesícula Biliar/cirurgia , Masculino , Implantação de Prótese/instrumentação , Suínos , Porco Miniatura
11.
Sci Rep ; 10(1): 10666, 2020 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-32606388

RESUMO

This retrospective study is to evaluate refractive and visual outcomes of topography-guided femtosecond laser-assisted in situ keratomileusis (TGL) for correcting corneal high-order aberrations (HoA) after multifocal intraocular lens (mIOL) implantation. Twenty-eight eyes of 28 patients with both corrected distance visual acuity (CDVA) under 20/25 and subjective visual discomfort at 3 months after mIOL implantation were included in the study. TGL was performed to correct corneal HoA. Visual acuity, manifest refraction, and corneal HoA were measured 3 months after TGL. CDVA was improved in 22 (78.57%) of 28 eyes after TGL. Uncorrected distance visual acuity (0.12 ± 0.16 logMAR) and uncorrected near visual acuity (0.081 ± 0.16 logMAR) were better than those before TGL (P < 0.001). Residual refractive astigmatism showed no difference compared to that before TGL. Root mean square (RMS) of HoA (P = 0.012), spherical aberration (P = 0.013), and RMS of coma (P = 0.001) were reduced relative to those before TGL. Amount of improvement in CDVA was correlated with amount of reduced coma RMS (R = 0.524; P = 0.005) and spherical aberration (R = 0.443; P = 0.021). TGL showed to improve both refractive and visual outcomes in patients with mIOL implantation by correcting corneal HoA.


Assuntos
Córnea/fisiopatologia , Córnea/cirurgia , Aberrações de Frente de Onda da Córnea/fisiopatologia , Refração Ocular/fisiologia , Acuidade Visual/fisiologia , Astigmatismo/cirurgia , Substância Própria/fisiopatologia , Substância Própria/cirurgia , Topografia da Córnea/métodos , Aberrações de Frente de Onda da Córnea/cirurgia , Feminino , Humanos , Ceratomileuse Assistida por Excimer Laser In Situ/métodos , Ceratoplastia Penetrante/métodos , Lasers de Excimer , Implante de Lente Intraocular/métodos , Masculino , Pessoa de Meia-Idade , Lentes Intraoculares Multifocais , Implantação de Prótese/métodos , Estudos Retrospectivos , Testes Visuais/métodos
13.
J Interv Cardiol ; 2020: 8615410, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32669982

RESUMO

Aim: The feasibility and safety of performing the combined procedure of catheter ablation (CA) and left atrial appendage closure (LAAC) for atrial fibrillation (AF) have been reported by observational studies without controls. The aim of this study was to compare the procedural and long-term outcomes of combined procedures with isolated CA or LAAC. Methods and Results: This study included patients who underwent combined CA and LAAC (combined group), CA alone (CA-only group), or LAAC alone (LAAC-only group). Propensity score matching was used to select controls from the CA-only and LAAC-only groups. Each group contained 76 subjects. The procedures were successfully performed in all the patients. Procedure-related complications of the combined group included one pericardial effusion and two groin haematomas, which did not differ significantly with those of the CA-only group (3.9% vs. 2.6%, P=0.650) or the LAAC-only group (3.9% vs. 2.6%, P=0.650), respectively. The AF-free rate of the combined group was comparable with that of the CA-only group after a mean of 2 years follow-up (67.1% vs. 69.7%, P=0.727). Compared with the LAAC-only group, the combined group achieved similar complete occlusion rate at implant (94.7% vs. 93.4%) and at 45 days (82.9% vs. 85.5%). At the end of follow-up, ischemic stroke and bleeding events of the combined group were low (3.9%) and were comparable with those of the CA-only group (5.3%) and the LAAC-only group (2.6%). Conclusions: The combination of AF-CA and LAAC is safe and efficacious compared with single procedures alone.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Ablação por Cateter , Complicações Pós-Operatórias , Implantação de Prótese , Dispositivo para Oclusão Septal , Idoso , Fibrilação Atrial/complicações , Estudos de Casos e Controles , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/métodos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
14.
BMC Surg ; 20(1): 159, 2020 Jul 20.
Artigo em Inglês | MEDLINE | ID: mdl-32689979

RESUMO

BACKGROUND: RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected. METHODS: In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction. RESULTS: There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects. CONCLUSION: The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02759094 . Registered 3 May, 2016.


Assuntos
Esfíncter Esofágico Inferior , Refluxo Gastroesofágico , Implantação de Prótese/métodos , Adulto , Esfíncter Esofágico Inferior/cirurgia , Esôfago/cirurgia , Feminino , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/cirurgia , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Próteses e Implantes , Inibidores da Bomba de Prótons/uso terapêutico , Qualidade de Vida , Estômago/cirurgia , Resultado do Tratamento
15.
Am J Otolaryngol ; 41(5): 102585, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32521300

RESUMO

INTRODUCTION: Determine the feasibility of a two-incision surgical approach to hypoglossal nerve stimulator implantation based on anatomic considerations. METHODS: Upper airway stimulation (UAS) using the Inspire system uses three implanted devices-the implantable pulse generator (IPG), stimulation lead and sensing chest wall lead. The traditional surgical approach requires three skin incisions located on the submandibular neck, anterosuperior chest wall and inferolateral chest wall. Our surgical team sought to determine the anatomic considerations of combining the two chest wall incisions into one. In order to minimize morbidity and reduce operative time, the chest wall sensing lead was placed posterolateral to the IPG site via the same incision. RESULTS: Using an adult cadaver for anatomical analysis, access to the third and fourth intercostal spaces was made more difficult by the pectoralis major humeral head and upper arm. The intercostal space was narrower, the musculature along the anterior axillary line and anterior chest wall was devoid of the innermost intercostal muscle group found more laterally. Furthermore, there were much thinner external and internal intercostal muscle components as they transitioned to a membranous layer anteriorly in comparison to the inferolateral chest wall. CONCLUSION: Lack of the innermost intercostal muscle and thinning of the external and internal intercostal muscles lateral to the IPG site leaves little barrier between the thoracic musculature and parietal pleural increasing the risk of complications such as pleurisy and pneumothorax. Given the anatomical findings, a two-incision surgical approach for UAS therapy is at higher risk for complications.


Assuntos
Terapia por Estimulação Elétrica/instrumentação , Terapia por Estimulação Elétrica/métodos , Eletrodos Implantados , Nervo Hipoglosso , Implantação de Prótese/métodos , Toracotomia/métodos , Cadáver , Estudos de Viabilidade , Humanos , Parede Torácica/anatomia & histologia , Parede Torácica/cirurgia
16.
J Am Coll Cardiol ; 75(25): 3122-3135, 2020 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-32586585

RESUMO

BACKGROUND: Percutaneous left atrial appendage closure (LAAC) is noninferior to vitamin K antagonists (VKAs) for preventing atrial fibrillation (AF)-related stroke. However, direct oral anticoagulants (DOACs) have an improved safety profile over VKAs, and their effect on cardiovascular and neurological outcomes relative to LAAC is unknown. OBJECTIVES: This study sought to compare DOACs with LAAC in high-risk patients with AF. METHODS: Left Atrial Appendage Closure vs. Novel Anticoagulation Agents in Atrial Fibrillation (PRAGUE-17) was a multicenter, randomized, noninferiority trial comparing LAAC with DOACs. Patients were eligible to be enrolled if they had nonvalvular AF; were indicated for oral anticoagulation (OAC); and had a history of bleeding requiring intervention or hospitalization, a history of a cardioembolic event while taking an OAC, and/or a CHA2DS2-VASc of ≥3 and HAS-BLED of >2. Patients were randomized to receive LAAC or DOAC. The primary composite outcome was stroke, transient ischemic attack, systemic embolism, cardiovascular death, major or nonmajor clinically relevant bleeding, or procedure-/device-related complications. The primary analysis was by modified intention to treat. RESULTS: A high-risk patient cohort (CHA2DS2-VASc: 4.7 ± 1.5) was randomized to receive LAAC (n = 201) or DOAC (n = 201). LAAC was successful in 181 of 201 (90.0%) patients. In the DOAC group, apixaban was most frequently used (192 of 201; 95.5%). At a median 19.9 months of follow-up, the annual rates of the primary outcome were 10.99% with LAAC and 13.42% with DOAC (subdistribution hazard ratio [sHR]: 0.84; 95% confidence interval [CI]: 0.53 to 1.31; p = 0.44; p = 0.004 for noninferiority). There were no differences between groups for the components of the composite endpoint: all-stroke/TIA (sHR: 1.00; 95% CI: 0.40 to 2.51), clinically significant bleeding (sHR: 0.81; 95% CI: 0.44 to 1.52), and cardiovascular death (sHR: 0.75; 95% CI: 0.34 to 1.62). Major LAAC-related complications occurred in 9 (4.5%) patients. CONCLUSIONS: Among patients at high risk for stroke and increased risk of bleeding, LAAC was noninferior to DOAC in preventing major AF-related cardiovascular, neurological, and bleeding events. (Left Atrial Appendage Closure vs. Novel Anticoagulation Agents in Atrial Fibrillation [PRAGUE-17]; NCT02426944).


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos , Inibidores do Fator Xa , Hemorragia , Implantação de Prótese , Acidente Vascular Cerebral , Idoso , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/instrumentação , Procedimentos Cirúrgicos Cardíacos/métodos , Inibidores do Fator Xa/administração & dosagem , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Humanos , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/métodos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
17.
J Card Surg ; 35(7): 1539-1547, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32579786

RESUMO

BACKGROUND: Despite improved survival and morbidity after durable left ventricular assist device (dLVAD), outcomes for cardiogenic shock patients are suboptimal. Temporary mechanical circulatory support (tMCS) can permit optimization before dLVAD. Excellent outcomes have been observed using minimally-invasive dLVAD implantation. However, some feel tMCS contraindicates this approach. To evaluate whether left thoracotomy/hemisternotomy (LTHS) dLVAD placement is safe in this setting, we compared patients who did and did not require tMCS. METHODS: Outcomes for patients receiving dLVADs via LTHS were compared among those bridged with extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pump (IABP), or no tMCS. We evaluated demographics, comorbidities, laboratory and hemodynamic data, and intraoperative and postoperative outcomes. RESULTS: Eighty-three patients underwent LTHS dLVAD placement. Fifty did not require tMCS, while 22 (26%) required IABP, and 11 (13%) ECMO. Non-tMCS patients were primarily Intermacs 3 (56%), while IABP recipients were mainly Intermacs 2 (45%). All patients with ECMO were Intermacs 1. Patients with tMCS had worse end-organ function. Operative outcomes were similar except more concomitant procedures and red-cell transfusions in patients with ECMO. Intensive care unit and hospital length of stay and inotrope duration were also similar. There were no differences in bleeding, stroke, and infection rates. Three- and 12-month survival were: no tMCS: 94%, 86%; IABP: 100%, 88%; and ECMO: 81%, 81% (P = .45). CONCLUSIONS: Patients with cardiogenic shock can safely undergo LTHS dLVAD implantation after stabilization with ECMO or IABP. Outcomes and complications in these patients were comparable to a less severely ill cohort without tMCS.


Assuntos
Oxigenação por Membrana Extracorpórea , Ventrículos do Coração/cirurgia , Coração Auxiliar , Balão Intra-Aórtico , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Implantação de Prótese/métodos , Choque Cardiogênico/terapia , Esternotomia/métodos , Toracotomia/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Resultado do Tratamento
18.
J Card Surg ; 35(7): 1721-1724, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32557829

RESUMO

Fontan patients with protein-losing enteropathy (PLE) represent poor candidates for cardiac transplantation due to end-organ injury and severely impaired clinical condition. Ventricular assist device (VAD) therapy has evolved as a promising bridge to transplant strategy improving quality of life and survival on the waiting list. However, VAD therapy for the Fontan circulation remains challenging. For Fontan patients with preserved ventricular function implantation of a right ventricular assist device (RVAD) has been described by Prêtre et al as bridge to transplant. We present the second case of RVAD support in a Fontan patient with PLE.


Assuntos
Técnica de Fontan , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Implantação de Prótese/métodos , Enteropatias Perdedoras de Proteínas/etiologia , Feminino , Cardiopatias Congênitas/complicações , Insuficiência Cardíaca/etiologia , Transplante de Coração , Ventrículos do Coração , Humanos , Qualidade de Vida , Listas de Espera , Adulto Jovem
19.
Plast Reconstr Surg ; 146(4): 883-890, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32590514

RESUMO

BACKGROUND: In open retromuscular ventral hernia repair, fixation-free mesh placement is increasingly prevalent and may minimize pain; the main concern with this technique is short-term technical failure and hernia recurrence. This study compared outcomes following mechanical mesh fixation (i.e., sutures, staples, tacks) versus fixation-free mesh placement. METHODS: Adults who underwent open, elective, retromuscular ventral hernia repair of 15 cm width or less with permanent synthetic mesh placement in a clean wound were identified. Propensity score matching was used to compare patients who received mechanical mesh fixation to those who received fixation-free mesh placement. Thirty-day hernia recurrence was the primary outcome, with secondary outcomes of 30-day hospital length of stay and 30-day rates of readmission, reoperation, wound events, pain, and abdominal wall function. One- and 2-year composite recurrence and 3-year cumulative composite recurrence were also evaluated. RESULTS: A 3:1 propensity score match was performed on 299 fixation-free patients identifying 897 mechanical fixation patients, with a mean body mass index of 31 kg/m and mean age of 57.5 years. There was no difference in 30-day recurrence between mechanical and fixation-free approaches (0.2 percent versus 0 percent; p = 1). Median length of stay was longer for mechanical fixation (4 versus 3 days; p = 0.002). In the mechanical fixation group, pain scores were higher (worse pain, 46 versus 44; p = 0.001), and abdominal wall function scores were lower (worse function, 47 versus 60; p = 0.003), with no differences in rates of hospital readmission, reoperation, or wound events. There were no differences in long-term outcomes of 1- and 2-year composite recurrence, or 3-year cumulative composite recurrence. CONCLUSION: For short-term technical durability, fixation-free mesh placement in open retromuscular ventral hernia repair is an acceptable alternative to mechanical fixation for hernia defects of 15 cm or less. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Hérnia Ventral/cirurgia , Herniorrafia/métodos , Telas Cirúrgicas , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Implantação de Prótese/métodos , Recidiva , Grampeamento Cirúrgico , Suturas , Resultado do Tratamento
20.
Ann R Coll Surg Engl ; 102(9): 689-692, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32538119

RESUMO

INTRODUCTION: Placement of a duodenal or pyloric stent is a recognised palliative procedure for symptomatic relief of malignant gastric outlet obstruction. This procedure can be associated with significant complications, reinterventions and poor long-term relief of obstructive symptoms. However, there may be a faster return to diet and shorter hospital stay in comparison to other palliative procedures (eg gastrojejunostomy). The aim of this study was to determine the safety and efficacy of duodenal stenting in our regional district general hospital in comparison to that of larger tertiary centres. MATERIALS AND METHODS: All patients with gastric outlet obstruction who had duodenal stent placement attempted in our region between 1 August 2013 and 31 July 2018 were identified by retrospective analysis of prospectively maintained coding databases and medical notes. Patient demographics, safety outcomes and efficacy outcomes were then extracted. Results were interpreted with respect to data from best available published evidence from larger tertiary centres. RESULTS: Of 43 duodenal stent insertion attempts, 84% had a successful return to diet, 18% underwent reintervention, 18% suffered adverse events, mean length of stay post-intervention was 8.6 days and mean survival post-intervention was 132 days. CONCLUSIONS: Patients with malignant gastric outlet obstruction in whom duodenal stent placement was attempted had similar outcomes to published data from larger tertiary centres. Duodenal stent placement remains an acceptable treatment option for these patients in our region.


Assuntos
Duodeno/cirurgia , Obstrução da Saída Gástrica/cirurgia , Stents , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitais de Distrito , Hospitais Gerais , Humanos , Masculino , Pessoa de Meia-Idade , Implantação de Prótese/efeitos adversos , Implantação de Prótese/métodos , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do Tratamento
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