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1.
Int Heart J ; 61(6): 1157-1164, 2020 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-33191351

RESUMO

The aim of this study was to prospectively assess the efficacy, safety, and predictive effect of intravenous nifekalant administration for persistent atrial fibrillation (PerAF) after pulmonary vein isolation (PVI) with second-generation cryoballoon ablation (CBA) on 1-year atrial tachyarrhythmia (ATa) -free survival by examining the pharmacological conversion rate.One hundred and two drug-refractory, consecutive PerAF patients undergoing PVI were enrolled in this prospective observational study. After PVI, nifekalant (50 mg) was given followed by 30 minutes of observation and no further intervention. PerAF was successfully converted to sinus rhythm (SR) in 60 patients (58.8%) after a median time of 7.75 (4.13-12) minutes (group N). In the remaining 42 patients (41.2%) (group C), PerAF was successfully converted to SR by external electrical cardioversion. Nonsustained ventricular tachycardia occurred in 1 patient in group N. The left atrial volume (LAV) in group C was larger than that in group N (128.2 ± 28.2 versus 111.8 ± 24.5 mL, P = 0.002). Phrenic nerve injury occurred in 4 of 102 patients (3.9%). No other complications occurred during the procedure or within the 1-year follow-up period. At the 1-year follow-up, after a 3-month blanking period (BP), ATa-free survival during 1-year follow-up in group C was significantly lower than that in group N (50.0% versus 71.7%, P = 0.026), and the overall ATa-free survival rate was 62.7%. Two patients in group C and 4 patients in group N underwent a second procedure with radiofrequency catheter ablation. Multivariate Cox regression analysis demonstrated that unsuccessful conversion to SR (P = 0.025), ATa relapse during the BP (P = 0.000), and larger LAV (P = 0.016) were independent predictors of ATa recurrence at the 1-year follow-up.In conclusion, at the 1-year follow-up, the ATa-free survival rate after PVI with CBA for PerAF patients was 62.7%, and successful conversion to SR with nifekalant could serve as a clinical predictor of reduced ATa recurrence.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Criocirurgia/métodos , Cuidados Intraoperatórios/métodos , Veias Pulmonares/cirurgia , Pirimidinonas/uso terapêutico , Idoso , Cardioversão Elétrica/métodos , Feminino , Átrios do Coração/diagnóstico por imagem , Átrios do Coração/patologia , Humanos , Infusões Intravenosas , Complicações Intraoperatórias/epidemiologia , Masculino , Pessoa de Meia-Idade , Tamanho do Órgão , Traumatismos dos Nervos Periféricos/epidemiologia , Nervo Frênico/lesões , Intervalo Livre de Progressão , Estudos Prospectivos , Recidiva , Taquicardia Ventricular/epidemiologia , Resultado do Tratamento
2.
PLoS One ; 15(6): e0235132, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32584880

RESUMO

BACKGROUND: Phrenic nerve injury (PNI) remains one of the most frequent complications during cryoballoon-based pulmonary vein isolation (CB-PVI). Since its introduction in 2013, the use of compound motor action potential (CMAP) for the prevention of PNI during CB-PVI is increasing; however, systematic outcome data are sparse. METHODS: The CMAP technique was applied in conjunction with abdominal palpation during pacing manoeuvres (10 mV, 2 ms) from the superior vena cava for 388 consecutive patients undergoing CB-PVI between January 2015 and May 2017 at our tertiary arrhythmia centre. Cryoablation was immediately terminated when CMAP amplitude was reduced by 30%. RESULTS: Reductions in CMAP amplitude were observed in 16 (4%) of 388 patients during isolation of the right veins. Of these, 11 (69%) patients did not manifest a reduction in diaphragmatic excursions. The drop in CMAP amplitude was observed in 10 (63%) patients during ablation of the right superior pulmonary veins (PVs) and in 7 (44%) patients during ablation of the right inferior PVs. Postprocedural persistent PNI was observed in three of four patients for a duration of 6 months, with one of these patients remaining symptomatic at the 24-month follow-up. One of the four patients was lost to long-term follow-up. CONCLUSIONS: All PNIs occurred during right-sided CB-PVI and were preceded by a reduction in CMAP amplitude. Thus, the standardized use of CMAP surveillance during CB-PVI is easily applicable, reliable and compared with other studies, results in a lower number of PNIs.


Assuntos
Potenciais de Ação , Fibrilação Atrial , Criocirurgia/efeitos adversos , Monitorização Neurofisiológica Intraoperatória , Nervo Frênico , Veias Pulmonares , Idoso , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Veias Pulmonares/fisiopatologia , Veias Pulmonares/cirurgia
3.
Circ Arrhythm Electrophysiol ; 13(6): e008580, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32372696

RESUMO

BACKGROUND: Pulsed field ablation (PFA) is a nonthermal energy that may provide safety advantages over radiofrequency ablation (RFA). One-shot PFA catheters have been developed for pulmonary vein isolation, but they do not permit flexible lesion sets. This study investigated a novel lattice-tip catheter designed for focal RFA or PFA ablation. METHODS: The effects of PFA (biphasic, 24 amperes) were investigated in 25 swine using a lattice-tip catheter and system (Affera Inc). Step 1 (n=14) examined the feasibility to create atrial line of block and described its acute effects on the phrenic nerve and esophagus. Step 2 (n=7) examined the subacute effects of PFA on block durability, phrenic nerve, and esophagus ≥2 weeks. Step 3 compared the effects of PFA and RFA on the esophagus using a mechanical deviation model approximating the esophagus to the right atrium (n=4) and by direct ablation within its lumen (n=4). The effects of endocardial PFA and RFA on the phrenic nerve were also compared (n=10). Histological analysis was performed. RESULTS: PFA produced acute block in 100% of lines, achieved with 2.1 (1.3-3.2) applications/cm line. Histological analysis following (35 [18-37]) days showed 100% transmurality (thickness range 0.4-3.4 mm) with a lesion width of 19.4 (10.9-27.4 mm). PFA selectively affected cardiomyocytes but spared blood vessels and nervous tissue. PFA applied from the posterior atria (23 [21-25] applications) to the approximated esophagus (6 [4.5-14] mm) produced transmural lesions without esophageal injury. PFA (16.5 [15-18] applications) applied inside the esophageal lumen produced mild edema compared with RFA (13 [12-14] applications) which produced epithelial ulcerations. PFA resulted in no or transient stunning of the phrenic nerve (<5 minutes) without histological changes while RFA produced paralysis. CONCLUSIONS: PFA using a lattice-tip ablation catheter for focal ablation produced durable atrial lesions and showed lower vulnerability to esophageal or phrenic nerve damage compared with RFA.


Assuntos
Cateterismo Cardíaco/instrumentação , Cateteres Cardíacos , Ablação por Cateter/instrumentação , Eletrodos , Átrios do Coração/cirurgia , Animais , Cateterismo Cardíaco/efeitos adversos , Ablação por Cateter/efeitos adversos , Desenho de Equipamento , Esôfago/lesões , Esôfago/patologia , Átrios do Coração/patologia , Átrios do Coração/fisiopatologia , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/patologia , Nervo Frênico/lesões , Nervo Frênico/patologia , Sus scrofa , Fatores de Tempo
4.
World Neurosurg ; 137: e75-e82, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31982596

RESUMO

BACKGROUND: Diaphragmatic paralysis after phrenic nerve injury is an infrequent but serious condition. The destruction of respiratory function after unilateral phrenic nerve injury has been the subject of many investigations. METHODS: In this study, we used a rat model of complete paralysis of the unilateral diaphragm to observe changes in pulmonary function. RESULTS: We found in young rats with complete paralysis of the unilateral diaphragm, the vital capacity and total lung capacity show compensation after 4 weeks, and contralateral phrenic nerve transfer can enhance pulmonary function. However, in the aged rats, respiratory function parameters do not show compensation until 16 weeks after injury. CONCLUSIONS: These findings suggest that contralateral phrenic nerve end-to-side anastomosis is a promising therapeutic strategy. In general, our results suggest that this surgical method may hold great potential to be a secure, feasible, and effective technique to rescue diaphragmatic function.


Assuntos
Diafragma/inervação , Transferência de Nervo/métodos , Nervo Frênico/lesões , Nervo Frênico/transplante , Paralisia Respiratória/cirurgia , Animais , Diafragma/fisiopatologia , Diafragma/cirurgia , Feminino , Pulmão/fisiopatologia , Ratos , Ratos Sprague-Dawley
5.
Ann Vasc Surg ; 62: 70-75, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31207398

RESUMO

BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.


Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/anormalidades , Descompressão Cirúrgica/efeitos adversos , Traumatismos dos Nervos Periféricos/etiologia , Nervo Frênico/anormalidades , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Humanos , Masculino , Maryland , Traumatismos dos Nervos Periféricos/fisiopatologia , Philadelphia , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Resultado do Tratamento
6.
Ann Thorac Surg ; 109(6): 1897-1902, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31733188

RESUMO

BACKGROUND: Although adverse effects of phrenic nerve palsy (PNP) on early Fontan circulation have been reported, detailed late impact remains unclear. METHODS: Of 218 patients undergoing extracardiac total cavopulmonary connection between 1995 and 2008, 160 who all underwent cardiac catheter examination, spirometry, and exercise capacity testing 10 years after the operation were enrolled. The cohort was divided into 2 groups: with (N = 21) or without PNP (control group, N = 139). The patients with PNP were further divided into the recovered PNP group (n = 10) and the persistent PNP group (n = 11). All but 2 patients who developed PNP (90.9%) underwent diaphragmatic plication. There was no difference in hemodynamic indices at pre-Fontan evaluation among the three groups. RESULTS: Ten years after the Fontan procedure, the averaged forced vital capacity was 81% ± 18% of predicted in the control group, 86% ± 17% in the recovered PNP group, and 56% ± 12% in the persistent PNP group (P < .001). Peak oxygen consumption was linearly correlated to the forced vital capacity (r = 0.222, P = .009). There was no significant difference in the peak oxygen consumption between groups. Significant veno-venous collaterals into the diaphragm from lower body to pulmonary vein(s) or atria more frequently developed in patients who underwent diaphragmatic plication compared with those who did not (P < .001). CONCLUSIONS: Persistent PNP resulted in reduced forced vital capacity; however, its influence on exercise intolerance could not be identified. Diaphragmatic plication should be reserved for patients who experience clinically significant respiratory or hemodynamic sequelae of PNP.


Assuntos
Técnica de Fontan/efeitos adversos , Cardiopatias Congênitas/cirurgia , Doenças do Sistema Nervoso Periférico/complicações , Nervo Frênico/lesões , Complicações Pós-Operatórias , Paralisia Respiratória/etiologia , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Doenças do Sistema Nervoso Periférico/fisiopatologia , Prognóstico , Paralisia Respiratória/fisiopatologia , Estudos Retrospectivos , Fatores de Tempo , Capacidade Vital/fisiologia
7.
J Pediatr Surg ; 55(2): 240-244, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31757507

RESUMO

BACKGROUND: Phrenic nerve injury (PNI) from birth trauma is a recognized phenomenon, generally occurring with ipsilateral brachial plexus palsy (BPP). In severe cases, PNI results in diaphragm paresis (DP) and respiratory insufficiency. Surgical diaphragmatic plication (SDP) is a potential management strategy for patients with PNI and DP, but timing and outcomes associated with SDP have not been rigorously studied. METHODS: Records from 49 tertiary United States pediatric hospitals in the Pediatric Health Information System from 2004 to 2018 were analyzed. The study cohort included patients diagnosed with BPP from birth trauma who were documented to have PNI or DP. Patients who underwent congenital cardiac operations were excluded. RESULTS: A total of 5832 patients were identified with BPP from birth trauma during the study period, 122 (2%) of whom were found to have concomitant DP. Of those, 65 (53%) were male, 39 (32%) were infants of diabetic mothers, 80 (65%) required mechanical ventilation, and 33 (27%) underwent SDP. SDP was performed at a median (range) age of 36 (7-95) days. Median (range) total and postoperative hospital lengths of stay (LOS) were 34 (6-180) and 15 (4-132) days, respectively. There was also an observed increase in post-operative LOS with increase in age at operation. CONCLUSION: Neonatal DP is rare and is managed with SDP in a minority of instances. Age at repair affects total and postoperative length of stay, proxies for resource utilization and morbidity. Repair prior to 45 days of life appears to result in a shorter postoperative hospital stay. This analysis will help guide surgeons with respect to indications and operative timing for infant DP. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.


Assuntos
Diafragma/cirurgia , Paralisia Obstétrica/etiologia , Paralisia Obstétrica/cirurgia , Nervo Frênico/lesões , Paralisia Respiratória/etiologia , Paralisia Respiratória/cirurgia , Feminino , Humanos , Recém-Nascido , Tempo de Internação , Masculino , Paralisia Obstétrica/terapia , Respiração Artificial , Paralisia Respiratória/terapia , Estudos Retrospectivos
8.
Rev. esp. anestesiol. reanim ; 66(10): 497-505, dic. 2019. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-192103

RESUMO

INTRODUCCIÓN: El marcapasos diafragmático (MD) ha demostrado su utilidad en la sustitución de la ventilación mecánica en pacientes afectos de lesiones medulares crónicas (LMC) y esclerosis lateral amiotrófica (ELA), mejorando la calidad de vida y reduciendo la morbimortalidad y los costes sanitarios asociados. El manejo anestésico de dichos pacientes y las particularidades del procedimiento quirúrgico suponen un reto anestésico. El objetivo de nuestro estudio es el análisis del manejo y las complicaciones intraoperatorias de los pacientes sometidos a MD en nuestra institución. METODOLOGÍA: Se trata de una revisión retrospectiva entre diciembre de 2007 y julio de 2018. Se recogieron datos sobre el estado previo del paciente, el manejo anestésico y las complicaciones intraoperatorias. RESULTADOS: Se incluyen 16 pacientes (5 pediátricos) con indicación de MD por LMC (63%), ELA (25%) y otras enfermedades neurológicas (12%). Se requirió anestesia general para la laparoscopia abdominal utilizando inducción intravenosa (87%) o inhalatoria (13%) y anestesia total intravenosa (50%) o balanceada (50%) para el mantenimiento anestésico. En un caso se administró rocuronio para un óptimo manejo de la vía aérea. Las complicaciones registradas incluyeron: hipotensión arterial (50%), dificultades en la ventilación mecánica durante la laparoscopia (31%), pneumotárax (12,5%) y disreflexia autonómica (6%). CONCLUSIONES: La colocación de MD bajo anestesia general es una intervención segura, tanto en el paciente adulto como en el pediátrico, en la que pueden aparecer complicaciones derivadas tanto de la enfermedad de base como de la técnica quirúrgica, siendo necesaria una rápida identificación y tratamiento de las mismas para el buen desarrollo del procedimiento


BACKGROUND: The diaphragm pacemaker (DP) has proven its utility in replacing mechanical ventilation in patients with chronic spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). The DP improves patient quality of life and reduces morbidity and mortality and their associated health care costs. The anesthetic management of these patients and the particularities of the surgical procedure are challenging. The aim of our study is to analyze anesthetic management and intraoperative complications in patients undergoing DP placement in our hospital. METHODS: We performed a chart review of patients treated between December 2007 and July 2017, recording the patients' preoperative status, anesthetic management and intraoperative complications. RESULTS: The study included 16 patients (5 pediatric) undergoing DP implantation for chronic SCI (63%), ALS (25%) and other neurologic conditions (12%). Abdominal laparoscopy was performed under general anesthesia, with intravenous (87%) or inhalational (13%) induction and maintenance using total intravenous (50%) or balanced (50%) anesthesia. Rocuronium was administered in one case to permit airway management. Complications included: hypotension (50%), difficulties in mechanical ventilation during laparoscopy (31%), pneumothorax (12.5%) and autonomic dysreflexia (6%). CONCLUSIONS: DP placement under general anesthesia is a safe intervention in both adult and pediatric patients. Complications derived from both the underlying disease and the surgical technique may appear, and must be rapidly identified and treated to obtain a satisfactory surgical outcome


Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Esclerose Amiotrófica Lateral/complicações , Anestesia Geral/métodos , Diafragma , Marca-Passo Artificial , Quadriplegia/complicações , Transtornos Respiratórios/terapia , Traumatismos da Medula Espinal/complicações , Disreflexia Autonômica/etiologia , Doença Crônica , Hipotensão/etiologia , Neuroestimuladores Implantáveis , Complicações Intraoperatórias/etiologia , Laparoscopia/efeitos adversos , Nervo Frênico/lesões , Pneumotórax/etiologia , Transtornos Respiratórios/etiologia , Respiração Artificial/efeitos adversos , Estudos Retrospectivos , Traqueotomia/estatística & dados numéricos
9.
Medicine (Baltimore) ; 98(26): e16252, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31261591

RESUMO

RATIONALE: Massive mediastinal tumors present a major challenge for surgery and anesthesia management due to possible perioperative circulation and respiratory dysfunction. PATIENT CONCERNS: A 36-year-old female underwent difficulty with tracheal extubation and required mechanical ventilation for 3 months after resection of a massive mediastinal tumor. DIAGNOSES: Postoperative B-ultrasound examination of diaphragmatic motor weakness and electrophysiological examination indicated respiratory failure due to phrenic nerve injury. INTERVENTIONS: The patient failed tracheal extubation several times after the operation and finally a tracheotomy was performed. Mechanical ventilation, anti-infective treatment, and systemic supportive treatment were provided. OUTCOMES: The patient recovered well after tracheotomy and approximately 3 months of ventilation support. LESSONS: Weaning difficulty caused by phrenic nerve injury seriously affected patient postoperative rehabilitation. To reduce the occurrence of similar problems, intraoperative phrenic nerve electrophysiological monitoring should be conducted.


Assuntos
Extubação , Complicações Intraoperatórias/etiologia , Intubação Intratraqueal , Neoplasias do Mediastino/cirurgia , Nervo Frênico/lesões , Adulto , Feminino , Humanos
12.
Aerosp Med Hum Perform ; 90(6): 581-583, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31101146

RESUMO

Laslie WPD. You're the flight surgeon: spontaneous diaphragmatic hemiparesis in an Air Force firefighter. Aerosp Med Hum Perform. 2019; 90(6):581-583.


Assuntos
Diafragma/diagnóstico por imagem , Dispneia/diagnóstico , Nervo Frênico/lesões , Medicina Aeroespacial , Diagnóstico Diferencial , Diafragma/inervação , Dispneia/etiologia , Bombeiros , Humanos , Masculino , Militares , Exame Físico , Espirometria
13.
Heart Vessels ; 34(10): 1710-1716, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30972550

RESUMO

Phrenic nerve (PN) stimulation is essential for the elimination of PN palsy during balloon-based pulmonary vein isolation (PVI). Although ultrasound-guided vascular access is safe, insertion of a PN stimulation catheter via central venous access carries a potential risk of the development of mechanical complications. We evaluated the safety of a left cubital vein approach for positioning a 20-electrode atrial cardioversion (BeeAT) catheter in the coronary sinus (CS), and the feasibility of right PN pacing from the superior vena cava (SVC) using proximal electrodes of the BeeAT catheter. In total, 106 consecutive patients who underwent balloon-based PVI with a left cubital vein approach for BeeAT catheter positioning were retrospectively assessed. The left cubital approach was successful in 105 patients (99.1%), and catheter insertion into the CS was possible for 104 patients (99.0%). Among these patients, constant right PN pacing from the SVC was obtained for 89 patients (89/104, 85.6%). In five patients, transient loss of right PN capture occurred during right pulmonary vein ablation. No persistent right PN palsy was observed. Small subcutaneous hemorrhage was observed in eight patients (7.5%). Neuropathy, pseudoaneurysm, arteriovenous fistula, and perforations associated with the left cubital approach were not detected. Body mass index was significantly higher in the right PN pacing failure group than in the right PN pacing success group (26.2 ± 3.2 vs. 23.8 ± 3.8; P = 0.025). CS catheter placement with a left cubital vein approach for right PN stimulation was found to be safe and feasible. Right PN pacing from the SVC using a BeeAT catheter was successfully achieved in the majority of the patients. This approach may prove to be preferable for non-obese patients.


Assuntos
Fibrilação Atrial/cirurgia , Estimulação Cardíaca Artificial/métodos , Ablação por Cateter/efeitos adversos , Traumatismos dos Nervos Periféricos/prevenção & controle , Nervo Frênico/lesões , Idoso , Idoso de 80 Anos ou mais , Seio Coronário/cirurgia , Feminino , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Traumatismos dos Nervos Periféricos/etiologia , Veias Pulmonares/cirurgia , Estudos Retrospectivos , Veia Cava Superior/cirurgia
14.
Pacing Clin Electrophysiol ; 42(5): 508-514, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30756393

RESUMO

BACKGROUND: The second-generation cryoballoon significantly improves outcome of pulmonary vein isolation (PVI) but may cause more complications than the first generation. Currently, no consensus regarding optimal cryoballoon application time exists. The 123-study aimed to assess the minimal cryoballoon application duration necessary to achieve PVI (primary endpoint) and the effect of application duration on prevention of phrenic nerve injury (PNI). METHODS: Patients <75 years of age with paroxysmal atrial fibrillation, normal PV anatomy, and left atrial size <40 cc/m² or <50 mm were randomized to two applications of different duration: "short," "medium," or "long." A total of 222 patients were enrolled, 74 per group. RESULTS: Duration per application was 105 (101-108), 164 (160-168), and 224 (219-226) s and isolation was achieved in 79, 89, and 90% (P < 0.001) of the PVs after two applications in groups short, medium, and long, respectively. Only for the left PVs, the success rate of the short group was significantly less compared to the medium- and long-duration groups (P < 0.001). PNI during the procedure occurred in 19 PVs (6.5%) in the medium and in 20 PVs (6.8%) in the long duration groups compared to only five PVs (1.7%) in the short duration group (P < 0.001). CONCLUSIONS: Short cryoballoon ablation application times, less than 2 min, did affect the success for the left PVs but not for the right PVs and resulted in less PNI. A PV tailored approach with shorter application times for the right PVs might be advocated.


Assuntos
Fibrilação Atrial/cirurgia , Criocirurgia/métodos , Nervo Frênico/lesões , Veias Pulmonares/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
15.
Pulmonology ; 25(4): 223-235, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30509855

RESUMO

The diaphragm is the main breathing muscle and contraction of the diaphragm is vital for ventilation so any disease that interferes with diaphragmatic innervation, contractile muscle function, or mechanical coupling to the chest wall can cause diaphragm dysfunction. Diaphragm dysfunction is associated with dyspnoea, intolerance to exercise, sleep disturbances, hypersomnia, with a potential impact on survival. Diagnosis of diaphragm dysfunction is based on static and dynamic imaging tests (especially ultrasound) and pulmonary function and phrenic nerve stimulation tests. Treatment will depend on the symptoms and causes of the disease. The management of diaphragm dysfunction may include observation in asymptomatic patients with unilateral dysfunction, surgery (i.e., plication of the diaphragm), placement of a diaphragmatic pacemaker or invasive and/or non-invasive mechanical ventilation in symptomatic patients with bilateral paralysis of the diaphragm. This type of patient should be treated in experienced centres. This review aims to provide an overview of the problem, with special emphasis on the diseases that cause diaphragmatic dysfunction and the diagnostic and therapeutic procedures most commonly employed in clinical practice. The ultimate goal is to establish a standard of care for diaphragmatic dysfunction.


Assuntos
Diafragma/fisiopatologia , Nervo Frênico/fisiopatologia , Paralisia Respiratória/terapia , Ultrassonografia/métodos , Diafragma/diagnóstico por imagem , Diafragma/inervação , Diafragma/cirurgia , Eventração Diafragmática/complicações , Eventração Diafragmática/diagnóstico por imagem , Eventração Diafragmática/fisiopatologia , Fluoroscopia/métodos , Humanos , Microcirurgia/métodos , Nervo Frênico/lesões , Nervo Frênico/patologia , Nervo Frênico/cirurgia , Radiografia/métodos , Respiração Artificial/métodos , Respiração Artificial/tendências , Testes de Função Respiratória/métodos , Paralisia Respiratória/etiologia , Estimulação Elétrica Nervosa Transcutânea/métodos
18.
J Cardiovasc Electrophysiol ; 29(10): 1363-1370, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30016008

RESUMO

INTRODUCTION: The HeartLight laser balloon ablation system was US Food and Drug Administration approved in 2016 for the treatment of paroxysmal atrial fibrillation (AF), but there have been numerous single-center and multicenter studies published reporting its outcomes, in addition to a few randomized trials. We aimed to systematically review and synthesize currently published outcome data on AF ablation using the laser balloon ablation system. METHODS AND RESULTS: We performed a systematic review and meta-analysis of published studies of AF ablation performed using the laser balloon ablation system. Human studies reporting acute procedural results with a minimum of 6 months follow-up were included. Outcomes of interest included acute and 12-month procedural efficacy, safety, and procedure duration. Aggregated data were analyzed with random effects models, using a Bayesian hierarchical approach. We identified 17 published manuscripts comprising a sample of 1188 patients (mean age 61 years, 80% paroxysmal). At procedure end, 98.8% of targeted pulmonary veins were successfully isolated. The pooled estimate for 12-month freedom from atrial arrhythmia without use of antiarrhythmic drugs for patients with paroxysmal AF was 74.3% (95% confidence interval [CI], 59.9% to 86.4%), and for all AF types combined was 72.9% (65.3% to 79.9%). The most commonly reported procedural complication was phrenic nerve injury (pooled incidence 2.6%; 95% CI, 1.4% to 3.9%), which resolved during follow-up in most cases. CONCLUSION: Laser balloon ablation is highly effective at achieving pulmonary vein isolation. Although comparisons are mainly indirect, safety and 12-month efficacy compare favorably with those observed using other currently used AF ablation technologies.


Assuntos
Fibrilação Atrial/cirurgia , Cateteres Cardíacos , Terapia a Laser/instrumentação , Veias Pulmonares/cirurgia , Potenciais de Ação , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Desenho de Equipamento , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Traumatismos dos Nervos Periféricos/etiologia , Traumatismos dos Nervos Periféricos/fisiopatologia , Nervo Frênico/lesões , Intervalo Livre de Progressão , Veias Pulmonares/fisiopatologia , Recidiva , Fatores de Risco , Fatores de Tempo
19.
J Interv Card Electrophysiol ; 53(1): 105-113, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30008046

RESUMO

PURPOSE: To demonstrate the feasibility of directional percutaneous epicardial ablation using a partially insulated catheter. METHODS: Partially insulated catheter prototypes were tested in 12 (6 canine, 6 porcine) animal studies in two centers. Prototypes had interspersed windows to enable visualization of epicardial structures with ultrasound. Epicardial unipolar ablation and ablation between two electrodes was performed according to protocol (5-60 W power, 0-60 mls/min irrigation, 78 s mean duration). RESULTS: Of 96 epicardial ablation attempts, unipolar ablation was delivered in 53.1%. Electrogram evidence of ablation, when analyzable, occurred in 75 of 79 (94.9%) therapies. Paired pre/post-ablation pacing threshold (N = 74) showed significant increase in pacing threshold post-ablation (0.9 to 2.6 mA, P < .0001). Arrhythmias occurred in 18 (18.8%) therapies (11 ventricular fibrillation, 7 ventricular tachycardia), mainly in pigs (72.2%). Coronary artery visualization was variably successful. No phrenic nerve injury was noted during or after ablation. Furthermore, there were minimal pericardial changes with ablation. CONCLUSIONS: Epicardial ablation using a partially insulated catheter to confer epicardial directionality and protect the phrenic nerve seems feasible. Iterations with ultrasound windows may enable real-time epicardial surface visualization thus identifying coronary arteries at ablation sites. Further improvements, however, are necessary.


Assuntos
Ablação por Cateter/instrumentação , Desenho de Equipamento , Complicações Intraoperatórias/prevenção & controle , Nervo Frênico/lesões , Taquicardia Ventricular/cirurgia , Animais , Área Sob a Curva , Cateteres Cardíacos , Ablação por Cateter/métodos , Modelos Animais de Doenças , Cães , Estudos de Viabilidade , Feminino , Distribuição Aleatória , Sensibilidade e Especificidade , Suínos , Taquicardia Ventricular/diagnóstico por imagem
20.
Medicine (Baltimore) ; 97(23): e10989, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29879056

RESUMO

RATIONALE: Many factors contribute to a complicated postoperative course following difficult weaning off a ventilator after lung transplantation. PATIENT CONCERNS: A female patient underwent a successful surgery but received a size-mismatched lung graft. The graft had been pruned before transplantation. She experienced delayed ventilator weaning 3 days after lung transplantation. DIAGNOSES: A postoperative X-ray revealed a normal mediastinal structure and diaphragm position. Diaphragmatic function was assessed by diaphragm electromyography (EMGdi) via esophageal and surface electrodes. EMGdi showed decreased left compound motor action potentials (CMAPs), prolonged left phrenic nerve conduction time (PNCT), failure to induce right CMAPs and PNCT under bilateral magnetic stimulation, and right phrenic nerve injury. INTERVENTIONS: She was treated with neural nutritional support and prescribed rehabilitation measures such as strengthening limb activities on the bed. OUTCOMES: The patient finally achieved satisfactory outcomes after an early diagnosis and medical interventions. LESSONS: Lung size mismatch before transplantation and phrenic nerve injury during surgery should be avoided wherever possible.


Assuntos
Diafragma/fisiologia , Eletromiografia/métodos , Transplante de Pulmão/efeitos adversos , Respiração Artificial/efeitos adversos , Transplantados , Desmame do Respirador/efeitos adversos , Adulto , Feminino , Humanos , Transplante de Pulmão/métodos , Terapia de Campo Magnético/métodos , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Complicações Pós-Operatórias , Transplantes/anatomia & histologia , Transplantes/transplante , Resultado do Tratamento
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