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1.
J Card Surg ; 35(11): 3010-3016, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33111446

RESUMO

BACKGROUND: Stroke remains a devastating complication of cardiac surgery. The aim of this study was to characterize the incidence of stroke and analyze the impact of stroke on patient outcomes and survival. METHODS: A retrospective analysis was performed of patients with a computed tomography-confirmed stroke diagnosis between 1 January 2015 and 31 March 2019 at a single center. 2:1 propensity matching was performed to identify a control population. RESULTS: Over the period 165 patients suffered a stroke (1.99%), with an incidence ranging from 0.85% for coronary artery bypass grafting to 8.14% for aortic surgery. The mean age was 70.3 years and 58.8% were male. 18% had experienced a previous stroke or transient ischemic attack. Compared to the comparison group, patients experiencing postoperative stroke had a significantly prolonged period of intensive care unit admission (8.0 vs 1.1 days P < .001) and hospital length of stay (12.94 vs 8.0 days P < .001). Patient survival was also inferior. In-hospital mortality was almost three times as high (17.0% vs 5.9%; P < .001). Longer-term survival was also inferior to Kaplan-Meier estimation (P < .001). The 1-year and 3-year survival were 61.5% and 53.8% respectively compared to 89.4% and 86.1% for the comparison group. CONCLUSION: Perioperative stroke is a devastating complication following cardiac surgery. Perioperative stroke is associated with significantly inferior outcomes in terms of both morbidity and mortality. Notably a 28% reduction in 1-year survival. Efforts should focus on identifying strategies aimed at reducing the incidence, morbidity, and mortality of perioperative stroke following cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias/prevenção & controle , Pontuação de Propensão , Estudos Retrospectivos , Acidente Vascular Cerebral/prevenção & controle , Taxa de Sobrevida , Resultado do Tratamento
2.
J Card Surg ; 35(10): 2574-2582, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32652707

RESUMO

OBJECTIVE: The mortality of coronary artery bypass graft surgery (CABG) in Asian patients predicted by Western population-based risk models is not ideal. We aimed to develop a risk scoring system based on a multiracial Asian patient population to predict early-stage mortality. METHODS: A total of 2495 patients who underwent isolated CABG in Singapore from 2009 to 2015 were included to develop a regional scoring system: the regional Asian System for Cardiac Operative Risk Evaluation in CABG (ASCORE-C). Predictors were identified via a stepwise multiple logistic regression to construct models for 30-day, 90-day, and 1-year cumulative mortality prediction. The optimal cut-offs of ASCORE-C risk strata were determined by the multiway χ2 and Interaction Detection decision tree. The performance of ASCORE-C was compared with European System for Cardiac Operative Risk Evaluation score (EuroSCORE) II and Society of Thoracic Surgeons (STS) score by observed/estimated mortality ratio. RESULTS: The observed postoperative 30-day, 90-day, and 1-year cumulative mortality following isolated CABG were 2.6%, 3.3%, and 4.6%, respectively. The ASCORE-C to predict these three events were constructed with age (>65 years), Malay ethnicity, congestive heart failure, abnormal heart rhythm, aortic atherosclerosis, estimated glomerular filtration rate, peripheral vascular disease, critical preoperative status, and emergency surgery. Tested by three different validation datasets, receiver operating characteristic curve of ASCORE-C model prediction performed well with the Hosmer-Lemeshow test. The ASCORE-C was found to have better predictive accuracy than EuroSCORE II and STS score in CABG mortality prediction, especially for the high-risk patients. CONCLUSION: The ASCORE-C system is reliable for early-stage CABG mortality prediction in a multiracial Asian population.


Assuntos
Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/cirurgia , Projetos de Pesquisa , Medição de Risco/métodos , Idoso , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Risco , Taxa de Sobrevida
3.
J Card Surg ; 35(10): 2785-2793, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32697006

RESUMO

BACKGROUND: Fractional flow reserve (FFR) is a well-established method for the evaluation of coronary artery stenosis before percutaneous coronary intervention. However, whether FFR assessment should be routinely used before coronary artery bypass graft surgery (CABG) remains unclear. A meta-analysis of prospectively randomized controlled trials (PRCTs) was carried out to compare the outcomes of FFR-guided CABG vs coronary angiography (CAG)-guided CABG. METHOD: The meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two PRCTs (the FARGO and GRAFFITI trials) were found and included reporting data on 269 patients with 6 and 12 month follow-up. Primary endpoints were rates of overall death, MACCE, target vessel revascularization, and spontaneous myocardial infarction (MI). Secondary endpoints were overall graft patency and patency of arterial and venous grafts. RESULTS: There were no significant differences between the FFR-guided and CAG-guided groups in the rates of overall death, MACCE, target vessel revascularization, spontaneous MI and graft patency. Meta-analysis of FARGO and GRAFFITI PRCTs showed that FFR-guided CABG and CAG-guided CABG produced similar clinical outcomes with similar graft patency rates up to a year postoperatively. CONCLUSION: Currently available PRCTs showes no sufficient evidence to support the use FFR in CABG.


Assuntos
Angiografia Coronária/métodos , Ponte de Artéria Coronária/métodos , Estenose Coronária/diagnóstico , Estenose Coronária/cirurgia , Reserva Fracionada de Fluxo Miocárdico , Resultados Negativos , Ensaios Clínicos Controlados Aleatórios como Assunto , Cirurgia Assistida por Computador/métodos , Angiografia Coronária/mortalidade , Ponte de Artéria Coronária/mortalidade , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Seguimentos , Humanos , Cirurgia Assistida por Computador/mortalidade , Taxa de Sobrevida , Resultado do Tratamento
4.
JAMA ; 324(2): 179-187, 2020 07 14.
Artigo em Inglês | MEDLINE | ID: mdl-32662861

RESUMO

Importance: Observational studies have suggested that the use of radial artery grafts for coronary artery bypass grafting may improve clinical outcomes compared with the use of saphenous vein grafts, but this has not been confirmed in randomized trials. Objective: To compare clinical outcomes between patients receiving radial artery vs saphenous vein grafts for coronary artery bypass grafting after long-term follow-up. Design, Setting, and Participants: Patient-level pooled analysis comparing radial artery vs saphenous vein graft in adult patients undergoing isolated coronary artery bypass grafting from 5 countries (Australia, Italy, Serbia, South Korea, and the United Kingdom), with enrollment from 1997 to 2009 and follow-up completed in 2019. Interventions: Patients were randomized to undergo either radial artery (n = 534) or saphenous vein (n = 502) grafts for coronary artery bypass grafting. Main Outcomes and Measures: The primary outcome was a composite of death, myocardial infarction, or repeat revascularization and the secondary outcome was a composite of death or myocardial infarction. Results: A total of 1036 patients were randomized (mean age, 66.6 years in the radial artery group vs 67.1 years in the saphenous vein group; 376 [70.4%] men in the radial artery group vs 351 [69.9%] in the saphenous vein group); 942 (90.9%) of the originally randomized patients completed 10 years of follow-up (510 in the radial artery group). At a median (interquartile range) follow-up of 10 (10-11) years, the use of the radial artery, compared with the saphenous vein, in coronary artery bypass grafting was associated with a statistically significant reduction in the incidence of the composite outcome of death, myocardial infarction, or repeat revascularization (220 vs 237 total events; 41 vs 47 events per 1000 patient-years; hazard ratio, 0.73 [95% CI, 0.61-0.88]; P < .001) and of the composite of death or myocardial infarction (188 vs 193 total events; 35 vs 38 events per 1000 patient-years; hazard ratio, 0.77 [95% CI, 0.63-0.94]; P = .01). Conclusions and Relevance: In this individual participant data meta-analysis with a median follow-up of 10 years, among patients undergoing coronary artery bypass grafting, the use of the radial artery compared with the saphenous vein was associated with a lower risk of a composite of cardiovascular outcomes.


Assuntos
Ponte de Artéria Coronária/métodos , Artéria Radial/transplante , Veia Safena/transplante , Idoso , Ponte de Artéria Coronária/mortalidade , Feminino , Seguimentos , Humanos , Incidência , Masculino , Infarto do Miocárdio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Reoperação/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
5.
J Cardiothorac Surg ; 15(1): 158, 2020 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-32611349

RESUMO

OBJECTIVE: As the population ages, increasing number of older patients are undergoing adult cardiac surgery. The purpose of the study is to assess the impact of age on postoperative outcomes in patients that undergo coronary artery bypass grafting (CABG). METHODS: Patients that are ≥70 years old who underwent CABG were selected from the Nationwide/National Inpatient Sample from 2010 to 2015 using ICD-9-CM diagnosis and procedure codes. The patients who were 70-79 years old were compared to patients aged 80-89 years old to determine if the age difference of the patients had an impact on surgical outcomes. In addition, a secondary endpoint is to compare surgical outcomes between the 2 genders of the patients 80-89 years old. The rates of postoperative complications, and mortality were compared. RESULTS: A total of 67,568 patients were identified who were ≥ 70 years old and underwent CABG. Compared to the Septuagenarians, the Octogenarians were more likely to develop cardiac complications (OR [odds ratio] =1.20, 95% CI [confidence interval] 1.12-1.23. They were also more likely to develop renal complications (P < 0001), and respiratory complications (P < 0001). The Octogenarians were also more likely to bleed postoperatively (P < 0.0001) and have a higher mortality (P < 0001). Furthermore, the female Octogenarians had a higher mortality (OR 1.25 95% CI 1.07-1.46) compared to males in the same age group. CONCLUSIONS: The patients who were ≥ 80-89 years old had worse postoperative outcomes. The Octogenarians who were females had a higher mortality compared to their male counterparts.


Assuntos
Fatores Etários , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Razão de Chances , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores Sexuais , Resultado do Tratamento
6.
PLoS One ; 15(7): e0236499, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32706808

RESUMO

We analyzed the clinical outcomes of open radial artery harvesting (OAH) and endoscopic radial artery harvesting (EAH) undergoing coronary artery bypass grafting (CABG). We designed this meta-analysis conducted using Pubmed, Medline, the Cochrane Library, and EMBASE. Articles with comparisons of OAH and EAH undergoing CABG were included. Primary outcomes included the wound infection rate, the wound complication rate, neurological complications of the forearm, in-hospital mortality, long-term survival, and the patency rate. The results of our study included six randomized controlled trials (RCTs), two non-randomized controlled trials (NRCTs) with matching, and 10 NRCTs. In total, 2919 patients were included in 18 studies, while 1187 (40.7%) and 1732 (59.3%) patients received EAH and OAH, respectively. EAH was associated with a lower incidence of wound infection (RR = 0.29, 95% confidence interval (CI) = 0.14 to 0.60, p = 0.03), and neurological complications over the harvesting site (RR = 0.41, 95% CI = 0.27 to 0.62, p < 0.0001). There was no significant difference in 30-day mortality, long-term survival (over one year), and the graft patency rate. According to our analysis, endoscopic radial artery harvesting can improve the outcome of the harvesting site, without affecting the mortality, long-term survival, and graft patency.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Endoscopia , Artéria Radial/cirurgia , Infecção da Ferida Cirúrgica , Idoso , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Endoscopia/métodos , Endoscopia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados não Aleatórios como Assunto , Artéria Radial/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
7.
Vascular ; 28(6): 808-815, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32493182

RESUMO

BACKGROUND: Coronary artery disease requiring coronary artery bypass graft (CABG) frequently coexists with critical carotid stenosis. The most optimized strategy for treating concomitant carotid and coronary artery disease remains debatable. OBJECTIVE: The aim of this meta-analysis was to compare synchronous CAS and CABG versus staged CAS and CABG for patients with concomitant coronary artery disease and carotid artery stenosis in terms of peri-operative (30-day) and long-term clinical outcomes. METHODS: This study was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane database until December 2019. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess heterogeneity. RESULTS: Four studies comprising 357 patients were included in this meta-analysis. Patients who were treated with the synchronous approach had a statistically significant higher risk for peri-operative stoke (OR: 3.71; 95% CI: 1.00-13.69; I2 = 0%) compared tο the staged group. Peri-operative mortality (OR: 4.50; 95% CI: 0.88-23.01; I2 = 0%), myocardial infarction (MI) (OR: 1.54; 95% CI: 0.18- 13.09; I2 = 0%), postoperative bleeding (OR: 0.27;95% CI: 0.02-3.12; I2 = 0%), transient ischemic attacks (TIA) (OR: 0.60; 95% CI: 0.04- 9.20; I2 = 0.0%), acute kidney injury (AKI) (OR: 0.34; 95% CI: 0.03-4.03; I2 = 0.0%) and atrial fibrillation rates (OR:0.27; 95% CI: 0.02-3.12; I2 = 0.0%) were similar between the two groups. Synchronous CAS-CABG and staged CAS followed by CABG were associated with similar rates of late mortality (OR: 3.75; 95% CI: 0.50-27.94; I2 = 0.0%), MI (OR: 0.33; 95% CI: 0.01-12.03; I2 = 0.0%) and stroke (OR:3.58; 95% CI:0.84-15.20; I2 = 0.0%) after a mean follow-up of 47 months. CONCLUSION: The simultaneous approach was associated with an increased risk of 30-day stroke compared to staged CAS and CABG. However, no statistically significant difference was found in long-term results of mortality, MI and stroke between the two approaches. Future studies are warranted to validate our results.


Assuntos
Estenose das Carótidas/terapia , Ponte de Artéria Coronária , Estenose Coronária/cirurgia , Procedimentos Endovasculares/instrumentação , Idoso , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Estenose Coronária/complicações , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Stents , Fatores de Tempo , Resultado do Tratamento
8.
Cardiovasc Diabetol ; 19(1): 86, 2020 06 13.
Artigo em Inglês | MEDLINE | ID: mdl-32534591

RESUMO

BACKGROUND: Type 2 diabetes mellitus (DM) is a risk factor for cardiovascular diseases and is common among patients undergoing coronary artery bypass grafting (CABG) surgery. The main objective of our study was to investigate the impact of DM type 2, and its treatment subgroups, on short- and long-term mortality in patients with acute coronary syndrome (ACS) who undergo CABG. METHODS: The study included 1307 patients enrolled from the biennial Acute Coronary Syndrome Israeli Survey between 2000 and 2016, who were hospitalized for ACS and underwent CABG. Of them, 527 (40%) patients were with and 780 (60%) were without DM. RESULTS: Compared with the non-diabetic group, the diabetic group of patients comprised more women and had more comorbidities such as hypertension, dyslipidemia, renal impairment, peripheral vascular disease and prior ischemic heart disease. Overall 30-day mortality rate was similar between DM and non-DM patients (4.2% vs. 4%, p = 0.976). Ten-year mortality rate was higher in DM compared with non-diabetic patients (26.6% vs. 17.7%, log-rank p < 0.001), and higher in the subgroup of insulin-treated patients compared to non-insulin treated patients (31.5% vs. 25.6%, log-rank p = 0.019). Multivariable analysis showed that DM increased the mortality hazard by 1.61-fold, and insulin treatment among the diabetic patients increased the mortality hazard by 1.57-fold. CONCLUSIONS: While type 2 DM did not influence the in-hospital mortality hazard, we showed that the presence of DM among patients with ACS referred to CABG, is a powerful risk factor for long-term mortality, especially when insulin was included in the diabetic treatment strategy.


Assuntos
Síndrome Coronariana Aguda/cirurgia , Ponte de Artéria Coronária/mortalidade , Diabetes Mellitus Tipo 2/mortalidade , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Idoso , Causas de Morte , Comorbidade , Ponte de Artéria Coronária/efeitos adversos , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/terapia , Dieta para Diabéticos , Feminino , Humanos , Hipoglicemiantes/uso terapêutico , Israel/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
9.
Zhonghua Wai Ke Za Zhi ; 58(5): 356-362, 2020 May 01.
Artigo em Chinês | MEDLINE | ID: mdl-32393002

RESUMO

Objective: To examine the short and long-term clinical outcomes of total arterial coronary artery bypass grafting. Methods: Clinic data of 208 patients with left main and multiple vessel coronary artery disease and undertaken total arterial coronary artery bypass grafting from February 2009 to December 2019 in Department of Cardiac Surgery, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine were analyzed retrospectively. There were 188 males and 20 females with an age of (54.7±10.7) years (range: 32 to 79 years). The harvest of arterial conduits and grafting strategies were depended upon the individual patient characteristics and surgeon's experience. Left internal thoracic artery (LITA) was applied in 207 cases, right internal thoracic artery (RITA) in 38 cases (bilateral internal thoracic artery (BITA) in 37 cases), and radial artery (RA) in 187 cases (188 grafts). The graft number per case was 2.6±0.7 (range: 2 to 4). Surgical procedures was completed with off-pump technique in 98.1% patients (204/208). Subgroup analysis was carried out between subgroup BITA (n=37) and subgroup SITA (single ITA+RA) (n=171). The t test, χ(2) test or Fisher exact test were used to compare the clinic characteristics between the two subgroups. The Kaplan-Meier curve was used to estimate the rate of late mortality, major adverse cardiac cerebrovascular event (MACCE), and target vessel revascularization (TVR). A Cox proportional hazards model was used to identify the independent prognosis factors of late mortality. Results: The overall mortality within 30 days postoperatively was 1.4%(3/208). The incidences of perioperative MACCE, re-operation for bleeding and deep sternal wound infection (DSWI) were 1.9%(4/208), 0.5%(1/208) and 1.4%(3/208), respectively. Perioperative myocardial infarction and TVR were not observed. There was no significant difference of 30-day mortality, MACCE, bleeding and DSWI between subgroup BITA and SITA+RA (all P>0.05). In a follow-up period of (5.4±2.8)years (range: 0.2 to 10.9 years), the incidence of all-cause mortality at 1-, 5- and 10-year was 2.3%, 3.4% and 6.9%, respectively. The incidence of MACCE was 3.9%,11.2% and 28.5%, respectively. The rate of TVR was 0.4%, 3.7% and 11.9%, respectively. Age>65 was an independent prognosis factor of late mortality (HR=1.125, 95% CI:1.050 to 1.205, P<0.01). Conclusions: Total arterial coronary bypass grafting is safe and achievable with proper patient selection and surgical strategies. It significantly decreases the risks of late mortality and repeated revascularization.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna/transplante , Adulto , Idoso , China , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
10.
J Cardiothorac Surg ; 15(1): 80, 2020 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-32393370

RESUMO

INTRODUCTION: Pain management after coronary artery bypass graft (CABG) surgery remains challenging. OBJECTIVE: This study aimed to compare the effects of Ketorolac and Paracetamol on postoperative CABG pain relief. METHOD: This double-blind randomized clinical trial study was conducted in Ahvaz, Iran, from September 2018-December 2019. Two consecutive groups of 60 patients undergoing elective on-pump coronary artery bypass graft surgery. INTERVENTION: The patients were divided into 0.5 mg/kg of ketorolac mg/dl and 10 mg/kg of Paracetamol after surgery for pain management. Primary outcomes were: visual analog pain scale (VAS) at the time point immediately after extubation (baseline) and at 6, 12, 24 and 48 h and the total dose of morphine consumption. Secondary outcomes included the hemodynamic variables, weaning time, chest tube derange, in-hospital mortality and myocardial infarction. STATISTICAL ANALYSIS: The data were analyzed using SPSS version 22(SPSS, Chicago, IL). The Mann-Whitney U-test was used to compare demographic data, VAS scores, vital signs, and side effects. Repeated measurements were tested within groups using Friedman's ANOVA and the Wilcoxon rank-sum test. Values were expressed as means ± standard deviations. Statistical significance was defined as a p-value < 0.05. RESULTS: Compared with baseline scores, there were significant declines in VAS scores in both groups throughout the time sequence (P< 0.05). The statistical VAS score was slightly higher in the Paracetamol group at most time points, except for the time of 6 h. However, at 24 and 48 h, the VAS score in group Paracetamol was significantly higher than in group Ketorolac. There were no significant differences between groups about hemodynamic variables. CONCLUSION: The efficacy of ketorolac is comparable to that of Paracetamol in postoperative CABG pain relief. TRIAL REGISTRY: IRCT20150216021098N5. Registered at 2019-09-12.


Assuntos
Acetaminofen/uso terapêutico , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Cetorolaco/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Analgésicos/uso terapêutico , Analgésicos Opioides , Ponte de Artéria Coronária/mortalidade , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Morfina , Infarto do Miocárdio , Manejo da Dor , Medição da Dor , Dor Pós-Operatória/etiologia , Fatores de Tempo , Escala Visual Analógica
11.
J Cardiothorac Surg ; 15(1): 100, 2020 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-32414388

RESUMO

OBJECTIVE: The study objective was to investigate the incidence and risk factors of continuous renal replacement therapy (CRRT) in patients undergoing emergency surgery for type A acute aortic dissection (TA-AAD) and evaluate the perioperative and long-term outcomes. METHODS: From January 2014 to December 2018, 712 consecutive patients were enrolled in the study. These patients were divided into two groups according to whether or not needed postoperative CRRT: the CRRT group vs the control group. Univariate analysis and binary logistic regression analysis were used to analyze the risk factors of CRRT. To avoid the selection bias and confounders, baseline characteristics were matched for propensity scores. Kaplan-Meier curves were generated to provide survival estimates at postoperative points in time. RESULTS: Before propensity score matching, univariate analysis showed that there were significant differences in age, preoperative hypertension, pericardial effusion, preoperative serum creatinine (sCr), intraoperative need for combined coronary artery bypass grafting (CABG) or mitral valve or tricuspid valve surgery, cardiopulmonary bypass (CPB) time, extracorporeal circulation assistant time, aortic cross-clamp time, drainage volume 24 h after surgery and ventilator time between two groups. All were higher in the CRRT group (P < 0.05). These risk factors were included in binary logistic regression. It showed that preoperative sCr and CPB time were independent risk factors for CRRT patients undergoing surgery for TA-AAD. And there were significant differences regarding 30-day mortality (P < 0.001) and long-term overall cumulative survival (P < 0.001) with up to a 6-year follow-up. After propensity scoring, 29 pairs (58 patients) were successfully matched. Among these patients, the analysis showed that CPB time was still significantly longer in the CRRT group (P = 0.004), and the 30-day mortality rate was also higher in this group (44.8% vs 10.3%; P = 0.003). CONCLUSION: CRRT after TA-AAD is common and worsened short- and long- term mortality. The preoperative sCr and CPB time are independent risk factors for postoperative CRRT patients. Shorten the CPB time as much as possible is recommended to reduce the risk of CRRT after the operation.


Assuntos
Aneurisma Dissecante/cirurgia , Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Valva Mitral/cirurgia , Terapia de Substituição Renal/efeitos adversos , Adulto , Idoso , Aneurisma Dissecante/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte de Artéria Coronária/mortalidade , Creatinina/sangue , Tratamento de Emergência/métodos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Pontuação de Propensão , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
12.
J Cardiothorac Surg ; 15(1): 86, 2020 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-32398141

RESUMO

OBJECTIVES: The optimal timing of coronary artery bypass grafting (CABG) in patients with ST elevated acute myocardial infarction (STEMI) is unclear. The purpose of the study is to evaluate and compare the outcomes in STEMI patients who underwent CABG within the various time intervals within the first 7 days of either emergent or urgent hospital admission. METHODS: Patients aged 30 years old and older diagnosed with STEMI who underwent CABG within first 7 days after non-elective hospital admission were selected from the National Inpatient Sample 2010-2014 using the appropriate ICD-9-CM diagnosis and procedure codes. These patients were divided into 3 cohorts based on timing of surgery: within 24 h (group A), 2nd-3rd day (group B), and 4th-7th day (group C). The rates of postoperative complications, mortality, and postoperative hospital length of stay (LOS) were compared using the Chi-square test, multivariable logistic regression analysis, and Wilcoxon rank sum test. RESULTS: A total of 5963 patients were identified: group A = 28.5%, group B = 36.1%, group C = 35.4%. Mean age overall was 63.1 ± 11.1 years; 76.9% were males and 72.9% were whites. Compared to groups B and C, patients in group A were more likely to develop cardiac complications (OR [odds ratio] =1.33, 95%CI [confidence interval] 1.12-1.59 and OR = 1.39, 95%CI 1.17-1.67, respectively) and respiratory complications (OR = 1.31, 95%CI 1.13-1.51 and OR = 1.53, 95%CI 1.32-1.78, respectively). They were also more likely to have renal complications (OR = 1.31, 95%CI 1.11-1.54) and bleeding (OR = 1.20, 95%CI 1.05-1.37) than patients in group B and had a similar tendency compared to group C. We did not find significant differences in the above complications between groups B and C. Postoperative stroke and sternal wound infection rates were similar between all three groups. In-hospital mortality was also higher in group A (8.2%) compared to group B (3.5%) and group C (2.9%, P < 0.0001 for both); differences between groups B and C were not significant. This was confirmed in the multivariable logistic regression analysis with controlling for age, gender, race, the Elixhauser Comorbidity Index, and complications (group A vs B: OR = 1.85, 95%CI 1.52-2.25; group A vs C: OR = 2.21; 95%CI 1.82-2.68). Patients in group A had a significantly longer postoperative LOS (median 7 days with IQR [interquartile range] 5-10 days) compared to those in group B (median 6 days, IQR 5-8 days) and group C (median 6 days, IQR 4-8 days; P < 0.0001 for both). CONCLUSIONS: The results of this study show that despite the urgency and severity of STEMI, patients who undergo CABG within the first 24 h after non-elective hospital admission have increased hospital morbidity and mortality. These findings suggest that a delay in surgery beyond the first 24 h may be beneficial to patient outcomes. Furthermore, there is a significant cost effectiveness when the patients delay surgery because the hospital length of stay is reduced as well as the subsequent hospital costs.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Mortalidade Hospitalar , Hemorragia Pós-Operatória/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Tempo para o Tratamento , Adulto , Idoso , Ponte de Artéria Coronária/mortalidade , Bases de Dados Factuais , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Nefropatias/etiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Doenças Respiratórias/etiologia , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Estados Unidos/epidemiologia
13.
J Card Surg ; 35(6): 1195-1201, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32362025

RESUMO

BACKGROUND: The optimal revascularization approach for patients with multivessel coronary artery disease (MVCAD) is controversial. We sought to investigate outcomes in patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for non-ST elevation myocardial infarction (NSTEMI). METHODS: Adult patients with MVCAD and NSTEMI undergoing either CABG or PCI at a single institution between 2011 and 2018 were included. Multivariable analysis was utilized to determine independent predictors of death, major adverse cardiac and cerebrovascular events (MACCE), and readmissions. A subanalysis examined patients undergoing complete revascularization. RESULTS: A total of 2001 patients were included, of whom 1480 (74.0%) underwent CABG. CABG was associated with a lower risk-adjusted hazard for death (hazard ratio, 0.59, P < .001) and with improved survival at 1 year (92.0 vs 81.8%, P < .001) and 5 years (80.7 vs 63.3%, P < .001). Additionally, freedom from MACCE (P < .001) was greater in the CABG group and cumulative readmission, rates of MI, and rates of repeat revascularization were lower with CABG (each P < .001). Among patients undergoing complete revascularization, overall survival (1 year: 92.7 vs 83.9%, P = .010; 5 years: 81.1 vs 69.4%, P < .001) and freedom from MACCE (1 year: 92.3 vs 75.2%, P < .001; 5 years: 81.7 vs 61.4%, P < .001) remained higher for the CABG group; cumulative incidence of readmission was also decreased in those undergoing CABG (P < .001). CONCLUSIONS: In this real-world analysis of patients with MVCAD presenting with NSTEMI, revascularization with CABG resulted in improved survival with lower rates of MACCE and readmission as compared to PCI, which persisted when accounting for complete revascularization.


Assuntos
Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/mortalidade , Doença das Coronárias/cirurgia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/mortalidade , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Transtornos Cerebrovasculares/epidemiologia , Ponte de Artéria Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Taxa de Sobrevida , Resultado do Tratamento
14.
Asian Cardiovasc Thorac Ann ; 28(4): 205-212, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32276539

RESUMO

BACKGROUND: Mechanical complications of percutaneous coronary interventions are treated percutaneously in most cases. If the rescue intervention is unsuccessful, bailout bypass surgery is necessary to restore the coronary flow. The surgical risk in these cases is higher than that of patients operated on for other indications. The aim of our study was to characterize patients who underwent surgical treatment at our institution and to compare their long-term outcomes with patients who underwent emergency bypass surgery for other indications. METHODS: We analyzed 707 consecutive patients who underwent isolated emergency bypass surgery at our institution from 2007 to 2015. In 44 of these cases, the surgery was necessitated by mechanical complications of percutaneous coronary interventions. There were 31 coronary dissections, 5 entrapped guidewires, and 8 coronary perforations. We compared patients in these three groups with one another. Follow-up was performed to assess long-term outcomes. RESULTS: The median age of the cohort was 68 years (range 59-75 years), and 36 (81.8%) patients presented in cardiogenic shock. Thirty-seven (84.1%) patients had history of a percutaneous coronary intervention. The courses were typical for bypass patients. The long-term survival was similar in all three subgroups (p = 0.16). The survival profiles within our sample did not differ significantly from that in patients who underwent emergency bypass surgery for other indications. CONCLUSIONS: Surgical risk and short- and long-term outcomes of patients undergoing emergency bypass surgery due to mechanical complications of percutaneous coronary interventions are similar to those of patients receiving the same surgery for other indications.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Vasos Coronários/cirurgia , Traumatismos Cardíacos/cirurgia , Doença Iatrogênica , Intervenção Coronária Percutânea/efeitos adversos , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/lesões , Emergências , Feminino , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
15.
Rev Cardiovasc Med ; 21(1): 65-73, 2020 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-32259905

RESUMO

Critical lesion of the unprotected left main coronary disease carries a tremendous mortality burden, often associated with a diabetes status or multivessel disease, with coronary artery bypass grafting being the standard treatment for over 40 years. Percutaneous coronary intervention with drug eluting stents should be taken into consideration and could be a better option for patients with low SYNTAX score as validated by the recently published studies. This review summarizes the major randomized clinical trials and meta-analyses concerning the debate regarding percutaneous coronary intervention with drug eluting stents versus coronary artery bypass grafting for unprotected left main coronary disease, along with the latest European and American revascularization guidelines and tries to shed light on this matter. The most results advocate that there is no convincing difference in survival rate for both therapies, especially in patients with isolated left main disease but with fewer major ischemic events for coronary artery bypass grafting when compared with percutaneous coronary intervention in multivessel coronary artery disease, at the rate of a higher stroke incidence. The gaps in evidence are also highlighted, especially the lack of randomized clinical trials with new generation drug eluting stents versus coronary artery bypass grafting or those regarding the best revascularization strategy for an acute coronary syndrome when unprotected left main coronary disease is involved.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea , Tomada de Decisão Clínica , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Medicina Baseada em Evidências , Humanos , Seleção de Pacientes , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Medição de Risco , Fatores de Risco , Resultado do Tratamento
16.
Vasc Endovascular Surg ; 54(5): 395-399, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32319354

RESUMO

OBJECTIVE: The management of patients with combined severe carotid artery and coronary artery disease (CAD) is controversial. Transcarotid stenting with flow reversal (TCAR) is a novel hybrid technique for carotid revascularization. We sought to investigate the safety and feasibility of simultaneous TCAR and coronary artery bypass grafting (CABG) for concomitant carotid and CAD. METHODS: A single-institution, retrospective study of patients with critical carotid artery stenosis and symptomatic CAD who underwent simultaneous TCAR-CABG was completed. The primary outcomes were technical success, perioperative stroke, death, and hemorrhage. RESULTS: Four patients underwent TCAR-CABG. All patients were male with a mean age of 64. Technical success was achieved in all cases. There were no perioperative strokes or deaths. There were no reexplorations for hemorrhage. CONCLUSIONS: Transcarotid stenting with flow reversal-CABG is a technically feasible hybrid approach for simultaneous carotid and coronary revascularization. It should be part of the vascular surgeon's armamentarium for coexisting carotid and coronary disease. Further research focused on patient selection and perioperative antiplatelet management is warranted prior to the widespread adoption of this technique.


Assuntos
Estenose das Carótidas/cirurgia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Procedimentos Endovasculares , Idoso , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Estenose das Carótidas/fisiopatologia , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/mortalidade , Estudos de Viabilidade , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Stents , Fatores de Tempo , Resultado do Tratamento
19.
Int J Cardiovasc Imaging ; 36(6): 1077-1084, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32200479

RESUMO

Functional tricuspid regurgitation (FTR) is defined as abnormal systolic tricuspid leakage with normal valve structures, and its prognostic role and management in patients with left-heart valve disease is well known. Due to paucity of data on FTR in patients with ischemic heart disease, the aim of our prospective study was to compare the prognostic effect of FTR between patients with moderate FTR and those with less-than-moderate FTR undergoing isolated coronary artery bypass graft (CABG) surgery. This prospective cohort study included all the patients who were candidate for isolated CABG and were referred for preoperative transthoracic echocardiography between April 2018 and November 2018. Patients were categorized into two groups: less-than-moderate FTR and moderate FTR. The endpoints of the study were the prognostic effect of FTR on short-term mortality and morbidities as a composite endpoint, as well as length of hospitalization, length of intensive care unit (ICU) stay, and ventilation time. Of a total of 410 patients, 363 patients (mean age = 62.4 years, 63.7% men) entered our final analysis. Logistic regression analysis demonstrated that composite endpoints of short-term mortality and morbidities was not significantly different between the two groups, but moderate FTR had a statistically significant effect on length of hospitalization (P = 0.002) and the ventilation time (P = 0.048). This effect, however, did not persist after adjustments for probable known confounders. Our study indicated no significant prognostic effect for preoperative FTR versus less-than-moderate FTR on short-term mortality and morbidities, as well as length of hospitalization, length of ICU stay, and the ventilation time.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Tempo de Internação , Insuficiência da Valva Tricúspide/fisiopatologia , Valva Tricúspide/fisiopatologia , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Insuficiência da Valva Tricúspide/mortalidade
20.
JACC Cardiovasc Interv ; 13(3): 361-371, 2020 02 10.
Artigo em Inglês | MEDLINE | ID: mdl-32029254

RESUMO

OBJECTIVES: The aim of this study was to investigate the long-term impact of SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score (SS) on differential outcomes after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease. BACKGROUND: The very long term prognostic effect of SS on mortality and major cardiovascular events after LMCA revascularization is still undetermined. METHODS: In the MAIN-COMPARE (Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease) registry, patients with baseline SS measurements were analyzed. The 10-year rates of all-cause mortality, the composite of death, Q-wave myocardial infarction, or stroke, and target vessel revascularization after PCI or CABG were compared according to baseline SS. RESULTS: Among 1,580 patients with baseline SS, 547 patients (34.6%) had low SS (≤22), 350 (22.2%) had intermediate SS (23 to 32), and 683 (43.2%) had high SS (≥33). In patients with low to intermediate SS, the adjusted 10-year risks for death and serious composite outcome were similar between the PCI group and the CABG group. However, in patients with high SS, PCI with stenting, compared with CABG, was associated with a higher risk for death (hazard ratio: 1.39; 95% confidence interval: 1.00 to 1.92; p = 0.048) and serious composite outcome (hazard ratio: 1.27; 95% confidence interval: 0.94 to 1.74; p = 0.123). In each revascularization group, conventional tertiles of SS had a differential prognostic impact on 10-year clinical outcomes in the PCI arm but not in the CABG arm. CONCLUSIONS: In this 10-year extended follow-up of patients undergoing LMCA revascularization, CABG showed a clear prognostic benefit over PCI in patients with high anatomic complexity measured by SS at baseline. The discriminative capacity of SS on long-term outcomes was relevant in the PCI group but not in the CABG group. (Ten-Year Outcomes of Stents Versus Coronary-Artery Bypass Grafting for Left Main Coronary Artery Disease [MAIN-COMPARE]; NCT02791412).


Assuntos
Angiografia Coronária , Ponte de Artéria Coronária , Doença da Artéria Coronariana/terapia , Vasos Coronários/cirurgia , Intervenção Coronária Percutânea , Idoso , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , República da Coreia , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Stents , Fatores de Tempo , Resultado do Tratamento
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