RESUMO
OBJECTIVE: Cerebrovascular autoregulation impairment has been associated with stroke risk in cardiac surgery. We hypothesized that greater arterial emboli exposure in open-chamber surgery might promote dysautoreguation. METHODS: Forty patients underwent closed or open-chamber surgery. Transcranial Doppler detected emboli and measured bilateral middle cerebral artery flow velocities. Cerebral autoregulation was assessed by averaging the mean velocity index ("Mx," a continuous moving correlation between cerebral blood flow velocity and mean arterial pressure) over 30 min before and after aortic cross-clamp removal. RESULTS: Median (interquartile range) emboli counts were 775 (415, 1211) and 2664 (793, 3734) in the closed-chamber and open-chamber groups. Most appeared after the removal of the aortic cross-clamp (open-chamber 1631 (606, 2296)), (closed-chamber 229 (142, 384)), with emphasis on the right hemisphere (open-chamber: 826 (371, 1622)), (closed-chamber 181 (66, 276)). Linear mixed model analyses of mean velocity index change showed no significant overall effect of group (0.08, 95% CI: -0.04, 0.21; p = 0.19) or side (0.01, 95% CI: -0.03, 0.05; p = 0.74). There was an interaction between group and side (p = 0.001), manifesting as a greater increase in mean velocity index in the right hemisphere in the open than the closed group (mean difference: 0.15, 95% CI: 0.02, 0.27; p = 0.03). CONCLUSIONS: Overall, change in mean velocity index before and after cross-clamp removal did not differ between groups. However, most emboli entered the right cerebral hemisphere where this change was significantly greater in the open-chamber group, suggesting a possible association between embolic exposure and dysautoregulation.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Humanos , Monitorização Intraoperatória , Estudos Prospectivos , Homeostase/fisiologia , Circulação Cerebrovascular/fisiologia , Ultrassonografia Doppler Transcraniana , Velocidade do Fluxo Sanguíneo/fisiologiaRESUMO
AIMS: Primary percutaneous coronary intervention (PCI) is the optimal management for ST segment elevation myocardial infarction (STEMI) patients. We reviewed the largest primary PCI regional service in New Zealand: the Auckland/Northland service based at Auckland City Hospital, to assess patient management, in particular the door to reperfusion times (DTRTs), and predictors of death in hospital. METHODS: We obtained patient details from a comprehensive prospective database of all primary PCI patients admitted with STEMI from 1/1/12 to 31/12/12 to the Auckland City Hospital cardiac catheterisation laboratory. Of four District Health Boards (DHBs) within the region, two accessed this regional service at all times, and two accessed the Auckland City Hospital cardiac catheterisation laboratory 'after hours': all times except for 08:00 to 16:00 hours on Monday to Friday. RESULTS: A total of 401 adult patients underwent a primary PCI at the Auckland City Hospital Regional centre for a STEMI presentation, over the 12 months period. The median patient age was 61 years, 77% were male. Overall 183 (46%) (95% CI 41, 51) patients achieved a DTRT of < 90 mins, and 266 (66%) (95% CI 61, 71) a DTRT of < 120 mins, with a clear geographical influence to these times. Of 27 patients with direct transfer to the catheter laboratory from the community, the DTRT was < 120 mins in 24 (92%) (95% CI 72, 96) patients. In-hospital mortality was 24 (6%) patients (95% CI 4, 9). CONCLUSIONS: The 2012 Auckland/Northland primary PCI service delivers good outcomes consistent with current Australasian standards. Although geographical isolation complicates door to reperfusion times, these may potentially be improved by more focus on direct transfer to the cardiac catheterisation laboratory, especially directly from the community.
Assuntos
Bases de Dados Factuais , Mortalidade Hospitalar , Intervenção Coronária Percutânea/mortalidade , Intervenção Coronária Percutânea/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Estudos RetrospectivosAssuntos
Catéteres , Oxigenação por Membrana Extracorpórea/métodos , Hemofiltração/métodos , Adulto , Fatores Etários , Cateterismo/instrumentação , Cateterismo/métodos , Oxigenação por Membrana Extracorpórea/instrumentação , Hemofiltração/instrumentação , Humanos , Síndrome do Desconforto Respiratório/epidemiologia , Síndrome do Desconforto Respiratório/terapiaAssuntos
Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/terapia , Insuficiência Respiratória/terapia , Adulto , Cateterismo Periférico/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/instrumentação , Coração Auxiliar , Hemorragia/terapia , Humanos , Hipóxia/terapia , Oxigênio/administração & dosagem , Oxigênio/fisiologia , Oxigenadores , Sepse/terapia , Resultado do TratamentoAssuntos
Oxigenação por Membrana Extracorpórea , Papiloma/cirurgia , Neoplasias da Traqueia/cirurgia , Anestesia Geral , Gasometria , Broncoscopia , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio , Papiloma/patologia , Tomografia Computadorizada por Raios X , Neoplasias da Traqueia/patologia , Prega Vocal/patologia , Prega Vocal/cirurgiaAssuntos
Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/terapia , Insuficiência Respiratória/terapia , Adulto , Contraindicações , Oxigenação por Membrana Extracorpórea/tendências , Humanos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Adulto JovemAssuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Marca-Passo Artificial/estatística & dados numéricos , Implantação de Prótese/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrocalcinose/induzido quimicamente , Nefrocalcinose/terapia , Nova Zelândia , Complicações Pós-Operatórias , Diálise Renal , Estudos Retrospectivos , Fatores de RiscoRESUMO
PURPOSE: The purpose of this study is to describe the first experience of implanting a new left ventricular assist device in pediatric patients with end-stage heart failure. DESCRIPTION: In two recent prospective, international, multicenter clinical trials, three children (aged = 16 years) were implanted successfully with the VentrAssist (Ventracor Limited, Chatswood, Australia), a relatively small, novel, continuous flow, third-generation left ventricular assist device. EVALUATION: Despite the patients' disease severity (each child was in extremis at the time of implantation), VentrAssist (Ventracor Limited) implantation enabled each patient to be discharged home from the hospital. All patients survived for more than 1 year. One patient was successfully transplanted and another was bridged to an adequate degree of recovery; unfortunately, the third patient died on postoperative day 375 while waiting for a suitable donor heart. Consistent with the complications associated with left ventricular assist devices in adults, the main complications in these pediatric patients were infection and thromboembolism. CONCLUSIONS: The VentrAssist may provide a major advancement in the management of larger children and adolescents with end-stage heart failure.
Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Adolescente , Cardiomiopatia Dilatada/cirurgia , Criança , Terapia Combinada , Desenho de Equipamento , Evolução Fatal , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/tratamento farmacológico , Transplante de Coração , Humanos , Masculino , Disfunção Ventricular Esquerda/tratamento farmacológico , Disfunção Ventricular Esquerda/etiologiaRESUMO
A 37-year-old man presented with severe dilated cardiomyopathy secondary to occult aortic coarctation. He was successfully managed with combined orthotopic heart transplantation and aortic coarctation repair.