RESUMO
Cardio-cerebral infarction (CCI) is a term coined to describe concomitant myocardial infarction and acute ischemic stroke. Acute myocardial infarction and stroke, as separate events, constitute some of the most important causes for disability and mortality in aging societies. Stroke can either occur simultaneously with myocardial infarction or become a serious complication of myocardial infarction and/or its treatment. The frequency of CCI has been reported at a 0.009% incidence rate in stroke patients and is associated with an extremely high mortality. Because of the rare occurrence of CCI, there are currently no guidelines for assessing its diagnosis and optimal treatment. Therefore, currently, the management of CCI cases needs to be individualized. Hopefully, in the future, the results of large clinical trials or prospective registries are expected to enhance our understanding of managing concomitant acute MI and stroke. In this review we have focused on the current literacy in the diagnosis and treatment of CCIs. The paper illustrates potential distinct scenarios of CCI through the analysis of three patient cases (Fig. 5, Ref. 65). Text in PDF www.elis.sk Keywords: myocardial infarction, stroke, cardio-cerebral infarction, carotid artery stenting, cardiac surgery.
Assuntos
Estenose das Carótidas , AVC Isquêmico , Infarto do Miocárdio , Acidente Vascular Cerebral , Humanos , Estudos Prospectivos , AVC Isquêmico/complicações , Resultado do Tratamento , Stents/efeitos adversos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Infarto Cerebral/complicações , Fatores de RiscoRESUMO
AIMS: To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) of implantable cardioverter-defibrillator (ICD) leads with a dwell time of >10 years (Group A) vs. younger leads (Group B) using mechanical extraction systems. METHODS AND RESULTS: Between October 2011 and July 2022, we performed TLE in 318 patients. Forty-six (14.4%) extracted ICD leads in 46 (14.5%) patients that had been implanted for >10 years. The median dwell time of all extracted ICD leads was 5.9 years. Cardiovascular implantable electronic device-related infection was an indication for TLE in 31.8% of patients. Complete ICD leads removal and complete procedural success in both groups were similar (95.7% in Group A vs. 99.6% in Group B, P = 0.056% and 95.6% in Group A vs. 99.6% in Group B, P = 0.056, respectively). We did not find a significant difference between major and minor complication rates in both groups (6.5% in Group A vs. 1.5% in Group B and 2.2% in Group A vs. 1.8% in Group B, P = 0.082, respectively). One death associated with the TLE procedure was recorded in Group B. CONCLUSION: The TLE procedures involving the extraction of old ICD leads were effective and safe. The outcomes of ICD lead removal with a dwell time of >10 years did not differ significantly compared with younger ICD leads. However, extraction of older ICD leads required more frequent necessity for utilizing multiple extraction tools, more experience and versatility of the operator, and increased surgery costs.
Assuntos
Desfibriladores Implantáveis , Marca-Passo Artificial , Humanos , Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/métodos , Resultado do Tratamento , Estudos RetrospectivosRESUMO
OBJECTIVE: To analyze and compare the effectiveness and safety of transvenous lead extraction (TLE) with mechanical systems of pacing leads older than 20 years (group A) versus younger leads (group B). METHODS: We performed TLE of 591 pacing leads in 377 patients. Fifty (8.5%) leads in 43 (11.4%) patients were implanted for equal to or more than 20 years. The mean dwell time of all extracted leads was 8.9 years (range, 0.1-36.0). Infection related to cardiovascular implantable electronic device was an indication for TLE in 18.3% of patients. RESULTS: Complete lead removal and complete procedural success rates were similar between both groups (94.7% in group A vs 97.1% in group B, P = 0.445, and 90.7% in group A vs 95.8% in group B, P = 0.329, respectively). Incomplete lead removal in group A was observed only in leads older than 20 years. Removal of leads in group A was associated with significantly longer fluoroscopy time compared with group B (4.6 vs 1.9 minutes, P < 0.001). We did not find a significant difference in major and minor complication rates between groups (2.3% in group A vs 0.9% in group B and 2.3% in group A vs 2.2% in group B, P = 0.687, respectively). There were no deaths associated with the TLE procedure within 30 days after the procedure in either group. CONCLUSION: This study shows that TLE of leads older than 20 years conducted at an experienced center seems to be comparably safe and effective as extraction of younger leads but requires longer fluoroscopy time.
Assuntos
Remoção de Dispositivo/métodos , Eletrodos Implantados , Marca-Passo Artificial , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Falha de Equipamento , Fluoroscopia , Humanos , Pessoa de Meia-Idade , Segurança do Paciente , Infecções Relacionadas à Prótese/etiologia , Estudos Retrospectivos , Fatores de TempoRESUMO
Objective The aim of this study was to evaluate the incidence of venous stenosis and occlusion (VSO) in patients referred for transvenous lead extraction (TLE) with regard to the indications for this treatment and to analyse the influence of VSO on efficacy, complications and technical challenges of TLE procedures. Methods The material consists of 133 consecutive TLE procedure records. The contrast venography examination of the ipsilateral access vein was performed prior to the operation. The whole study population was divided into two subgroups, based on the presence (subgroup I) or absence (subgroup II) of VSO. Results Phlebography was performed in 133 patients with age ranging from 25.7 to 86.1 years, 44 female (33.1%). The VSO was confirmed in 48 (36.1%) patients - subgroup I. Most of the patients were referred to TLE due to non-infectious reasons (100 pts-75.2%). The absence of VSO was observed substantially more frequently in patients with diabetes (P = 0.02). Procedural success rate reached 93.3% in subgroup I and 98.8% in subgroup II (P = 0.1). There was no significant difference in the use of advanced tools and alternative access sites. Conclusion The presence of VSO can be expected in one third of patients referred for lead extraction. There is no association between indication for TLE (infected or noninfected lead extraction) and the incidence of VSO. Diabetes proved to have a protective effect on venous patency in the previously mentioned group. VSO does not influence the effectiveness, safety, and the use of additional tools during TLE procedures.
Assuntos
Veias Braquiocefálicas , Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/métodos , Marca-Passo Artificial/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/terapia , Constrição Patológica/diagnóstico , Constrição Patológica/etiologia , Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Flebografia , Fatores de RiscoRESUMO
Background The aim of the study was to analyze perioperative outcomes after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Patient selection criteria, anesthesia protocol, and surgical technique are presented. Methods A retrospective analysis of 194 patients electively scheduled for RAT-AVR was performed between January 2009 and June 2013. For preoperative planning, computed tomography was performed. Results Among studied patients, there were 48.5% females and 51.5% males with a mean age of 69.9 ± 9.2 years. The predicted mortality calculated with EuroSCORE II was 3.2 ± 0.9%, and observed mortality of RAT-AVR patients was 1.5%. Finally, RAT-AVR surgery was performed on 97.9% of patients (n = 190). Reasons for conversions to median sternotomy were bleeding from aortotomy site (n = 4) and from the right ventricle after epicardial pacing wire placement (n = 1), pleural adhesions (n = 2), and ascending aorta hidden under the sternum (n = 2). The second intercostal space was chosen for surgical access in 97.9% of patients.There were 3.6% reoperations for bleeding: aortotomy place (n = 1), epicardial pacing wire placement (n = 3), right lung tear (n = 2), and intercostal vessels (n = 1). The intensive care unit and hospital length of stays were 1.3 ± 1.2 and 5.7 ± 1.4 days, respectively. Strokes were present in 1.5% of patients. The perioperative complications rate diminished with time, occurring in 44.9% of the patients between 2009 and 2010 and in 15.6% of patients in 2013. Conclusions RAT-AVR can be safely performed without increased morbidity and mortality. Reduced complication rates over time reflect a learning curve.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Toracotomia , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/fisiopatologia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/mortalidade , Insuficiência da Valva Aórtica/fisiopatologia , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Competência Clínica , Conversão para Cirurgia Aberta , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/instrumentação , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Curva de Aprendizado , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Reoperação , Estudos Retrospectivos , Fatores de Risco , Esternotomia , Toracotomia/efeitos adversos , Toracotomia/mortalidade , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
OBJECTIVE: To compare the function of the respiratory system after aortic valve replacement through median sternotomy (AVR) or the minimally invasive right anterior minithoracotomy (RAT-AVR) approach among elderly (aged≥75 years) patients. DESIGN: Observational cohort study. SETTINGS: University hospital. PARTICIPANTS: The study included 65 elderly patients scheduled for RAT-AVR and 82 for standard AVR. INTERVENTIONS: Pulmonary function tests (PFT) were performed preoperatively, 1 week, 1 month, and 3 months after surgery. In addition, respiratory complications were analyzed. MEASUREMENTS AND MAIN RESULTS: Respiratory complications occurred in 12.3% of patients in the RAT-AVR group and 18.3% of patients in the AVR group (p = 0.445). Mechanical ventilation time in the intensive care unit was 7.7±3.6 hours for RAT-AVR patients and 9.7±5.4 hours for AVR patients (p = 0.003). Most PFT were worse in the AVR group than in the RAT-AVR group when performed 1 week after surgery. After 1 month, forced expiratory volume in the first second, vital capacity, and total lung capacity differed significantly in favor of the RAT-AVR group (p = 0.002, p<0.001, and p = 0.001, respectively). After 3 months, the PFT parameters still had not returned to preoperative values, but the differences were no longer significant between the RAT-AVR and AVR groups. The multivariable median regression analysis demonstrated that RAT-AVR surgery was a key factor in a patient's higher postoperative PFT parameter values. CONCLUSIONS: RAT-AVR surgery resulted in shorter postoperative mechanical ventilation time and improved the recovery of pulmonary function in elderly patients, but it did not reduce the incidence of pulmonary complications when compared with surgery performed through a median sternotomy.
Assuntos
Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Complicações Pós-Operatórias/fisiopatologia , Sistema Respiratório/fisiopatologia , Esternotomia/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Masculino , Testes de Função Respiratória/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: The coexistence of mitral regurgitation (MR) and severe aortic stenosis (AS) has been associated with worse outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). Herein, the aim was to assess the etiology and degree of MR in an unselected TAVI population and investigate the impact of MR reduction at mid-term follow-up. METHODS: Patients subjected to TAVI as a treatment for severe AS in a single center were retrospectively analyzed. The primary endpoint was the MR reduction after TAVI. The secondary endpoint was all-cause mortality and heart failure hospitalization at a 3-year follow-up. RESULTS: Patients undergoing TAVI (n = 283) in the years 2017-2019 were screened for the presence of hemodynamically significant MR. Sixty-nine subjects (24.4%) with severe (16, 23.2%) and moderate (53, 76.8%) MR were included. The primary MR was predominant (39 subjects, 56.5%). The median age of the patients was 82 years. MR improved in 25 patients (36.2%, p < 0.001). Baseline severe MR was more prone to reduce (8 subjects, 50%) than moderate (17 subjects, 32.1%, p = 0.04). The primary MR improved in 14 patients (35.9%), while secondary in 11 patients (36.7%, p = 1). Patients showing MR reduction had lower mortality (8 vs. 29.55%, p = 0.047) and were less frequently hospitalized (20 vs. 45.45%, p = 0.03) at 3-year follow-up. CONCLUSIONS: Hemodynamically significant MR improves after TAVI regardless of its etiology. Moreover, MR reduction after TAVI is associated with better clinical outcomes.
RESUMO
Introduction: Minimally invasive and hybrid procedures for patients with aortic valve pathology and coronary artery disease are innovative solutions. Aim: To report the results of hybrid aortic valve replacement through right anterior minithoracotomy (RT-AVR)/percutaneous coronary intervention (PCI) and conventional aortic valve replacement (AVR)/coronary artery bypass grafting (CABG) surgery for patients with aortic valve and coronary artery disease. Material and methods: Analysis of prospectively gathered data of 187 patients - 86 hybrid and 101 conventional procedures. For 21 patients, RT-AVR was followed by PCI during the same session, and for 65 patients RT-AVR was performed within 90 days of PCI. Results: Hospital mortality in the AVR/CABG and RT-AVR/PCI groups was 3.0% and 1.2%, respectively (p = 0.237). Complications occurred in 18.6% of patients in the RT-AVR/PCI group and 33.7% in the AVR/CABG group (p = 0.020). Two-stage RT-AVR/PCI was performed due to ACS (100%); one-stage was due to the intention to perform a minimally invasive procedure instead of AVR/CABG (71.4%) or due to replacing CABG with PCI because of a lack of vascular grafts for CABG (19.1%). In 38.5% of patients from the two-stage subgroup, antiplatelet therapy was stopped before RT-AVR, 32.3% of patients from the two-stage subgroup were on single, and 29.2% on dual antiplatelet therapy until RT-AVR, which had no influence on postoperative blood requirements or postoperative myocardial infarction (p = 0.410 and p = 0.077, respectively). Conclusions: The hybrid procedure presented in our series showed similar mortality and morbidity results and may be an alternative to conventional AVR and CABG through full sternotomy in selected patients.
RESUMO
BACKGROUND: Transfemoral approach (TFA) is the most common access route for transcatheter aortic valve implantation (TAVI). Percutaneous femoral access (PA) is preferred over the surgical approach (SA), however, may be associated with a higher risk of access site complications. Thus, we aimed to assess outcomes of computed tomography-guided tailored approach to percutaneous and surgical TFA in patients undergoing TAVI. METHODS: We evaluated data of 158 patients, who underwent TAVI via femoral route between January 2017 and December 2018. In the PA group, vascular closure was performed with the use of two percutaneous suture devices and an additional mechanical seal device. We compared complications rate and outcomes. RESULTS: Of the 158 patients (92%; mean age 79.6 years, 60.8% female), in 92 (61%) patients PA was performed and in 66 (39%) patients SA was used. Median (interquartile range) radiation exposure as well as contrast volume dose was higher in the PA group compared to the SA group 614.0 (410.0; 1104.0) mGy vs. 405 (240.5; 658.0) mGy (p < 0.001) and 150.0 (120.0; 180.7) mL vs. 130.0 (100.0; 160.0) mL (p = 0.04), respectively. Bleeding complications were similar in the PA group 11 (12.2%) compared to 5 (8.62%) in the SA group (p = 0.48). Median length of hospital stay was also similar in the PA and the SA group 6.00 (5.00; 8.00) days vs. 6.00 (4.00; 8.00) days, respectively (p = 0.31). CONCLUSIONS: Computed tomography-guided PA in TAVI may provide comparable procedural outcomes compared to the SA, despite a higher radiation dose and the use of contrast dye, while being less invasive.
Assuntos
Estenose da Valva Aórtica , Substituição da Valva Aórtica Transcateter , Humanos , Feminino , Idoso , Masculino , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Resultado do Tratamento , Tomografia Computadorizada por Raios X , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Artéria Femoral , Estudos RetrospectivosRESUMO
BACKGROUND: In patients at urgent need for cardiac surgery coexisting with increased-stroke-risk carotid stenosis, any staged intervention increases the risk of complications from the primarily unaddressed pathology. In this challenging cohort, we assessed safety and feasibility of endovascular carotid revascularization under open-chest extracorporeal circulation (ECC) combined with cardiac surgery (hybrid-room true simultaneous treatment). METHODS: Per-protocol (PP), after general anesthesia induction, chest-opening and ECC stand-by installation, carotid stenting (CAS) was performed (femoral/radial or direct carotid access) with ad-hoc/on-hand switch to ECC cardiac surgery. RESULTS: Over 78 months, 60 patients (70.7±6.9years, 85% male, all American Society of Anesthesiology grade IV) were enrolled. All were at increased carotid-related stroke risk (ipsilateral recent stroke/transient ischemick attack, asymptomatic cerebral infarct, increased-risk lesion morphology, bilateral severe stenosis). Majority of study procedures involved CAS+coronary bypass surgery or CAS+valve replacement±coronary bypass. 45 (75%) patients were PP- and 15 (25%) not-PP (NPP-) managed (context therapy). CAS was 100% neuroprotected (transient flow reversal-64.4%, filters-35.6%) and employed micronet-covered plaque-sequestrating stents with routine post-dilatation optimization/embedding. 4 deaths (6.7%) and 7 strokes (11.7%) occurred by 30-days. Despite CAS+surgery performed on aspirin and unfractionated heparin-only (delayed clopidogrel-loading), no thrombosis occurred in the stented arteries, and 30-days stent patency was 100%. NPP-management significantly increased the risk of death/ipsilateral stroke (OR 38.5; P<0.001) and death/any stroke (OR 12.3; P=0.002) by 30-days. CONCLUSIONS: In cardiac unstable patients at increased carotid-related stroke risk who require urgent cardiac surgery, simultaneous cardiac surgery and CAS with micronet-covered stent lesion sequestration is feasible and safe and shows efficacy in minimizing stroke risk. Larger-scale, multicentric evaluation is warranted. (SIMGUARD NCT04973579).
Assuntos
Procedimentos Cirúrgicos Cardíacos , Estenose das Carótidas , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Humanos , Masculino , Estados Unidos , Feminino , Heparina , Fatores de Risco , Resultado do Tratamento , Acidente Vascular Cerebral/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Stents/efeitos adversos , Endarterectomia das Carótidas/efeitos adversos , Circulação Extracorpórea/efeitos adversosRESUMO
INTRODUCTION: Transapical access (TA) transcatheter aortic valve implantation (TAVI) (TA-TAVI) represents one of the possible routes in patients with severe aortic stenosis (AS) who are not suitable for transfemoral access. AIM: To assess early- and mid-term clinical outcomes after TA-TAVI. MATERIAL AND METHODS: Patients with severe symptomatic AS undergoing TA-TAVI from November 2008 to December 2019 were enrolled. Clinical and procedural characteristics as well as clinical outcomes including all-cause mortality during 12-month follow-up were assessed. RESULTS: Sixty-one consecutive patients underwent TA-TAVI for native AS. Patients were elderly with median age of 80.0 (76.0-84.0) years; 55.7% were males. Median baseline EuroSCORE I and STS scores were 18.2% (11.6-27.7) and 4.8% (3.3-8.2), respectively. The procedural success rate was 96.7%. In-hospital, 30-day and 12-month mortality rates were 9.8%; 18.0% and 24.6%, respectively. The main periprocedural and in-hospital complications were bleeding complications (14.8%). The following factors were associated with 12-month mortality: previous cerebrovascular event (CVE), glomerular filtration rate (GFR), aortic valve area (AVA), right ventricular systolic pressure (RVSP) and serum level of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) (RR for CVE 3.17, 95% confidence interval (CI): 1.15-8.76: p = 0.026; RR for AVA per 0.1 cm2 1.28, 95% CI: 1.03-1.55: p = 0.024; RR for GFR per 1 ml/min 0.96: 95% CI: 0.94-0.99: p = 0.007; RR for NT-proBNP per 1000 pg/ml 1.07: 95% CI: 1.01-1.17: p = 0.033; RR for RVSP per 1 mm Hg 1.07: 95% CI 1.02-1.16: p = 0.011). CONCLUSIONS: Transapical TAVI in high-risk patients provides good hemodynamic results with acceptable outcomes.
RESUMO
INTRODUCTION: Radial or brachial access may be preferred in the case of severe peripheral artery disease (PAD) or difficult aortic arch anatomy during carotid artery stenting (CAS). AIM: To evaluate the clinical conditions indicating potential benefit from non-femoral access as well as feasibility and safety of transradial/transbrachial access (TRA/TBA) as an alternative approach for CAS. MATERIAL AND METHODS: Since 2013, 67 patients (mean age: 70 years old, 44 men, 42% symptomatic) were selected for CAS with the TRA/TBA approach. The composite endpoint was stroke/death/myocardial infarction within 30 days of the procedure and compared to the propensity score matched transfemoral approach (TFA) group. Clinical (including neurological) examination and Doppler ultrasonography were performed before the procedure, at discharge and at 30 days. RESULTS: CAS with TRA/TBA was successful in 63/67 patients. Transfemoral access was not feasible due to PAD in 35 (52.2%) patients, bovine arch in 10 (14.9%), obesity (BMI > 35 kg/m2) in 9 (13.4%), severe degenerative disease of the spine in 7 (10.5%), arch type III in 5 (7.5%) and excessive subclavian stent protrusion in 1 (1.5%) patient. Mean NASCET carotid artery stenosis was reduced from 81% to 9% (p < 0.001). The composite endpoint occurred in 3 (4.8%) cases and it was not statistically significantly different from the matched TFA group (6.3%; p = 0.697). No access site complications requiring surgical intervention or blood transfusion developed. CONCLUSIONS: Transradial and transbrachial CAS may be an effective and safe procedure, and it may constitute a viable alternative to the femoral approach in patients with severe PAD, difficult aortic arch anatomy or obesity.
RESUMO
INTRODUCTION: Due to the prolonged survival of patients with cardiovascular implantable electronic devices, leads often need to be removed in elderly individuals. OBJECTIVES: We aimed to analyze indications for transvenous lead extraction (TLE), procedure effectiveness and safety, as well as 30day followup in younger patients (≤80 years) and octogenarians (>80 years). PATIENTS AND METHODS: This prospective study included 667 patients who underwent TLE: 90 octogenarians (13.5%) at a mean age of 83.8 (range, 80.4-93) years and 577 younger patients (86.5%) at a mean age of 64.2 (range, 18.9-79.9) years. RESULTS: Octogenarians had a greater number of comorbidities, fewer implantable cardioverterdefibrillators implanted, and more frequently had infection as an indication for TLE, as compared with younger patients (33.3% vs 17.1%; P <0.001). In octogenarians, 138 leads were extracted, as compared with 894 leads in younger patients. Octogenarians and younger patients had similar rates of complete lead removal (98.6% and 97.1%, respectively; P = 0.48), total procedural success (97.8% and 96%, respectively; P = 0.7), major complications (0% and 1.6%, respectively; P = 0.45), and minor complications (2.2% and 1.6%, respectively; P = 0.45). There was 1 death associated with TLE in younger patients. Non-procedurerelated deaths within 30 days after TLE were more frequent in octogenarians than in younger patients (5.6% vs 1.9%; P = 0.04). CONCLUSION: We showed that TLE in patients older than 80 years seems to be as effective as in younger patients; however, it is associated with significantly higher non-procedurerelated 30day mortality.
Assuntos
Desfibriladores Implantáveis , Remoção de Dispositivo , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Polônia , Estudos Prospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
INTRODUCTION: Prevention of peri- and postprocedural complications is still a challenge in carotid artery stenting (CAS). AIM: To assess immediate and long-term safety and effectiveness of CAS using the Roadsaver double-nitinol-layer-micromesh stent. MATERIAL AND METHODS: Since 2014, 298 CAS procedures in 287 non-consecutive patients (203 men, mean age 70.5 ±8.6 years, 100% symptomatic/high risk lesions) have been performed using the Roadsaver stent and proximal (40%) or distal (60%) neuroprotection system. Clinical and neurological examinations as well as duplex ultrasound were completed before CAS, before discharge, at 1, 6 and 12 months, then annually. RESULTS: All CAS procedures were successful. Carotid stenosis was reduced from 84.9 ±9.9% to 11.0 ±9.4% (p < 000.1). In hospital, 1 ipsilateral periprocedural major (0.3%) and 3 minor (1.34%) ischemic strokes occurred, 2 (0.7%) patients died due to a cerebral hemorrhage on day 9 and 21. Three (1.0%) additional ipsilateral minor strokes within 30 consecutive days occurred. Thus, 30-day complications were observed in 9 (3.0%) patients. Two minor strokes were associated with in-stent thrombosis (0.7%). The 4-year follow-up showed 82% overall survival (95% CI: 69-91%) with no significant difference between asymptomatic (77%) and symptomatic patients (97%; p = 0.076). The stroke-free survival was 89% (95% CI: 77-95%), 84% asymptomatic vs. 98% symptomatic (p = 0.187). Seven (2.3%) patients developed > 50% in-stent restenosis. CONCLUSIONS: Carotid artery stenting using the Roadsaver stent for symptomatic patients and high risk lesions showed to be safe and effective, with a low complication rate and acceptable in-stent restenosis risk in 4-year follow-up.
RESUMO
BACKGROUND: Rapid ventricular pacing is used during balloon aortic valvuloplasty, balloonexpandable transcatheter aortic valve implantation (TAVI), and for postdilatation. Right ventricular (RV) lead pacing has been regarded as a gold standard. Direct left ventricular (LV) wire pacing has recently been considered safe and effective in TAVI interventions. AIMS: This study aimed to analyze procedural outcomes of direct LV pacing compared with RV stimulation in unselected patients undergoing TAVI. METHODS: Direct LV wire pacing was provided via available preshaped guidewires and used only when no predictors of atrioventricular block were present. The primary study objective was the assessment of the efficacy of direct LV wire pacing. The secondary objectives included the evaluation of procedure duration and safety in comparison with the conventional method. A combined endpoint (major adverse cardiovascular event) was defined as the occurrence of death, stroke, venous puncture-related complications, and cardiac tamponade. RESULTS: In 2017 and 2018, 143 patients underwent transfemoral TAVI. Of these, 114 (79.7%) had self expandable valves implanted. Direct LV wire pacing was the dominant method of pacing (82 patients [57.3%]), and its efficacy reached 97.6%. The median (interquartile range) procedure time was shorter in the direct LV wire pacing group (80 [70-90] min vs 85 [70-95] min; P = 0.02). Major adverse cardiovascular events were more frequent in the RV lead pacing group (11.5% vs 4.9%), but no statistical significance was achieved (P = 0.13). CONCLUSIONS: Direct LV wire pacing during TAVI is a simple, reproducible, and safe technique, which provides reliable, sustained stimulation with a low complication rate and potential reduction of procedural time.
Assuntos
Estenose da Valva Aórtica , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Valvuloplastia com Balão , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do TratamentoRESUMO
The available literature lacks data concerning direct comparison of the effectiveness and safety of single- versus dual-coil implantable cardioverter-defibrillator (ICD) leads transvenous extraction. Certainly, additional shocking coil in superior vena cava adds to the amount of metal in the vascular system. Adhesions developing around the superior vena cava coil add to the difficulty of extraction of ICD lead if lead removal is required. The aim of the study was to assess the effectiveness and safety of single- and dual-coil ICD leads transvenous extraction using mechanical systems. We performed transvenous lead extraction (TLE) of 197 ICD leads in 196 patients. There were 46 (23.3%) dual-coil leads removed from 46 (23.5%) patients. Cardiovascular implantable electronic device-related infection was an indication for TLE in 25.0% of patients. The following extracting techniques were used: manual direct traction, mechanical telescopic sheaths, controlled-rotation mechanical sheaths, and femoral approach. Complete ICD lead removal and complete procedural success in both groups were similar (99.3% in single-coil vs 97.8% in dual-coil, Pâ=â.41 and 99.3% in single-coil vs 97.8% in dual-coil, Pâ=â0.41, respectively). We did not find significant difference between major and minor complication rates in both groups (2.0% in single-coil vs 4.3% in dual-coil, and 0.7% in single-coil vs 0.0% in dual-coil, Pâ=â.58, respectively). There was 1 death associated with the TLE procedure of single-coil lead.This study shows that extraction of dual-coil leads seems to be comparably safe and effective to extraction of single-coil leads. On the other hand, it requires longer fluoroscopy time and frequent utilization of advanced tools.
Assuntos
Desfibriladores Implantáveis/efeitos adversos , Remoção de Dispositivo/métodos , Desenho de Equipamento/efeitos adversos , Fluoroscopia/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Remoção de Dispositivo/efeitos adversos , Feminino , Fluoroscopia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Aderências Teciduais/etiologia , Aderências Teciduais/cirurgia , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Veia Cava Superior/patologia , Veia Cava Superior/cirurgia , Adulto JovemRESUMO
OBJECTIVE: The aim of the study was to comparatively analyze respiratory system function after minimally invasive, through right minithoracotomy aortic valve replacement (RT-AVR) to conventional AVR. METHODS: Analysis of 201 patients scheduled for RT-AVR and 316 for AVR between January 2010 and November 2013. Complications of the respiratory system and pulmonary functional status are presented. RESULTS: Complications of the respiratory system occurred in 16.8% of AVR and 11.0% of RT-AVR patients (P = 0.067). The rate of pleural effusions, thoracenteses, pneumonias, or phrenic nerve dysfunctions was not significantly different between groups. Perioperative mortality was 1.9% in AVR and 1.0% in RT-AVR (P = 0.417). Mechanical ventilation time after surgery was 9.7 ± 5.9 hours for AVR and 7.2 ± 3.2 hours for RT-AVR patients (P < 0.001). Stroke (odds ratio [OR] = 13.4, P = 0.008), increased postoperative blood loss (OR = 9.6, P < 0.001), and chronic obstructive pulmonary disease (OR = 7.7, P < 0.001) were risk factors of prolonged mechanical lung ventilation. A week after surgery, the results of most pulmonary function tests were lower in the AVR than in the RT-AVR group (P < 0.001 was seen for forced expiratory volume in the first second, vital capacity, total lung capacity, maximum inspiratory pressure and maximum expiratory pressure, P = 0.377 was seen for residual volume). CONCLUSIONS: Right anterior aortic valve replacement minithoracotomy surgery with single-lung ventilation did not result in increased rate of respiratory system complications. Spirometry examinations revealed that pulmonary functional status was more impaired after AVR in comparison with RT-AVR surgery.
Assuntos
Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/métodos , Pulmão/fisiopatologia , Toracotomia/métodos , Idoso , Estudos de Casos e Controles , Feminino , Doenças das Valvas Cardíacas/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Testes de Função Respiratória , Resultado do TratamentoRESUMO
BACKGROUND: The authors present their own experience of the treatment of patients qualified for transcatheter aortic valve implantation (TAVI) carried out in a modern hybrid operating room. The objective of the present study was to demonstrate the initial results of conducting anaesthesia in high-risk patients qualified for the TAVI procedure (transcatheter aortic valve implantation). In addition, the authors' aim was also to point out to the special challenges of an anaesthesiologist conducting local anaesthesia in such a type of procedures and to evaluate the safety and efficacy of the TAVI procedure conducted under remifentanil analgosedation. METHODS: A retrospective analysis included patients treated during the period from September 2015, when local anaesthesia for the transcatheter aortic valve implantation was used for the first time at our centre, up to February 2016. The studied population consisted of 11 patients treated for severe aortic valve stenosis. The mean age of patients was 80 ± 7 years. Three patients were men (27%) and eight were women (73%). The study included all subsequent patients (n = 11), treated in our centre, for whom it was decided to perform TAVI under local anaesthesia. RESULTS: The total hospital mortality rate was 0%. All procedures were performed in a hybrid operating room. Despite the complications observed in the described group, the hospital mortality rate during TAVI was 0%. All patients, after 12 ± 5 days of treatment, left the hospital in a good neurological condition, which was assessed based on the CPC-1 (Cerebra Performance Categories Scale) and GCS-15 (Glasgow Coma Scale) scales. With an ejection fraction of the left ventricle of 53 ± 11%, the transcatheter aortic valve was successfully implanted. CONCLUSIONS: Percutaneous aortic valve implantation can be successfully conducted under remifentanil analgosedation. TAVI procedures should be performed in the conditions of a modern, well-equipped hybrid room. The aim of the anaesthesiologist should consist of conducting the least invasive anaesthesia/analgesia, bearing in mind the safety and comfort of the patient.
Assuntos
Anestesia Local/métodos , Estenose da Valva Aórtica/cirurgia , Piperidinas/administração & dosagem , Substituição da Valva Aórtica Transcateter/métodos , Idoso , Idoso de 80 Anos ou mais , Anestésicos Intravenosos/administração & dosagem , Feminino , Mortalidade Hospitalar , Humanos , Hipnóticos e Sedativos/administração & dosagem , Masculino , Pessoa de Meia-Idade , Remifentanil , Estudos Retrospectivos , Fatores de Risco , Substituição da Valva Aórtica Transcateter/efeitos adversosRESUMO
INTRODUCTION: Reports describing respiratory function of patients after conventional or minimally invasive cardiac surgery are infrequent. AIM: To compare pulmonary functional status after conventional (AVR) and after minimally invasive, through right anterior minithoracotomy, aortic valve replacement (RT-AVR). MATERIAL AND METHODS: This was an observational analysis of 212 patients scheduled for RT-AVR and 212 for AVR between January 2011 and December 2014 selected using propensity score matching. Respiratory function based on spirometry examinations is presented. RESULTS: Hospital mortality was 1.4% in RT-AVR and 1.9% in AVR (p = 0.777). Predicted mortality (EuroSCORE II) was 3.2 ±1.1% in RT-AVR and 3.1 ±1.6% in AVR (p = 0.298). Mechanical ventilation time in intensive care unit (ICU) was 7.3 ±3.9 h for RT-AVR and 9.6 ±5.5 h for AVR patients (p < 0.001). Seven days and 1 month after surgery, the reduction of spirometry functional tests was greater in the AVR group than in the RT-AVR group (p < 0.001). Three months after surgery, all spirometry parameters were still reduced and had not returned to preoperative values in both RT-AVR and AVR groups. However, the difference in spirometry values was no longer statistically significant between RT-AVR and AVR groups. Presence of chronic obstructive pulmonary disease and conventional AVR surgical technique were associated with lower values of spirometry parameters after surgery in linear median regression. CONCLUSIONS: Respiratory function based on spirometry examinations was less impaired after minimally invasive RT-AVR surgery in comparison to conventional AVR surgery through median sternotomy.