RESUMO
BACKGROUND AND AIM OF THE STUDY: Postoperative pericardial effusion is frequent and can be complicated by cardiac tamponade. Although the different drainage techniques are well described in the setting of medical effusion, there is not a standard postoperative effusion treatment. The aim of this work was to assess the feasibility and effectiveness of the percutaneous pericardial drainage. METHODS: This a retrospective study involving 197 patients from 1990 to 2008. Drainage was performed by subxiphoid puncture (91.9%) or left parasternal puncture (8.1%) between 3 and 690 days following a cardiac procedure via median sternotomy. Effusion thickness was at least 10 mm in the subcostal echocardiography view. RESULTS: No deaths directly related to the procedure were observed. Complete and enduring drainage was achieved in 158 patients (80.2%). The procedure failed for 22 patients (11.2%) because no fluid was drained in 14 cases (7.1%) and a right ventricular puncture in 8 cases (4.1%). Recurrence of the effusion, which occurred for 17 patients (8.6%), was more frequent if an effusion of more than 5 mm persisted after the first drainage (P = 0.024) and if the drainage was performed outside the operating room because of emergency (P = 0.046). Risk factors for mortality were recurrence of the effusion (P = 0.04) and drainage performed outside the operating room (P = 0.007). CONCLUSIONS: Percutaneous pericardial drainage is effective to treat postoperative pericardial effusion. When the effusion is thicker than 10 mm and accessible, it can be the initial strategy and surgical drainage can serve as an alternate strategy in case of failure and complications of this procedure.
Assuntos
Drenagem/métodos , Derrame Pericárdico/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/etiologia , Derrame Pericárdico/mortalidade , Complicações Pós-Operatórias , Recidiva , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
PURPOSE: To report initial experience with endovascular stent-grafting in aortic intramural hematoma (IMH). MATERIALS AND METHODS: From 2000 to 2006, 15 patients (mean age, 67 years; range, 54-83 y) underwent endovascular treatment of aortic IMH. Thirteen patients were admitted for acute aortic syndrome and two for traumatic aortic injury. An endovascular procedure was performed as primary treatment for four patients (type A IMH, n = 3; type B IMH, n = 1) and as a second-line therapy in 11 patients because of unfavorable evolution (type A IMH, n = 1; type B IMH, n = 10). All stent-grafts were placed in the descending aorta, even for type A IMH. The mean follow-up was 21 months (range, 6-72 months). RESULTS: The primary success rate was 93%, with complete exclusion of the lesion (n = 14). Exclusion was partial for one patient with a type I endoleak (7%). The 30-day mortality rate was zero. IMH evolution was favorable in all cases, with decreased aortic wall thickening (n = 8) or complete regression (n = 7). Complications associated with endovascular repair were mainly related to aneurysm formation (20%). The late death rate was 7%. CONCLUSIONS: Endovascular stent-graft treatment can be performed in the management of complicated IMH, even in some cases of type A IMH, when an intimal lesion is located in the isthmus or descending aorta with contraindications to surgery. This procedure offers low morbidity and mortality rates, representing a feasible therapeutic option especially for elderly patients with comorbidities. Further studies are necessary to confirm these preliminary results.
Assuntos
Doenças da Aorta/diagnóstico , Doenças da Aorta/cirurgia , Prótese Vascular , Hematoma/diagnóstico , Hematoma/cirurgia , Stents , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
We report the case of 31-year-old man who was admitted for cerebellar ischemia. The echocardiography showed an intraventricular mass, mobile with the cardiac activity compatible with a thrombus or a myxoma. He successfully underwent a video-assisted removal of the mass, through the mitral valve.
Assuntos
Isquemia Encefálica/diagnóstico por imagem , Procedimentos Cirúrgicos Cardíacos/instrumentação , Neoplasias Cardíacas/cirurgia , Ventrículos do Coração/cirurgia , Valva Mitral/cirurgia , Cirurgia Torácica Vídeoassistida , Adulto , Isquemia Encefálica/patologia , Isquemia Encefálica/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/patologia , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/patologia , Humanos , Masculino , Valva Mitral/patologia , Mixoma/cirurgia , Cirurgia Torácica Vídeoassistida/métodos , UltrassonografiaRESUMO
BACKGROUND: Lung transplantation (LT) may represent a therapeutic option in case of advanced pulmonary Langerhans' cell histiocytosis (PLCH). Little is known however about the characteristics of the patients considered for LT or its results. METHODS: We conducted a retrospective multicenter study by questionnaire on 39 patients who underwent LT for end-stage PLCH at seven centers in France. RESULTS: Of the 39 patients, 15 received single lung transplantation, 15 double lung transplantation and 9 heart-lung transplantation. At evaluation, extrapulmonary involvement was present in 31% of the patients, pulmonary hypertension (PAPm>25 mm Hg) was observed in 92% of cases and was moderate-to-severe (PAPm> or =35 mm Hg) in 72.5%. The survival was 76.9% at 1 year, 63.6% at 2 years, 57.2% at 5 years, and 53.7% at 10 years. Recurrence of the disease occurred in eight cases (20.5%) with no impact on the survival rate. The sole risk factor for recurrence of the disease was the presence of preoperative extrapulmonary involvement. CONCLUSION: Severe pulmonary hypertension is a common feature in patients with end-stage PLCH. Given the good postransplant survival rate and despite a recurrence rate of the disease of approximately 20% after LT, we conclude that LT is a therapeutic option in this setting.
Assuntos
Histiocitose de Células de Langerhans/diagnóstico , Histiocitose de Células de Langerhans/cirurgia , Hipertensão Pulmonar/diagnóstico , Pneumopatias/diagnóstico , Pneumopatias/cirurgia , Transplante de Pulmão , Adolescente , Adulto , Feminino , Transplante de Coração-Pulmão/mortalidade , Histiocitose de Células de Langerhans/mortalidade , Humanos , Hipertensão Pulmonar/mortalidade , Hipertensão Pulmonar/cirurgia , Pneumopatias/mortalidade , Transplante de Pulmão/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: To compare surgical and endovascular stent graft (ESG) treatment of blunt thoracic aortic injury (BAI) in the emergency setting. DESIGN AND SETTING: Retrospective case control study in two surgical intensive care units of a university hospital. PATIENTS: 30 patients who presented with BAI between 1995 and 2005: 17 treated surgically and 13 by ESG. The two groups were comparable for the severity of trauma and mean delay before treatment; the mean age was higher in the ESG group (46+/-18 vs. 35+/-15 years). RESULTS: In the surgical group time spent in the operating theater was longer (310+/-130 vs. 140+/-48 min) and blood losses higher (2000+/-1300 vs. no significant bleeding); aortic clamping time was 48+/-20 min. The mortality rate was 15% with ESG (n=2) and 23% with surgery (n=4). Complications of the procedure were more frequent in the surgical group (1 vs. 7). In the ESG group there was one pulmonary embolism. In the surgical group there were three neurological complications, one acute aortic dissection, one perioperative rupture, one periprosthetic leak, and one septic shock. Two complications (postoperative aortic dissection and paraplegia) appeared in the same patient in the surgical group. Intensive care unit length of stay, duration of mechanical ventilation, and catecholamine support were similar in the two groups. CONCLUSIONS: Stent graft for emergency treatment of BAI is efficient and is associated with fewer complications than surgical treatment.
Assuntos
Implante de Prótese Vascular , Serviços Médicos de Emergência , Stents , Artérias Torácicas/lesões , Ferimentos não Penetrantes/cirurgia , Adulto , Feminino , França , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Artérias Torácicas/cirurgiaRESUMO
Percutaneous closure of the secundum type atrial septal defects is becoming increasingly popular. We report the case of a 49-year-old man who presented for an unusual embolization of an Amplatzer occluder (AO) 6 weeks after a percutaneous closure of his secundum type atrial septal defect. Emergency cardiac surgery was performed and the device was safely removed by a combined surgical and endovascular approach with no need of circulatory arrest or of profound hypothermia.
Assuntos
Aorta Torácica/cirurgia , Oclusão com Balão/instrumentação , Embolia/cirurgia , Comunicação Interatrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Remoção de Dispositivo/métodos , Embolia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Implantação de Prótese/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Total arterial and off-pump revascularization are increasingly used in coronary artery bypass grafting. This study describes our experience with the exclusive use of both left internal thoracic artery and gastroepiploic artery by means of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of patients with two-vessel disease. METHODS: From January 1995 to July 2000, 171 consecutive patients were reviewed in a prospective database. Ninety-one patients underwent coronary artery bypass grafting without cardiopulmonary bypass (group A), and 80 patients were operated on under cardiopulmonary bypass with aortic cross-clamp and cardioplegia (group B). RESULTS: Patient data were similar in both groups except for the Euroscore (mean; 3.4+/-6.1, group A versus 2.5+/-4.5, group B; Euroscore > 6: 26.4%, group A versus 10%, group B; p < 0.05) and ejection fraction (mean, 54.6%+/-15.8%, group A versus 63.1%+/-12.7%, group B; p < 0.001). Severe aortic calcification was present in 6 group A patients, versus no patient in group B. Operative time was shorter in group A (185 versus 213 minutes, p < 0.0001), with less distal anastomoses (2.26 versus 2.5, p < 0.05). Conversion to cardiopulmonary bypass occurred in 1 patient, who was excluded from the study. Bleeding was higher in group A (852.6+/-288 mL versus 712.4+/-274 mL, p < 0.05), but transfusion was similar in both groups. Atrial fibrillation, postoperative inotropic support, and hospital stay were similar in both groups. Myocardial infarction was less frequent in group A (1 versus 4). Postoperative intraaortic balloon pump was used in 2 patients (group B). One patient died (group A) and 1 had an embolic stroke (group B). After discharge, 2 more patients died (group A, day 91; group B day 141), and 1 patient suffered an embolic stroke (group B). One patient in each group presented with dysfunction of the gastroepiploic artery graft requiring successful percutaneous transluminal angioplasty on the right posterolateral artery. CONCLUSIONS: These results suggest that off-pump coronary artery bypass grafting using the left internal thoracic artery and gastroepiploic artery is safe even in high-risk patients. This approach allows an absolute no-touch technique of the aorta.
Assuntos
Artérias/transplante , Ponte Cardiopulmonar , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Idoso , Feminino , Seguimentos , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Fatores de Risco , Esterno/cirurgia , Acidente Vascular Cerebral/etiologia , Resultado do TratamentoRESUMO
Cardiac involvement in Whipple's discase is frequent. However, its clinical occurrence without gastrointestinal symptoms is rarely described. Whipple's endocarditis occurs ollen in patients wilh native valves, without underlying, disease. It affects frequently more than one valve h, the same patient. Its clhlical presentation is generally subacute or chronic. Fever and congestive heart failure are fickle. Histological findings on the valves suggest the diagnosis, that con be confirmed by PCR technique. Treatment must be prolonged. We report a case of Whipple's endocarditis revealed by arterial embolisms and fever appeured 3 weeks after the onset.
Assuntos
Endocardite/microbiologia , Doença de Whipple , Endocardite/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Whipple/diagnósticoRESUMO
BACKGROUND: Methods of objectively measuring rotational knee laxity are either experimental or difficult to use in daily practice. A new method has been developed to quantitatively assess rotatory laxity using an open MRI system and new tool, the KneeM device. PURPOSE/HYPOTHESIS: To perform a preliminary evaluation of a novel knee rotation measurement device to assess knee kinematics during flexion in an MRI field, in both anterior cruciate ligament (ACL)-deficient and healthy contralateral knees. The hypothesis was that the KneeM device would allow in vivo reproduction and analysis of knee kinematics during flexion in healthy and ACL-deficient knees. STUDY DESIGN: Controlled laboratory study. METHODS: Ten subjects (7 men and 3 women; mean age ± standard deviation, 32.3 ± 9.4 years) with ACL-deficient knees and contralateral uninjured knees participated in the study. An open MRI was performed with the KneeM device at a mean 4.9 months (range, 3.0-7 months) after ACL injury. The device exerted on the knee an anterior drawer force of 100 N, with an internal rotation of 20°, through the range of flexion (0°, 20°, 40°, and 60°). Both ACL-deficient and healthy contralateral knees were analyzed using the Iwaki method. RESULTS: There was no statistical difference of anterior translation in the medial compartment between intact and ACL-deficient knees at all degrees of flexion. However, significant differences in the anterior translation of the lateral compartment were observed between ACL-deficient and intact contralateral knees at 0° and 20° of flexion (P = .005 and P = .002, respectively). Between 20° and 40°, the lateral plateau of ACL-deficient knees translated 7.7 mm posteriorly, whereas the medial compartment remained stable, reflecting a sudden external rotation of the lateral plateau under the femoral condyle. CONCLUSION: This preliminary study suggests that measurement of tibiofemoral movements in both compartments during flexion using the KneeM device was useful for quantifying rotatory laxity in ACL-deficient knees. Moreover, this device seemed to allow a "mechanized pivot shift" and allowed reproduction of the "pivot" phase in the MRI field between 20° and 40° of flexion. CLINICAL RELEVANCE: This device could be used for diagnostic purposes or to investigate the outcomes of ACL reconstructions.
RESUMO
Heart wounds are frequently fatal. The haemorrhage from a right ventricle-gunshot wound in a male patient was successfully controlled using a novel haemostatic vacuum device. This case report shows how this simple, quick and efficient method can be used to control critical bleedings.
Assuntos
Traumatismos Cardíacos/cirurgia , Técnicas Hemostáticas/instrumentação , Ferimentos por Arma de Fogo/cirurgia , Idoso de 80 Anos ou mais , Tamponamento Cardíaco/etiologia , Tamponamento Cardíaco/cirurgia , Desenho de Equipamento , Evolução Fatal , Traumatismos Cardíacos/diagnóstico , Traumatismos Cardíacos/etiologia , Ventrículos do Coração/lesões , Humanos , Masculino , Esternotomia , Tentativa de Suicídio , Técnicas de Sutura , Resultado do Tratamento , Vácuo , Ferimentos por Arma de Fogo/diagnóstico , Ferimentos por Arma de Fogo/etiologiaRESUMO
The extraction by cervicotomy of substernal goitres may be impossible and sometimes requires the enlargement of the thoracic inlet with at least a sternal-split. We present the extraction of a posterior mediastinal substernal goitre with the application of an innovative vacuum-based suction device, previously used for the control of bleeding from the heart and great vessels in clinical and experimental conditions.
Assuntos
Bócio Subesternal/cirurgia , Tireoidectomia/instrumentação , Idoso , Humanos , Masculino , Tireoidectomia/métodos , VácuoRESUMO
AIMS: We report the feasibility and outcomes of emergency extracorporeal membrane oxygenation (ECMO) implantation by a cardiac catheterisation team in patients in severe cardiogenic shock or refractory cardiac arrest in a hospital without cardiac surgical facilities. METHODS AND RESULTS: This prospective cohort study involved 51 consecutive patients who had ECMO implantation (September 2006 - September 2010). Twenty-seven were in severe cardiogenic shock and 24 in refractory cardiac arrest (17 with out-of-hospital cardiac arrest; seven with in-hospital cardiac arrest). Implantations were done via a percutaneous femoral approach by a local interventional cardiologist team, and in collaboration with the nearest cardiac surgical institution. Patients' mean age was 51±15 years; 38 (74.5%) were men. Stable ECMO implantation was achieved in 26/27 (96.3%) patients in severe cardiogenic shock and in 18/24 (75.0%) patients in refractory cardiac arrest. In-hospital complications occurred in 23/27 cardiogenic shock patients; 13/27 were discharged alive. In patients with refractory cardiac arrest, complications occurred in 20/24; 21/24 were disconnected from ECMO because of brain death or multiorgan failure occurring ≤24 hours; one patient was discharged alive. CONCLUSIONS: Emergency ECMO implantation by an interventional cardiologist in a hospital without cardiac surgical facilities is feasible, with a failure rate concordant with the literature.
Assuntos
Oxigenação por Membrana Extracorpórea , Cirurgia Torácica , Adulto , Idoso , Estudos de Coortes , Emergências , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de SobrevidaRESUMO
Bleeding is one of the major problems during surgery as well as in cases of accidental vascular injury. Control of bleeding can be life threatening in two surgical circumstances: when the wound is difficult to expose, and when the tissue too fragile to suture. Following more than 100 animal tests, we developed an innovative vacuum-based suction device, which enables us to address this challenge. We set up a proof-of-concept protocol in humans and report here our first clinical experience.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Hemostasia Cirúrgica/métodos , Animais , Aorta/lesões , Ponte de Artéria Coronária/efeitos adversos , Átrios do Coração/lesões , Hemostasia Cirúrgica/instrumentação , Humanos , Estudos Prospectivos , Ovinos , Sucção/instrumentação , Vácuo , CicatrizaçãoRESUMO
BACKGROUND: Acute type A aortic dissection (ATAAD) is a life-threatening condition with a poor acute prognosis, which requires rapid and effective surgical management. The aim of this study is to assess our strategy with regard to this condition. METHODS: According to a regional emergency protocol, patients with diagnosed or highly suspected ATAAD are directly transferred to the cardiac operating room. Transesophageal echocardiography is performed under anaesthesia, and the patient then undergoes surgery if the diagnosis is confirmed. The present retrospective study examines the implementation of this management strategy between January 1, 1990 and December 31, 2009. RESULTS: Out of 380 patients, 245 were directly admitted to the operating room. Three hundred twelve cases of ATAAD, 15 cases of aneurysm of the ascending aorta, 9 cases of acute type B dissection, 4 cases of chronic dissection, 4 cases of hemopericardium, and 7 other diagnoses were observed. In 10 cases, no etiology was found. Nineteen patients died before surgery could be performed. Out of the 307 cases of ATAAD undergoing surgery, 15 patients were operated with cardiac massage (14 cases of aortic rupture). This management strategy was justified in 93.1% of patients (228/245) directly admitted to the operating room, because of the need for surgery or aortic rupture. CONCLUSIONS: Our management strategy enabled patients with ATAAD to receive effective and unselective treatment. Despite appropriate management, the large number of patients still dying before surgery, or undergoing surgery with cardiac massage, justifies and consolidates the need for immediate treatment of this condition.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/cirurgia , Emergências , Guias como Assunto , Salas Cirúrgicas/estatística & dados numéricos , Admissão do Paciente , Procedimentos Cirúrgicos Vasculares , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/epidemiologia , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/epidemiologia , Diagnóstico Diferencial , Ecocardiografia Transesofagiana , Feminino , Seguimentos , França/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: To investigate the effect of home-based exercise training on exercise tolerance, muscle function and quality of life in lung transplant recipients (LTR). METHODS: Twelve LTR and 7 age-matched healthy subjects underwent exercise training (ET, 12-wk, 3×/wk, 40 min). Peak aerobic capacity VO2peak, endurance time (T(end)), minute ventilation (VE) quadriceps strength, percentage of type I fiber (%Ifb), fiber diameters and chronic respiratory questionnaire were assessed before and after ET. A positive response to ET was defined as an improvement in T(end) at least comparable to the mean change observed in healthy subjects. RESULTS: Training significantly improved T(end) (+12 ± 11 min), isowatt during exercise (-5.5 ± 2.6L/min), muscle strength (+4.6 ± 2.6 kg) and dyspnea score (+0.6 ± 0.9) in LTR (p < 0.05), leading to recovery of T(end) and muscle strength up to healthy subjects' values. In responders (n = 6), VO2peak, %Ifb and fatigue score were improved after training (p < 0.05). Non-responders had lower %Ifb and greater delay between surgery and the beginning of the study than responders (56 [21-106] vs. 8 [2-59] months respectively, p = 0.03). CONCLUSIONS: Home-based ET was effective to improve exercise tolerance, muscle strength and quality of life in LTR but more successful in patients with moderate muscle dysfunction and in the first years after transplantation. Multicenter and controlled-studies are needed to confirm the benefits and optimal modalities of home training in LTR.
Assuntos
Terapia por Exercício/métodos , Transplante de Pulmão/reabilitação , Resistência Física/fisiologia , Qualidade de Vida , Transplante/reabilitação , Adulto , Idoso , Exercício Físico/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Ventilação Pulmonar/fisiologia , Testes de Função Respiratória , Transplante/fisiologia , Adulto JovemRESUMO
UNLABELLED: Plasma levels of PIIINP a marker of extracellular matrix metabolism activity have been linked to abdominal aortic aneurysm growth rate, but its relationship with thoracic aortic aneurysm (TAA) growth has never previously been studied. OBJECTIVE: To demonstrate the value of assay of "aminoterminal propeptide of type III procollagen" (PIIINP) to predict the growth of ascending TAA. METHODS AND RESULTS: Thirty consecutive patients with asymptomatic ascending TAA were recruited and PIIINP was measured. The patients were then followed up in the usual way, by annual imaging tests. The patients were then divided into two groups: Group 1=patients with a stable TAA or with a slow growth rate (≤2 mm/year) (n=23) and Group 2=patients with a fast-growing TAA (>2 mm/year) (n=7). Mean age of the patients was 65.8±10.8 years. At inclusion, the mean value for maximum aneurysm diameter was 44.6±3.4 mm. The mean follow-up period was 1.6±0.8 years. The patients presenting a significant increase in maximum aneurysm size have a significantly higher PIIINP level than those demonstrating no or limited growth in maximum aneurysm diameter (4.51±1.09 vs 3.38±0.96 µg/l respectively, p=0.02). There is no difference between the two groups for the other clinical or laboratory parameters. Following multivariate analysis the PIIINP level remains significantly higher in Group 1 (p=0.03). CONCLUSIONS: Our results suggest that it may in the future be possible to monitor TAA growth by means of PIIINP levels.
Assuntos
Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/patologia , Fragmentos de Peptídeos/sangue , Pró-Colágeno/sangue , Idoso , Aneurisma da Aorta Torácica/sangue , Biomarcadores/sangue , Seguimentos , Humanos , Pessoa de Meia-Idade , Projetos Piloto , Estudos ProspectivosRESUMO
OBJECTIVES: Multiplicity of aortic valve repair or sparing techniques results in a lack of standardisation, limiting widespread adoption of such procedures. To treat dilated diameters at the aortic annular base and sinotubular junction while maintaining root dynamics, we propose a standardised and physiological repair approach to the surgical management of aortic root aneurysms, consisting of root remodelling, cusp re-suspension and subvalvular aortic ring annuloplasty. METHODS: From May 2003 to September 2009, 144 unselected patients with aortic root aneurysms underwent remodelling with external subvalvular ring annuloplasty in 13 centres (21 surgeons). Preoperative aortic insufficiency (AI) > or =grade 2 was present in 63.9% (92), Marfan syndrome in 12.5% (18) and bicuspid valve in 22.9% (33). Cusp repair was performed in 40.3% (58) patients. RESULTS: Valve repair was successful in all but two cases. Repair of cusp prolapse was necessary in 58 patients, significantly more frequent in bicuspid (24/33, 72.7%) than in tricuspid (34/111, 30.6%) valves (p<0.05). Operative mortality was 2.8% (four). Subvalvular ring implantation produced a significant annular base reduction from 27.6+/-2.5 mm to 20.5+/-2.6 mm (p<0.01) without significant mean trans-valvular gradient (7.2+/-1.7 mmHg). During follow-up (median 2.2 years (0.75-4.4, maximum 6.25 years)), five patients died while eight required a re-operation. Six were operated on during our early experience. Strategy for cusp re-suspension evolved over three operative periods, with a significant increase in the rate of cusp repair. From May 2003 to December 2006: eye balling evaluation (15/67 (22.4%)); from January 2007 to August 2008: alignment of cusp free edges (17/38 (44.7%)); and from September 2008 to September 2009: a two-step standardised repair consisting of alignment of cusp free edges and effective height re-suspension (26/39 (66.7%) p<0.05). Freedom from AI> or =grade 2 was 91.3% (115) at the end of follow-up. CONCLUSIONS: Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.
Assuntos
Aneurisma Aórtico/cirurgia , Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/anormalidades , Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/cirurgia , Anuloplastia da Valva Cardíaca/métodos , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Síndrome de Marfan/cirurgia , Pessoa de Meia-Idade , Estudos Prospectivos , Próteses e Implantes , Reoperação , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty. METHODS: A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation. RESULTS: The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation. CONCLUSIONS: A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.