RESUMO
BACKGROUND:: Vacuum-assisted venous drainage (VAVD) is widely used to enhance venous blood return from patients undergoing cardiopulmonary bypass (CPB). This vacuum can accidentally reach the oxygenator of the heart-lung machine and draw gas bubbles into the blood. This is known as bubble transgression (BT) and may cause air emboli in the arterial blood line. In order to avoid BT and minimize the risk of patient injury, knowledge of oxygenator tolerance to vacuum load is critical. Thus, the main aim of this thesis was to investigate how much vacuum a membrane oxygenator can withstand before BT appears. METHODS:: We investigated four different adult oxygenators: Quadrox-i, Affinity Fusion, Capiox RX25 and Inspire 6M. They were tested in an in vitro setup where VAVD vacuum was allowed to reach the oxygenator through a non-occlusive roller pump. An ultrasonic clinical bubble counter, Gampt BCC 200, was used to count bubbles on the arterial line when the arterial pump was restarted. RESULTS:: We observed a significant increase in bubble count for two of the oxygenators, caused by -30 mmHg of VAVD vacuum in the blood reservoir (Affinity Fusion and Inspire 6M). Massive air ingress was shown in two of the oxygenators, caused by -30 mmHg of VAVD vacuum in the reservoir (Capiox RX25) and -40 mmHg of VAVD vacuum in the reservoir (Affinity Fusion). CONCLUSION:: VAVD vacuum may cause bubble transgression in an oxygenator. This was shown for all the oxygenators in this test. VAVD vacuum may cause visible massive air ingress in an oxygenator. This was shown for two of the oxygenators in this test (Capiox RX25 and Affinity Fusion). An alarm triggering on negative pressure in the oxygenator or a pressure relief valve might improve safety when using VAVD.
RESUMO
The complement system can be activated via the lectin pathway by the recognition molecules mannose-binding lectin (MBL) and the ficolins. Ficolin-2 exhibits binding against a broad range of ligands, including biomaterials in vitro, and low ficolin-2 levels are associated with increased risk of infections. Thus, we investigated the biocompatibility of the recognition molecules of the lectin pathway in two different types of cardiopulmonary bypass circuits. Bloods were drawn at five time-points before, during and postoperatively from 30 patients undergoing elective cardiac surgery. Patients were randomized into two groups using different coatings of cardiopulmonary bypass circuits, Phisio® (phosphorylcholine polymer coating) and Bioline® (albumin-heparin coating). Concentrations of MBL, ficolin-1, -2 and -3 and soluble C3a and terminal complement complex (TCC) in plasma samples were measured. Ficolin-3-mediated complement activation potential was evaluated with C4, C3 and TCC as output. There was no significant difference between the two circuit materials regarding MBL, ficolin-1 and -3. In the Bioline® group the ficolin-2 levels decreased significantly after initiation of surgery (P < 0.0001) and remained reduced throughout the sampling period. This was not seen for Phisio®-coated circuits. Ficolin-3-mediated complement activation potential was reduced significantly in both groups after start of operation (P < 0.0001), whereas soluble C3a and TCC in the samples were increased (P < 0.0001). Ficolin-2 was depleted from plasma during cardiac surgery when using heparin-coated bypass circuits and did not reach baseline level 24 h postoperation. These findings may have implications for the postoperative susceptibility to infections in patients undergoing extracorporeal circulation procedures.
Assuntos
Anticoagulantes , Ponte Cardiopulmonar , Lectina de Ligação a Manose da Via do Complemento , Stents Farmacológicos , Heparina , Lectinas/sangue , Proteínas do Sistema Complemento/metabolismo , Feminino , Glicoproteínas/sangue , Humanos , Masculino , Período Pós-Operatório , Fatores de Tempo , FicolinasRESUMO
OBJECTIVES: Experimental studies have shown involvement of Wnt signalling in heart failure (HF). We hypothesized that secreted frizzled-related protein 3 (sFRP3), a modulator of Wnt signalling, is related to the progression of HF. DESIGN: Circulating sFRP3 was measured in 153 HF patients and compared with 25 healthy controls. The association of sFRP3 with mortality was evaluated in 1202 patients (GISSI-HF trial). sFRP3 mRNA expression was assessed in failing human and murine left ventricles (LV), and cellular localization was determined after fractioning of myocardial tissue. In vitro studies were carried out in cardiac fibroblasts subjected to cyclic mechanical stretch. RESULTS: (i) Heart failure patients had significantly raised serum sFRP3 levels compared with controls, (ii) during a median follow-up of 47 months, 315 patients died in the GISSI-HF substudy. In univariable Cox regression, tertiles of baseline sFRP3 concentration were significantly associated with all-cause and cardiovascular mortality. After adjustment for demographic and clinical variables, but not for CRP and NT-proBNP, the associations with mortality remained significant for the third tertile (all-cause, HR 1.45, P = 0.011; cardiovascular, HR 1.66, P = 0.003), (iii) sFRP3 mRNA expression was increased in failing human LV, with a decline following LV assist device therapy. LV from post-MI mice showed an increased sFRP3 mRNA level, particularly in cardiac fibroblasts, and (iv) mechanical stretch enhanced sFRP3 expression and release in myocardial fibroblasts. CONCLUSION: There is an association between increased sFRP3 expression and adverse outcome in HF, suggesting that the failing myocardium itself contributes to an increase in circulating sFRP3.
Assuntos
Modelos Animais de Doenças , Insuficiência Cardíaca , Infarto do Miocárdio/metabolismo , Proteínas , Idoso , Animais , Progressão da Doença , Feminino , Regulação da Expressão Gênica , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/genética , Insuficiência Cardíaca/metabolismo , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/patologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Pessoa de Meia-Idade , Miocárdio/metabolismo , Miocárdio/patologia , Gravidade do Paciente , Modelos de Riscos Proporcionais , Proteínas/genética , Proteínas/metabolismo , Disfunção Ventricular Esquerda/metabolismo , Disfunção Ventricular Esquerda/patologia , Disfunção Ventricular Esquerda/fisiopatologia , Via de Sinalização Wnt/genéticaRESUMO
Heart transplant (HTx) recipients usually have reduced exercise capacity with reported VO(2peak) levels of 50-70% predicted value. Our hypothesis was that high-intensity interval training (HIIT) is an applicable and safe form of exercise in HTx recipients and that it would markedly improve VO(2peak.) Secondarily, we wanted to evaluate central and peripheral mechanisms behind a potential VO(2peak) increase. Forty-eight clinically stable HTx recipients >18 years old and 1-8 years after HTx underwent maximal exercise testing on a treadmill and were randomized to either exercise group (a 1-year HIIT-program) or control group (usual care). The mean ± SD age was 51 ± 16 years, 71% were male and time from HTx was 4.1 ± 2.2 years. The mean VO(2peak) difference between groups at follow-up was 3.6 [2.0, 5.2] mL/kg/min (p < 0.001). The exercise group had 89.0 ± 17.5% of predicted VO(2peak) versus 82.5 ± 20.0 in the control group (p < 0.001). There were no changes in cardiac function measured by echocardiography. We have demonstrated that a long-term, partly supervised and community-based HIIT-program is an applicable, effective and safe way to improve VO(2peak) , muscular exercise capacity and general health in HTx recipients. The results indicate that HIIT should be more frequently used among stable HTx recipients in the future.
Assuntos
Teste de Esforço/métodos , Tolerância ao Exercício/fisiologia , Transplante de Coração/reabilitação , Consumo de Oxigênio/fisiologia , Qualidade de Vida , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Insuficiência Cardíaca/cirurgia , Frequência Cardíaca/fisiologia , Transplante de Coração/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Cooperação do Paciente/estatística & dados numéricos , Educação Física e Treinamento/métodos , Estudos Prospectivos , Valores de Referência , Estatísticas não ParamétricasRESUMO
Although malignancy is a major threat to long-term survival of heart transplant (HT) recipients, clear strategies to manage immunosuppression in these patients are lacking. Several lines of evidences support the hypothesis of an anticancer effect of proliferation signal inhibitors (PSIs: mammalian target of rapamycin [mTOR] inhibitors) in HT recipients. This property may arise from PSI's ability to replace immunosuppressive therapies that promote cancer progression, such as calcineurin inhibitors or azathioprine, and/or through their direct biological actions in preventing tumor development and progression. Given the lack of randomized studies specifically exploring these issues in the transplant setting, a collaborative group reviewed current literature and personal clinical experience to reach a consensus aimed to provide practical guidance for the clinical conduct in HT recipients with malignancy, or at high risk of malignancy, with a special focus on advice relevant to potential role of PSIs.
Assuntos
Proliferação de Células/efeitos dos fármacos , Cardiopatias/complicações , Transplante de Coração/efeitos adversos , Imunossupressores/uso terapêutico , Neoplasias/tratamento farmacológico , Neoplasias/etiologia , Complicações Pós-Operatórias , Cardiopatias/cirurgia , HumanosRESUMO
A randomized open-heart surgery study comprising 30 patients was undertaken to compare the biocompatibility of Phisio-(phosphorylcholine) and PMEA-(poly-2-methoxyethyl acrylate) coated cardiopulmonary bypass (CPB) circuits and to assess the initial complement pathway activation during open-heart surgery. Blood samples were obtained at five time points, from the start of surgery to 24 hours postoperatively. The following analyses were performed: haemoglobin, lactate dehydrogenase, leukocyte and platelet counts, myeloperoxidase and neutrophil-activating peptide-2, thrombin-anti-thrombin complexes, syndecan-1 and the complement activation products C1rs-C1-inhibitor complexes, C4bc, C3bc, C3bBbP and the terminal complement complex (TCC). No significant inter-group difference was found in any parameters, except for the concentration of TCC which was moderately lower in the PMEA group at termination of CPB. Complement activation during open-heart surgery was mainly mediated through the alternative pathway. In conclusion, PMEA- and Phisio-coated circuits displayed similar biocompatibility with respect to inflammatory and haemostatic responses during and after open-heart surgery.
Assuntos
Acrilatos/imunologia , Ponte Cardiopulmonar/instrumentação , Materiais Revestidos Biocompatíveis/metabolismo , Ativação do Complemento , Fosforilcolina/imunologia , Idoso , Procedimentos Cirúrgicos Cardíacos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , PolímerosRESUMO
The neonate cardiopulmonary bypass (CPB) circuit, including a KIDS D100 oxygenator (The Sorin Group, Mirandola, Italy) and a D130 arterial filter (The Sorin Group), was evaluated in vitro with respect to the removal of free micro gas bubbles. No gas bubbles > 40microm were measured after the arterial filter D130 upon manual introduction of 10 ml of air into the venous line or during the use of vacuum-assisted venous drainage (VAVD). The D130 arterial filter removed 88 % of gas bubbles < 40 microm during manual introduction of air into the venous line; however, only 50 % of gas bubbles < 40 microm were removed during the use of VAVD. The same CPB circuit was evaluated in vivo to compare with another CPB circuit, including a D901 oxygenator (The Sorin Group) and arterial filter D736 (The Sorin Group), in 155 neonates weighing < or =5 kg. The D100 circuit required significantly less priming volume than the D901 circuit. Postoperative haemoglobin was significantly higher, artificial ventilation time was significantly shorter and postoperative bleeding was significantly less in the D100 group. This neonate CPB circuit effectively removed the gas bubbles and required up to 37% less priming volume and, thus, decreased the need for blood transfusion.
Assuntos
Peso Corporal , Ponte Cardiopulmonar/instrumentação , Ponte Cardiopulmonar/métodos , Circulação Extracorpórea/instrumentação , Embolia Aérea/diagnóstico , Embolia Aérea/etiologia , Embolia Aérea/prevenção & controle , Circulação Extracorpórea/métodos , Feminino , Humanos , Lactente , Recém-Nascido , MasculinoRESUMO
BACKGROUND: The biocompatibility of cardiopulmonary bypass surfaces has been improved by heparin and polymer surface modifications. The present study compared the effect of two such coatings on the inflammatory reactions after open heart surgery. METHODS: Thirty patients undergoing elective heart surgery were randomly assigned to receive one of two types of coated circuits: Bioline (n=15) or phosphorylcholine (Phisio, n=15). The platelet and leukocyte counts, neutrophil activation (myeloperoxidase), complement activation (C3a and TCC), concentrations of lactate dehydrogenase, 27 cytokines (including interleukins, chemokines and growth factors), thrombin-antithrombin complexes, and the endothelial cell marker syndecan-1 were analyzed at five predetermined time points until 24 hrs post operatively. RESULTS: Most measurements were comparable in both groups. However, myeloperoxidase was significantly higher in the Bioline group (p < 0.001). Postoperative lactate dehydrogenase concentrations were significantly higher in the Phisio group (p<0.01) and the maximal concentration of thrombin-antithrombin complexes 2 hours postoperatively tended to be higher in the Phisio group (p=0.08), consistent with a longer aortic cross-clamp and cardiopulmonary bypass time. CONCLUSIONS: The two circuits exhibited a comparable degree of in vivo biocompatibility.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar/métodos , Materiais Revestidos Biocompatíveis/efeitos adversos , Inflamação/etiologia , Fosforilcolina/efeitos adversos , Trombose/imunologia , Idoso , Anticoagulantes/efeitos adversos , Anticoagulantes/imunologia , Antitrombina III , Complemento C3a/metabolismo , Citocinas/sangue , Feminino , Hemoglobinas/metabolismo , Heparina/efeitos adversos , Heparina/imunologia , Humanos , Inflamação/imunologia , L-Lactato Desidrogenase/sangue , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Peptídeo Hidrolases/sangue , Peptídeos/efeitos adversos , Peptídeos/imunologia , Peroxidase/sangue , Fosforilcolina/imunologia , Contagem de Plaquetas , Sindecana-1/sangue , Trombose/tratamento farmacológicoRESUMO
BACKGROUND: In order to meet the increasing demand for donor organs, the concept of donation after circulatory death (DCD) was reintroduced in Norway, first as a pilot study, followed by the use of DCD as institutional practice. We report the current Norwegian experience with liver transplant after DCD. METHODS: After acceptance from next of kin, life support was withdrawn from patients with devastating brain injury and cardiac arrest observed. After a 5-minute "no-touch" period, extracorporeal membrane oxygenation for post mortem normothermic regional perfusion (NRP) by extracorporeal membrane oxygenator circuit was established. Data from all liver transplant recipients receiving controlled DCD (cDCD) livers in Oslo were analyzed. RESULTS: From 2015 to 2017, a total of 8 patients underwent liver transplant with cDCD and NRP liver grafts in Norway. Median Model for End-Stage Liver Disease score was 26 (range, 6-40). There were no cases of delayed graft function or graft loss. Seven patients have reached 1 year of follow-up, and 1 patient has reached 6 months. Two patients have recurrence of primary disease (primary sclerosing cholangitis and steatohepatitis). All patients had normalized liver function at last follow-up. Two patients underwent procedures for biliary complications. In 1 patient, leakage from the cystic duct was successfully handled endoscopically by stenting. In the other patient, a suspected stricture on magnetic resonance imaging led to an endoscopic retrograde cholangiopancreatography, which did not confirm signs of biliary stenosis. There was 1 instance of hepatic artery stenosis, which was managed with endovascular technique. CONCLUSION: The results after liver transplant using cDCD with NRP are good. The rate of complications seems to be within the same range as when using conventional donation after brain death grafts.
Assuntos
Oxigenação por Membrana Extracorpórea , Transplante de Fígado/métodos , Fígado/irrigação sanguínea , Doadores de Tecidos/provisão & distribuição , Adulto , Morte Encefálica , Função Retardada do Enxerto , Feminino , Sobrevivência de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Noruega , Estudos RetrospectivosRESUMO
The xenotransplantation research is driven by the shortage of allografts for transplantation of patients with end-stage organ failure and by lack of success in developing suitable artificial organs. Pigs are now generally accepted to be the donor species of choice, although a possible risk for transmission of xenozoonoses, particularly pig endogenous retroviruses, should be born in mind. A vascular xenograft from pig to human is usually rejected hyperacutely due to naturally occurring antibodies and complement. This hyperacute rejection can be prevented by manipulating with either of these systems. In this review we briefly describe the hyperacute rejection and how it can be prevented by complement modulation. Pigs made transgenic for human complement regulatory proteins seem very promising for future clinical experiments. Control of fluid-phase complement activation should be obtained as well. The latter is discussed based on our own recent studies in this field.
Assuntos
Proteínas do Sistema Complemento/efeitos adversos , Proteínas do Sistema Complemento/fisiologia , Transplante Heterólogo/métodos , Animais , Humanos , Transplante Heterólogo/efeitos adversosRESUMO
BACKGROUND: The possibility that human cytomegalovirus (HCMV) may infect porcine endothelial cells (ECs) was investigated. This may be relevant during xenotransplantation of porcine cells or organs into human recipients. METHODS: HCMV was inoculated into low-passage porcine ECs. Replication of virus was detected by development of characteristic cytopathogenic effect. Appearance of immediate early, early, and late antigens was studied by immunocytochemical staining. Infectious virus was detected in human fibroblast cells. Presence of HCMV RNA was studied by Northern Blot and reverse transcriptase polymerase chain reaction. RESULTS: All parameters indicated that a fresh clinical HCMV isolate productively infects porcine ECs. The same cells do not fully support replication of the laboratory strain Ad 169. CONCLUSION: Our results may indicate the possibility of cross-species infectivity of HCMV to porcine cells.
Assuntos
Infecções por Citomegalovirus/transmissão , Citomegalovirus/fisiologia , Endotélio Vascular/virologia , Suínos , Zoonoses , Animais , Células Cultivadas , Citomegalovirus/genética , Infecções por Citomegalovirus/genética , Infecções por Citomegalovirus/patologia , Endotélio Vascular/citologia , Humanos , RNA Viral/análiseRESUMO
BACKGROUND: Whereas complement is a key mediator of hyperacute xenograft rejection, its role in acute vascular rejection (AVR) is a matter of controversy. AVR is associated with de novo synthesis of endothelial cell-derived inflammatory mediators, including the leukocyte-recruiting adhesion molecule E-selectin. Here we investigate the role and mechanism of complement in human serum-induced porcine endothelial cell activation. METHODS: An in vitro xenotransplantation method was designed using porcine aortic endothelial cells stimulated with human serum in microculture wells. E-selectin expression was measured by cell-enzyme immunoassay. Complement inhibitors acting at different levels in the cascade were investigated for their effect on E-selectin expression. RESULTS: E-selectin was strongly induced by normal human serum but not by heat-inactivated serum. Compstatin, a synthetic C3 inhibitor, markedly reduced human serum-induced E-selectin expression. Purified C1-inhibitor suppressed E-selectin induction completely, indicating activation through the classical or lectin pathway. Furthermore, a monoclonal antibody (mAb) that inhibits cleavage of C5 or another mAb that blocks the function of C7, completely inhibited the expression of serum-induced E-selectin, consistent with the terminal C5b-9 complement complex being the mediator of the endothelial cell activation. Inhibition of the alternative pathway using a novel antifactor D mAb did not reduce E-selectin expression. CONCLUSION: Human serum-induced expression of porcine E-selectin is totally complement dependent, induced by a C1-inhibitor regulated pathway and mediated through the terminal complement complex. The data may have implications for therapeutic strategies, particularly of C1-inhibitor and anti-C5 mAb, to protect against endothelial cell activation and subsequent AVR of porcine xenografts.
Assuntos
Aorta/metabolismo , Fenômenos Fisiológicos Sanguíneos , Proteínas do Sistema Complemento/fisiologia , Selectina E/metabolismo , Endotélio Vascular/metabolismo , Suínos/metabolismo , Animais , Anticorpos Monoclonais/farmacologia , Aorta/citologia , Aorta/fisiologia , Células Cultivadas , Complemento C1/efeitos dos fármacos , Complemento C5/imunologia , Complemento C7/imunologia , Proteínas Inativadoras do Complemento/farmacologia , Complexo de Ataque à Membrana do Sistema Complemento/fisiologia , Selectina E/efeitos dos fármacos , Endotélio Vascular/citologia , Endotélio Vascular/fisiologia , Humanos , Peptídeos Cíclicos/farmacologiaRESUMO
Transplantation shows good results for patients with end-stage disease, but there is an increasing lack of organs. Xenotransplantation, the transfer of live animal cells, tissues, or organs to another species, offers a potential solution to this shortfall. Pig is regarded as the animal of choice for this purpose. Meanwhile demonstration of pig endogenous retrovirus (PERV) in all porcine herds has caused serious concern with respect to a possible transmission of the virus to humans with a transplanted organ. Transmission to human cells has been documented under certain in vitro conditions. However, no such transmission has been demonstrated in vivo. The possible consequences of introducing PERV into immunocompromised human organisms are not known and it is necessary to collect more information. Novel and sensitive genomic assays to detect PERV infection are now available in addition to established virological, immunoserological and molecular methods. In order to minimise the risk of PERV transmission rigorous procedures should be established. International guidelines to reduce the risk should be followed. Although a number of immunological, physiological and virological questions need to be answered before the introduction of xenotransplantation as an alternative clinical treatment, some problems can only be solved by judicious clinical trials.
Assuntos
Retrovirus Endógenos/patogenicidade , Infecções por Retroviridae/diagnóstico , Suínos/virologia , Transplante Heterólogo , Animais , Retrovirus Endógenos/genética , Retrovirus Endógenos/isolamento & purificação , Humanos , Hospedeiro Imunocomprometido , Infecções por Retroviridae/transmissão , Zoonoses/virologiaRESUMO
BACKGROUND: The aim of the study was to evaluate our clinical experience with the CarboMedics Heart Valve Prosthesis. METHODS: Nine hundred ninety-seven consecutive patients underwent mechanical valve implantation (aortic, 771; mitral, 169; double, 52; tricuspid, 5) with this prosthesis from September 1987 through December 1993. The mean age was 62.3+/-13.7 years (range, 0.4 to 84 years); 56.6% (564 patients) were men. Four hundred seventy patients (47.1%) underwent additional surgical procedures. Mean follow-up was 4.1+/-2.2 years (range, 0 to 8.3 years) with a total of 4,040 patient-years. RESULTS: Early mortality was 5.0% (50/997; aortic, 4.4%; mitral, 6.4%; double, 9.6%). Late mortality was 14.8% (140/947). Survival at 7 years was 75.9%+/-1.8% (aortic, 78.4%+/-2%; mitral, 70.7%+/-4.5%; double, 60.8%+/-7.4%). When matched for sex and age and compared with the normal Norwegian population, our patients had an increased standard mortality ratio in both men (1.9+/-0.4) and women (2.9+/-0.6). The linearized rate of major thromboembolism was 0.9% per patient-year, valve thrombosis 0.2% per patient-year, major bleeding event 0.6% per patient-year, paravalvular leak needing reoperation 0.5% per patient-year, prosthetic valve endocarditis 0.1% per patient-year, and of all reoperations 0.6% per patient-year. CONCLUSIONS: The CarboMedics Heart Valve Prosthesis has incidences of morbid events comparable with or better than reported for other mechanical valves.
Assuntos
Implante de Prótese de Valva Cardíaca , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica , Criança , Pré-Escolar , Endocardite/etiologia , Feminino , Seguimentos , Implante de Prótese de Valva Cardíaca/efeitos adversos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Valva Mitral , Complicações Pós-Operatórias , Falha de Prótese , Reoperação , Taxa de Sobrevida , Valva TricúspideRESUMO
BACKGROUND: Atrial fibrillation is the most common rhythm disturbance encountered after open heart operations, with a reported incidence up to 40%. Despite its high incidence and clinical relevance its etiology remains obscure. It has been hypothesized that atrial fibrillation might be related to extracorporeal circulation. We performed a retrospective study (January 1, 1997 to December 31, 1997) comparing the incidence of atrial fibrillation in 3 groups of patients revascularized with and without extracorporeal circulation. METHODS: The first group comprised patients with coronary artery disease operated on with standard revascularization technique with cardiopulmonary bypass (n = 685). The second group included patients who had minimally invasive coronary artery bypass grafting without the use of extracorporeal circulation (n = 19). Patients in the third group had off-pump transmyocardial laser revascularization (n = 19). RESULTS: There was no significant difference in the incidence of atrial fibrillation in the group that had conventional coronary artery bypass and the group that had minimally invasive coronary artery bypass without cardiopulmonary bypass. The incidence of atrial fibrillation was significantly lower in the transmyocardial laser group compared with the other two groups. CONCLUSIONS: The present study found that postoperative atrial fibrillation is not caused solely by extracorporeal circulation, but patients who had transmyocardial laser revascularization had a significantly lower incidence of atrial fibrillation.
Assuntos
Fibrilação Atrial/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Idoso , Ponte de Artéria Coronária/efeitos adversos , Feminino , Humanos , Terapia a Laser , Masculino , Revascularização Miocárdica , Estudos RetrospectivosRESUMO
BACKGROUND: This study examined the midterm results with the CarboMedics prosthetic valve. METHODS: From 1987 through 1991 a total of 569 patients received the CarboMedics prosthesis. RESULTS: Early mortality was 4.9% and related to emergency operation, presence of diabetes mellitus, coronary artery disease, preoperative New York Heart Association class, duration of cardiopulmonary bypass, and aortic cross-clamp time. Midterm follow-up with respect to mortality was 100% complete. All patients were followed up in the hospital after 1 year. In addition 86% of the patients responded to a questionnaire. Mean follow-up was 3 years (range, 0 to 5.6 years). Cumulative survival at 1 and 4 years was 91.2% +/- 1.2% and 83.7% +/- 1.8%, respectively. Five patients experienced obstructive valve thrombosis (0.3%/patient-year), 16 patients had major thromboembolic events (0.9%/patient-year), and 10 patients had major warfarin-related bleeding (0.6%/patient-year) requiring hospitalization or blood transfusions. Eight patients were reoperated on for paraprosthetic leak (0.4%/patient-year). Prosthetic valve endocarditis developed in 4 patients (0.2%/patient-year). No structural valve failure was observed. CONCLUSIONS: Midterm follow-up demonstrates that the CarboMedics mechanical prosthesis is reliable and has an acceptable rate of valve-related complications.
Assuntos
Próteses Valvulares Cardíacas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/cirurgia , Criança , Estudos de Avaliação como Assunto , Feminino , Seguimentos , Doenças das Valvas Cardíacas/fisiopatologia , Doenças das Valvas Cardíacas/cirurgia , Próteses Valvulares Cardíacas/efeitos adversos , Próteses Valvulares Cardíacas/mortalidade , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Fatores de Risco , Valva Tricúspide/cirurgiaRESUMO
BACKGROUND AND AIMS OF THE STUDY: Mechanical valves are the prosthesis of choice in valve replacement in children. However, the problem of somatic growth leading to patient-valve mismatch remains present, and the appropriate anticoagulation regimen remains controversial. We present our experience of valve replacement in a young population over 20 years. MATERIALS AND METHODS: Between 1972 and 1992, 48 patients (34 males and 14 females), mean age 11.2 years (range 0.4-27.4 years), underwent mechanical valve replacement at our institution. Aortic valve replacement was performed in 28 patients (58.3%), mitral valve replacement in 13 (27.1%), tricuspid valve replacement in six (12.5%) and pulmonary valve replacement in one patient (2.1%). The prostheses used were: St. Jude Medical (n = 2), Björk-Shiley (n = 14), Medtronic Hall (n = 16), Duromedics (n = 2) and CarboMedics (n = 14). Early mortality was 14.3%, 10.7% for aortic valve replacement and 30.8% for mitral valve replacement. Mean follow up for all patients was 8.3 years (range 0-22 years), with a total of 398 patient-years. RESULTS: Seven patients died during the follow up (17.1%). Survival after 10 years, including operative mortality, was 81% for aortic valve replacement, 33% for mitral valve replacement, 83% for tricuspid valve replacement and 100% for pulmonary valve replacement. All patients were anticoagulated with warfarin. In eight patients (16.7%) an antiplatelet drug (aspirin or dipyridamole) was added. Major events included paravalvular leak in six patients (1.5%/pty), valve thrombosis in five (mitral position in two, tricuspid in three) (1.3%/pty) and endocarditis in one patient (0.3%/pty). Minor thromboembolic events occurred in three patients (0.8%/pty) and minor hemorrhagic events in three (0.8%/pty). No patients developed hemolytic anemia and there was no case of structural failure. CONCLUSIONS: In our experience, mechanical prostheses in congenital heart disease were associated with significant morbidity and mortality, however long term survival after aortic valve replacement was good (81% at 10 years). Thromboembolic and hemorrhagic events were of minor significance. Atrio-ventricular valve replacement carried the highest risk of valve thrombosis and we now give warfarin and an antiplatelet drug to children undergoing mechanical valve implantation in this position.
Assuntos
Cardiopatias Congênitas/cirurgia , Próteses Valvulares Cardíacas , Valvas Cardíacas/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Emprego , Feminino , Seguimentos , Cardiopatias Congênitas/mortalidade , Cardiopatias Congênitas/reabilitação , Humanos , Lactente , Masculino , Complicações Pós-Operatórias/mortalidade , Qualidade de Vida , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
Pulmonary arteriovenous fistula wherein the malformation has venous drainage directly to the left atrium is a rare anomaly. Two case reports present such unusual arteriovenous malformations successfully treated by surgery.