RESUMO
Objectives: Analyses of incidence and time required to heal sternal wound infections after heart surgery performed via a median sternotomy between 2020 and 2022. Results: Superficial wound infections (SWI) were five times more common (2.7%) than mediastinitis (0.5%) among 2693 patients. The median time between the operation and diagnosis of SWI was 26 (interquartile range [IQR] 15-33) days vs. 16 (IQR 9-25) days for mediastinitis (p = .12). Gram-negative bacteria caused 44% of the 85 infections. Sternal wound infection correlated to higher body mass index, female sex, smoking, diabetes mellitus, previous myocardial infarction, coronary artery bypass grafting, use of internal mammary graft, and re-entry for postoperative bleeding. Eight of 59 patients (13.6%) with sternal wound infections had bilateral mammary grafts, compared to 102 of 1191 patients (8.6%) without wound infections (p = .28). Negative pressure wound therapy was always used to treat mediastinitis and applied in 63% of patients with SWI. Two of 13 patients with mediastinitis (15%) and none of 72 patients with SWI died within 90 days after the operation. The median time until the wound healed was 1.9 (IQR 1.3-3.7) months after SWI vs. 1.7 (IQR 1.3-5.3) months after mediastinitis (p = .63). Six patients (7%) required longer than one year to treat the infection. Conclusions: Postoperative sternal wound infections usually appeared several weeks after surgery and were associated with factors as high body mass index, diabetes mellitus and coronary artery bypass. SWI were more common than mediastinitis and often required negative pressure wound therapy and similar treatment time as mediastinitis.
Assuntos
Diabetes Mellitus , Mediastinite , Feminino , Humanos , Incidência , Mediastinite/diagnóstico , Mediastinite/epidemiologia , Estudos Retrospectivos , Fatores de Risco , Esterno/cirurgia , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/terapia , MasculinoRESUMO
AIMS: An observational nationwide all-comers prospective register study to analyse outcomes after coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in unprotected left main coronary artery (LMCA) disease. METHODS AND RESULTS: All patients undergoing coronary angiography in Sweden are registered in the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry. Between 01/01/2005 and 12/31/2015, 11 137 patients with LMCA disease underwent CABG (n = 9364) or PCI (n = 1773). Patients with previous CABG, ST-elevation myocardial infarction (MI) or cardiac shock were excluded. Death, MI, stroke, and new revascularization during follow-up until 12/31/2015 were identified using national registries. Cox regression with inverse probability weighting (IPW) and an instrumental variable (IV), administrative region, were used. Patients undergoing PCI were older, had higher prevalence of comorbidity but lower prevalence of three-vessel disease. PCI patients had higher mortality than CABG patients after adjustments for known cofounders with IPW analysis (hazard ratio [HR] 2.0 [95% confidence interval (CI) 1.5-2.7]) and known/unknown confounders with IV analysis (HR 1.5 [95% CI 1.1-2.0]). PCI was associated with higher incidence of major adverse cardiovascular and cerebrovascular events (MACCE; death, MI, stroke, or new revascularization) than CABG, with IV analysis (HR 2.8 [95% CI 1.8-4.5]). There was a quantitative interaction for diabetic status regarding mortality (P = 0.014) translating into 3.6 years (95% CI 3.3-4.0) longer median survival time favouring CABG in patients with diabetes. CONCLUSION: In this non-randomized study, CABG in patients with LMCA disease was associated with lower mortality and fewer MACCE compared to PCI after multivariable adjustment for known and unknown confounders.
Assuntos
Doença da Artéria Coronariana , Diabetes Mellitus , Intervenção Coronária Percutânea , Acidente Vascular Cerebral , Humanos , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea/métodos , Resultado do Tratamento , Ponte de Artéria Coronária/métodos , Diabetes Mellitus/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Sistema de RegistrosRESUMO
Objectives. The coronavirus disease 2019 (COVID-19) pandemic, which commenced in 2020, is known to frequently cause respiratory failure requiring intensive care, with occasional fatal outcomes. In this study, we aimed to conduct a retrospective nationwide observational study on the influence of the pandemic on cardiac surgery volumes in Sweden. Results. In 2020, 9.4% (n = 539) fewer patients underwent open-heart operations in Sweden (n = 5169) than during 2019 (n = 5708), followed by a 5.8% (n = 302) increase during 2021 (n = 5471). The reduction was greater than 15% in three of the eight hospitals in Sweden performing open-heart operations. Compared to 2019, in 2020, the waiting times for surgery were longer, and the patients were slightly younger, had better renal function, and a lower European System for Cardiac Operative Risk Evaluation; moreover, few patients had a history of myocardial infarction. However, more patients had insulin-treated diabetes mellitus, hypertension, peripheral vascular disease, reduced left ventricular function, and elevated pulmonary artery pressure. Urgent procedures were more common, but acute surgery was less common in 2020 than in 2019. Early mortality and postoperative complications were low and did not differ during the three years. Conclusion. The 9.4% decrease in the number of heart surgeries performed in Sweden during the 2020 COVID-19 pandemic, compared to 2019, partially recovered during 2021; however, there was no backlog of patients awaiting heart surgery.
Assuntos
COVID-19 , Procedimentos Cirúrgicos Cardíacos , Humanos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Pandemias , Estudos Retrospectivos , Suécia/epidemiologiaRESUMO
BACKGROUND: Elevated apolipoprotein B (apoB) and elevated apoB/apoA-1 ratio increase the risk of myocardial infarction (MI) and stroke, whereas high apoA-1 is protective. We study how these apolipoproteins are associated with major adverse cardiovascular events (MACEs), whether apoA-1 contributes to this association, and whether abnormal values occur decades before such events develop. METHODS AND FINDINGS: In the Swedish AMORIS (Apolipoprotein-related MOrtality RISk) cohort study, 137,100 men and women aged 25-84 years were followed an average 17.8 years. ApoB, apoA-1, and the apoB/apoA-1 ratio were analysed in relation to MACEs (non-fatal MI, stroke, and cardiovascular [CV] mortality), yielding 22,473 events. Hazard ratios (HRs) were estimated using Cox regression. Kaplan-Meier estimates were used to investigate the relationship of MACEs with increasing quintiles of the apoB/apoA-1 ratio in all age groups for both sexes. In nested case-control analyses, cases were randomly matched to age- and sex-matched controls, yielding population trajectories for apolipoproteins. Increased level of apoB and increased apoB/apoA-1 ratio were associated with risk of MACE and all clinical sub-components in both men and women across all ages (10th versus first decile in both sexes combined: HR 1.7 for MACE and 2.7 for non-fatal MI). Decreased values of apoA-1 potentiated the impact of apoB at all levels of apoB (on average across apoB range: 40% increase in HR for MACE and 72% increase in HR for non-fatal MI), indicating that the apoB/apoA-1 ratio covers a broader range of persons with dyslipidaemia at risk than apoB alone. In both men and women, MACEs occurred earlier on average for each increasing quintile of the apoB/apoA-1 ratio. Individuals with the highest levels of apoB/apoA-1 ratio experienced CV events on average several years earlier than those with lower ratios. Higher apoB/apoA-1 ratio in cases of MACE versus controls was seen already about 20 years before the event. A limitation of this study was that adjustment for tobacco smoking and hypertension was only possible in a small validation study. CONCLUSIONS: An imbalance between apoB and apoA-1 resulting in an increased apoB/apoA-1 ratio is strongly associated with the outcome MACE and its sub-components, in both men and women of all ages. An increased apoB/apoA-1 ratio already 2 decades before events calls for early recognition and primary prevention. Simple evidence-based cut values should be considered in future cardiovascular guidelines.
Assuntos
Apolipoproteína A-I/sangue , Apolipoproteínas B/sangue , Doenças Cardiovasculares/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Estudos de Coortes , Intervalos de Confiança , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio , Curva ROC , Fatores de Risco , Suécia , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Lipoproteins are associated with acquired aortic valve stenosis (AS). This study investigated whether an elevated apolipoprotein (apo)B/apoA-1 ratio was associated with an increased risk of AS and if this association was influenced by a history of a major adverse cardiovascular event (MACE) defined as stroke, myocardial infarction or revascularisation. METHODS: A study was undertaken of 131,816 individuals, aged ≥30 years, from the Swedish Apolipoprotein MOrtality RISk (AMORIS) cohort, with measurements of apolipoproteins B and A-1 at health examinations during 1985-1996. RESULTS: There were fewer women and the average age was 4 years older in the highest apoB/apoA-1 quintile compared with the lowest. Being overweight, having reduced renal function and diabetes mellitus were more frequent. Low-density lipoprotein cholesterol, triglyceride and apolipoprotein B levels were higher in the top apoB/apoA-1 quintile. During follow-up through 2011, non-rheumatic aortic valve disease was diagnosed in 2,999 individuals (2.3%). Using ICD-10 codes from 1997, AS was identified in 1,887 patients. An elevated apoB/apoA-1 ratio was associated with an increased incidence of aortic valve disease after multivariable adjustment [hazard ratio (HR) (95% CI) for the fifth vs first quintile of 1.28 (1.09-1.50)]. Restricting the analyses to incident AS during 1997-2011 yielded an HR of 1.41 (1.15-1.72). This increased incidence was primarily seen in women and individuals aged ≥65 years. History of MACE did not influence these associations. CONCLUSIONS: An elevated apoB/apoA-1 ratio was associated with an increased incidence of AS, particularly in women and individuals aged ≥65 years, regardless of previous MACE.
Assuntos
Estenose da Valva Aórtica , Apolipoproteínas B , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/epidemiologia , Apolipoproteína A-I , Apolipoproteínas , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Fatores de RiscoRESUMO
Objective. Evaluate if the use of active clearance of chest tubes after aortic valve surgery influenced bleeding and reduced postoperative residual pericardial effusion. Design. Prospective randomised trial comparing PleuraFlow® 32 F chest tube with FlowGlide™ active clearance to a standard Argyle® 32 F chest tube in 100 patients undergoing aortic valve surgery. Chest tube outputs and pericardial effusion measurements assessed by two-dimensional transthoracic echocardiography were recorded before hospital discharge. Results. Postoperative chest tube outputs per hour did not differ between the two groups. The median chest tube output was 400 mL for patients who had a PleuraFlow® chest tube vs. 490 mL for patients with an Argyle® chest tube (p = .08). Pericardial effusions ≥ 2 mm were detected in 76% vs. 68% of the patients (p = .50) and postoperative atrial fibrillation occurred in 42% vs. 34% (p = .54), respectively. Conclusions. Use of active clearance chest tubes, compared to standard chest tubes after aortic valve surgery did not differ significantly regarding postoperative bleeding or degree of pericardial effusion as measured by echocardiography prior to hospital discharge.
Assuntos
Valva Aórtica/cirurgia , Tubos Torácicos , Drenagem/instrumentação , Implante de Prótese de Valva Cardíaca/efeitos adversos , Derrame Pericárdico/prevenção & controle , Hemorragia Pós-Operatória/prevenção & controle , Idoso , Drenagem/efeitos adversos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/diagnóstico por imagem , Derrame Pericárdico/etiologia , Hemorragia Pós-Operatória/etiologia , Estudos Prospectivos , Suécia , Fatores de Tempo , Resultado do TratamentoRESUMO
Inflammatory mechanisms are activated, and thrombotic complications occur during the initial months after coronary artery bypass grafting (CABG). Therefore, changes over time of platelet activation and platelet-leukocyte interactions after CABG are of interest. Whole-blood flow cytometry was performed before, and 4-6 days, one month, and three months after elective CABG in 54 men with stable coronary artery disease treated with acetylsalicylic acid (ASA). Single platelets and platelet-leukocyte aggregates (PLAs) among monocytes (P-Mon), neutrophils (P-Neu), and lymphocytes (P-Lym) were studied without and with stimulation by submaximal concentrations of ADP, thrombin, and the thromboxane analog U46619. White blood cell counts were increased during the initial postoperative course, and platelet counts were increased after one month. Platelet P-selectin expression was significantly enhanced at one month when stimulated by thrombin and U46619 and at three months with ADP and thrombin. All PLAs subtypes were increased at one month without stimulation in vitro. P-Mon and P-Neu stimulated by ADP, thrombin, or U46619 were significantly increased one month after the operation but decreased compared to baseline at three months. Agonist stimulated P-Lyms were increased at one month and remained increased at three months after ADP stimulation. There was significant platelet activation and formation of PLAs unstimulated and after agonist stimulation by ADP, thrombin, and a thromboxane analog after CABG in patients with stable coronary artery disease irrespective of ASA treatment. Changes observed up to three months after CABG support further studies of the clinical implications of protracted increases in platelet activation and platelet-leukocyte interactions.
Assuntos
Ponte de Artéria Coronária/métodos , Leucócitos/metabolismo , Ativação Plaquetária/fisiologia , Agregação Plaquetária/fisiologia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Scientific knowledge on risk factors for work disability in terms of long-term sickness absence (SA) and disability pension (DP) following acute myocardial infarction (AMI) is limited. The study aimed to investigate socio-demographic, work-related and medical characteristics as risk factors for long-term SA (>90 days) and DP in patients with a first AMI. METHODS: This is a population-based cohort study of 8199 individuals aged 19-60 years who had a first AMI during 2008-10 and were alive 30 days after AMI. Univariate and multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) with regard to long-term SA and DP with a 3-year follow-up were estimated by Cox regression. RESULTS: We found a higher risk of long-term SA and DP after AMI in women, those with lower education and previous SA (range of HRs: 1.29-7.34). Older age and being born in non-European countries were associated with a 2- to 3-fold higher risk of DP. Moreover, ST-elevation myocardial infarction (STEMI), musculoskeletal and common mental disorders (CMDs) were risk factors for long-term SA and DP, while diabetes mellitus and stroke were associated with a higher risk of DP (range of HRs: 1.12-2.98). Coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention was associated with a 2-fold higher risk of work disability. CONCLUSIONS: Older women, those with lower education and non-European immigrants had a higher risk of work disability after AMI, particularly permanent work disability. STEMI, CABG, diabetes mellitus, stroke, musculoskeletal disorders and CMDs provide important clinical information for work disability after AMI.
Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Emprego/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Infarto do Miocárdio com Supradesnível do Segmento ST , Adulto , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , SuéciaRESUMO
Aims: Common mental disorders i.e. depressive and anxiety disorders (CMD) are frequent comorbid conditions in individuals with ischaemic heart disease (IHD). Still, their effect on preterm exit from the labour market [i.e. disability pension (DP)] in individuals with IHD has to date not been scrutinized. The aim of this study was to investigate the separate and joint effect of IHD and CMD on the risk of DP for women and men of working age. Material and methods: This population-based cohort study included all non-pensioned 4 823 069 individuals, registered as living in Sweden 31 December 2004 and then 16-64 years of age. Individuals with IHD or CMD were identified through using data on sickness absence, prescribed medication or in- or specialized outpatient care in 2005. Crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) for being granted DP in 2006-10 were estimated by means of Cox proportional hazard regression. Results: In the fully adjusted models, HRs for DP were 2.84 (95% CI; 2.57-3.13) and 2.83 (2.66-3.01) in women and men with IHD, respectively. Hazard ratios for DP in women and men with CMD were 5.13 (5.03-5.24) and 6.08 (5.93-6.24). In women and men with both conditions, crude HRs for DP were 18.38 (15.01-22.50) and 25.58 (22.27-29.37). There was a significant synergistic effect between IHD and CMD in both sexes in the crude models, which disappeared in women after adjusting for socio-demographic variables, and in men after additionally adjusting for comorbid somatic disorders. Conclusion: A comorbid CMD worsens the prognosis of IHD in terms of early exit from the labour market. Processes leading to DP in individuals with IHD are multifactorial and may involve the presence of CMD as well as comorbidity with other somatic diseases.
Assuntos
Transtornos Mentais , Isquemia Miocárdica , Licença Médica/estatística & dados numéricos , Adolescente , Adulto , Comorbidade , Feminino , Humanos , Masculino , Transtornos Mentais/complicações , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Isquemia Miocárdica/complicações , Isquemia Miocárdica/epidemiologia , Pensões/estatística & dados numéricos , Estudos Prospectivos , Suécia/epidemiologia , Adulto JovemAssuntos
Dispneia , Átrios do Coração , Neoplasias Cardíacas , Mixoma , Humanos , Dispneia/etiologia , Dispneia/diagnóstico , Ecocardiografia , Átrios do Coração/diagnóstico por imagem , Neoplasias Cardíacas/complicações , Neoplasias Cardíacas/diagnóstico , Neoplasias Cardíacas/cirurgia , Mixoma/complicações , Mixoma/cirurgia , Mixoma/diagnósticoRESUMO
AIMS: Excessive bleeding impairs outcome after coronary artery bypass grafting (CABG). Current guidelines recommend withdrawal of clopidogrel and ticagrelor 5 days (120 h) before elective surgery. Shorter discontinuation would reduce the risk of thrombotic events and save hospital resources, but may increase the risk of bleeding. We investigated whether a shorter discontinuation time before surgery increased the incidence of CABG-related major bleeding complications and compared ticagrelor- and clopidogrel-treated patients. METHODS AND RESULTS: All acute coronary syndrome patients in Sweden on dual antiplatelet therapy with aspirin and ticagrelor (n = 1266) or clopidogrel (n = 978) who underwent CABG during 2012-13 were included in a retrospective observational study. The incidence of major bleeding complications according to the Bleeding Academic Research Consortium-CABG definition was 38 and 31%, respectively, when ticagrelor/clopidogrel was discontinued <24 h before surgery. Within the ticagrelor group, there was no significant difference between discontinuation 72-120 or >120 h before surgery [odds ratio (OR) 0.93 (95% confidence interval, CI, 0.53-1.64), P = 0.80]. In contrast, clopidogrel-treated patients had a higher incidence when discontinued 72-120 vs. >120 h before surgery (OR 1.71 (95% CI 1.04-2.79), P = 0.033). The overall incidence of major bleeding complications was lower with ticagrelor [12.9 vs. 17.6%, adjusted OR 0.72 (95% CI 0.56-0.92), P = 0.012]. CONCLUSION: The incidence of CABG-related major bleeding was high when ticagrelor/clopidogrel was discontinued <24 h before surgery. Discontinuation 3 days before surgery, as opposed to 5 days, did not increase the incidence of major bleeding complications with ticagrelor, but increased the risk with clopidogrel. The overall risk of major CABG-related bleeding complications was lower with ticagrelor than with clopidogrel.
Assuntos
Adenosina/análogos & derivados , Ponte de Artéria Coronária/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Hemorragia Pós-Operatória/prevenção & controle , Ticlopidina/análogos & derivados , Adenosina/efeitos adversos , Idoso , Transfusão de Sangue/estatística & dados numéricos , Clopidogrel , Feminino , Humanos , Masculino , Hemorragia Pós-Operatória/induzido quimicamente , Sistema de Registros , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Suécia , Ticagrelor , Ticlopidina/efeitos adversos , Fatores de TempoRESUMO
BACKGROUND: There are limited data regarding long-term results after coronary artery bypass grafting (CABG) in young adults. We performed a nationwide population-based cohort study to analyze long-term survival, major adverse cardiovascular events, and factors associated with elevated risk in young adults undergoing CABG. METHODS AND RESULTS: We included all adult patients ≤50 years of age who underwent primary isolated CABG in Sweden between 1997 and 2013 from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) register. Patient data were linked from national Swedish health data registers to create a study database. We identified 4086 young adults with a mean age of 46 years and 18% women. During a median follow-up time of 10.9 years (interquartile range, 6.4-14.1) 490 (12%) patients died. Survival at 5, 10, and 15 years was 96% (95% CI, 95-96), 90% (95% CI, 89-91), and 82% (95%CI, 80-83), respectively, which was significantly better in comparison with patients aged 51 to 70 years and >70 years who underwent CABG during the same period. The cumulative incidence of death or a major adverse cardiovascular event during 17 years after CABG was mainly driven by myocardial infarction or the need for repeat revascularization. The most important risk factors for all-cause mortality were chronic kidney disease, reduced left ventricular ejection fraction, peripheral vascular disease, or chronic obstructive pulmonary disease. CONCLUSIONS: Long-term survival and freedom from major cardiovascular events after CABG was better in young adults than in older patients. Factors significantly associated with an elevated long-term risk of death or adverse outcome were similar to well-known risk factors for older age groups following CABG. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02276950.
Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Adulto , Fatores Etários , Doenças Cardiovasculares/mortalidade , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Nefropatias/mortalidade , Masculino , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Doença Pulmonar Obstrutiva Crônica/mortalidade , Fatores de Risco , Fatores Socioeconômicos , Análise de Sobrevida , Suécia/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: Using a multi-tissue, genome-wide gene expression approach, we recently identified a gene module linked to the extent of human atherosclerosis. This atherosclerosis module was enriched with inherited risk for coronary and carotid artery disease (CAD) and overlapped with genes in the transendothelial migration of leukocyte (TEML) pathway. Among the atherosclerosis module genes, the transcription cofactor Lim domain binding 2 (LDB2) was the most connected in a CAD vascular wall regulatory gene network. Here, we used human genomics and atherosclerosis-prone mice to evaluate the possible role of LDB2 in TEML and atherosclerosis. APPROACH AND RESULTS: mRNA profiles generated from blood macrophages in patients with CAD were used to infer transcription factor regulatory gene networks; Ldlr(-/-)Apob(100/100) mice were used to study the effects of Ldb2 deficiency on TEML activity and atherogenesis. LDB2 was the most connected gene in a transcription factor regulatory network inferred from TEML and atherosclerosis module genes in CAD macrophages. In Ldlr(-/-)Apob(100/100) mice, loss of Ldb2 increased atherosclerotic lesion size ≈2-fold and decreased plaque stability. The exacerbated atherosclerosis was caused by increased TEML activity, as demonstrated in air-pouch and retinal vasculature models in vivo, by ex vivo perfusion of primary leukocytes, and by leukocyte migration in vitro. In THP1 cells, migration was increased by overexpression and decreased by small interfering RNA inhibition of LDB2. A functional LDB2 variant (rs10939673) was associated with the risk and extent of CAD across several cohorts. CONCLUSIONS: As a key driver of the TEML pathway in CAD macrophages, LDB2 is a novel candidate to target CAD by inhibiting the overall activity of TEML.
Assuntos
Aterosclerose/fisiopatologia , Doenças das Artérias Carótidas/patologia , Quimiotaxia de Leucócito/fisiologia , Doença da Artéria Coronariana/patologia , Proteínas com Domínio LIM/fisiologia , Fatores de Transcrição/fisiologia , Migração Transendotelial e Transepitelial/fisiologia , Animais , Apolipoproteína B-100/genética , Doenças das Artérias Carótidas/genética , Linhagem Celular Tumoral , Quimiocina CCL2/farmacologia , Doença da Artéria Coronariana/genética , Perfilação da Expressão Gênica , Regulação da Expressão Gênica , Estudo de Associação Genômica Ampla , Humanos , Proteínas com Domínio LIM/deficiência , Proteínas com Domínio LIM/genética , Macrófagos/metabolismo , Camundongos , Camundongos Knockout , RNA Mensageiro/biossíntese , Fatores de Transcrição/deficiência , Fatores de Transcrição/genética , Migração Transendotelial e Transepitelial/genéticaRESUMO
BACKGROUND: Cardiac arrest as a consequence of deep accidental hypothermia is associated with high mortality. Standardized prehospital management as well as rewarming with extracorporeal circulation (ECC) are important factors to improve survival. The objective of this case report is to illustrate the importance of effective cardiopulmonary resuscitation (CPR) and ECC in a cardiac arrest following deep accidental hypothermia. CASE REPORT: A 42-year-old man was found unresponsive to external stimuli and pulseless at an outdoor temperature of 1°C. CPR was started at the scene by laypersons, and the emergency medical services (EMS) arrived 5 minutes after the emergency call. Resuscitation according to International Liaison Committee on Resuscitation (ILCOR) guidelines was initiated by EMS. The first recorded rhythm was ventricular fibrillation (VF), which persisted, despite repeated defibrillation. The patient showed signs of severe hypothermia and, during ongoing CPR, was transported to hospital where on arrival the patient's rectal temperature was measured at 22°C. Resuscitation measures were continued and warming was started at the emergency room. Due to persistent VF and deep hypothermia, the patient was transferred to a cardiothoracic surgical unit for rewarming with ECC. At commencement of ECC, CPR had been going for approximately 130 minutes and a total of 38 defibrillations had been made. During this time interval the patients was pulseless. At a core temperature of 30°C, one defibrillation restored sinus rhythm and subsequently stable circulation was achieved. The patient received a further 24 hours of hypothermia treatment at 32-34°C. He was discharged to rehabilitation facilities after 3 weeks of hospital care. Three months after the cardiac arrest the patient was fully recovered, was back to work, and had resumed normal activities. CONCLUSIONS: We demonstrate a case of cardiac arrest due to deep accidental hypothermia that stresses the importance of effective CPR and early-stage consideration of the use of ECC for safe and effective rewarming.
Assuntos
Reanimação Cardiopulmonar/métodos , Serviços Médicos de Emergência/métodos , Parada Cardíaca/terapia , Hipotermia/complicações , Fibrilação Ventricular/complicações , Acidentes , Adulto , Serviço Hospitalar de Emergência , Seguimentos , Parada Cardíaca/etiologia , Parada Cardíaca/fisiopatologia , Humanos , Hipotermia/terapia , Masculino , Reaquecimento/métodos , Medição de Risco , Sobreviventes , Fatores de Tempo , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/terapiaRESUMO
OBJECTIVES: To investigate the association between adenosine diphosphate (ADP)-induced platelet aggregation measured by single-platelet count testing and postoperative blood loss in clopidogrel-treated patients with acute coronary syndromes undergoing coronary artery bypass grafting (CABG). DESIGN: Prospective observational study. SETTING: Clinical study in one cardiac surgery center. PARTICIPANTS: Eighty-eight patients treated with clopidogrel (300-600 mg loading dose followed by 75 mg daily) within 7 days before CABG. INTERVENTIONS: Platelet function was assessed preoperatively by single-platelet count ADP-induced platelet aggregation. Postoperative blood loss and transfusion requirements were recorded. MEASUREMENTS AND MAIN RESULTS: There was no significant association between ADP-induced platelet aggregation and blood loss 12 hours postoperatively (estimate -7.51; 95% confidence interval [CI]: -16.9-1.9; p = 0.12). ADP-induced platelet aggregation was associated significantly with the number of platelet concentrates administered within 24 hours after surgery (incidence rate ratio [IRR] 0.95; 95% CI: 0.92-0.98; p<0.01), but not to the number of packed red blood cells (IRR 0.98; 95% CI: 0.95-1.01; p = 0.14). CONCLUSIONS: Preoperative ADP-induced platelet aggregation measured by single-platelet count testing in clopidogrel-treated patients with acute coronary syndromes undergoing CABG was not associated with postoperative blood loss or packed red blood cells transfused, but was associated significantly with number of platelet concentrates administered during the initial 24 postoperative hours.
Assuntos
Difosfato de Adenosina/farmacologia , Ponte de Artéria Coronária , Inibidores da Agregação Plaquetária/uso terapêutico , Agregação Plaquetária/efeitos dos fármacos , Contagem de Plaquetas , Hemorragia Pós-Operatória/epidemiologia , Ticlopidina/análogos & derivados , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/cirurgia , Idoso , Anestesia , Aspirina/uso terapêutico , Transfusão de Sangue , Tubos Torácicos , Clopidogrel , Intervalos de Confiança , Cuidados Críticos , Contagem de Eritrócitos , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Testes de Função Plaquetária , Estudos Prospectivos , Fatores de Risco , Ticlopidina/efeitos adversos , Ticlopidina/uso terapêuticoRESUMO
OBJECTIVES: To investigate whether point-of-care platelet function testing immediately before coronary artery bypass grafting correlates to postoperative blood loss and transfusion requirements. DESIGN: Blood samples from 50 patients on antiplatelet therapy were analysed by Plateletworks(®). Thirty-three of the patients had received clopidogrel, 300-600 mg loading dose followed by 75 mg once daily, within 7 days. Postoperative chest drainage volume was recorded every hour. RESULTS: Plateletworks(®) ADP-induced platelet aggregation correlated significantly to postoperative chest drainage volume at 5 hours (r = -0.83; p < 0.01) and 12 hours (r = -0.55; p < 0.01), and the tertile of patients with the lowest aggregation had higher postoperative transfusion requirements (p < 0.01) and about three times larger chest drainage volume than remaining patients during the first 5 hours after surgery (p < 0.01). Cessation of clopidogrel correlated to chest drainage volume at 5 hours (r = -0.48; p < 0.01) and 12 hours (r = -0.47; p < 0.01) after surgery. CONCLUSIONS: The significant correlation between Plateletworks(®) ADP-induced platelet aggregation and blood loss suggests that this test may be useful to predict risk of excessive bleeding and to guide timing of surgery and bleeding treatment in patients undergoing coronary artery bypass grafting.
Assuntos
Ponte de Artéria Coronária , Agregação Plaquetária/fisiologia , Testes de Função Plaquetária , Hemorragia Pós-Operatória/diagnóstico , Idoso , Aspirina/efeitos adversos , Transfusão de Sangue , Clopidogrel , Ponte de Artéria Coronária/efeitos adversos , Vasos Coronários/cirurgia , Feminino , Hemorragia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Sistemas Automatizados de Assistência Junto ao Leito , Cuidados Pós-Operatórios , Ticlopidina/análogos & derivados , Ticlopidina/farmacologia , Ticlopidina/uso terapêuticoRESUMO
OBJECTIVES: To investigate the prognostic importance of acute kidney injury on early mortality, postoperative stroke, and mediastinitis in patients undergoing a first isolated coronary artery bypass grafting. DESIGN: 7594 patients undergoing coronary artery bypass grafting with information on pre- and postoperative serum-creatinine values were included. Patients were classified using the Acute Kidney Injury Network classification. Odds ratios (OR) for mortality and postoperative complications within 60 days of surgery were calculated after adjustment for confounders separately for stage 1 and for stages 2 and 3 together. RESULTS: 1047 (14%) patients developed acute kidney injury. There were 132 (1.7%) deaths, 103 (1.4%) strokes and 118 (1.6%) cases of mediastinitis during follow-up. Among patients in stage 1 the adjusted odds ratio for death was 4.36 (95% confidence interval 2.83-6.71) and for stage 2 plus 3; 21.5 (12.0-38.6) compared to patients without acute kidney injury. Corresponding OR for stroke were 2.34 (1.43-3.82) and 6.52 (2.97-14.3) and for mediastinitis 2.88 (1.84-4.50) and 4.68 (2.07-10.6), respectively. CONCLUSIONS: Acute kidney injury following coronary artery bypass grafting is related to postoperative mortality, stroke, and mediastinitis. Patients undergoing coronary artery bypass grafting should be assessed for presence of acute kidney injury postoperatively, in order to predict early prognosis.
Assuntos
Injúria Renal Aguda/etiologia , Ponte de Artéria Coronária/efeitos adversos , Complicações Pós-Operatórias/etiologia , Injúria Renal Aguda/sangue , Injúria Renal Aguda/mortalidade , Idoso , Intervalos de Confiança , Ponte de Artéria Coronária/mortalidade , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Indicadores Básicos de Saúde , Humanos , Masculino , Mediastinite/etiologia , Razão de Chances , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/mortalidade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Análise de Sobrevida , Suécia , Fatores de Tempo , Resultado do TratamentoRESUMO
Environmental exposures filtered through the genetic make-up of each individual alter the transcriptional repertoire in organs central to metabolic homeostasis, thereby affecting arterial lipid accumulation, inflammation, and the development of coronary artery disease (CAD). The primary aim of the Stockholm Atherosclerosis Gene Expression (STAGE) study was to determine whether there are functionally associated genes (rather than individual genes) important for CAD development. To this end, two-way clustering was used on 278 transcriptional profiles of liver, skeletal muscle, and visceral fat (n = 66/tissue) and atherosclerotic and unaffected arterial wall (n = 40/tissue) isolated from CAD patients during coronary artery bypass surgery. The first step, across all mRNA signals (n = 15,042/12,621 RefSeqs/genes) in each tissue, resulted in a total of 60 tissue clusters (n = 3958 genes). In the second step (performed within tissue clusters), one atherosclerotic lesion (n = 49/48) and one visceral fat (n = 59) cluster segregated the patients into two groups that differed in the extent of coronary stenosis (P = 0.008 and P = 0.00015). The associations of these clusters with coronary atherosclerosis were validated by analyzing carotid atherosclerosis expression profiles. Remarkably, in one cluster (n = 55/54) relating to carotid stenosis (P = 0.04), 27 genes in the two clusters relating to coronary stenosis were confirmed (n = 16/17, P<10(-27 and-30)). Genes in the transendothelial migration of leukocytes (TEML) pathway were overrepresented in all three clusters, referred to as the atherosclerosis module (A-module). In a second validation step, using three independent cohorts, the A-module was found to be genetically enriched with CAD risk by 1.8-fold (P<0.004). The transcription co-factor LIM domain binding 2 (LDB2) was identified as a potential high-hierarchy regulator of the A-module, a notion supported by subnetwork analysis, by cellular and lesion expression of LDB2, and by the expression of 13 TEML genes in Ldb2-deficient arterial wall. Thus, the A-module appears to be important for atherosclerosis development and, together with LDB2, merits further attention in CAD research.
Assuntos
Movimento Celular/genética , Doença da Artéria Coronariana/genética , Células Endoteliais/patologia , Perfilação da Expressão Gênica , Redes Reguladoras de Genes/genética , Leucócitos/patologia , Fatores de Transcrição/metabolismo , Idoso , Animais , Aterosclerose/genética , Artérias Carótidas/patologia , Análise por Conglomerados , Estudos de Coortes , Biologia Computacional , Células Endoteliais/metabolismo , Feminino , Regulação da Expressão Gênica , Predisposição Genética para Doença , Humanos , Proteínas com Domínio LIM , Leucócitos/metabolismo , Masculino , Camundongos , Especificidade de Órgãos/genética , Reprodutibilidade dos Testes , Suécia , Fatores de Transcrição/genéticaRESUMO
BACKGROUND: The aim was to analyze routine preoperative testing for coronavirus disease 2019 (COVID-19) performed to avoid infected cardiac surgical patients transmitting virus during the pandemic. METHODS: Every patient scheduled to undergo cardiac surgery from March 2020 through December 2021 had preoperative polymerase-chain-reaction (PCR) test for COVID-19 by nasopharynx swabs. Any history of COVID-19 was recorded. RESULTS: In 15 of 1870 patients (0.8%) with minimal or no airway symptoms unexpected positive PCR tests were detected, and surgery was deferred for two weeks. Totally 38 patients with negative tests had recovered without sequelae from previous COVID-19 a mean of 5 months before the operation. Sixteen patients (0.8%) developed airway symptoms within six weeks after the operation and had positive COVID-19 tests. Body Mass Index was higher and female gender, diabetes mellitus, chronic obstructive pulmonary disease and reduced left ventricular ejection fraction were more common in patients with than in those without COVID-19. Early postoperative outcomes did not differ significantly in patients with versus without COVID-19. CONCLUSIONS: An unexpected preoperative positive COVID-19 test was detected in less than one percent of patients admitted for cardiac surgery during the pandemic. These operations were deferred to avoid transmission of virus in the hospital. Additionally, one percent of patients were diagnosed with positive COVID-19 tests within six weeks after the operation. There was no outbreak of COVID-19 among hospital staff or patients. All patients with COVID-19 before the operation were operated on safely and postoperative outcomes did not differ significantly compared with COVID-19 negative patients.