RESUMO
INTRODUCTION: Transvenous lead extraction (TLE), while mostly a safe procedure, has risk of serious periprocedural complications. As such, overnight hospitalization remains a routine practice. In our center, we routinely discharge patients on the same day following an uncomplicated TLE. METHODS: This is a retrospective study of 265 consecutive patients who underwent uncomplicated TLE in our center between 2019 and 2021. Same-day discharge (SDD) patients are compared with those who stayed at least overnight for observation after the TLE procedure (non-SDD group). To assess the safety of an SDD strategy after uncomplicated TLE, the main study endpoint was to compare the rate of major procedure-related complications at 1-, 7-, and 30-days. To identify the factors influencing the operator's decision to discharge the patient on the same day, the secondary endpoint was to analyze clinical and procedural predictors of SDD. RESULTS: A total of 153 patients were discharged the same day after uncomplicated TLE (SDD), while 112 stayed at least overnight after the procedure (non-SDD). There was no significant difference in major procedure-related complications at 1-day (SDD 0% vs. non-SDD 1.8%, p value = ns), while patients in the SDD group had a lower rate of 7- and 30-day complications when compared with those in the non-SDD group (2.1% vs. 8.2%, p value = .0308; and 3.5% vs. 16%, p value = .0049, respectively). Noninfectious indication for TLE (OR 16.1, 95% confidence interval [CI] 4.29-77.6) and procedure end time before 12:00 (OR 2.82, 95% CI 1.11-7.27) were the only independent predictors of SDD. CONCLUSION: SDD discharge following uncomplicated TLE in selected patients (i.e., those without device infection and when the TLE procedure is completed in the morning) is feasible and safe.
Assuntos
Hospitalização , Alta do Paciente , Humanos , Remoção de Dispositivo , Estudos de Viabilidade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Although donors with well-functioning bicuspid aortic valves (BAV) are not a contraindication for transplantation, BAV patients are at risk for long-term aortopathy and valve dysfunction. We report a case of a patient status-post heart transplant 13 years ago who presented to our institution with a BAV and severe aortic regurgitation associated with an aortic root aneurysm and underwent aortic root replacement.
Assuntos
Aneurisma Aórtico/etiologia , Aneurisma Aórtico/cirurgia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Implante de Prótese Vascular , Transplante de Coração/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Valva Aórtica/transplante , Doença da Válvula Aórtica Bicúspide , Feminino , Doenças das Valvas Cardíacas , Humanos , Pessoa de Meia-Idade , Índice de Gravidade de DoençaRESUMO
OBJECTIVES: Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a "single" dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia. METHODS: We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis. RESULTS: The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (p<0.001). Mean cardiopulmonary bypass time and mean aortic cross-clamp time were significantly shorter in the del Nido group compared to the conventional group: 71 ± 16 min vs. 84 ± 28 min (p<0.01), 52 ± 14 min vs. 60 ± 16 min (p<0.01), respectively. Postoperative inotropic support was required in 11 patients (20.4 %) in the del Nido group and 13 patients (24.1 %) in the conventional group (p=0.82) with no statistical difference. No patient required a postoperative intra-aortic balloon pump and in-hospital mortality was 0% in both groups. There was no significant difference in postoperative complications between the two groups. CONCLUSIONS: Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.
Assuntos
Soluções Cardioplégicas/administração & dosagem , Soluções Cardioplégicas/efeitos adversos , Implante de Prótese de Valva Cardíaca , Mortalidade Hospitalar , Adulto , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND AND AIM OF THE STUDY: The advantages of minimally invasive aortic valve replacement (AVR) are well documented, but whether the benefits extend to subsequent reoperative aortic valve surgery and beyond is unknown. The study aim was to compare in-hospital outcomes and long-term survival following reoperative AVR between patients who had previous undergone either minimally invasive AVR (mini-AVR) or full sternotomy AVR (sAVR). METHODS: All reoperative, isolated AVRs performed between July 1997 and September 2013 at the authors' institution, with or without non-complex aortic surgery, were identified. Patients were excluded if AVR was not isolated, had occurred prior to July 1997, or if the initial AVR was performed before the patient was aged 18 years. All reoperations were performed through a full sternotomy. The main outcomes of interest were operative results and long-term survival. RESULTS: A total of 101 patients was identified, of which 34 had undergone previous mini-AVR and 67 previous sAVR. The time from the previous AVR was similar in both groups (median 7.6 years overall). Of previous valve implants, 57 were bioprostheses and 44 mechanical; structural valve degeneration was the most common indication for surgery (43/101). Mini-AVR and sAVR patients did not differ significantly with regards to patient demographics and preoperative risk factors. A strong trend towards shorter skin-to-skin operative times was observed for mini-AVR (330 min versus 356 min; p = 0.053). Postoperatively, mini-AVR patients had a shorter ventilation time (5.7 h versus 8.4 h; p = 0.005), intensive care unit stay (37 h versus 63 h; p ≤ 0.001) and hospital length of stay (6.5 days versus 8.0 days; p = 0.038). There was one operative mortality in the sAVR, and none in the mini-AVR group. Mid-term survival at one and five years for mini-AVR was 100% (95% CI 100-100) and 100% (95% CI 100-100), and for sAVR was 93.9% (95% CI 88.2-99.7) and 85.0% (95% CI 75.1-94.9), respectively (p = 0.041). CONCLUSION: Mini-AVR confers benefits during subsequent reoperative AVR, with shorter hospital stays and improved long-term survival. These findings suggest that mini-AVR should be considered for patients at risk for aortic valve reoperation, and describes a previously unreported advantage of this well-established technique.
Assuntos
Implante de Prótese de Valva Cardíaca , Idoso , Bioprótese , Transfusão de Sangue/estatística & dados numéricos , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Implante de Prótese de Valva Cardíaca/mortalidade , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Duração da Cirurgia , Reoperação , Estudos Retrospectivos , EsternotomiaRESUMO
BACKGROUND: Del Nido cardioplegia, a crystalloid-based solution with lidocaine as a key element, is given as a single dose and has been used successfully in congenital cardiac surgery. HYPOTHESIS: We retrospectively compared a lidocaine containing "modified del Nido" solution with our standard whole blood cardioplegia to investigate its safety and efficacy in adult cardiac surgery. METHODS: From June 1, 2013 to December 30, 2013, we used a single dose of lidocaine containing cardioplegia (LC group) in 92 consecutive operations. Propensity matching analysis was undertaken to compare the outcomes of such patients with those who underwent their surgery by the same surgeon using standard whole blood cardioplegia (WB group), n = 396. Propensity score matching yielded 79 pairs of patients. RESULTS: After propensity matching, LC and WB groups were similar in baseline operative characteristics including cross-clamp time (LC: 65 minutes [range 54 to 89] vs. WB: 70 minutes [54 to 86], p = 0.993). Postoperative outcomes were similar including inotropic requirements (30.4% [24/72] vs. 25.3% [20/72], p < 0.60), median ventilation time (4.7 hours vs. 5.3, p < 0.74) and median length of stay was seven days for both groups (p < 0.82). Despite higher median postoperative, 24-hour CK-MB levels LC group (LC:22.3 ng/ml, range [15.6 to 40.3] vs. WB:18.4 ng/ml [13.9 to 28.2], p = 0.040), operative and one-year mortality were comparable among study groups (both p > 0.798). CONCLUSIONS: Lidocaine containing cardioplegia appears to be safe in adults undergoing cardiac procedure when administered for the first 60 minutes of aortic cross clamping. Higher CK-MB levels did not translate into adverse clinical outcomes.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Parada Cardíaca Induzida/métodos , Cardiopatias/cirurgia , Lidocaína/administração & dosagem , Compostos de Potássio/administração & dosagem , Idoso , Creatina Quinase Forma MB/análise , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Pontuação de Propensão , Estudos Retrospectivos , Instrumentos Cirúrgicos , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVES: The search continues for the ideal composite biologic graft (CBG). We have performed aortic root replacements with CBGs, initially with a stented pericardial valve in a Valsalva graft (Gen1) and subsequently with the stentless 3f valve (Gen2). The valve is sewn at the base of the graft sinuses, leaving residual proximal graft to sew separately to the left ventricular outflow tract. This allows for CBG size standardization and permits fabrication prior to bypass. We share our institutional experience and aim to show noninferiority of this technique, as well as discuss potential advantages. METHODS: The first 75 patients to receive each generation of CBG were identified and assessed retrospectively. Overall survival was assessed as our primary outcome. Various secondary outcomes were also analyzed, including operative times and short-term outcomes. RESULTS: Operative times were shorter for Gen2, with cardiopulmonary bypass times that were significantly reduced (126.3 ± 5.2 minutes vs. 157.6 ± 5.8 minutes for Gen1, p = 0.001) and aortic cross-clamp times that trended lower (98.2 ± 4.2 minutes vs. 107.7 ± 3.8 minutes for Gen1, p = 0.095). There were no postoperative myocardial infarctions (MIs) or aortic insufficiency graded 2+ or greater in either group. There was only one stroke in a Gen1 patient who recovered fully. Kaplan-Meier survival analysis showed a strong trend toward improved survival among Gen2 patients (p = 0.0566). CONCLUSIONS: Our experience with Gen2 CBG showed decreased operative times and a trend toward improved survival, though further patient follow-up and larger sample sizes in prospective studies are necessary. Further research with this CBG and additional improvements are warranted.
Assuntos
Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Desenho de Prótese , Estudos Retrospectivos , Stents , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Despite recent public policy initiatives, rheumatic heart disease (RHD) remains a major source of morbidity worldwide. Rheumatic heart disease occurs as a sequela of Streptococcus pyogenes (group A streptococcal [GAS]) infection in patients with genetic susceptibility. Strategies for prevention of RHD or progression of RHD include prevention of GAS infection with community initiatives, effective treatment of GAS infection, and secondary prophylaxis with intramuscular penicillin. The cardiac surgical community has attempted to improve the availability of surgery in RHD-endemic areas with some success, and operative techniques and outcomes of valve repair continue to improve, potentially offering patients a safer, more durable operation. Innovation offers hope for a more scalable solution with improved biomaterials and transcatheter delivery technology; however, cost remains a barrier.
RESUMO
Increased thresholds in permanent epicardial leads pose a special challenge in the postoperative period. We present a case of complete heart block after surgical correction of a congenital heart defect that required conversion of an axial bipolar lead to unipolar lead to avoid lead replacement. We review the options for repair and describe our approach to this patient.
Assuntos
Bloqueio Cardíaco/terapia , Marca-Passo Artificial , Complicações Pós-Operatórias/terapia , Cardiopatias Congênitas/cirurgia , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/cirurgia , Reoperação , Insuficiência da Valva Tricúspide/cirurgiaAssuntos
Ablação por Cateter , Traumatismos Cardíacos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fibrilação Atrial/cirurgia , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/cirurgia , Resultado do TratamentoRESUMO
OBJECTIVES: Bicuspid aortic valve (BAV) is the most common congenital valvular abnormality and frequently presents with accelerated calcific aortic valve disease, requiring aortic valve replacement (AVR) and thoracic aortic aneurysm and dissection. Supporting evidence for Association Guidelines of aortic dimensions for aortic resection is sparse. We sought to determine whether concurrent repair of dilated or aneurysmal aortic disease during AVR in patients with BAV substantially improves morbidity and mortality outcomes. METHODS: Mortality and reoperation outcomes of 1301 adults with BAV and dilated aorta undergoing AVR-only surgery were compared to patients undergoing AVR with aortic resection (AVR-AR) using Cox proportional hazards modelling and patient matching. RESULTS: Clinically important differences in patient characteristics, aortic valve function and aortic dimensions were identified between cohorts. Event rates were low, with rates of reoperation and death within 1 year of only 1.8% and 5.4%, respectively, and no aortic dissection observed during follow-up. There were no significant differences in reoperation or mortality outcomes between the AVR-only and AVR-AR cohorts. Age, aortic dimension or a combination thereof was not associated with better or worse outcomes after each AVR-AR compared with AVR. CONCLUSIONS: We conclude AVR-only and AVR-AR surgery have low morbidity and mortality and have utility over a wide range of age and aortic sizes. Our results do not provide support for the 45-mm aortic dimension recommended in the current guidelines for aortic resection while performing AVR or any other specific dimension.
Assuntos
Valva Aórtica/anormalidades , Valva Aórtica/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/cirurgia , Doença da Válvula Aórtica Bicúspide , Feminino , Próteses Valvulares Cardíacas , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Isolated tricuspid valve (ITV) operations are infrequent and the decision to operate is controversial. We report a series of ITV operations to outline the current disease status requiring this uncommon procedure with an emphasis on the results of tricuspid valve repair (TVr) versus replacement (TVR). METHODS: Using our prospective cardiac surgery database, 57 patients who underwent ITV operations between 01/02-03/14 were identified. Median follow up time was 3.5 years [interquartile range (IQR), 0.8-6.7 years]. RESULTS: Fifty-seven patients underwent ITV surgery with a mean age of 54.4±14.9 yrs and 61% were women. Baseline characteristics were similar between patients who underwent TVr (n=18) or TVR (n=39). The etiologies of TV dysfunction were: ITV endocarditis 14/57 (25%), persistent TV regurgitation after left-sided valve surgery in 12/57 (21%), traumatic biopsies and iatrogenic injury from pacing leads in 11/57 (19%), orthotopic heart transplant 9/57 (16%), carcinoid syndrome 3/57 (5%), congenital 2/57 (5%) and idiopathic 5/57 (9%). Overall, 32/57 (56%) patients had prior heart surgery; of which 10/32 (31%) were TV procedures. Bioprosthetic prostheses were used in 34/39 (87%) patients. Of those who had repair, 11/18 (61%) had ring annuloplasty, 3/18 (17%) bicuspidization, and 3/18 (17%) De Vega annuloplasty and one had vegetectomy. Operative mortality was 5.1% (n=2) and 16.7% (n=3) for TVR and TVr groups, respectively (P=0.32), with an overall mortality rate of 8.6%. Postoperative complications included new onset renal failure in 6/39 (15%) of TVr and 2/18 (11%) of TVR (P=0.71) and there were no strokes. Overall survival rates and degree of residual RV dysfunction were similar for the two groups (both P=0.3). Five-year survival was 77% and 84% for TVr and TVR respectively (P=0.52). There was no difference in rates of recurrent tricuspid regurgitation for TVr and TVR (35.7% vs. 23.5%, respectively, P=0.4). CONCLUSIONS: ITV surgery is associated with improved but still relatively high operative mortality. Mid-term outcomes for TVr and TVR are similar with regards to postoperative complications, survival, and freedom from recurrent tricuspid regurgitation.
RESUMO
BACKGROUND: Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR). METHODS: From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF). RESULTS: The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001). CONCLUSIONS: In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.
RESUMO
BACKGROUND: The current study assesses outcomes and risk factors for aortic valve replacement (AVR) for aortic regurgitation (AR) in the setting of markedly reduced left ventricular (LV) function compared with moderately reduced LV function and preserved LV function. METHODS: Between January 2002 and June 2013, 485 consecutive patients underwent AVR for severe AR. Overall, 37 of 485 patients (8%) had an LV ejection fraction (EF) less than or equal to 35% (low EF) with median of 30%; 141 of 485 patients (27%) had an LVEF of 36% to 50% (moderate) with median of 45%, and 307 of 485 patients (65%) had an LVEF greater than 50% (preserved) with median of 60%. RESULTS: Preoperative characteristics were similar across groups, except patients with low EF were older (67.4 ± 12.1 years versus moderate [58.6 ± 15.0 years], p = 0.003 versus preserved [56.9 ± 14.3 years], p = 0.001), more often had reoperations (35.1% versus preserved 19.9%, p = 0.054), and had more concomitant coronary artery bypass grafts (37.6% versus preserved 14.3%, p = 0.001). Operative mortality for the entire cohort was 1.9% (9 or 485) and was similar across groups, 0% in the low EF group, 2.1% (3 of 141) in the moderate group, and 2.0% (6 of 307) in the preserved group (all p > 0.5). Cox proportional hazard modeling indicated that age (hazard ratio [HR] 1.061, p ≤ 0.001), preoperative creatinine (HR 1.478, p ≤ 0.014), history of atrial fibrillation (HR 1.920, p = 0.095), and New York Heart Association class III/IV (HR 2.127, p = 0.004) predicted survival. At median follow-up of 26 months, in the low EF group, the mean LVEF at follow-up was 49.5% ± 10.2% versus baseline 30% ± 4.6% (p ≤ 0.001). CONCLUSIONS: In this series, patients with markedly reduced LV function (LVEF ≤35%) had similar postoperative outcomes and survival as patients with moderate LV dysfunction or preserved LV function.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Próteses Valvulares Cardíacas , Substituição da Valva Aórtica Transcateter/métodos , Disfunção Ventricular Esquerda/cirurgia , Função Ventricular Esquerda/fisiologia , Idoso , Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/diagnóstico , Insuficiência da Valva Aórtica/fisiopatologia , Ecocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Volume Sistólico/fisiologia , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
BACKGROUND: Minimally invasive aortic valve surgery (mini AVR) is a safe and effective treatment option at many hospital centers, but there has not been widespread adoption of the procedure. Critics of mini AVR have called for additional evidence with direct comparison to aortic valve replacement (AVR) via full sternotomy (FS). METHODS: Our mini AVR approach is through a hemi-sternotomy (HS). We performed a propensity-score matched analysis of all patients undergoing isolated AVR via FS or HS at our institution since 2002, resulting in 552 matched pairs. Baseline characteristics were similar. Operative characteristics, transfusion rates, in-hospital outcomes as well as short and long term survival were compared between groups. RESULTS: Median cardiopulmonary bypass and cross clamp times were shorter in the HS group: 106 minutes [inter-quartile ranges (IQR) 87-135] vs. 124 minutes (IQR 90-169), P≤0.001, and 76 minutes (IQR 63-97) vs. 80 minutes (IQR 62-114), P≤0.005, respectively. HS patients had shorter ventilation times (median 5.7 hours, IQR 3.5-10.3 vs. 6.3 hours, IQR 3.9-11.2, P≤0.022), shorter intensive care unit stay (median 42 hours, IQR 24-71 vs. 45 hours, IQR 24-87, P≤0.039), and shorter hospital length of stay (median 6 days, IQR 5-8 vs. 7 days, IQR 5-10, P≤0.001) compared with the FS group. Intraoperative transfusions were more common in FS group: 27.9% vs. 20.0%, P≤0.003. No differences were seen in short or long term survival, or time to aortic valve re-intervention. CONCLUSIONS: Our study confirms the clinical benefits of minimally invasive AVR via HS, which includes decreased transfusion requirements, ventilation times, intensive care unit and hospital length of stay without compromising short and long term survival compared to conventional AVR via FS.
RESUMO
OBJECTIVES: Aortic valve replacement (AVR) in patients with severely atherosclerotic aortas (porcelain aorta) presents a significant technical challenge. Two strategies are deep hypothermic circulatory arrest (DHCA) during conventional surgery and transcatheter aortic valve replacement (TAVR). The aim of this study was to examine the outcomes in patients who underwent DHCA for AVR with a porcelain aorta to identify whether older patients are more suitable for TAVR. METHODS: Between October 2004 and December 2012, 122 patients underwent AVR using DHCA for atherosclerotic aorta. Patients with concomitant valve surgery were excluded. Overall, 63.9% (78/122) were of age <80 (non-octogenarian group, NOG) and 36.1% (44/122) were >80 (octogenarian group, OG). Of the total cohort, 62.3% (76/122) had concomitant coronary artery bypass graft surgery. RESULTS: The mean age for the whole cohort was 75.7 ± 8.5 years; 70.2 ± 8.1 years for the NOG and 83.4 ± 2.6 years for the OG (P = 0.001). The OG had a higher rate of preoperative renal failure (20.5%, 9/44 vs 7.7%, 6/78, P = 0.048) and trends towards a greater history of cerebrovascular disease (9.1%, 4/44 vs 1.3%, 1/78, P = 0.056), but fewer reoperations (6.8%, 3/44 vs 19.2%, 15/78, P = 0.069). Cardiopulmonary bypass time, aortic cross-clamp time and circulatory arrest time were similar between the two groups. Postoperative complication rates were similar except for permanent stroke (OG 18.2%, 8/44 vs NOG 6.4%, 5/78, P = 0.065). The overall operative mortality rate was 8.2% (10/122); however, the OG had significantly higher operative mortality compared with the NOG (15.9%, 7/44 vs 3.8%, 3/78, P = 0.035). One- and 5-year survival rates were 88.9 and 79.3% for the NOG versus 75.0 and 65.9% for the OG (P = 0.027), respectively. CONCLUSIONS: Postoperative neurological events and operative mortality were, respectively, 3- and 4-fold higher in octogenarians undergoing AVR using DHCA. Such patients may represent suitable candidates for TAVR if favourable outcomes are demonstrated in patients with atherosclerotic aortas. Surgical AVR remains the standard treatment option with excellent outcomes for patients <80 years old with unclampable aortas.
Assuntos
Doenças da Aorta/complicações , Aterosclerose/complicações , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Calcificação Vascular/complicações , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doenças da Aorta/diagnóstico , Doenças da Aorta/mortalidade , Aterosclerose/diagnóstico , Aterosclerose/mortalidade , Boston , Parada Circulatória Induzida por Hipotermia Profunda/mortalidade , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Calcificação Vascular/diagnóstico , Calcificação Vascular/mortalidadeRESUMO
BACKGROUND: Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period. METHODS: Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients. RESULTS: Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018). CONCLUSIONS: This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.
Assuntos
Embolectomia , Embolia Pulmonar/cirurgia , Idoso , Contraindicações , Embolectomia/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Terapia Trombolítica , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Valve endocarditis is associated with high morbidity and mortality and requires a thorough evaluation including early surgical consultation to identify patients who may benefit from surgery. We review 5 recent articles that highlight the current debates related to best treatment strategies for valve endocarditis. Recent publications have focused on neurologic risk assessment, timing of surgery, and prognostic factors associated with native and prosthetic valve endocarditis. The initial patient assessment and management is best performed by a multidisciplinary team. Future investigations should focus on identifying surgical candidates early and the outcomes affected by replacement valve choice in both native and prosthetic valve endocarditis.
Assuntos
Valva Aórtica , Gerenciamento Clínico , Ecocardiografia/métodos , Embolia/prevenção & controle , Endocardite Bacteriana/cirurgia , Endocardite/mortalidade , Endocardite/cirurgia , Endocardite/terapia , Doenças das Valvas Cardíacas/terapia , Próteses Valvulares Cardíacas/microbiologia , Guias de Prática Clínica como Assunto , Infecções Relacionadas à Prótese/cirurgia , Infecções Estafilocócicas/terapia , Valva Tricúspide/cirurgia , Feminino , Humanos , MasculinoRESUMO
Modern treatment of cardiovascular disease requires a patient-centered approach. With several technological advances, the options for treatment must be carefully weighed and novel approaches tested for safety and efficacy. In this article, we outline some of the new approaches available to cardiothoracic surgeons for the treatment of cardiovascular diseases, including off-pump coronary artery bypass grafting, transcatheter valve replacement, and hybrid and robotic technology. We discuss current evidence and controversies and highlight the challenges that we face in training surgeons in an environment of ever-evolving surgical techniques.