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1.
Catheter Cardiovasc Interv ; 82(5): 778-81, 2013 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-23378258

RESUMO

An 85-year-old gentlemen with a history of previous triple vessel coronary bypass grafting presented with severe aortic stenosis and occlusion of the previous saphenous vein grafts but with patent left internal mammary artery (LIMA)-left anterior descending. The patient underwent uncomplicated repeat sternotomy and aortic valve replacement with repeated coronary bypass. On post-operative day 21 the patient was successfully resuscitated from a pulseless electrical activity (PEA) arrest, and was found to have a 1-cm pseudoaneurysm of the left internal mammary artery at the level of sternomanubrial junction with associated hemothorax. The LIMA remained patent and a pinhole source of extravasation was discovered by angiography at the aneurysmal site. The defect was successfully repaired by endovascular implant of a 3.5 mm × 12 mm Graft Master covered stent (Abbott Vascular). The patient recovered well from the procedure without further complications and was discharged after a total of 48 days of hospital stay. Our experience confirms the feasibility of repairing post-operative pseudoaneurysm in the internal mammary artery by endovascular stent grafting, thereby avoiding the risks and complications of a repeat open chest procedure.


Assuntos
Falso Aneurisma/terapia , Estenose da Valva Aórtica/cirurgia , Ponte de Artéria Coronária/efeitos adversos , Procedimentos Endovasculares/instrumentação , Oclusão de Enxerto Vascular/cirurgia , Artéria Torácica Interna/cirurgia , Veia Safena/transplante , Stents , Esternotomia/efeitos adversos , Idoso de 80 Anos ou mais , Falso Aneurisma/diagnóstico , Falso Aneurisma/etiologia , Falso Aneurisma/fisiopatologia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico , Oclusão de Enxerto Vascular/diagnóstico , Oclusão de Enxerto Vascular/etiologia , Implante de Prótese de Valva Cardíaca , Humanos , Masculino , Artéria Torácica Interna/diagnóstico por imagem , Artéria Torácica Interna/lesões , Artéria Torácica Interna/fisiopatologia , Desenho de Prótese , Reoperação , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Grau de Desobstrução Vascular
2.
Catheter Cardiovasc Interv ; 82(3): 361-9, 2013 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-23197480

RESUMO

BACKGROUND: Although high-risk left main PCI populations have been previously described, there is little data describing outcomes and the role of the logistic EuroSCORE in surgical turndown cohorts or patients in extremis due to acute infarction or cardiogenic shock from left main ischemia. METHODS: Consecutive patients with unprotected LM PCI who were surgical turndowns or in extremis were included in this retrospective cohort from 2004 to 2009 at two tertiary centers. Predictors of in-hospital mortality were identified utilizing routine and stepwise logistic regression. RESULTS: There were a total of 56 patients with mean age of 69 (±13). There were 23 (41%) patients with cardiogenic shock. The mean logistic EuroSCORE was 23.5% ± 21%. In-hospital death occurred in 12 (21%) patients, largely restricted to the shock subgroup (11/12). Univariate predictors of mortality included peak CK levels (P = 0.01), transfusion (P = 0.01), cardiogenic shock (P < 0.002), male gender (P = 0.027), and logistic EuroSCORE (P = 0.01). Stepwise logistic regression yielded logistic EuroSCORE (P = 0.04, OR: 1.25 (95% CI: 1.01-1.56) for every 5% increase) and peak CK level (P = 0.001, OR: 1.23 (95% CI: 1.09-1.40) for every 500 unit increase) as independent predictors of in-hospital mortality. The AUC ROC for logistic EuroSCORE was 0.73; and for logistic EuroSCORE plus peak CK level was 0.89. CONCLUSION: PCI appears to be a reasonable option in the high risk "no option" LM population, with the logistic EuroSCORE and peak CK levels being independent predictors of in-hospital mortality. Specifically, the logistic EuroSCORE and peak CK level combined discriminate in-hospital mortality with a high degree of certainty.


Assuntos
Doença da Artéria Coronariana/terapia , Técnicas de Apoio para a Decisão , Mortalidade Hospitalar , Intervenção Coronária Percutânea/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Biomarcadores/sangue , Doença da Artéria Coronariana/sangue , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/mortalidade , Creatina Quinase/sangue , Feminino , Humanos , Modelos Logísticos , Masculino , Manitoba/epidemiologia , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Seleção de Pacientes , Intervenção Coronária Percutânea/efeitos adversos , Curva ROC , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento
4.
Can J Physiol Pharmacol ; 90(9): 1325-31, 2012 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-22913597

RESUMO

We aim to describe the in-hospital outcomes of the first reported Canadian cohort of patients with cardiogenic shock and acute myocardial infarction (MI) due to acute and total occlusion of the left main coronary artery, treated with initial percutaneous coronary intervention (PCI). Acute left main thromboses with cardiogenic shock were identified (N = 8) from a retrospective consecutive cohort of high risk left main PCI (N = 56) performed at our institution from 2004-2009. The mean age was 62.3 ± 13.2 years, with 6 (75%) male patients. Successful PCI was performed in all patients, with thrombectomy utilized in 4 patients (50%), stenting in 7 patients (88%), and intra-aortic balloon pump augmentation in 7 patients (88%). Two patients (25%) required extracorporeal membrane oxygenation (ECMO) and 2 other patients required ventricular assist devices. Post-PCI coronary artery bypass grafting (CABG) was performed for 2 patients (25%). The mean SYNTAX score was 26.6 ± 10.5. The mean logistic EuroSCORE was 30.4 ± 12.6%. In-hospital mortality occurred in 3 patients (38%). Acute left main occlusion is a rare but devastating presentation of myocardial infarction, invariably with cardiogenic shock. Emergent PCI may be an effective method to acutely revascularize this subset of patients; however, aggressive post-PCI care including ECMO, CABG, and ventricular support may be required to improve patient survival.


Assuntos
Oclusão Coronária/cirurgia , Trombose Coronária/cirurgia , Mortalidade Hospitalar , Intervenção Coronária Percutânea , Choque Cardiogênico/cirurgia , Doença Aguda , Canadá , Estudos de Coortes , Oclusão Coronária/complicações , Oclusão Coronária/mortalidade , Trombose Coronária/complicações , Trombose Coronária/mortalidade , Feminino , Hospitais Universitários/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/mortalidade , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Resultado do Tratamento
5.
Catheter Cardiovasc Interv ; 78(4): 540-8, 2011 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-21547996

RESUMO

OBJECTIVES: To identify predictors of survival in a retrospective multicentre cohort of patients with cardiogenic shock undergoing coronary angiography and to address whether complete revascularization is associated with improved survival in this cohort. BACKGROUND: Early revascularization is the standard of care for cardiogenic shock. Coronary bypass grafting and percutaneous intervention have complimentary roles in achieving this revascularization. METHODS: A total of 210 consecutive patients (mean age 66 ± 12 years) at two tertiary centres from 2002 to 2006 inclusive with a diagnosis of cardiogenic shock were evaluated. Univariate and multivariate predictors of in-hospital survival were identified utilizing logistic regression. RESULTS: ST elevation infarction occurred in 67% of patients. Thrombolysis was administered in 34%, PCI was attempted in 62% (88% stented, 76% TIMI 3 flow), CABG was performed in 22% (2.7 grafts, 14 valve procedures), and medical therapy alone was administered to the remainder. The overall survival to discharge was 59% (CABG 68%, PCI 57%, medical 48%). Independent predictors of mortality included complete revascularization (P = 0.013, OR = 0.26 (95% CI: 0.09-0.76), hyperlactatemia (P = 0.046, OR = 1.14 (95% CI: 1.002-1.3) per mmol increase), baseline renal insufficiency (P = 0.043, OR = 3.45, (95% CI: 1.04-11.4), and the presence of anoxic brain injury (P = 0.008, OR = 8.22 (95% CI: 1.73-39.1). Within the STEMI with concomitant multivessel coronary disease subgroup of this population (N = 101), independent predictors of survival to discharge included complete revascularization (P = 0.03, OR = 2.5 (95% CI: 1.1-6.2)) and peak lactate (P = 0.02). CONCLUSIONS: The ability to achieve complete revascularization may be strongly associated with improved in-hospital survival in patients with cardiogenic shock.


Assuntos
Angioplastia Coronária com Balão/mortalidade , Fármacos Cardiovasculares/uso terapêutico , Ponte de Artéria Coronária/mortalidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Choque Cardiogênico/mortalidade , Choque Cardiogênico/terapia , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Fármacos Cardiovasculares/efeitos adversos , Cateterismo de Swan-Ganz , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Manitoba , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Razão de Chances , Alta do Paciente/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Análise de Sobrevida , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
7.
Resuscitation ; 84(7): 878-82, 2013 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-23428352

RESUMO

OBJECTIVE: Since the introduction of telemetry over a half century ago, it has expanded to various units and wards within health care institutions outside of the traditional critical care setting. Little is known on whether routine telemetry use is beneficial in this patient population. The aim of this study was to determine the impact of telemetry monitoring on survival of in-hospital cardiac arrests in patients admitted to non-critical care units. METHODS: A retrospective study of cardiac arrests in patients admitted to non-critical care units within the Winnipeg Regional Health Authority from 2002 to 2006 inclusive was performed. Baseline demographic, cardiac arrest, and outcome data were collected. RESULTS: Of the total 668 patients, the mean age was 70±14 years with 404 (61%) males. Patients presenting with asystole or pulseless electrical activity (PEA) demonstrated an increased mortality as compared to those presenting with ventricular tachycardia (VT) or ventricular fibrillation (VF). Overall, 268 of 668 patients (40%) survived their initial arrest, 66 (10%) survived to hospital discharge and 49 (7%) survived transfer to another facility. Patients on telemetry vs. no telemetry had higher survival rates immediately following cardiac arrest (66% vs. 34%, OR=3.67, p=0.02), as well as higher survival to hospital discharge (30% vs. 6%, OR=7.17, p=0.01). Finally, patients with cardiac arrest during the night and early morning benefited proportionally the greatest from telemetry use. CONCLUSION: Regardless of whether cardiac arrest was witnessed or unwitnessed, telemetry use was an independent and strong predictor of survival to hospital discharge.


Assuntos
Parada Cardíaca/mortalidade , Telemetria , Adulto , Idoso , Feminino , Parada Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Avaliação de Resultados da Assistência ao Paciente , Estudos Retrospectivos , Taquicardia Ventricular/epidemiologia , Fibrilação Ventricular/epidemiologia
8.
Can J Cardiol ; 28(4): 423-31, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22494815

RESUMO

BACKGROUND: Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times. METHODS: In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physician's hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room. RESULTS: From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%. CONCLUSIONS: Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.


Assuntos
Angioplastia Coronária com Balão/métodos , Dor no Peito/etiologia , Computadores de Mão , Eletrocardiografia , Serviços Médicos de Emergência/métodos , Auxiliares de Emergência/educação , Fidelidade a Diretrizes/normas , Capacitação em Serviço , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Processamento de Sinais Assistido por Computador , Terapia Trombolítica/métodos , Centros Médicos Acadêmicos , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Idoso , Angioplastia Coronária com Balão/educação , Angiografia Coronária , Ponte de Artéria Coronária , Feminino , Hospitais Urbanos , Humanos , Masculino , Manitoba , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Taxa de Sobrevida , Telemedicina , Estudos de Tempo e Movimento
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