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BACKGROUND: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. METHODS: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). RESULTS: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. CONCLUSION: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.
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Aneurisma da Aorta Torácica/diagnóstico , Dissecção Aórtica/diagnóstico , Procedimentos Endovasculares/métodos , Sistema de Registros , Stents , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/mortalidade , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Torácica/mortalidade , Aneurisma da Aorta Torácica/cirurgia , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Espanha/epidemiologia , Taxa de Sobrevida/tendências , Síndrome , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto JovemRESUMO
Until recently the treatment of atrial fibrillation (AF) consisted primarily of palliation, mostly in the form of pharmacological intervention. However because of recent advances in nonpharmacologic therapies, the current expectation of patients and referring physicians is that AF will be cured, rather than palliated. In recent years there has been a rapid expansion in the availability and variety of energy sources and devices for ablation. One of these energies, microwave, has been applied clinically only in the last few years, and may be a promising technique that is potentially capable of treating a wide range of ventricular and supraventricular arrhythmias. The purpose of this study was to review microwave energy ablation in surgical treatment of AF with special interest in histology and ultrastructure of lesions produced by this endocardial ablation procedure.
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BACKGROUND AND AIM OF THE STUDY: Clinical experience with the Omnicarbon mechanical valve implanted in the aortic position is reported in this retrospective survey. METHODS: A total of 110 patients (mean age 56 years) undergoing isolated aortic valve replacement with Omnicarbon mechanical prostheses at the authors' institution between November 1991 and October 2000 was included. Follow was available in 94.5% of patients (mean follow up 4 years per patient; total follow up was 415 patient-years (pt-yr)). RESULTS: Hospital mortality was 3.6%. There were no instances of valve thrombosis or structural failure. The incidence of valve-related complications (linearized rates in events per 100 pt-yr/actuarial freedom at 9 years, in %) was: valve-related mortality 2.4+/-0.7 / 80.3+/-8.0; non-structural failure 0.7+/-0.4 / 93.8+/-4.2; thromboembolism 0.2+/-0.2 / 99.0+/-1.0; anticoagulant-related hemorrhage 0.9+/-0.5 / 93.7+/-3.3; prosthetic valve endocarditis 0.2+/-0.2 / 99.0+/-1.0; and reoperation 0.7+/-0.4 / 93.8+/-4.2. CONCLUSION: In the authors' experience the Omnicarbon mechanical prosthesis provides a good clinical performance for up to nine years in the aortic position.
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Valva Aórtica/cirurgia , Bioprótese , Causas de Morte , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/mortalidade , Adulto , Idoso , Feminino , Seguimentos , Doenças das Valvas Cardíacas/mortalidade , Implante de Prótese de Valva Cardíaca/métodos , Mortalidade Hospitalar/tendências , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Desenho de Prótese , Estudos Retrospectivos , Espanha , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
INTRODUCTION AND OBJECTIVES: Analysis and comparison of the clinical performance and hemodynamics in vivo of 21 mm Carpentier-Edwards supra-annular (CESA) and Perimount (CEPM) aortic bioprostheses. METHODS: A follow-up study was made of 40 patients implanted a 21 mm CESA (n = 21) or CEPM (n = 19) prosthesis between October 1992 and September 1997. All eligible survivors (14 CESA, 12 CEPM) were assessed echocardiographically. RESULTS: There were no significant differences between models in the effective orifice area (1.6 cm2 for CESA, 1.44 cm2 for CEPM), peak flow rate (rest: 2.5 m/s for CESA, 2.3 m/s for CEPM; post-dobutamine: 3.4 m/s for CESA, 3.3 m/s for CEPM), mean flow rate (rest: 1.7 m/s for CESA, 1.6 m/s for CEPM; post-dobutamine: 2.5 m/s for CESA, 2.2 m/s for CEPM), peak gradient (rest: 28.3 mmHg for CESA, 21.6 mmHg for CEPM; post-dobutamine: 48.4 mmHg for CESA, 41.6 mmHg for CEPM), and mean gradient (rest: 15.8 mmHg for CESA, 12.0 mmHg for CEPM; post-dobutamine: 28.5 mmHg for CESA, 22.5 mmHg for CEPM). CONCLUSION: In our experience, these two prosthetic models have similar hemodynamic characteristics in small aortic annuli.
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Estenose da Valva Aórtica/cirurgia , Valva Aórtica , Bioprótese , Próteses Valvulares Cardíacas , Idoso , Ecocardiografia , Feminino , Seguimentos , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de TempoRESUMO
BACKGROUND: Atrial ischemia, and sinus node ischemia in particular, may be involved in the pathogenesis of atrial fibrillation. In this study we compared the sinus node blood capillary content in normal hearts in sinus rhythm and in pathologic hearts with chronic atrial fibrillation and we analyzed the ultrastructural features of such capillaries. METHODS: Sinus node biopsy specimens were obtained from 16 patients in chronic atrial fibrillation undergoing open heart surgery. Control sinus node specimens of normal hearts were obtained at autopsy from 7 subjects. Specimens were processed for immunohistochemical, light microscopy and transmission electron microscopy analysis and compared grossly and with morphometric techniques. RESULTS: The proportion of sinus node tissue corresponding to capillaries, defined as blood vessel density (or BVD), was estimated as 1.06 +/- 1.47% for the atrial fibrillation group versus 2.12 +/- 2.0% for controls (p < 0001). Internal capillary diameter averaged 21.6 microm in the atrial fibrillation group and 24.2 microm in controls (p = 0.175), whereas external diameter averaged 32.2 microm in the atrial fibrillation group and 38.9 microm in controls (p = 0.052). Ultrastructural analysis demonstrated scarce and interrupted myoendocardial bridges and abnormal deposits of elastic fibers under the endothelial basal membrane at the level of precapillary sphincters and metaarterioles of atrial fibrillation specimens. CONCLUSIONS: There is a significant reduction in the amount of capillaries in the sinus node of hearts in chronic atrial fibrillation. Our findings would support a potential association between sinus node tissue ischemia and chronic atrial fibrillation.
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Fibrilação Atrial/patologia , Capilares/ultraestrutura , Nó Sinoatrial/patologia , Idoso , Idoso de 80 Anos ou mais , Biópsia , Vasos Coronários/ultraestrutura , Feminino , Seguimentos , Humanos , Masculino , Microscopia Eletrônica de Transmissão , Pessoa de Meia-Idade , Miocárdio/patologia , Fatores de TempoRESUMO
OBJECTIVES: There is little information in the literature on the long-term outcome of young patients undergoing coronary bypass grafting surgery. The aim of this study is to analyze the long-term clinical outcome of this technique when performed in young adults. METHODS: We included in this retrospective study all patients aged 40 years or younger undergoing coronary bypass surgery in our unit between January, 1989 and December, 2006. Relevant clinical data were retrieved from the patients' clinical records. Follow-up data were obtained by means of personal or telephone interviews with the patients themselves or with their relatives. RESULTS: There were 42 patients (3 females, 39 males), mean age 36.9 years (range 29-40 years). Nineteen of them suffered a previous myocardial infarction. Left ventricular function was impaired (ejection fraction lower than 50%) in six instances. Twenty-two patients underwent surgery in a state of unstable angina. The indication for surgery was 3-vessel disease in 17 patients, 2-vessel disease in 17 patients and single-vessel disease in seven instances, and in six cases the main steam of the left coronary artery was affected. A total of 102 grafts were constructed (mean 2.4 grafts per patient), 56 (54.9%) of them being arterial. There were no hospital deaths. Mean hospital stay was of 8.1 days. Four patients suffered relevant perioperative complications. One patient (2.3%) was lost for follow-up. Cumulative follow-up was 389.1 years, with a mean of 9.5 years per patient. There were five late deaths, all of them of cardiac origin, with an estimated actuarial probability of survival of 81.4%. Thirteen patients suffered 17 major cardiac non-lethal complications, with an estimated actuarial freedom from cardiac morbidity of 43.9%. Major peripheral vascular morbid events occurred in nine patients, the estimated actuarial probability of freedom from peripheral vascular complications being of 62.1%. Overall actuarial freedom from any cardiovascular lethal or morbid event was estimated at 27.7%. CONCLUSIONS: Peri-operative mortality and morbidity is low in young patients undergoing coronary bypass surgery. However, these patients present a high risk of suffering major adverse events of cardiovascular origin in the long-term.
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Ponte de Artéria Coronária/métodos , Estenose Coronária/cirurgia , Adulto , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Recidiva , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do TratamentoRESUMO
Temporary epicardial pacing wires are routinely placed in patients undergoing cardiac surgery. Eighteen suitable patients undergoing elective surgery were prospectively studied. Their sensing and stimulating characteristics were studied at various locations. Subepicardial pacing leads were applied to the lateral wall of the LV, apex of the LV, anterior wall of the RV, diaphragmatic wall of the RV, and diaphragmatic wall of the LV. Impedance, R wave amplitude, slew rate, and stimulation thresholds were measured on postoperative days 1 and 5. Impedance remained unchanged in time with no significant differences between locations. R waves and slew rates were significantly lower in the anterior RV wall. Stimulation thresholds displayed no differences on day 1, but they increased significantly in all locations on day 5. These thresholds were significantly lower in the lateral and diaphragmatic LV walls on day 5, and the rate of voltage increase was also lower in these two locations. Five patients presented phrenic nerve stimulation when stimulating the lateral LV wall. The authors advocate the diaphragmatic wall of the LV as the best location for placing temporary leads. The anterior wall of the RV is not recommended for pacing purposes.
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Estimulação Cardíaca Artificial/métodos , Procedimentos Cirúrgicos Cardíacos , Eletrodos Implantados , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Estudos Prospectivos , Estatísticas não ParamétricasRESUMO
Between February 2003 and January 2004 a microwave-modified Maze III procedure was performed as an associated procedure in nine patients in chronic atrial fibrillation undergoing surgery for heart valve disease. Clinical follow-up was carried out in all survivors, and an echocardiographic assessment done in all those in sinus rhythm, during the first week of February 2004. There were six women and three men with a mean age of 60 +/- 9.4 years. Their rhythm at the end of surgery was sinus in 2 patients, nodal in 4, and complete AV block in 3. One patient died in hospital and there patients had no other complications related to the procedure. By the time of hospital discharge, four patients were in sinus rhythm and four were in atrial fibrillation. After a mean follow-up of 5.2 +/- 3.3 months there were no late deaths, 5 patients were in sinus rhythm, 1 required a permanent pacemaker in DDDR mode for persistent sinus bradycardia, and 2 remained in atrial fibrillation. Echocardiographic assessment, performed at a mean of 4.9 +/- 2.5 months after surgery in all patients in sinus rhythm or with a pacemaker, demonstrated biatrial contraction in five patients. The Cox-Maze III procedure can be performed safely and with good results using microwave energy instead of the conventional "cut and sew" technique.
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Fibrilação Atrial/cirurgia , Ablação por Cateter , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Micro-Ondas/uso terapêutico , Taquicardia por Reentrada no Nó Atrioventricular/cirurgia , Idoso , Fibrilação Atrial/diagnóstico por imagem , Terapia Combinada , Desfibriladores Implantáveis , Ecocardiografia , Endocárdio/diagnóstico por imagem , Endocárdio/cirurgia , Feminino , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Veias Pulmonares/diagnóstico por imagem , Veias Pulmonares/cirurgia , Taquicardia por Reentrada no Nó Atrioventricular/diagnóstico por imagemRESUMO
INTRODUCTION: The aim of this study was to investigate the early qualitative and quantitative structural changes in the left atrial wall after endocardial microwave ablation in patients with chronic atrial fibrillation (AF) undergoing mitral surgery. METHODS AND RESULTS: Seven patients with chronic AF of for at least 6 months underwent surgical microwave energy ablation. Linear isolation of pulmonary veins was performed in all patients by microwave energy applications to the endocardial surface delivered by catheter at 65-W constant power for 45 seconds. Biopsies were obtained from a selected site (below the right lower pulmonary vein) of the left atrial posterior wall before and after the ablation procedure in all patients. Control tissues from the same sites were obtained at autopsy from patients with noncardiac causes of death. Light and electron microscopy was used to examine qualitative and quantitative changes in tissue morphology. Tissues after endocardial ablation procedure showed significantly increased loss of contractile material. Electron microscopy of atrial tissue demonstrated loss of profile of perinuclear and plasma membranes of myocytes, disruption of the endothelial cells of capillary vessels, and presence of macrophages. CONCLUSION: Lesions created by endocardial microwave energy ablation revealed a transmural effect on the left atrial wall without a significant reduction in thickness but a significant increase in the myolytic areas involving the entire cytosol and occlusion of the small intramyocardial vessels within the ablative lesion.