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1.
Clin Transplant ; 34(1): e13764, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31830339

RESUMO

INTRODUCTION: Patients with end-stage heart failure eligible for orthotopic heart transplantation (OHT) exceed the number of available donor organs. With highly effective hepatitis C virus (HCV) antiviral therapy now available, HCV+ organs are increasingly utilized. We seek to describe our experience with patients receiving HCV viremic organs as compared to non-HCV transplant recipients. METHODS: Our center began utilizing HCV hearts in February 2018. We retrospectively reviewed baseline demographics, laboratory data and outcomes for those undergoing OHT with majority being from a viremic HCV donor. RESULTS: Twenty-three of 25 HCV recipients received hearts from NAT+ donors with 22 of 23 seroconverting within 7 days. Fifteen recipients have completed HCV treatment, with the longest duration of follow-up being 13 months. No differences in rates of rejection, hospitalizations or death were seen between non-HCV and HCV transplant patients. DISCUSSION: With the advent of available direct-acting antivirals (DAAs), viremic HCV hearts provide an opportunity to increase organ availability. Moreover, treatment for HCV in the setting of immunosuppression is well-tolerated and results in sustained viremic response. CONCLUSION: Viremic, discordant HCV OHT can be performed in a safe and effective manner utilizing a systematic, multidisciplinary approach without an effect on short-term outcomes.


Assuntos
Transplante de Coração , Hepatite C Crônica , Hepatite C , Antivirais/uso terapêutico , Hepacivirus , Hepatite C/tratamento farmacológico , Hepatite C Crônica/tratamento farmacológico , Humanos , Estudos Retrospectivos , Doadores de Tecidos
2.
Semin Cardiothorac Vasc Anesth ; 27(1): 64-67, 2023 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-36418868

RESUMO

Central airway obstruction due to tracheal tumors presents unique challenges to the anesthesiologist. We present the case of a 44-year-old male taken to the OR for biopsy and resection of an undiagnosed tracheal mass. Intraoperative management was complicated by bleeding and significant hemodynamic instability, necessitating rapid surgical and anesthetic intervention. This ultimately led to abortion of surgical resection. Pathologic examination revealed a primary tracheal plasmacytoma, a rare type of tracheal tumor. Here, we describe anesthetic and hemodynamic considerations for a tracheal plasmacytoma. We discuss the approach to airway management in variable intrathoracic tracheal obstruction and the unpredictability of tracheal tumors.


Assuntos
Obstrução das Vias Respiratórias , Anestésicos , Plasmocitoma , Neoplasias da Traqueia , Masculino , Humanos , Adulto , Neoplasias da Traqueia/complicações , Neoplasias da Traqueia/patologia , Neoplasias da Traqueia/cirurgia , Plasmocitoma/complicações , Plasmocitoma/patologia , Plasmocitoma/cirurgia , Traqueia/cirurgia , Obstrução das Vias Respiratórias/etiologia , Manuseio das Vias Aéreas
3.
JACC Case Rep ; 27: 102098, 2023 Dec 06.
Artigo em Inglês | MEDLINE | ID: mdl-38094718

RESUMO

Tachycardia-mediated cardiomyopathy is an established cause of left ventricular dysfunction. The development of cardiomyopathy depends on type, rate, and duration of tachyarrhythmia. Early recognition and treatment are critical in preventing left ventricular dysfunction and heart failure. Normal physiologic changes in pregnancy can complicate the early recognition and treatment of pathologic tachyarrhythmia.

4.
J Cardiothorac Surg ; 15(1): 329, 2020 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-33189134

RESUMO

BACKGROUND: Left ventricular assist devices (LVAD) have been increasingly used in the treatment of end-stage heart failure. While warfarin has been uniformly recommended in the long-term as anticoagulation strategy, no clear recommendation exists for the post-operative period. We sought to evaluate the feasibility of enoxaparin in the immediate and early postoperative period after LVAD implantation. METHODS: This is a two-center, retrospective analysis of 250 consecutive patients undergoing LVAD implantation between January 2017 and December 2018. Patients were bridged postoperatively to therapeutic INR by either receiving unfractionated heparin (UFH) or low molecular weight heparin (LMWH). Patients were followed while inpatient and for 3 months after LVAD implantation. The efficacy outcome was occurrence of first and subsequent cerebrovascular accident while safety outcome was the occurrence of bleeding events. Length of stay (LOS) was also assessed. RESULTS: Two hundred fifty and 246 patients were analyzed for index admission and 3-month follow up respectively. No statistically significant differences were found between the two groups in CVA (OR = 0.67; CI = 0.07-6.39, P = 0.73) or bleeding events (OR = 0.91; CI = 0.27-3.04, P = 0.88) during index admission. Similarly, there were no differences at 3 months in either CVAs or bleeding events (OR = 0.85; 0.31-2.34; p = 0.76). No fatal events occurred during the study follow-up period. Median LOS was significantly lower (4 days; p = 0.03) in the LMWH group. CONCLUSIONS: LMWH in the immediate and early postoperative period after LVAD implantation appears to be a concurrently safe and efficacious option allowing earlier postoperative discharge and avoidance of recurrent hospitalizations due to sub-therapeutic INR.


Assuntos
Anticoagulantes/uso terapêutico , Enoxaparina/uso terapêutico , Insuficiência Cardíaca/terapia , Coração Auxiliar , Heparina de Baixo Peso Molecular/uso terapêutico , Heparina/uso terapêutico , Anticoagulantes/administração & dosagem , Esquema de Medicação , Enoxaparina/administração & dosagem , Feminino , Heparina/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Humanos , Indiana , Coeficiente Internacional Normatizado , Kansas , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos
5.
Ann Thorac Surg ; 110(5): 1714-1721, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32497643

RESUMO

BACKGROUND: Postoperative analgesia is paramount to recovery after thoracic surgery, and opioids play an invaluable role in this process. However, current 1-size-fits-all prescribing practices produce large quantities of unused opioids, thereby increasing the risk of nonmedical use and overdose. This study hypothesized that patient and perioperative characteristics, including 24-hour before-discharge opioid intake, could inform more appropriate postdischarge prescriptions after thoracic surgery. METHODS: This prospective observational cohort study was conducted in 200 adult thoracic surgical patients. The cohort was divided into 3 groups on the basis of 24-hour before-discharge opioid intake in morphine milligram equivalents (MME): (1) no (0 MME), (2) low (>0 to ≤22.5 MME), or (3) high (>22.5 MME) before-discharge opioid intake. Logistic regression was used to analyze the association of patient and perioperative characteristics with self-reported after-discharge opioid use. RESULTS: Univariate analysis showed that preoperative opioid use, 24-hour before-discharge acetaminophen and gabapentinoid intake, and 24-hour before-discharge opioid intake were associated with higher after-discharge opioid use. Multivariable modeling demonstrated that 24-hour before-discharge opioid intake was most significantly associated with after-discharge opioid use. For example, compared with patients who took high amounts of opioids before discharge, patients who took no opioids before discharge were 99% less likely to take a high amount of opioids after discharge compared with taking none (odds ratio, 0.011; 95% confidence interval, 0.003 to 0.047; P < .001). CONCLUSIONS: Assessment of 24-hour before-discharge opioid intake may inform patient requirements after discharge. Opioid prescriptions after thoracic surgery can thereby be targeted on the basis of anticipated needs.


Assuntos
Manejo da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Assistência Centrada no Paciente/métodos , Procedimentos Cirúrgicos Torácicos , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
6.
Am J Physiol Lung Cell Mol Physiol ; 297(1): L52-63, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19376887

RESUMO

Toll-like receptors (TLRs) of the innate immune system contribute to noninfectious inflammatory processes. We employed a murine model of hilar clamping (1 h) with reperfusion times between 15 min and 3 h in TLR4-sufficient (C3H/OuJ) and TLR4-deficient (C3H/HeJ) anesthetized mice with additional studies in chimeric and myeloid differentiation factor 88 (MyD88)- and TLR4-deficient mice to determine the role of TLR4 in lung ischemia-reperfusion injury. Human pulmonary microvascular endothelial monolayers were subjected to simulated warm ischemia and reperfusion with and without CRX-526, a competitive TLR4 inhibitor. Functional TLR4 solely on pulmonary parenchymal cells, not bone marrow-derived cells, mediates early lung edema following ischemia-reperfusion independent of MyD88. Activation of MAPKs and NF-kappaB was significantly blunted and/or delayed in lungs of TLR4-deficient mice as a consequence of ischemia-reperfusion injury, but edema development appeared to be independent of activation of these signaling pathways. Pretreatment with a competitive TLR4 inhibitor prevented edema in vivo and reduced actin cytoskeletal rearrangement and gap formation in pulmonary microvascular endothelial monolayers subjected to simulated warm ischemia and reperfusion. In addition to its well-accepted role to alter gene transcription, functioning TLR4 on pulmonary parenchymal cells plays a key role in very early and profound pulmonary edema in murine lung ischemia-reperfusion injury. This may be due to a novel mechanism: regulation of endothelial cell cytoskeleton affecting microvascular endothelial cell permeability.


Assuntos
Edema Pulmonar/complicações , Edema Pulmonar/metabolismo , Traumatismo por Reperfusão/complicações , Traumatismo por Reperfusão/metabolismo , Receptor 4 Toll-Like/metabolismo , Actinas/metabolismo , Animais , Citoesqueleto/efeitos dos fármacos , Citoesqueleto/metabolismo , Células Endoteliais/efeitos dos fármacos , Células Endoteliais/metabolismo , Ativação Enzimática/efeitos dos fármacos , Glucosamina/análogos & derivados , Glucosamina/farmacologia , Humanos , Ligantes , Pulmão/efeitos dos fármacos , Pulmão/enzimologia , Pulmão/patologia , Camundongos , Camundongos Endogâmicos C57BL , Proteínas Quinases Ativadas por Mitógeno/metabolismo , NF-kappa B/metabolismo , Comunicação Parácrina/efeitos dos fármacos , Edema Pulmonar/enzimologia , Edema Pulmonar/prevenção & controle , Traumatismo por Reperfusão/enzimologia , Traumatismo por Reperfusão/patologia , Receptor 4 Toll-Like/antagonistas & inibidores , Isquemia Quente
8.
Ann Thorac Surg ; 107(5): 1348-1355, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30529215

RESUMO

BACKGROUND: Tricuspid valve regurgitation (TR) is a common finding immediately after cardiac transplantation. However, there is a scarcity of data regarding its implication if left untreated on long-term outcomes and the role of early surgical repair. METHODS: We retrospectively reviewed the Duke University Medical Center transplant database from January 2000 to June 2012 and identified 542 patients who underwent orthotropic heart transplantation. Patients were excluded if they underwent surgical repair for TR during the transplant or if the transplant was part of a multiorgan transplant or redo heart transplantation. TR was assessed intraoperatively after weaning from cardiopulmonary bypass. Independent variables were grade of TR and changes in TR grade during follow-up. TR grades were classified as insignificant (none or mild) versus significant (moderate or severe). Survival and need for posttransplant valve repair during follow-up were assessed. RESULTS: Significant TR was detected in 114 patients (21%) after weaning from cardiopulmonary bypass, with no significant difference in preoperative recipient pulmonary vascular resistance. Significant TR was associated with increased maximum postoperative plasma creatinine (median [interquartile range], 2.2 [1.5 to 3.2] mg/dL vs 1.8 [1.4 to 2.6] mg/dL, p = 0.008), prolonged postoperative stay (median [interquartile range], 12 [9 to 21] days vs 10 [8 to 14] days; p < 0.001), and decreased adjusted survival. Significant TR regressed to insignificant in 91% of recipients by 1 year after transplant. Six recipients (1%) who had significant TR after cardiopulmonary bypass underwent delayed tricuspid valve repair for significant TR during follow-up. CONCLUSIONS: Significant TR is a common finding immediately after transplant and is associated with early morbidity and reduced adjusted survival. Most significant TR resolves by 1 year after transplant. Optimal algorithms for follow-up and treatment of significant TR after heart transplantation need to be defined.


Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Insuficiência da Valva Tricúspide/epidemiologia , Adulto , Bases de Dados Factuais , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
9.
Artigo em Inglês | MEDLINE | ID: mdl-18396220

RESUMO

In contrast with adults, thoracic aortic aneurysms in children are usually associated with connective tissue defect syndromes. As such, there are phenotypic clues to identify patients at risk. Marfan syndrome, Loeys-Dietz syndrome, and bicuspid aortic valve syndrome account for the majority of these aneurysms. Indications for surgery as well as surgical options differ according to diagnosis and are reviewed herein.


Assuntos
Aneurisma da Aorta Torácica/genética , Aneurisma da Aorta Torácica/cirurgia , Fator de Crescimento Transformador beta/genética , Aneurisma da Aorta Torácica/etiologia , Valva Aórtica/anormalidades , Implante de Prótese Vascular , Criança , Síndrome de Ehlers-Danlos/complicações , Síndrome de Ehlers-Danlos/cirurgia , Humanos , Síndrome de Marfan/complicações , Síndrome de Marfan/cirurgia , Mutação , Fenótipo , Síndrome
11.
Clin Appl Thromb Hemost ; 24(1): 145-150, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27624738

RESUMO

Unfractionated heparin (UFH) is a frequently utilized indirect anticoagulant that induces therapeutic effect by enhancing antithrombin (AT)-mediated procoagulant enzyme inhibition. In suspected heparin resistance (HR) during cardiopulmonary bypass, AT activity may be decreased and AT supplementation helps restore UFH responsiveness. The benefit of AT supplementation in HR over longer durations of UFH therapy is unclear. The objective of this study was to describe and evaluate the use of AT III concentrate in the intensive care units (ICUs) at our institution for improving UFH therapy response over 72 hours. A total of 44 critically ill patients were included in the analysis-22 patients received at least 1 dose of AT and 22 patients received no AT. Thirty (68.2%) of the 44 patients were receiving mechanical circulatory support. Baseline characteristics were similar between groups. The average AT activity prior to AT supplementation was 57.9% in the treatment group, and the median cumulative dose of AT was 786.5 U (9.26 U/kg) per patient. There were no significant differences observed in proportion of time spent in therapeutic range (31.9% vs 35.2%, P = .65), time to therapeutic goal (16.5 vs 15.5 hours, P = .97), or patients who experienced a bleeding event (5 vs 5, P = .99) between groups. In conclusion, AT supplementation had minimal impact on anticoagulant response in this cohort of ICU patients with mild to moderate HR receiving a prolonged UFH infusion. Additional research is needed to define AT activity targets and to standardize AT supplementation practices in patients receiving prolonged heparin infusion.


Assuntos
Anticoagulantes/administração & dosagem , Ponte Cardiopulmonar , Fibrinolíticos/administração & dosagem , Heparina/administração & dosagem , Unidades de Terapia Intensiva , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
Cardiol Clin ; 35(3): 367-385, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28683908

RESUMO

Aortic arch surgery remains one of the most technically challenging procedures in cardiac surgery. It demands consideration of myocardial, brain, spinal cord, and lower body protection and rigorous surgical technique. Novel surgical approaches and refinements in brain and end organ protection strategies, liberal use of antegrade cerebral perfusion and moderate hypothermia have made arch repair safer. As endovascular technology and open surgical techniques evolve, aortic surgeons will need to continue to learn and incorporate these methods into practice in order to improve outcomes.


Assuntos
Aorta Torácica/cirurgia , Complicações Intraoperatórias/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/métodos , Circulação Cerebrovascular , Parada Cardíaca Induzida/métodos , Humanos , Resultado do Tratamento
13.
Ann Thorac Surg ; 101(5): 1980-2, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27106435

RESUMO

Anomalous origin of the coronary arteries may limit the applicability of aortic valve sparing techniques during root replacement. We report a case of a right coronary artery that originated from the left sinus and coursed intramurally in a patient with an aortic root aneurysm. Attention to the anatomic relation between the anomalous coronary and aortic root structures and right coronary safety button reconstruction allowed safe aortic root replacement while preserving the native aortic valve.


Assuntos
Aorta/cirurgia , Aneurisma Aórtico/cirurgia , Valva Aórtica , Implante de Prótese Vascular/métodos , Anomalias dos Vasos Coronários/cirurgia , Tratamentos com Preservação do Órgão/métodos , Seio Aórtico/cirurgia , Aneurisma Aórtico/etiologia , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Bioprótese , Prótese Vascular , Tronco Braquiocefálico/cirurgia , Humanos , Masculino , Síndrome de Marfan/complicações , Pessoa de Meia-Idade , Reimplante , Seio Aórtico/anormalidades , Técnicas de Sutura
15.
Ital Heart J ; 6(10): 861-8, 2005 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-16270481

RESUMO

A percentage ranging from 0.1 to 4.0 of patients recovering from acute pulmonary embolism develop chronic thromboembolic pulmonary hypertension (CTEPH). Without intervention, CTEPH is a progressive and lethal disease for which there is no effective medical therapy. Pulmonary endarterectomy (PEA) is the treatment of choice. Lung transplantation is indicated only in few cases when PEA is not feasible. Since 1994 at the IRCCS San Matteo Hospital - University of Pavia (Italy), 134 PEAs have been performed. Preoperatively, NYHA class distribution was respectively 3-II, 56-III, and 75-IV; mean pulmonary artery pressure and pulmonary vascular resistances were 47 +/- 13 mmHg and 1149 +/- 535 dynes*s*cm(-5) respectively. The overall operative mortality has been 9.7% (4.5% in 2004). Survival at 3-month, 1-year, and 3-year follow-up was 89.5 +/- 2.6, 87.8 +/- 2.9, and 83.3 +/- 3.5% respectively; this last rate was unchanged up to 10 years. After PEA, mean pulmonary artery pressure and pulmonary vascular resistances were 25 +/- 9 mmHg and 322 +/- 229 dynes*s*cm(-5) respectively and these results were stable over time. At the 3-year follow-up, 94% of patients were in NYHA class I or II and the only therapy is anticoagulation.


Assuntos
Endarterectomia , Hipertensão Pulmonar/cirurgia , Artéria Pulmonar/cirurgia , Embolia Pulmonar/complicações , Doença Crônica , Humanos , Hipertensão Pulmonar/etiologia , Embolia Pulmonar/cirurgia
16.
Thorac Surg Clin ; 25(4): 421-7, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26515942

RESUMO

Empyema after anatomic lung resection is rare but causes serious morbidity, particularly if associated with a bronchopleural fistula. Careful assessment of preoperative risk factors and proper surgical technique can minimize risks. Empyema after segmentectomy or lobectomy may respond to simple drainage and antibiotics, or may require decortication with or without muscle transposition. After pneumonectomy, treatment principles include initial drainage of the intrathoracic space, closure of the fistula if present, and creation of an open thoracostomy, which is packed and later closed. Success rates can exceed 80%.


Assuntos
Fístula Brônquica/etiologia , Empiema Pleural/etiologia , Pleura , Doenças Pleurais/etiologia , Pneumonectomia/efeitos adversos , Fístula do Sistema Respiratório/etiologia , Humanos , Pneumonectomia/métodos
17.
Transplantation ; 97(10): 1079-85, 2014 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-24646771

RESUMO

BACKGROUND: Coronary artery disease has a high prevalence among lung transplant recipients and has historically been a contraindication to transplant at many institutions. In patients with mild-to-moderate coronary artery disease (Mod-CAD) undergoing lung transplant, outcomes are not well defined. METHODS: All patients who underwent pulmonary transplantation from January 1996 through November 2010 with pretransplant coronary angiogram were included in our study. Recipients of multivisceral, redo, and lobar lung transplants and those who underwent pretransplant coronary revascularization were excluded. Patients were grouped into Mod-CAD or no-coronary artery disease group (No-CAD). Primary end point was overall survival. Secondary end points were 30-day events and the need for posttransplant coronary revascularization. RESULTS: Approximately 539 patients were included in the study: 362 in the No-CAD, 177 in the Mod-CAD group. Patients with Mod-CAD were predominantly male, older, and had a higher body mass index. No difference in either perioperative morbidity and mortality (Mod-CAD, 4.2% vs. No-CAD 3.3%, P=0.705) or late overall mortality was shown between groups. Mod-CAD patients had a shorter hospitalization (median: 12 days vs. 14 days, P=0.009) and required a higher rate of late coronary revascularization procedures (PCI: Mod-CAD vs. No-CAD, 0.3% vs. 4.0%, P=0.0035; CABG: Mod-CAD vs. No-CAD, 0.3% vs. 2.3%, P=0.0411). CONCLUSIONS: Mod-CAD does not appear to be associated with increased perioperative morbidity or decreased survival after transplant. Coronary artery disease may worsen and require coronary revascularization in patients with risk factors for disease progression. In these patients, close follow-up and screening for progression of coronary artery disease may help prevent late cardiac morbidity.


Assuntos
Doença da Artéria Coronariana/diagnóstico , Pneumopatias/cirurgia , Transplante de Pulmão , Adulto , Idoso , Cateterismo Cardíaco , Angiografia Coronária , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/epidemiologia , Feminino , Seguimentos , Humanos , Pneumopatias/complicações , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto Jovem
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