RESUMEN

An increasing number of patients with severe aortic stenosis and concomitant critical coronary artery disease were referred to our hospital. Some of those patients were classified as high-risk patients qualifying for a transcatheter therapy with the additional need for coronary revascularization. As a consequence of their comorbidities, the established transapical as well as transfemoral approach were either not possible or not favored owing to the indispensable need for coronary revascularization. We present 4 successfully combined off-pump procedures consisting of a transcatheter aortic valve implantation (Edwards SAPIEN XT) via the transaortic approach and an off-pump coronary artery bypass grafting. All patients were discharged free from stroke, myocardial infarction, or access site complications either to rehabilitation facility or to the referring hospital with none or trace aortic regurgitation and patent grafts. These cases confirm the feasibility of those combined operations and should be considered as realistic alternative for surgical treatment in high-risk patients who are clearly identified to benefit from transcatheter approach to treat aortic stenosis and who have severe concomitant coronary artery disease.

Asunto(s)

Estenosis de la Válvula Aórtica/cirugía , Puente de Arteria Coronaria Off-Pump/métodos , Enfermedad de la Arteria Coronaria/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Anciano , Anciano de 80 o más Años , Comorbilidad , Estudios de Factibilidad , Femenino , Insuficiencia Cardíaca/etiología , Prótesis Valvulares Cardíacas , Humanos , Masculino , Diseño de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del Tratamiento

RESUMEN

BACKGROUND: For patients with end-stage renal failure hemodialysis with an autogenous arteriovenous fistula (AVF) has proven to be the ideal vascular access. OBJECTIVE: The aim of this study is to discover potential predictors of a well-functioning hemodialysis fistula. METHODS: From December 2009 to March 2011, 80 patients undergoing first time AVF creation were enrolled in our retrospective study. We analyzed pre- and postoperative vessel diameters and flow characteristics gained by duplex ultrasonography (DUS) and intraoperative ultrasound transit-time flow measurements regarding intraoperative blood flow and pulsatility index (PI). Follow-up was defined until the end of the first month with regular hemodialysis, 10 weeks after AVF creation. We performed statistical analyses by employing Spearman correlation, t test, analysis of variance, χ2 test, and receiver operating characteristics (ROC). RESULTS: At the end of the follow-up, 62 patients (78%) featured functioning AVFs and 18 patients (22%) featured nonfunctioning AVFs. Factors influencing AVF function were radial artery diameter (χ2 = 5.23, p = 0.02), intraoperative flow (χ2 = 7.09, p = 0.01), intraoperative PI (χ2 = 6.5, p = 0.01), and postoperative flow (χ2 = 16.29, p = 0.01). According to the ROC analyses, we could develop cut-off values for predicting an ideal AVF function: radial artery diameter more than 2.3 mm, cephalic vein diameter more than 2.7 mm, intraoperative mean flow more than 113 mL/min, PI less than 1.4, and postoperative mean flow more than 160 mL/min. CONCLUSION: Intraoperative ultrasound transit-time flow measurements gained at surgery and postoperative follow-up with DUS can help identify AVFs that are unlikely to function and therefore need early intervention.

Asunto(s)

Derivación Arteriovenosa Quirúrgica , Fallo Renal Crónico/terapia , Arteria Radial/cirugía , Diálisis Renal , Anciano , Derivación Arteriovenosa Quirúrgica/efectos adversos , Velocidad del Flujo Sanguíneo , Distribución de Chi-Cuadrado , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/fisiopatología , Oclusión de Injerto Vascular/cirugía , Humanos , Masculino , Flujo Pulsátil , Curva ROC , Arteria Radial/diagnóstico por imagen , Arteria Radial/fisiopatología , Flujo Sanguíneo Regional , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía Doppler Dúplex , Grado de Desobstrucción Vascular

RESUMEN

We represent a successful minimally invasive combined off-pump procedure consisting of a transapical aortic valve implantation and a direct coronary artery bypass grafting in a woman with a severe aortic stenosis and a critical coronary artery disease. Due to her comorbidities, she was classified as a high-risk patient qualifying for a transcatheter procedure. We performed this combined procedure in a hybrid operation room, starting with the coronary bypass to maintain a coronary blood flow during the transapical valve implantation. The operation processed without any complications and she was discharged at the seventh postoperative day into the allocating hospital.