RESUMEN
Whether simultaneous automated ascertainments of prevalent vertebral fracture (auto-PVFx) and abdominal aortic calcification (auto-AAC) on vertebral fracture assessment (VFA) lateral spine bone density (BMD) images jointly predict incident fractures in routine clinical practice is unclear. We estimated the independent associations of auto-PVFx and auto-AAC primarily with incident major osteoporotic and secondarily with incident hip and any clinical fractures in 11 013 individuals (mean [SD] age 75.8 [6.8] years, 93.3% female) who had a BMD test combined with VFA between March 2010 and December 2017. Auto-PVFx and auto-AAC were ascertained using convolutional neural networks (CNNs). Proportional hazards models were used to estimate the associations of auto-PVFx and auto-AAC with incident fractures over a mean (SD) follow-up of 3.7 (2.2) years, adjusted for each other and other risk factors. At baseline, 17% (n = 1881) had auto-PVFx and 27% (n = 2974) had a high level of auto-AAC (≥ 6 on scale of 0 to 24). Multivariable-adjusted hazard ratios (HR) for incident major osteoporotic fracture (95% CI) were 1.85 (1.59, 2.15) for those with compared with those without auto-PVFx, and 1.36 (1.14, 1.62) for those with high compared with low auto-AAC. The multivariable-adjusted HRs for incident hip fracture were 1.62 (95% CI, 1.26 to 2.07) for those with compared to those without auto-PVFx, and 1.55 (95% CI, 1.15 to 2.09) for those high auto-AAC compared with low auto-AAC. The 5-year cumulative incidence of major osteoporotic fracture was 7.1% in those with no auto-PVFx and low auto-AAC, 10.1% in those with no auto-PVFx and high auto-AAC, 13.4% in those with auto-PVFx and low auto-AAC, and 18.0% in those with auto-PVFx and high auto-AAC. While physician manual review of images in clinical practice will still be needed to confirm image quality and provide clinical context for interpretation, simultaneous automated ascertainment of auto-PVFx and auto-AAC can aid fracture risk assessment.
Individuals with calcification of their abdominal aorta (AAC) and vertebral fractures seen on lateral spine bone density images (easily obtained as part of a bone density test) are much more likely to have subsequent fractures. Prior studies have not shown if both AAC and prior vertebral fracture both contribute to fracture prediction in routine clinical practice. Additionally, a barrier to using these images to aid fracture risk assessment at the time of bone density testing has been the need for expert readers to be able to accurately detect both AAC and vertebral fractures. We have developed automated computer methods (using artificial intelligence) to accurately detect vertebral fracture (auto-PVFx) and auto-AAC on lateral spine bone density images for 11 013 older individuals having a bone density test in routine clinical practice. Over a 5-year follow-up period, 7.1% of those with no auto-PVFx and low auto-AAC, 10.1% of those with no auto-PVFx and high auto-AAC, 13.4% of those with auto-PVFx and low auto-AAC, and 18.0% of those with auto-PVFx and high auto-AAC had a major osteoporotic fracture. Auto-PVFx and auto-AAC, ascertained simultaneously on lateral spine bone density images, both contribute to the risk of subsequent major osteoporotic fractures in routine clinical practice settings.
Asunto(s)
Aorta Abdominal , Fracturas de la Columna Vertebral , Humanos , Femenino , Anciano , Fracturas de la Columna Vertebral/epidemiología , Fracturas de la Columna Vertebral/diagnóstico por imagen , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/patología , Masculino , Medición de Riesgo , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/epidemiología , Prevalencia , Anciano de 80 o más Años , Factores de Riesgo , Automatización , Fracturas Osteoporóticas/epidemiología , Fracturas Osteoporóticas/diagnóstico por imagen , IncidenciaRESUMEN
BACKGROUND: Convolutional neural networks (CNNs) can identify vertebral compression fractures in GE vertebral fracture assessment (VFA) images with high balanced accuracy, but performance against Hologic VFAs is unknown. To obtain good classification performance, supervised machine learning requires balanced and labeled training data. Active learning is an iterative data annotation process with the ability to reduce the cost of labeling medical image data and reduce class imbalance. PURPOSE: To train CNNs to identify vertebral fractures in Hologic VFAs using an active learning approach, and evaluate the ability of CNNs to generalize to both Hologic and GE VFA images. METHODS: VFAs were obtained from the OsteoLaus Study (labeled Hologic Discovery A, n = 2726), the Manitoba Bone Mineral Density Program (labeled GE Prodigy and iDXA, n = 12,742), and the Canadian Longitudinal Study on Aging (CLSA, unlabeled Hologic Discovery A, n = 17,190). Unlabeled CLSA VFAs were split into five equal-sized partitions (n = 3438) and reviewed sequentially using active learning. Based on predicted fracture probability, 17.6% (n = 3032) of the unlabeled VFAs were selected for expert review using the modified algorithm-based qualitative (mABQ) method. CNNs were simultaneously trained on Hologic, GE dual-energy and GE single-energy VFAs. Two ensemble CNNs were constructed using the maximum and mean predicted probability from six separately trained CNNs that differed due to stochastic variation. CNNs were evaluated against the OsteoLaus validation set (n = 408) during the active learning process; ensemble performance was measured against the OsteoLaus test set (n = 819). RESULTS: The baseline CNN, prior to active learning, achieved 55.0% sensitivity, 97.9% specificity, 57.9% positive predictive value (PPV), F1-score 56.4%. Through active learning, 2942 CLSA Hologic VFAs (492 fractures) were added to the training data-increasing the proportion of Hologic VFAs with fractures from 4.2% to 12.5%. With active learning, CNN performance improved to 80.0% sensitivity, 99.7% specificity, 94.1% PPV, F1-score 86.5%. The CNN maximum ensemble achieved 91.9% sensitivity (100% for grade 3 and 95.5% for grade 2 fractures), 99.0% specificity, 81.0% PPV, F1-score 86.1%. CONCLUSION: Simultaneously training on a composite dataset consisting of both Hologic and GE VFAs allowed for the development of a single manufacturer-independent CNN that generalized to both scanner types with good classification performance. Active learning can reduce class imbalance and produce an effective medical image classifier while only labeling a subset of available unlabeled image data-thereby reducing the time and cost required to train a machine learning model.
Asunto(s)
Fracturas por Compresión , Fracturas de la Columna Vertebral , Canadá , Fracturas por Compresión/diagnóstico por imagen , Humanos , Estudios Longitudinales , Redes Neurales de la Computación , Fracturas de la Columna Vertebral/diagnóstico por imagenRESUMEN
INTRODUCTION: Rotator-cuff injury (RCI) represents 50% of shoulder injuries, and prevalence increases with age. Even with successful tendon repair, muscle and joint function may not return. METHODS: To explore the dysfunction, supraspinatus and ipsilateral deltoid (control) muscles were biopsied during arthroscopic RCI repair for pair-wise histological and protein-expression studies. RESULTS: Supraspinatus showed fiber atrophy (P < 0.0001), fibrosis (by Sirius Red, P = 0.05), reduced vascular density (P < 0.001), and a lower proportion of slow fibers (P < 0.0001) compared with the ipsilateral control muscle. There were also higher levels of atrogin-1 (P = 0.05), vascular endothelial growth factor (VEGF, P < 0.01), and dystrophin (P < 0.008, relative to fiber diameter) versus control. CONCLUSIONS: Adaptive changes in vascular endothelial growth factor and dystrophin were likely associated with reduced vascular supply, fatigue resistance, and fibrosis, accompanied by disuse atrophy from mechanical unloading of supraspinatus after tendon tear. Treatment to promote growth and vascularity in atrophic supraspinatus muscle may help improve functional outcome after surgical repair. Muscle Nerve 55: 715-726, 2017.
Asunto(s)
Fibras Musculares de Contracción Rápida/patología , Atrofia Muscular/patología , Lesiones del Manguito de los Rotadores/patología , Anciano , Miosinas Cardíacas/metabolismo , Distrofina/metabolismo , Femenino , Fibrosis/diagnóstico por imagen , Fibrosis/metabolismo , Fibrosis/patología , Fibrosis/fisiopatología , Humanos , Imagen por Resonancia Magnética , Masculino , Metaloproteinasa 9 de la Matriz/metabolismo , Persona de Mediana Edad , Fibras Musculares de Contracción Rápida/metabolismo , Proteínas Musculares/metabolismo , Atrofia Muscular/diagnóstico por imagen , Atrofia Muscular/metabolismo , Atrofia Muscular/fisiopatología , Cadenas Pesadas de Miosina/metabolismo , Lesiones del Manguito de los Rotadores/diagnóstico por imagen , Lesiones del Manguito de los Rotadores/metabolismo , Lesiones del Manguito de los Rotadores/fisiopatología , Proteínas Ligasas SKP Cullina F-box/metabolismo , Factor A de Crecimiento Endotelial Vascular/metabolismoRESUMEN
It is unclear if surgical exposure confers a risk advantage compared with a percutaneous approach for patients undergoing endovascular procedures requiring large-bore femoral artery access. From the randomized controlled Placement of Aortic Transcatheter Valve trials A and B and the continued access registries, a total of 1,416 patients received transfemoral transcatheter aortic valve replacement, of which 857 underwent surgical, and 559 underwent percutaneous access. Thirty-day rates of major vascular complications and quality of life scores were assessed. Propensity matching was used to adjust for unmeasured confounders. Overall, there were 116 major vascular complications (8.2%). Complication rates decreased dramatically during the study period. In unadjusted analysis, major vascular complications were significantly less common in the percutaneous access group (35 [6.3%] vs 81 [9.5%] p = 0.032). However, among 292 propensity-matched pairs, there was no difference in major vascular complications (22 [7.5%] vs 28 [9.6%], p = 0.37). Percutaneous access was associated with fewer total in-hospital vascular complications (46 [16%] vs 66 [23%], p = 0.036), shorter median procedural duration (97 interquartile range [IQR 68 to 166] vs 121 [IQR 78 to 194] minutes, p <0.0001), and median length of stay (4 [IQR 2 to 8] vs 6 [IQR 3 to 10] days, p <0.0001). There were no significant differences in quality of life scores at 30 days. Surgical access for large-bore femoral access does not appear to confer any advantages over percutaneous access and may be associated with more minor vascular complications.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Cateterismo Cardíaco/métodos , Prótesis Valvulares Cardíacas , Complicaciones Posoperatorias/epidemiología , Sistema de Registros , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Estenosis de la Válvula Aórtica/mortalidad , Arteria Femoral , Estudios de Seguimiento , Humanos , Incidencia , Calidad de Vida , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Endovascular stent graft placement has been used to facilitate resection of tumors invading the thoracic aorta. Here we describe the first use of an aortic endograft for preoperative protection of the thoracic descending aorta before left pneumonectomy for a primary lung cancer invading the thoracic spine and thoracic descending aorta.
Asunto(s)
Adenocarcinoma/secundario , Procedimientos Endovasculares/métodos , Neoplasias Pulmonares/patología , Neoplasias de la Columna Vertebral/secundario , Stents , Neoplasias Vasculares/secundario , Adenocarcinoma/diagnóstico por imagen , Adenocarcinoma/cirugía , Anciano , Aorta Torácica/cirugía , Dolor de Espalda/diagnóstico , Dolor de Espalda/etiología , Terapia Combinada , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/cirugía , Masculino , Invasividad Neoplásica/patología , Estadificación de Neoplasias , Neumonectomía/métodos , Medición de Riesgo , Neoplasias de la Columna Vertebral/cirugía , Vértebras Torácicas/patología , Vértebras Torácicas/cirugía , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Neoplasias Vasculares/diagnóstico por imagen , Neoplasias Vasculares/cirugíaRESUMEN
With the development of the transcatheter aortic valve replacement, innovative approaches can be geared to atypical and challenging cases. We describe a case of transcatheter aortic valve replacement via a left anterior thoracotomy in a patient with pectus excavatum and unusual intrathoracic anatomy where surgical and traditional transcatheter aortic valve replacement approaches were deemed inapplicable.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Tórax en Embudo/cirugía , Toracoplastia/métodos , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano de 80 o más Años , Angiografía , Estenosis de la Válvula Aórtica/complicaciones , Tórax en Embudo/complicaciones , Tórax en Embudo/diagnóstico , Humanos , Masculino , Índice de Severidad de la Enfermedad , Tomografía Computarizada por Rayos XAsunto(s)
Insuficiencia Cardíaca/diagnóstico por imagen , Monitoreo Intraoperatorio/métodos , Líquido Pericárdico/diagnóstico por imagen , Pleura/diagnóstico por imagen , Ultrasonografía Intervencional/métodos , Anciano de 80 o más Años , Ecocardiografía/métodos , Insuficiencia Cardíaca/cirugía , Humanos , MasculinoRESUMEN
The high frequency of poor outcome and chronic pain after surgical repair of shoulder rotator-cuff injury (RCI) prompted this study to explore the potential to amplify muscle regeneration using nitric oxide (NO)-based treatment. After preoperative magnetic resonance imaging (MRI), biopsies of supraspinatus and ipsilateral deltoid (as a control) were collected during reparative surgery for RCI. Muscle fiber diameter, the pattern of neuromuscular junctions observed with alpha-bungarotoxin staining, and the γ:ε subunit ratio of acetylcholine receptors in Western blots were examined in tandem with experiments to determine the in vitro responsiveness of muscle satellite cells to activation (indicated by uptake of bromodeoxyuridine, BrdU) by the NO-donor drug, isosorbide dinitrate (ISDN). Consistent with MRI findings of supraspinatus atrophy (reduced occupation ratio and tangent sign), fiber diameter was lower in supraspinatus than in deltoid. ISDN induced a significant increase over baseline (up to 1.8-fold), in the proportion of BrdU+ (activated) Pax7+ satellite cells in supraspinatus, but not in deltoid, after 40 h in culture. The novel application of denervation indices revealed a trend for supraspinatus muscle to have a higher γ:ε subunit ratio than deltoid (P = 0.13); this ratio inversely with both occupancy ratio (P < 0.05) and the proportion of clusters at neuromuscular junctions (P = 0.05). Results implicate possible supraspinatus denervation in RCI and suggest NO-donor treatment has potential to promote growth in atrophic supraspinatus muscle after RCI and improve functional outcome.
Asunto(s)
Músculo Deltoides/inervación , Músculo Deltoides/patología , Fibras Musculares Esqueléticas/patología , Atrofia Muscular/patología , Manguito de los Rotadores/inervación , Manguito de los Rotadores/patología , Células Satélite del Músculo Esquelético/patología , Anciano , Animales , Músculo Deltoides/metabolismo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Desnervación Muscular , Fibras Musculares Esqueléticas/metabolismo , Unión Neuromuscular/metabolismo , Unión Neuromuscular/patología , Óxido Nítrico/metabolismo , Regeneración/fisiología , Células Satélite del Músculo Esquelético/metabolismo , Hombro/inervación , Hombro/patologíaRESUMEN
A variety of access routes have been employed for transcatheter aortic valve replacement (TAVR). We report a TAVR case using the abdominal aorta as the direct access route when other approaches are not feasible.
Asunto(s)
Aorta Abdominal , Estenosis de la Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano , Humanos , Masculino , Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
BACKGROUND: Based on the early results of the Placement of Aortic Transcatheter Valves (PARTNER) trial, transcatheter aortic valve replacement (TAVR) is an accepted treatment for patients with severe aortic stenosis who are not suitable for surgery. However, little information is available about the late clinical outcomes in such patients. METHODS: We did this randomised controlled trial at 21 experienced valve centres in Canada, Germany, and the USA. We enrolled patients with severe symptomatic inoperable aortic stenosis and randomly assigned (1:1) them to transfemoral TAVR or to standard treatment, which often included balloon aortic valvuloplasty. Patients and their treating physicians were not masked to treatment allocation. The randomisation was done centrally, and sites learned of the assignment only after a patient had been screened, consented, and entered into the database. The primary outcome of the trial was all-cause mortality at 1 year in the intention-to-treat population, here we present the prespecified findings after 5 years. This study is registered with ClinicalTrials.gov, number NCT00530894. FINDINGS: We screened 3015 patients, of whom 358 were enrolled (mean age 83 years, Society of Thoracic Surgeons Predicted Risk of Mortality 11·7%, 54% female). 179 were assigned to TAVR treatment and 179 were assigned to standard treatment. 20 patients crossed over from the standard treatment group and ten withdrew from study, leaving only six patients at 5 years, of whom five had aortic valve replacement treatment outside of the study. The risk of all-cause mortality at 5 years was 71·8% in the TAVR group versus 93·6% in the standard treatment group (hazard ratio 0·50, 95% CI 0·39-0·65; p<0·0001). At 5 years, 42 (86%) of 49 survivors in the TAVR group had New York Heart Association class 1 or 2 symptoms compared with three (60%) of five in the standard treatment group. Echocardiography after TAVR showed durable haemodynamic benefit (aortic valve area 1·52 cm(2) at 5 years, mean gradient 10·6 mm Hg at 5 years), with no evidence of structural valve deterioration. INTERPRETATION: TAVR is more beneficial than standard treatment for treatment of inoperable aortic stenosis. TAVR should be strongly considered for patients who are not surgical candidates for aortic valve replacement to improve their survival and functional status. Appropriate selection of patients will help to maximise the benefit of TAVR and reduce mortality from severe comorbidities. FUNDING: Edwards Lifesciences.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/fisiopatología , Canadá , Causas de Muerte , Comorbilidad , Ecocardiografía , Femenino , Estudios de Seguimiento , Alemania , Hemodinámica , Humanos , Estimación de Kaplan-Meier , Masculino , Medición de Riesgo , Accidente Cerebrovascular/epidemiología , Tasa de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: The Placement of Aortic Transcatheter Valves (PARTNER) trial showed that mortality at 1 year, 2 years, and 3 years is much the same with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for high-risk patients with aortic stenosis. We report here the 5-year outcomes. METHODS: We did this randomised controlled trial at 25 hospitals, in Canada (two), Germany (one), and the USA (23). We used a computer-generated randomisation sequence to randomly assign high-risk patients with severe aortic stenosis to either SAVR or TAVR with a balloon-expandable bovine pericardial tissue valve by either a transfemoral or transapical approach. Patients and their treating physicians were not masked to treatment allocation. The primary outcome of the trial was all-cause mortality in the intention-to-treat population at 1 year, we present here predefined outcomes at 5 years. The study is registered with ClinicalTrials.gov, number NCT00530894. FINDINGS: We screened 3105 patients, of whom 699 were enrolled (348 assigned to TAVR, 351 assigned to SAVR). Overall mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 11·7%. At 5 years, risk of death was 67·8% in the TAVR group compared with 62·4% in the SAVR group (hazard ratio 1·04, 95% CI 0·86-1·24; p=0·76). We recorded no structural valve deterioration requiring surgical valve replacement in either group. Moderate or severe aortic regurgitation occurred in 40 (14%) of 280 patients in the TAVR group and two (1%) of 228 in the SAVR group (p<0·0001), and was associated with increased 5-year risk of mortality in the TAVR group (72·4% for moderate or severe aortic regurgitation vs 56·6% for those with mild aortic regurgitation or less; p=0·003). INTERPRETATION: Our findings show that TAVR as an alternative to surgery for patients with high surgical risk results in similar clinical outcomes. FUNDING: Edwards Lifesciences.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/epidemiología , Estenosis de la Válvula Aórtica/epidemiología , Canadá , Causas de Muerte , Comorbilidad , Femenino , Estudios de Seguimiento , Alemania , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Análisis de Supervivencia , Tasa de Supervivencia , Resultado del Tratamiento , Estados UnidosRESUMEN
We sought to evaluate the principles of disruptive innovation, defined as technology innovation that fundamentally shifts performance and utility metrics, as applied to transcatheter aortic valve implantation (TAVI). In particular, we considered implantation procedure, device design, cost, and patient population. Generally cheaper and lower performing, classical disruptive innovations are first commercialized in insignificant markets, promise lower margins, and often parasitize existing usage, representing unattractive investments for established market participants. However, despite presently high unit cost, TAVI is less invasive, treats a "new," generally high risk, patient population, and is generally done by a multidisciplinary integrated heart team. Moreover, at least in the short-term TAVI has not been lower-performing than open surgical aortic valve replacement in high-risk patients. We conclude that TAVI extends the paradigm of disruptive innovation and represents an attractive commercial opportunity space. Moreover, should the long-term performance and durability of TAVI approach that of conventional prostheses, TAVI will be an increasingly attractive commercial opportunity.
Asunto(s)
Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Animales , HumanosAsunto(s)
Cateterismo Cardíaco , Cardiología/normas , Fármacos Cardiovasculares/uso terapéutico , Prueba de Esfuerzo , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/terapia , Implantación de Prótesis de Válvulas Cardíacas , Fiebre Reumática/prevención & control , HumanosRESUMEN
With the recent emergence of transcatheter valve replacement, high-risk cases of structural valve deterioration after mitral bioprosthesis can be treated with valve-in-valve transcatheter mitral valve replacement (TMVR). The transapical approach has become the principal access for TMVR, but we report an alternative direct access for TMVR--transjugular transseptal route--in an 81-year-old woman with a degenerated mitral bioprosthesis.
Asunto(s)
Cateterismo Cardíaco , Implantación de Prótesis de Válvulas Cardíacas/métodos , Venas Yugulares/cirugía , Válvula Mitral/cirugía , Anciano , Anciano de 80 o más Años , Femenino , HumanosRESUMEN
OBJECTIVES: To determine the incidence and etiology of thrombocytopenia following transcatheter Aortic valve replacement (TAVR). BACKGROUND: the use of TAVR in the United States has grown rapidly. Anecdotally, thrombocytopenia following TAVR with the Sapien valves has been observed, though little is known about this phenomenon. METHODS: All patients treated with TAVR using a Sapien valve or who underwent isolated balloon aortic valvuloplasty (BAV) at Brigham and Women's Hospital from October 2009 through November 2012 were analyzed. Post-procedure thrombocytopenia severity was stratified as none (>150,000 cells/µL), mild (100-150,000), and moderate to severe (<100,000). Summary statistics and simple comparisons were evaluated. Linear regression models were used to identify patient or procedural factors associated with platelet count nadir. RESULTS: 112 TAVR and 105 BAV patients were analyzed. Following TAVR the prevalence of thrombocytopenia was 69% and the incidence of new thrombocytopenia was 45% compared to 37% and 17% respectively following BAV (P < 0.01). Similar results were found across all strata of thrombocytopenia severity. Post-TAVR platelet nadirs were greater by 1,840 cells/µL for each 1% increase in STS score (P = 0.03) and 670 cells/µL greater for each 1 mmHg increase in pre-TAVR mean aortic stenosis gradient. Among TAVR patients, thrombocytopenia appears to spontaneously resolve an average of 8 days post-procedure. No differences in clinical outcomes based on thrombocytopenia severity were observed except for an increased use of blood products (P = 0.05). CONCLUSIONS: Thrombocytopenia following TAVR with the Edwards' Sapien valves is a frequent but generally self-limited process. The etiology of this phenomenon is unknown.
Asunto(s)
Estenosis de la Válvula Aórtica/terapia , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Trombocitopenia/epidemiología , Anciano , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/diagnóstico , Valvuloplastia con Balón , Boston/epidemiología , Femenino , Humanos , Incidencia , Masculino , Recuento de Plaquetas , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Trombocitopenia/sangre , Trombocitopenia/diagnóstico , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The present study assessed the clinical and echocardiographic outcomes for 1000 patients undergoing minimally invasive mitral valve surgery. METHODS: The Brigham Cardiac Valve database was reviewed. From August 1996 to November 2011, 1000 patients had undergone minimally invasive mitral valve surgery (median follow-up, 7 years). Data on the surgical approach, complications, reoperations, and late survival were tabulated. Late echocardiographic data on the recurrence of mitral regurgitation after mitral repair in myxomatous disease were also collected. Survival, freedom from reoperation and recurrent mitral regurgitation (grade ≥ 3+) were evaluated with life tables and Kaplan-Meier analyses. RESULTS: The mean patient age was 57 years. Of the 1000 patients, 41% were women. Myxomatous degenerative disease was the predominant pathologic entity (86%). A lower hemisternotomy was the predominant surgical approach (75%). Mitral repair was performed in 923 patients and replacement in 77. Eight operative deaths (0.8%) occurred. A total of 44 patients with failed mitral repairs underwent reoperation, with 1 mitral valve replaced again on the same operative day for atrioventricular groove disruption. Nine failed repairs were repaired again (9/44 [20%]). A total of 106 late deaths occurred. The overall survival at 15 years was 79% ± 3%. Freedom from reoperation at 15 years was 90% ± 3% for repairs and 100% for replacements. Late echocardiograms were acquired for 615 of 815 eligible mitral repair patients with myxomatous disease (75%). Freedom from recurrent mitral regurgitation (grade ≥ 3+) at 1, 5, and 10 years was 99% ± 1%, 87% ± 2%, and 69% ± 4%, respectively. CONCLUSIONS: Minimally invasive mitral valve surgery is effective, with excellent late results. The durability of minimally invasive mitral valve repair compared favorably with conventional full sternotomy methods at late follow-up.