RESUMEN
BACKGROUND: The Society of Thoracic Surgeons current (STS) guidelines recommend delaying coronary artery bypass graft surgery (CABG) for several days or performing platelet function testing in stable patients who received P2Y12 inhibitors. Our program routinely uses thromboelastography-platelet mapping (TEG-PM) to expedite CABG in P2Y12 nonresponders. We hypothesize that P2Y12 nonresponders had no difference in length of stay to surgery and blood product transfusion compared with patients undergoing urgent inpatient CABG not treated with a P2Y12 inhibitor. METHODS: A total of 221 patients from 2015 to 2019 were P2Y12 nonresponders based on TEG-PM result of less than 50% adenosine diphosphate inhibition. The control group was 232 consecutive patients who also had urgent inpatient CABG but were not treated preoperatively with a P2Y12 inhibitor. Exclusion criteria were identical between groups. RESULTS: Sixty-seven percent of inpatient CABG patients who were treated preoperatively with a P2Y12 inhibitor were nonresponders. The mean number of days from cardiac surgical consultation to CABG in the TEG-PM nonresponders group was 1.6 ± 0.1 vs 2.1 ± 0.1 in the control group (P < .01). The mean total number of blood product units transfused was 1.6 ± 0.2 in the TEG-PM nonresponders group vs 1.6 ± 0.4 in the control group (P = .91). CONCLUSIONS: Our results demonstrate a very high incidence of P2Y12 nonresponders among patients undergoing urgent CABG at our program. These patients underwent surgery at least 3 days earlier than STS recommendations and common practice with no difference in transfusion requirement. Routine use of TEG-PM to identify P2Y12 nonresponders can safely decrease preoperative hospital length of stay and associated cost and improve resource utilization and patient satisfaction.
Asunto(s)
Inhibidores de Agregación Plaquetaria , Tromboelastografía , Plaquetas , Puente de Arteria Coronaria/métodos , Humanos , Inhibidores de Agregación Plaquetaria/efectos adversos , Pruebas de Función Plaquetaria/métodos , Tromboelastografía/métodosRESUMEN
BACKGROUND: To determine if racial disparities exist between African Americans (AA) and Non-Hispanic Whites (NHW) for patients undergoing repair of acute type A aortic dissection (ATAAD) at a rural tertiary academic medical center. METHODS: There were 215 consecutive AA and NHW patients who underwent ATAAD repair at our institution from 1999 to 2019 included in a retrospective analysis of our Society of Thoracic Surgeons Adult Cardiac Surgery Database. Statistical analysis was performed with a p value of less than .05 considered statistically significant. RESULTS: Patients undergoing ATAAD repair were 47% AA despite comprising only 27% of the total population in our region. AAs were significantly younger (54.0 vs. 61.2 years), were more likely to be hypertensive (94.1% vs. 79.7%), had higher creatinine levels (1.7 vs. 1.1 mg/dL), and higher body mass index (30.8 vs. 28.1 kg/m2 ) (all p values < .006). There were no significant differences in type of repair or intraoperative variables. A logistic regression analysis showed AAs had an increased rate of postoperative acute renal failure not requiring hemodialysis when compared to NHWs (20.8% vs. 10.6%, p value = .042). Thirty-day mortality was not significantly different (15.7% vs. 13.4%) nor was 1-year survival (78% vs. 79%) in AAs and NHWs, respectively. CONCLUSIONS: Despite AAs having more medical comorbidities at presentation, there were no differences in short- and intermediate-term survival. In our catchment of 1.8 million people, AAs appear to undergo ATAAD repair at a disproportionate rate versus NHWs. These findings may alter strategies for surveillance and prevention of aortic disease in this high-risk population.
Asunto(s)
Disección Aórtica , Centros Médicos Académicos , Adulto , Disección Aórtica/cirugía , Humanos , Estudios Retrospectivos , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVE: Despite improved outcomes for open repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA), these operations remain challenging in octogenarians. Patients unsuitable for thoracic endovascular aortic repair require open surgery to avoid catastrophic rupture. We analyzed our results for DTA/TAAA repair in these elderly patients. METHODS: Our institutional aortic database was queried to identify those ≥80 years old and those <80 years old undergoing open DTA/TAAA repair. Logistic and Cox regression analyses were used to account for confounders and to identify predictors of perioperative and long-term outcomes. RESULTS: From 1997 to 2017, there were 783 patients who underwent open repair of DTA or TAAA; 96 (12.3%) were ≥80 years old. Octogenarians were more likely to be female (P = .018), with chronic pulmonary disease (P = .012), severe peripheral vascular disease (P < .001), and hypertension (P = .025). Degenerative aneurysms were more common among octogenarians (P < .001), whereas chronic and acute dissections were more common among those younger than 80 years (P < .001 for both). Operative mortality was 5.6% and was not negatively affected by advanced age (<80 years, 5.7%; ≥80 years, 5.6%; P = .852). Other than an increased incidence of left recurrent nerve palsy in the younger cohort (<80 years, 6.7%; ≥ 80 years, 1.0%; P = .029), there were no significant differences in the incidence of major postoperative complications. Logistic regression modeling showed that age ≥80 years was not predictive of operative mortality or postoperative complications. A greater percentage of octogenarians had aortic reconstruction with a clamp and sew strategy (85.4% vs 61.6%; P < .001), which led to significantly shorter cross-clamp times in this cohort (26.6 minutes vs 30.7 minutes; P < .004). In octogenarians, the incidence of major postoperative adverse events was associated with extent II aneurysms (odds ratio, 2.6; P < .025). Short- and long-term survival was significantly reduced in octogenarians. CONCLUSIONS: In select octogenarians, open repair of DTA/TAAA can be performed with acceptable risk. A simplified surgical approach may provide the best opportunity for a successful outcome.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Factores de Edad , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Tempo Operativo , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The optimal brain protection strategy for prolonged periods of circulatory arrest is still controversial. This study evaluated whether retrograde cerebral perfusion (RCP) provides adequate brain protection for prolonged periods of deep hypothermic circulatory arrest (DHCA). METHODS: From January 1997 to December 2014, 1,043 patients underwent aortic arch operations using RCP and DHCA at 18°C. The DHCA time for 993 patients was 49 minutes or less and the DHCA time for the remaining 50 patients was 50 minutes or more. Propensity matching between the two groups was performed, taking into account the main preoperative and surgical variables and all the preoperative and intraoperative neurologic risk factors. Logistic regression analysis was performed to identify independent predictors of operative death and postoperative cerebral complications. RESULTS: In the unmatched population, mortality in the 50 minutes or more vs the 49 minutes or less group was 8% vs 3.8% (p = 0.143), and the stroke rate was 2% vs 1.2% (p = 0.623). Propensity matching resulted in 48 pairs. Operative death and incidence of transient and permanent neurologic deficit were similar and not statistically significant in the matched groups for all comparisons. No difference in the incidence of other major postoperative complications was found between the two groups. Midterm survival was similar. Regression analysis showed DHCA duration was not independently associated with operative death or postoperative neurologic deficits. CONCLUSIONS: RCP is an effective adjunctive cerebral protection strategy for complex aortic arch aneurysm repair with prolonged DHCA and is not associated with increased death or neurologic complications.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Circulación Cerebrovascular/fisiología , Paro Circulatorio Inducido por Hipotermia Profunda/métodos , Perfusión/métodos , Accidente Cerebrovascular/prevención & control , Procedimientos Quirúrgicos Vasculares/métodos , Anciano , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico , Aneurisma de la Aorta Torácica/fisiopatología , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Masculino , Persona de Mediana Edad , New York/epidemiología , Complicaciones Posoperatorias , Estudios Retrospectivos , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del TratamientoRESUMEN
Accessory mitral valve (AMV) is a rare congenital cardiac malformation associated with left ventricular outflow tract obstruction and endocarditis. We report a patient with an AMV who presented with a cerebellar infarct and discuss the management of this anomaly.
Asunto(s)
Válvula Aórtica/cirugía , Cardiopatías Congénitas/complicaciones , Válvula Mitral/anomalías , Accidente Cerebrovascular/etiología , Animales , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Bioprótesis , Bovinos , Cuerdas Tendinosas , Diagnóstico Diferencial , Errores Diagnósticos , Ecocardiografía Transesofágica , Endocarditis , Cardiopatías Congénitas/diagnóstico por imagen , Tabiques Cardíacos/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Resultado del Tratamiento , Obstrucción del Flujo Ventricular Externo/etiología , Obstrucción del Flujo Ventricular Externo/cirugíaRESUMEN
PURPOSE: To determine whether resurfacing submacular human Bruch's membrane with a cell-deposited extracellular matrix (ECM) improves retinal pigment epithelial (RPE) survival. METHODS: Bovine corneal endothelial (BCE) cells were seeded onto the inner collagenous layer of submacular Bruch's membrane explants of human donor eyes to allow ECM deposition. Control explants from fellow eyes were cultured in medium only. The deposited ECM was exposed by removing BCE. Fetal RPE cells were then cultured on these explants for 1, 14, or 21 days. The explants were analyzed quantitatively by light microscopy and scanning electron microscopy. Surviving RPE cells from explants cultured for 21 days were harvested to compare bestrophin and RPE65 mRNA expression. Mass spectroscopy was performed on BCE-ECM to examine the protein composition. RESULTS: The BCE-treated explants showed significantly higher RPE nuclear density than did the control explants at all time points. RPE expressed more differentiated features on BCE-treated explants than on untreated explants, but expressed very little mRNA for bestrophin or RPE65. The untreated young (<50 years) and African American submacular Bruch's membrane explants supported significantly higher RPE nuclear densities (NDs) than did the Caucasian explants. These differences were reduced or nonexistent in the BCE-ECM-treated explants. Proteins identified in the BCE-ECM included ECM proteins, ECM-associated proteins, cell membrane proteins, and intracellular proteins. CONCLUSIONS: Increased RPE survival can be achieved on aged submacular human Bruch's membrane by resurfacing the latter with a cell-deposited ECM. Caucasian eyes seem to benefit the most, as cell survival is the worst on submacular Bruch's membrane in these eyes.