RESUMEN
OBJECTIVES: Minimally invasive extracorporeal circuits have been introduced to cardiac surgery in an attempt to reduce the negative effects of cardiopulmonary bypass on patient outcome. On the other hand, transcatheter aortic valve replacement (TAVR) provides an excellent option to replace the aortic valve without the need for cardiopulmonary bypass. Several studies have compared TAVR to surgical aortic valve replacement (SAVR) but none have utilized a minimally invasive extracorporeal circuit. METHODS: We retrospectively analysed the results of both procedures among octogenarians operated in our department from 2003 to 2016. Excluded were patients with an active endocarditis, a history of previous cardiac surgery, as well as those who had a minimally invasive surgical approach. This yielded 81 and 142 octogenarians in the SAVR and TAVR groups, respectively. To compensate for a lack of randomization, we performed a propensity score analysis, which yielded 68 patient pairs for the final analysis. RESULTS: The 30-day postoperative mortality was lower in the SAVR group (1.5% vs 5.9%) but not statistically significant (P = 0.4). In contrast, the incidence of postoperative atrial fibrillation was lower in the TAVR group (13% vs 29%) but also non-significant (P = 0.2). Finally, the incidence of paravalvular leakage was in favour of the SAVR group (2.9% vs 52%; P = 0.001) while the transfusion requirement was significantly lower in the TAVR group (29% vs 72%; P < 0.001). CONCLUSIONS: SAVR utilizing a minimally invasive extracorporeal circuit improves the quality of patient care and can offer an alternative to TAVR in octogenarians.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Oxigenación por Membrana Extracorpórea/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Complicaciones Posoperatorias/epidemiología , Factores de Edad , Anciano de 80 o más Años , Femenino , Alemania/epidemiología , Humanos , Incidencia , Masculino , Puntaje de Propensión , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of this study was to compare narcotic use in the perioperative hospital stay as a measure of pain in patients undergoing robotic versus conventional coronary artery bypass grafting (CABG). METHODS: Propensity score matching of patients undergoing robotically assisted CABG and conventional CABG over a period of 5 years was performed. A retrospective chart review was performed to identify the total amount of narcotics used by both groups calculated as morphine equivalent dosing (MED). RESULTS: From 2007 to 2012, 154 patients underwent robotic CABG, and 1660 underwent conventional CABG. Propensity matching resulted in 142 patients in each group. Patients undergoing robotic CABG received less blood transfusion, were more frequently extubated in the operating room, and had a shorter length of stay. The robotic group had a lower MED than the conventional group as defined by the primary end point [181 (11) vs 251 (8)]. If intraoperative narcotic use was eliminated, there was no difference in MED from postoperative days 0 to 3. CONCLUSIONS: Patients undergoing robotic CABG use fewer narcotics over the first three hospital days than patients undergoing conventional CABG. The surrogate of narcotics use for postoperative pain shows that the minithoracotomy of robotic CABG may result in either less or equivalent pain than the sternotomy of conventional CABG.
Asunto(s)
Puente de Arteria Coronaria/métodos , Narcóticos/administración & dosificación , Procedimientos Quirúrgicos Robotizados/métodos , Anciano , Transfusión Sanguínea , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Periodo Perioperatorio , Puntaje de Propensión , Estudios Retrospectivos , Toracotomía/métodos , Resultado del TratamientoRESUMEN
Acute type A retrograde aortic dissection is characterized by a port of entry located in the descending aorta near the subclavian take-off, and is currently treated with surgery. Our experience with two patients who underwent a complicated postoperative course stimulated a review of the current literature and discussion of possible alternative strategies in light of recent advances in endovascular treatment.
Asunto(s)
Aneurisma de la Aorta Torácica/terapia , Disección Aórtica/terapia , Implantación de Prótesis Vascular/métodos , Procedimientos Endovasculares/métodos , Adulto , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/cirugía , Aortografía , Humanos , Masculino , Persona de Mediana Edad , Stents , Resultado del TratamientoRESUMEN
: Images and movie clips documenting the rare occurrence of a percutaneous prosthesis embolization into the left ventricle are presented. The case outcome and the circumstances leading to the event are discussed.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Embolia/etiología , Migración de Cuerpo Extraño/etiología , Prótesis Valvulares Cardíacas , Ventrículos Cardíacos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Anciano , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Valvuloplastia con Balón , Cineangiografía , Remoción de Dispositivos , Embolia/diagnóstico por imagen , Embolia/cirugía , Femenino , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/cirugía , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/cirugía , Humanos , Diseño de Prótesis , Tomografía Computarizada por Rayos X , Resultado del TratamientoAsunto(s)
Válvula Aórtica , Cateterismo Cardíaco/efectos adversos , Procedimientos Quirúrgicos Cardíacos , Migración de Cuerpo Extraño/cirugía , Accesibilidad a los Servicios de Salud , Enfermedades de las Válvulas Cardíacas/terapia , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Anciano , Cateterismo Cardíaco/instrumentación , Cateterismo Cardíaco/normas , Procedimientos Quirúrgicos Cardíacos/normas , Oxigenación por Membrana Extracorpórea , Femenino , Migración de Cuerpo Extraño/etiología , Accesibilidad a los Servicios de Salud/normas , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/normas , Humanos , Guías de Práctica Clínica como Asunto , Resultado del TratamientoRESUMEN
We prospectively evaluated 46 patients who underwent aortic valve repair (AVR) for AV regurgitation. Rest/stress echocardiography follow-up was performed. Follow-up duration was 30.7 months, age 56 ± 14 years, ejection fraction% 57.5 ± 10.5%. Preoperative bicuspid AV was present in 14 (30.4%), leaflets calcifications in 8 (17.4%), thickening in 17 (37.0%) and prolapse in 22 (47.8%). Surgical technique included commissuroplasty (22, 47.8%), leaflet remodelling (17, 37.0%), decalcification (7, 15.2%) and raphe removal (14, 30.4%). At follow-up, rest/stress echocardiography median AV regurgitation (rest 1.0 vs. stress 1.0) and mean indexed AV area (IAVA) (rest 2.6 ± 0.74 cm(2)/m(2) vs. stress 2.8 ± 0.4 cm(2)/m(2)) were unchanged (P = ns). Mean (rest 4.7 ± 3.9 mmHg vs. stress 9.7 ± 5.8 mmHg) and peak (rest 9.5 ± 7.2 mmHg vs. stress 19.0 ± 10.5 mmHg) transvalvular gradients were significantly increased (P < 0.0001). At linear regression, there was an independent inverse correlation between commissuroplasty and AV gradients during stress (B = -9.9, P = 0.01, confidence interval= -17.7 to -2.1). Although follow-up haemodynamics of repaired AVs are satisfactory, there was a fixed IAVA and significant increase in AV gradients. We were not able to identify any pre-existing anatomical condition independently related to this non-physiological behaviour under stress. Moreover, commissuroplasty seems to prevent abnormal increase of the AV gradients.
Asunto(s)
Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Procedimientos Quirúrgicos Cardíacos , Ecocardiografía Doppler de Pulso , Ecocardiografía de Estrés , Prueba de Esfuerzo , Adulto , Anciano , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/fisiopatología , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Femenino , Hemodinámica , Humanos , Italia , Modelos Lineales , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Volumen Sistólico , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular IzquierdaRESUMEN
OBJECTIVE: Dynamic performance of the aortic valve (AV) after ascending aorta replacement with reimplantation of the native AV (David) was investigated. METHODS: We prospectively evaluated 17 patients who underwent David procedure. Rest/stress echocardiography follow-up was performed and results were compared with those of matched healthy controls. RESULTS: There were no significant differences in terms of age, height, weight, BSA, left ventricular mass, left ventricular ejection fraction (LVEF) and tele-diastolic volume between the David and control group. At rest echocardiography, patients in the David group had a lower indexed aortic valve area (IAVA) (1.1 ± 0.2 vs. 1.5 ± 0.2 cm(2)/m(2), P < 0.0001), with comparable transvalvular gradients (TVG). At maximal physical stress, although the IAVA in the David group was significantly increased from the rest values (P = 0.001), the difference with the control group persisted (David 1.4 ± 0.3 vs. Control 1.7 ± 0.2 cm(2)/m(2), P < 0.0001) maintaining similar peak TVG (David 13.6 ± 5.3 vs. Control 11.7 ± 4.5 mmHg, P = ns) and mean TVG (David 7.2 ± 3.0 vs. 6.2 ± 2.4 mmHg, P = ns). AV regurgitation in the David group was absent in five (29.4%), grade I in nine (52.9%) and grade II in three (17.6%) patients and remained unchanged during stress. At multiple linear regression, David operation was inversely correlated to rest IAVA (OR = -0.4; P = 0.01; CI: -0.7-0.1). CONCLUSIONS: Although IAVA is significantly smaller after David procedure in comparison with matched controls, no pathological increase in TVG is noticed. A significant increase in the IAVA during physical stress documents the preserved pliability/elasticity of the aortic unit after David procedure preventing pathological increase in the TVG even during strenuous effort.
Asunto(s)
Aorta/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Anciano , Aorta/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Estudios de Casos y Controles , Ecocardiografía de Estrés , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
During aortic arch replacement, construction of the distal anastomosis represents the crucial step because of the time limit of circulatory arrest. If the aneurysmal neck is located at the level of the 5(th) thoracic vertebra, it becomes difficult to carry out through a sternotomy approach. We describe a case in which an interrupted suture technique, similar to that used for valve replacement, was employed to maximize the limited exposure and achieve a water-tight anastomosis.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Técnicas de Sutura , Enfermedad Aguda , Anastomosis Quirúrgica , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/etiología , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVES: Thoracic endovascular aortic repair (TEVAR) is particularly indicated in a patient with complicated type B dissection. The object of this communication is to report a case of deployment of the endograft in the false lumen, to propose a protocol in order to prevent it and discuss the possible surgical options when this complication has occurred. METHODS: A case of complicated acute type B dissection is described where the endovascular prosthesis was positioned in the false lumen. The literature on the subject is briefly reviewed for the insertion techniques and conversion to surgery. RESULTS: The occurrence was recognized and treated with replacement of the entire aorta from the sinotubular junction to a level of the eighth thoracic vertebra under deep circulatory arrest with selective antegrade cerebral perfusion. CONCLUSIONS: TEVAR for complicated type B dissection should be carried out according to a precise and stepwise protocol in institutions familiar with all the different options of conversion to open repair.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Stents , Enfermedad Aguda , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/fisiopatología , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/fisiopatología , Aortografía/métodos , Implantación de Prótesis Vascular/efectos adversos , Circulación Cerebrovascular , Paro Circulatorio Inducido por Hipotermia Profunda , Remoción de Dispositivos , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
OBJECTIVES: The patient with a diagnosis of heparin-induced thrombocytopenia and thrombosis who requires urgent cardiac surgery represents a formidable challenge. Among the alternatives to heparin, argatroban has gained widespread use in non-cardiac surgery patients. The object of this communication is to report our recent experience with this agent during cardiopulmonary bypass (CPB) and to review the cases previously published in order to better define indications, dosage, monitoring and limitations in cardiac surgery patients. METHODS: A case of mitral valve replacement where argatroban was used for anticoagulation during CPB is described. The literature on the subject is reviewed and the relationship between argatroban dosage and activated clotting time (ACT) is studied by regression analysis. RESULTS: Clotting of the oxygenator requiring prompt replacement occurred after release of cross-clamp. Upon termination of the drug, ACT remained elevated beyond the expected half-life. A significative (P<0.05) relationship was disclosed between increasing dosage and ACT, while the same relationship was absent on decreasing dosage. CONCLUSIONS: Because of unresolved issues like the possibility of clotting in the extracorporeal circuit and prolonged anticoagulation after discontinuing the drug, at present, the use of argatroban as a substitute of heparin during CPB should be restricted to those cases where the other thrombin inhibitors are contraindicated.