RESUMEN
BACKGROUND AND AIM OF THE WORK: The aim of this study was to report the incidence of early neurological complications after heart surgery, to identify preoperative and procedural risk factors for these complications and to assess their influence on postoperative outcome. METHODS: Data were prospectively collected from 954 procedures: 520 coronary artery bypass grafting (CABG), 233 valve surgery, 100 combined CABG and valve surgery, 88 major aortic surgery, and 13 other procedures. Independent risk factors were analyzed by multivariate stepwise logistic regression model. RESULTS: Early cerebral complications occurred in 94 patients (9.85%). Eleven patients (11.7%) had permanent cerebral symptoms and 83 (88.3%) had transient neurological symptoms only. Risk factors for early neurological complications were older age, chronic obstructive pulmonary disease, open cardiac chambers procedures, higher end-cardiopulmonary bypass lactate levels, blood transfusion, and the use of insulin in ICU. CONCLUSION: The results of this study suggest a relationship between metabolic and technical aspects of cardiopulmonary bypass management and early occurrence of neurological injury. Preoperative screening and intraoperative measures that ensure adequate cerebral perfusion, minimize embolization and improve systemic inflammatory response and hemodynamic performance appear mandatory in these patients. Future efforts will be necessary to strongly validate surrogate markers of early neurologic damage to predict neuropsychological dysfunction after cardiac surgery.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Puente de Arteria Coronaria , Puente Cardiopulmonar , Humanos , Estudios Prospectivos , Factores de RiesgoRESUMEN
The purpose of this study was to review the outcome of dialysis-dependent patients undergoing cardiac surgery. We retrospectively reviewed 81 dialysis-dependent patients with a mean age of 62.5 ± 9.4 years who underwent cardiac operations. Mean EuroScore was 7.1 ± 3.9 (>9 in 18 patients). Surgery included coronary artery bypass grafting (CABG) in 43 patients (53.1%), valve surgery in 16 (19.7%), combined CABG plus valve surgery in 19 (23.5%) and major aortic surgery in three patients. In-hospital mortality rate was 13.6%. Most of the deaths occurred in patients who underwent valve procedures or combined surgery. Preoperative New York Heart Association class IV, previous acute myocardial infarction, combined surgical procedures, major aortic surgery, age >70 years, history of heart failure, female gender, the duration of dialysis ≥ 5 years and urgent/emergent surgery were associated with high relative risk for perioperative death. The actuarial survival was 72.2% at 5 years. Predictors of increased late mortality were heart failure, urgent/emergent surgery, the complexity of the surgical procedures (valve surgery, combined CABG + valve and major aortic surgery) and postoperative low cardiac output syndrome. In dialysis-dependent patients, CABG has an acceptable risk. Results in patients affected by valve lesions associated or not with coronary artery disease are improved by an early referral to surgery, before the onset of symptoms of heart failure.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Cardiopatías/cirugía , Fallo Renal Crónico/terapia , Diálisis Renal , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Distribución de Chi-Cuadrado , Femenino , Cardiopatías/complicaciones , Cardiopatías/mortalidad , Mortalidad Hospitalaria , Humanos , Italia , Estimación de Kaplan-Meier , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Selección de Paciente , Modelos de Riesgos Proporcionales , Diálisis Renal/efectos adversos , Diálisis Renal/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM OF THE STUDY: Cardiac surgery can be performed on elderly patients in good physical and mental health, thus improving their mortality, morbidity, and quality of life. Nevertheless, for some elderly patients aortic valve replacement (AVR) is still denied because of the presence of preoperative characteristics, such as older age and left ventricular dysfunction. The study aim was to review early and long-term results in patients aged > or = 80 years who underwent AVR for severe aortic stenosis, and to identify risk factors for in-hospital and late mortality. METHODS: A total of 165 patients (mean age 82 +/- 2.1 years) underwent AVR for severe aortic stenosis, with or without concomitant coronary revascularization, at the authors' institution. The mean aortic valve area was 0.61 +/- 0.2 cm2. Preoperatively, 20 patients (12%) had a left ventricular ejection fraction < 35%. The mean EuroSCORE was 9.45 +/- 1.52. RESULTS: Seven patients (4%) experienced low cardiac output syndrome, and acute renal failure occurred in 24. No perioperative myocardial infarction, stroke or sternal wound infection was detected. In total, 23 patients (14%) required prolonged ventilatory support. The in-hospital mortality was 3%. After a mean follow up of 43 +/- 35.6 months there were 18 late deaths: the cardiac-related mortality was 7%. The mean NYHA class was improved from 2.86 +/- 0.67 to 1.44 +/- 0.57 (p < 0.0001). CONCLUSION: Conventional AVR remains the standard of care, and can be performed with satisfactory in-hospital mortality, long-term life expectancy and quality of life in high-risk elderly patients. Although the transcatheter aortic valve technique seems to be a promising option, its long-term value must be established in prospective, randomized trials.
Asunto(s)
Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Factores de Edad , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
The aim of this study was to examine perioperative mortality and morbidity and midterm results in patients undergoing coronary bypass graft and mitral valve annuloplasty with advanced dilated cardiomyopathy. Sixty-one patients with ischemic dilated cardiomyopathy underwent coronary artery bypass grafting and mitral valve annuloplasty between January 1998 and December 2003. Patients eligible for revascularization that presented a mild or more severe mitral valve regurgitation at echocardiography (effective regurgitant orifice > 0.2 cm(2)) were considered for annuloplasty with a Cosgrove ring. New York Heart Association class (NYHA) III/IV was present in 40 patients (66%) and Canadian Cardiovascular Society class III-IV in 19 (31%). A previous acute myocardial infarction was reported in 48 patients (79%). The mean number of graft anastomoses was 2.5 +/- 0.7 and the left internal mammary artery was used in 49 patients (80%). In-hospital mortality was 4.9% (3 patients), due to unsuccessful weaning from cardiopulmonary bypass, multiple organ failure, and stroke, respectively. Left ventricle ejection fraction improved from 28.9% +/- 5.2% preoperatively to 35.4% +/- 8.1% at follow-up (P = 0.0001) and a significant reduction in NYHA III/IV was detected: from 40 patients preoperatively (66%) to 14 (31%) at follow-up (P = 0.031). Midterm cardiac-related mortality rate was 3.4%. In our experience combined coronary artery bypass grafting and ring annuloplasty for ischemic dilated cardiomyopathy can be performed with acceptable risks for in-hospital mortality and morbidity. Midterm results show a good survival rate and a durable functional improvement in this subset of patients.
Asunto(s)
Cardiomiopatía Dilatada/cirugía , Puente de Arteria Coronaria , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Isquemia Miocárdica/cirugía , Anciano , Cardiomiopatía Dilatada/diagnóstico por imagen , Cardiomiopatía Dilatada/mortalidad , Cardiomiopatía Dilatada/fisiopatología , Ecocardiografía , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Anastomosis Interna Mamario-Coronaria , Italia , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/fisiopatología , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/mortalidad , Isquemia Miocárdica/fisiopatología , Índice de Severidad de la Enfermedad , Volumen Sistólico , Tasa de Supervivencia , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/cirugíaRESUMEN
Coronary artery bypass grafting (CABG) still plays a fundamental role in the management of acute coronary syndromes. The aim of this study is to report the experience of our center in the treatment of patients with acute coronary sindromes without persistent ST elevation urgently operated on with CABG, and to discuss surgical problems related. Two-hundred and six patients were urgently operated on for CABG for acute coronary syndromes without persistent ST-segment elevation from January 2001 to February 2003. The majority of them had three vessel coronary disease (72%) and left main stem disease occurred in 20% of the patients. Mean LVEF (left ventricular ejection fraction) was 54 +/- 12% whereas 9% of the patients had a LVEF < 40%. Twenty-one patients (10%) received glycoprotein IIb/IIIa receptor inhibitors and 35 (17%) received intravenous heparin therapy before surgery. Mean interval time between the onset of symptoms and surgery was 16 +/- 10 days (range 4-50). In-hospital mortality was 2% (4 patients). Perioperative AMI (acute myocardial infarction) occurred in 4% (8 patients) and a transient low cardiac output syndrome in 27 patients (13%). Bleeding requiring surgery occurred in 1% of the patients. Transient respiratory insufficiency was present in 12 patients (6%) and acute renal failure in 8 patients (4%). Mean I.C.U. time was 2.4 days (1-17). Urgent CABG for acute coronary syndromes shows a low risk for in-hospital mortality and morbidity. In acute patients arterial grafts are not detrimental for the outcome, but are recommended in the absence of contraindications to improve long-term results. In spite of recent developments in cardioplegic cardiac arrest, optimal myocardial protection against perioperative myocardial infarction still remains a challenge.
Asunto(s)
Angina Inestable/fisiopatología , Angina Inestable/cirugía , Puente de Arteria Coronaria , Infarto del Miocardio/fisiopatología , Infarto del Miocardio/cirugía , Enfermedad Aguda , Anciano , Electrocardiografía , Femenino , Humanos , Masculino , SíndromeRESUMEN
BACKGROUND: One of the most frequent causes of reoperation after heart valve replacement is periprosthetic leakage (PPL). Previous studies have failed to determine whether PPL is linked to specific anatomic details. The aim of this study was to examine the location within the aortic annulus where PPL occurs, and to evaluate the postoperative outcome after surgical correction. METHODS: Between January 1985 and December 2001, 28 patients underwent reoperation because of PPL after aortic valve replacement. The aortic annulus was analyzed in a clockwise format with hour 1 corresponding to the commissure between the left coronary sinus and the right coronary sinus, hour 5 to the commissure between the right coronary sinus and the noncoronary sinus, and hour 9 to the commissure between the noncoronary sinus and the left coronary sinus. RESULTS: Overall operative mortality was 7.1% (2 patients). Repair of PPL was carried out in 8 patients whereas prosthetic valve replacement was necessary in 20 patients. Urgency or emergency operation (p < 0.0037), preoperative New York Heart Association class IV (p < 0.04), need for prosthetic valve replacement (p = 0.05), and implant of mechanical valve (p = 0.031) were independent determinants of dismal prognosis. Periprosthetic leakage occurred more frequently between hour 4 and hour 8 (19 patients), with the risk of leakage being two times greater than in other annular areas. CONCLUSIONS: Our study suggests that PPL occurs more frequently in a specific portion of the peculiar aortic annulus. In case of PPL diagnosis, a timely reoperation might decrease operative risks by avoiding emergency procedures and unfavorable preoperative clinical conditions, and preventing prosthetic valve replacement.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Procedimientos Quirúrgicos Electivos , Urgencias Médicas , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Falla de Prótesis , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
We report two cases of type A acute aortic dissection in which the traditional ascending aorta replacement was completed by aortic arch stenting to achieve a complete treatment and to avoid the risks that are connected to aortic arch replacement. Correct deployment of the stent was evaluated through an endoscope inserted in the transverse arch, which avoided fluoroangiography and the involvement of a radiologic team.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Enfermedad Aguda , Adulto , Anciano , Disección Aórtica/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta/diagnóstico por imagen , Ecocardiografía Transesofágica , Humanos , Masculino , Stents , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Patients with prosthetic heart valves have a higher risk of developing valve thrombosis and arterial thromboembolism. Antithrombotic therapy in the early postoperative period after biological aortic valve replacement (BAVR) is controversial. The American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend the use of warfarin for the first 3 months after BAVR, although the American College Chest Physician guidelines suggest that the recommendations are very weak and that the risk/benefit is unclear. This prospective study investigated the efficacy of postoperative warfarin compared with aspirin in patients after aortic valve replacement. METHODS AND RESULTS: Patients undergoing BAVR between 2001 and 2002 received 2 antithrombotic therapies: 141 patients received warfarin for the first 3 months, and 108 patients received only aspirin. The major end points evaluated were the rate of cerebral ischemic events, bleeding, and survival. There were 3 and 5 postoperative cerebral ischemic events between 24 hours and 3 months for patients treated with aspirin and warfarin, respectively. After 3 months, the incidence of cerebral ischemic events did not differ between the 2 groups. The rate of major bleeding events, the stroke-free survival, and the overall survival rates were not statistically significant between the warfarin and aspirin groups. CONCLUSIONS: There seem to be no advantages in performing early anticoagulation therapy compared with a low-antiplatelet regimen with regard to early cerebral ischemic events, bleeding, and survival. Currently there is no evidence to support the fact that warfarin is more effective than aspirin.
Asunto(s)
Anticoagulantes/uso terapéutico , Aspirina/uso terapéutico , Isquemia Encefálica/prevención & control , Prótesis Valvulares Cardíacas , Complicaciones Posoperatorias/prevención & control , Tromboembolia/prevención & control , Warfarina/uso terapéutico , Anciano , Anticoagulantes/efectos adversos , Aspirina/efectos adversos , Bioprótesis , Isquemia Encefálica/etiología , Supervivencia sin Enfermedad , Femenino , Hemorragia/inducido químicamente , Hemorragia/epidemiología , Humanos , Incidencia , Tablas de Vida , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Análisis de Supervivencia , Warfarina/efectos adversosRESUMEN
BACKGROUND: The aim of this study was to evaluate the incidence of complications in the upper limbs as a new event after radial artery (RA) harvesting for coronary artery bypass grafting (CABG). METHODS: From June 1997 to August 2001, the RA graft was used in 271 patients who underwent cardiac surgery at our department. These patients were prospectively reviewed. All patients were preoperatively examined to determine the presence of normal sensation and circulation in the upper limbs; then we evaluated the incidence of complications at discharge, 8 weeks, and 6 months. RESULTS: No donor arms developed symptoms of ischemia or motor dysfunction. At 8 weeks 2 patients (0.7%) reported donor arm weakness, and cutaneous paresthesia was noted postoperatively in 10 upper limbs (3.7%). The univariate statistical analysis showed that significant risk factors for persistent cutaneous paresthesia were diabetes and smoking. CONCLUSIONS: This study demonstrates that complications after harvesting the RA for CABG are a rare consequence. The main symptom is a persistent cutaneous paresthesia present in 10 patients at 6-month follow-up.