RESUMEN
OBJECTIVES: The objective of the European Multicenter Registry to Assess Outcomes in coronary artery bypass grafting (CABG) patients (DuraGraft Registry) was to determine clinical outcomes and quality of life (QoL) after contemporary CABG that included isolated CABG and combined CABG/valve procedures, using an endothelial damage inhibitor (DuraGraft) intraoperatively for conduit preservation. Here, we report outcomes in the patient cohort undergoing isolated CABG. METHODS: The primary outcome was the composite of all-cause death, myocardial infarction (MI), or repeat revascularization (RR) [major adverse cardiac events (MACE)] at 1 year. Secondary outcomes included the composite of all-cause death, MI, RR, or stroke [major adverse cardiac and cerebrovascular events (MACCE)], and QoL. QoL was assessed with the EuroQol-5 Dimension questionnaire. Independent risk factors for MACE at 1 year were determined using Cox regression analysis. RESULTS: A total of 2532 patients (mean age, 67.4±9.2 years; 82.5% male) underwent isolated CABG. The median EuroScore II was 1.4 [interquartile range (IQR), 0.9-2.3]. MACE and MACCE rates at 1 year were 6.6% and 7.8%, respectively. The rates of all-cause death, MI, RR, and stroke were 4.4, 2.0, 2.2, and 1.9%, respectively. The 30-day mortality rate was 2.3%. Age, extracardiac arteriopathy, left ventricular ejection fraction less than 50%, critical operative state, and left main disease were independent risk factors for MACE. QoL index values improved from 0.84 [IQR, 0.72-0.92] at baseline to 0.92 [IQR, 0.82-1.00] at 1 year ( P <0.0001). CONCLUSION: Contemporary European patients undergoing isolated CABG have a low 1-year clinical event rate and an improved QoL.
Asunto(s)
Enfermedad de la Arteria Coronaria , Infarto del Miocardio , Accidente Cerebrovascular , Humanos , Masculino , Persona de Mediana Edad , Anciano , Femenino , Calidad de Vida , Estudios Prospectivos , Volumen Sistólico , Resultado del Tratamiento , Función Ventricular Izquierda , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Infarto del Miocardio/epidemiología , Infarto del Miocardio/etiología , Accidente Cerebrovascular/etiologíaRESUMEN
OBJECTIVES: Left main coronary artery disease (LMCAD) is considered an independent risk factor for clinical events after coronary artery bypass grafting (CABG). We have conducted a subgroup analysis of the multicentre European DuraGraft Registry to investigate clinical event rates at 1 year in patients with and without LMCAD undergoing isolated CABG in contemporary practice. METHODS: Patients undergoing isolated CABG were selected. The primary end point was the incidence of a major adverse cardiac event (MACE) defined as the composite of death, myocardial infarction (MI) or repeat revascularization (RR) at 1 year. The secondary end point was major adverse cardiac and cerebrovascular events (MACCE) defined as MACE plus stroke. Propensity score matching was performed to balance for differences in baseline characteristics. RESULTS: LMCAD was present in 1033 (41.2%) and absent in 1477 (58.8%) patients. At 1 year, the MACE rate was higher for LMCAD patients (8.2% vs 5.1%, P = 0.002) driven by higher rates of death (5.4% vs 3.4%, P = 0.016), MI (3.0% vs 1.3%, P = 0.002) and numerically higher rates of RR (2.8% vs 1.8%, P = 0.13). The incidence of MACCE was 8.8% vs 6.6%, P = 0.043, with a stroke rate of 1.0% and 2.4%, P = 0.011, for the LMCAD and non-LMCAD groups, respectively. After propensity score matching, the MACE rate was 8.0% vs 5.2%, P = 0.015. The incidence of death was 5.1% vs 3.7%, P = 0.10, MI 3.0% vs 1.4%, P = 0.020, and RR was 2.7% vs 1.6%, P = 0.090, for the LMCAD and non-LMCAD groups, respectively. Less strokes occurred in LMCAD patients (1.0% vs 2.4%, P = 0.017). The MACCE rate was not different, 8.5% vs 6.7%, P = 0.12. CONCLUSIONS: In this large registry, LMCAD was demonstrated to be an independent risk factor for MACE after isolated CABG. Conversely, the risk of stroke was lower in LMCAD patients. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02922088.
Asunto(s)
Enfermedad de la Arteria Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Accidente Cerebrovascular , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/complicaciones , Humanos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/etiología , Intervención Coronaria Percutánea/métodos , Sistema de Registros , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/etiología , Resultado del TratamientoAsunto(s)
Válvula Aórtica/microbiología , Bioprótesis/microbiología , Candidiasis/microbiología , Endocarditis/microbiología , Prótesis Valvulares Cardíacas/microbiología , Válvula Mitral/microbiología , Anciano , Válvula Aórtica/diagnóstico por imagen , Candida albicans/aislamiento & purificación , Candidiasis/diagnóstico por imagen , Remoción de Dispositivos , Endocarditis/diagnóstico por imagen , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Válvula Mitral/diagnóstico por imagen , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/microbiología , ReoperaciónRESUMEN
Background The determinants and consequences of pulmonary hypertension after successfully corrected valvular heart disease remain poorly understood. We aim to clarify the hemodynamic bases and risk factors for mortality in patients with this condition. Methods and Results We analyzed long-term follow-up data of 222 patients with pulmonary hypertension and valvular heart disease successfully corrected at least 1 year before enrollment who had undergone comprehensive hemodynamic and imaging characterization as per the SIOVAC (Sildenafil for Improving Outcomes After Valvular Correction) clinical trial. Median (interquartile range) mean pulmonary pressure was 37 mm Hg (32-44 mm Hg) and pulmonary artery wedge pressure was 23 mm Hg (18-26 mm Hg). Most patients were classified either as having combined precapillary and postcapillary or isolated postcapillary pulmonary hypertension. After a median follow-up of 4.5 years, 91 deaths accounted for 4.21 higher-than-expected mortality in the age-matched population. Risk factors for mortality were male sex, older age, diabetes mellitus, World Health Organization functional class III and higher pulmonary vascular resistance-either measured by catheterization or approximated from ultrasound data. Higher pulmonary vascular resistance was related to diabetes mellitus and smaller residual aortic and mitral valve areas. In turn, the latter correlated with prosthetic nominal size. Six-month changes in the composite clinical score and in the 6-minute walk test distance were related to survival. Conclusions Persistent valvular heart disease-pulmonary hypertension is an ominous disease that is almost universally associated with elevated pulmonary artery wedge pressure. Pulmonary vascular resistance is a major determinant of mortality in this condition and is related to diabetes mellitus and the residual effective area of the corrected valve. These findings have important implications for individualizing valve correction procedures. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00862043.
Asunto(s)
Enfermedades de las Válvulas Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Hipertensión Pulmonar , Efectos Adversos a Largo Plazo , Complicaciones Posoperatorias , Citrato de Sildenafil/administración & dosificación , Diabetes Mellitus/epidemiología , Método Doble Ciego , Femenino , Enfermedades de las Válvulas Cardíacas/fisiopatología , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Válvulas Cardíacas/patología , Humanos , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/tratamiento farmacológico , Hipertensión Pulmonar/etiología , Hipertensión Pulmonar/mortalidad , Efectos Adversos a Largo Plazo/diagnóstico , Efectos Adversos a Largo Plazo/tratamiento farmacológico , Efectos Adversos a Largo Plazo/mortalidad , Masculino , Persona de Mediana Edad , Tamaño de los Órganos , Inhibidores de Fosfodiesterasa 5/administración & dosificación , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Presión Esfenoidal Pulmonar , Factores de Riesgo , Resistencia VascularAsunto(s)
Aneurisma de la Aorta/complicaciones , Disnea/etiología , Anciano , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/cirugía , Aortografía , Angiografía por Tomografía Computarizada , Femenino , HumanosRESUMEN
No disponible
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Diseño de Equipo , Trasplante de Corazón , EspañaAsunto(s)
Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Diseño de Equipo , Femenino , Trasplante de Corazón , Humanos , Masculino , Persona de Mediana Edad , EspañaRESUMEN
We report on the case of spontaneous rupture of an On-X-pure pyrolytic carbon mechanical valve prosthesis implanted seven years earlier, in a mitral position, at our hospital. The patient was admitted with valvular dysfunction and acute pulmonary edema requiring emergency surgery (prosthesis replacement); the absence of a leaflet was confirmed intraoperatively. The patient presented severe respiratory failure, which prolonged the postoperative period. A CT scan showed that the migrated leaflet was located in the aortic bifurcation with no apparent arterial lesion. Four months later, once the patient had recovered, laparotomy and aortotomy were performed in order to retrieve the leaflet, which was found to have become included (neoendothelized) in the aortic wall without compromising the latter's integrity or obstructing the blood flow. A subsequent CT scan confirmed the persistence of the leaflet in its initial position. The literature review highlights two singular facts: 1) this is the second published case of the escape of a leaflet from an On-X prosthesis (the first patient died); 2) this is the first case in which a laparotomy was performed to retrieve the leaflet but finally a decision was made to leave it in situ. Seven months later, the patient remained asymptomatic.
Asunto(s)
Bioprótesis/efectos adversos , Migración de Cuerpo Extraño/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Insuficiencia de la Válvula Mitral/cirugía , Falla de Prótesis , Enfermedad Aguda , Procedimientos Quirúrgicos Cardíacos/métodos , Servicio de Urgencia en Hospital , Estudios de Seguimiento , Migración de Cuerpo Extraño/diagnóstico por imagen , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Edema Pulmonar/diagnóstico , Edema Pulmonar/etiología , Reoperación/métodos , Factores de Tiempo , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
Leaflet escape in contemporary mechanical valves is an extremely rare and potentially lethal condition. We report the case of a 77-year-old man who presented with embolization of a leaflet from an On-X mitral valve (CryoLife, Kennesaw, GA) with Conform-X Sewing Ring prosthesis (CryoLife) after exercise. The patient recovered completely 6 months after surgery, and he is currently asymptomatic.
Asunto(s)
Prótesis Valvulares Cardíacas , Válvula Mitral/cirugía , Falla de Prótesis , Anciano , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Diseño de Prótesis , Inducción de Remisión , RetratamientoRESUMEN
A patient with advanced rheumatic heart valve disease underwent aortic and mitral valve replacement with tricuspid ring annuloplasty. There was an anomalous left circumflex coronary artery (LCCA) arising from the right coronary artery (RCA) running along the anterior surface of an enlarged right ventricle (RV). During the immediate postoperative course, signs of inferior and lateral myocardial ischemia developed. An emergent coronary angiography revealed LCCA entrapment. An additional suture placed in the RV outflow tract used to optimize exposition of the aortic root during the aortotomy was determined to be the origin of the coronary entrapment. No similar case of LCCA occlusion has previously been reported. This is a description of successful management of this complication.
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Oclusión Coronaria/diagnóstico , Anomalías de los Vasos Coronarios/diagnóstico , Cardiopatía Reumática/cirugía , Válvula Tricúspide , Anciano , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/cirugía , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Diagnóstico Diferencial , Femenino , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/cirugía , StentsAsunto(s)
Aorta/cirugía , Enfermedades de la Aorta/cirugía , Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Estenosis de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Calcificación Vascular/cirugía , Aorta/diagnóstico por imagen , Aorta/fisiopatología , Enfermedades de la Aorta/diagnóstico por imagen , Enfermedades de la Aorta/fisiopatología , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/fisiopatología , Diseño de Prótesis , Resultado del Tratamiento , Calcificación Vascular/diagnóstico por imagen , Calcificación Vascular/fisiopatologíaRESUMEN
A 52-year-old male patient, who underwent mitral replacement with a mechanical prosthesis as a child, sustained a cardiac arrest which was successfully resuscitated. Further investigation showed prosthesis malfunction with significant regurgitation in the context of multi-organ failure. In such a life-threatening condition, veno-arterial extracorporeal membrane oxygenation was considered as a rescue procedure to achieve optimisation of clinical status to allow definitive surgical treatment. An unusual complete fracture of the prosthesis was subsequently identified as the cause of acute dysfunction.
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Trastorno del Sistema de Conducción Cardíaco/etiología , Trombosis Coronaria/etiología , Complicaciones Posoperatorias/diagnóstico , Anciano de 80 o más Años , Estenosis de la Válvula Aórtica/cirugía , Trastorno del Sistema de Conducción Cardíaco/diagnóstico , Trastorno del Sistema de Conducción Cardíaco/patología , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/patología , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Complicaciones Posoperatorias/patologíaRESUMEN
Postoperative bleeding with its important socioeconomic cost is associated with an increased morbidity and mortality. It causes hemodynamic instability, increases blood loss, and multiplies the number of transfusions required. Especially in vascular or aortic surgery, postoperative bleeding can become a life-threatening complication due to anticoagulant or antiaggregation preoperative status or postoperative coagulation dysfunction after a high level of heparinization. Presently described is the case of a patient who underwent an aortic valve and ascending aorta replacement. A simple but effective method to achieve hemostasis, designed particularly for aortic surgery and the use of Dacron grafts, is presented. No residual adherence or contraindications exist, and it can potentially be applied to any kind of surgical process. This method offers a cheap, biocompatible, and highly effective means to achieve complete hemostasis without the use of extra sutures, or expensive synthetic or allogeneic hemostatic agents or sealants.
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Tejido Adiposo , Procedimientos Quirúrgicos Cardíacos/métodos , Técnicas Hemostáticas , Tejido Adiposo/cirugía , Tejido Adiposo/trasplante , Aorta/cirugía , Válvula Aórtica/cirugía , Humanos , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/prevención & controlRESUMEN
Introducción y objetivos: El número de pacientes ancianos con insuficiencia cardiaca terminal ha crecido espectacularmente. Considerando que el número de trasplantes cardiacos se ha estancado, se requiere una alternativa terapéutica. Desde hace poco se están aplicando como terapia de destino (TD) dispositivos de asistencia ventricular izquierda (DAVI). Asumiendo que los pacientes de más edad tienen mayor riesgo quirúrgico, es presumible que la cirugía menos invasiva (CMI) para el DAVI contribuya a mejorar los resultados operatorios en pacientes en TD. Métodos: Se realizó un estudio prospectivo con un seguimiento de 2 años de 46 pacientes en TD (edad mayor de 60 años) consecutivos a los que se trató con DAVI (HVAD, HeartWare) en nuestra institución entre 2011 y 2013. Se formaron 2 grupos según el método quirúrgico de implante: CMI (n = 20) o cirugía convencional (n = 26). Resultados: A pesar de que no se hallaron diferencias estadísticas significativas respecto a la supervivencia a 2 años, sí se observó una tendencia a mayor supervivencia en el grupo CMI (el 85,0 frente al 69,2%; p = 0,302). Asimismo, los pacientes del grupo de CMI presentaron menor incidencia de hemorragias tras la cirugía (0 frente al 26,9%; p < 0,05), junto con menores tasas de uso prolongado de inotrópicos tras la cirugía (el 15,0 frente al 46,2%; p < 0,05). Conclusiones: Los datos indican que los pacientes sometidos a CMI para implante de DAVI como TD muestran tras la cirugía menor incidencia de hemorragias, menor necesidad de apoyo con inotrópicos y una tendencia a menor mortalidad que los pacientes operados de manera convencional (AU)
Introduction and objectives: The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients. Methods: We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26). Results: There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P < .05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P < .05). Conclusions: Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique (AU)