RESUMEN
BACKGROUND: The choice of a mechanical (MP) or biological prosthesis (BP) for patients with valvular heart disease undergoing replacement is still not a consensus. OBJECTIVE: We aimed to determine the clinical outcomes of MP or BP placement in those patients. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared biological prostheses and mechanical prostheses in patients with valvular heart diseases and assessed the outcomes. RCTs were searched in the MEDLINE, EMBASE, LILACS, CENTRAL, SCOPUS and Web of Science (from inception to November 2014) databases. Meta-analyses were performed using inverse variance with random effects models. The GRADE system was used to rate the quality of the evidence. A P-value lower than 0.05 was considered significant. RESULTS: A total of four RCTs were included in the meta-analyses (1,528 patients) with follow up ranging from 2 to 20 years. Three used old generation mechanical and biological prostheses, and one used contemporary prostheses. No significant difference in mortality was found between BP and MP patients (risk ratio (RR = 1.07; 95% CI 0.99-1.15). The risk of bleeding was significantly lower in BP patients than MP patients (RR = 0.64; 95% CI 0.52-0.78); however, reoperations were significantly more frequent in BP patients (RR = 3.60; 95% CI 2.44-5.32). There were no statistically significant differences between BP and MP patients with respect to systemic arterial embolisms and infective endocarditis (RR = 0.93; 95% CI 0.66-1.31, RR = 1.21; CI95% 0.78-1.88, respectively). Results in the trials with modern and old prostheses were similar. CONCLUSIONS: The mortality rate and the risk of thromboembolic events and endocarditis were similar between BP and MP patients. The risk of bleeding was approximately one third lower for BP patients than for MP patients, while the risk of reoperations was more than three times higher for BP patients.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas/normas , Bioprótesis , Medicina Basada en la Evidencia , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Reoperación , Resultado del TratamientoRESUMEN
Abstract Background: The choice of a mechanical (MP) or biological prosthesis (BP) for patients with valvular heart disease undergoing replacement is still not a consensus. Objective: We aimed to determine the clinical outcomes of MP or BP placement in those patients. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared biological prostheses and mechanical prostheses in patients with valvular heart diseases and assessed the outcomes. RCTs were searched in the MEDLINE, EMBASE, LILACS, CENTRAL, SCOPUS and Web of Science (from inception to November 2014) databases. Meta-analyses were performed using inverse variance with random effects models. The GRADE system was used to rate the quality of the evidence. A P-value lower than 0.05 was considered significant. Results: A total of four RCTs were included in the meta-analyses (1,528 patients) with follow up ranging from 2 to 20 years. Three used old generation mechanical and biological prostheses, and one used contemporary prostheses. No significant difference in mortality was found between BP and MP patients (risk ratio (RR = 1.07; 95% CI 0.99-1.15). The risk of bleeding was significantly lower in BP patients than MP patients (RR = 0.64; 95% CI 0.52-0.78); however, reoperations were significantly more frequent in BP patients (RR = 3.60; 95% CI 2.44-5.32). There were no statistically significant differences between BP and MP patients with respect to systemic arterial embolisms and infective endocarditis (RR = 0.93; 95% CI 0.66-1.31, RR = 1.21; CI95% 0.78-1.88, respectively). Results in the trials with modern and old prostheses were similar. Conclusions: The mortality rate and the risk of thromboembolic events and endocarditis were similar between BP and MP patients. The risk of bleeding was approximately one third lower for BP patients than for MP patients, while the risk of reoperations was more than three times higher for BP patients.
Resumo Fundamento: A escolha de próteses mecânicas ou biológicas para pacientes com doença de válvula cardíaca ainda não é um consenso. Objetivo: Determinar os desfechos clínicos de próteses mecânicas e biológicas nesses pacientes. Métodos: Conduzimos uma revisão sistemática e metanálise e estudos controlados randomizados (RCTs) que compararam próteses mecânicas e biológicas em pacientes com doenças de válvulas cardíaca, e avaliamos seus resultados. A busca por RCTs foi feita nas bases de dados MEDLINE, EMBASE, LILACS, CENTRAL, SCOPUS e Web of Science (do início a novembro de 2014). As metanálises foram realizadas usando variação inversa com modelos de efeitos aleatórios. Usamos o sistema GRADE para avaliar a qualidade da evidência. Um valor menor que 0,05 foi considerado significativo. Resultados: Um total de quatro RCTs foi incluído na metanálise (1528 pacientes) com acompanhamento de 2 a 20 anos. Em três estudos, foram utilizadas próteses mecânicas e biológicas mais antigas, e em um estudo próteses contemporâneas. Não foi observada diferença de mortalidade entre os pacientes que receberam próteses mecânicas e biológicas (risco relativo, RR = 1,07; IC95% 0,99-1,15). O risco de sangramento foi significativamente mais baixo nos pacientes que receberam próteses biológicas que naqueles com próteses mecânicas (RR = 0,64; IC95% 0,52-0,78). Contudo, as reoparações foram mais frequentes em pacientes com próteses biológicas (RR = 3,60; IC95% 2,44-5,32). Não houve diferenças estatisticamente significativas entre pacientes com próteses biológicas e mecânicas em relação à embolia arterial sistêmica e endocardite infecciosa (RR = 0,93; IC95% 0,66-1,31; RR = 1,21; IC95% 0,78-1,88, respectivamente). Resultados entre os estudos com próteses modernas e antigas foram similares. Conclusões: A taxa de mortalidade e o risco de eventos tromboembólicos e endocardite foram similares entre os pacientes que receberam próteses biológicas e mecânicas. O risco de sangramentos foi aproximadamente um terço menor nos pacientes com próteses biológicas que mecânicas, ao passo que o risco de reoperação foi mais que três vezes maior nos pacientes com próteses biológicas.
Asunto(s)
Humanos , Prótesis Valvulares Cardíacas/normas , Enfermedades de las Válvulas Cardíacas/cirugía , Reoperación , Bioprótesis , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento , Medicina Basada en la Evidencia , Implantación de Prótesis de Válvulas Cardíacas/métodosAsunto(s)
Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/terapia , Brasil/epidemiología , Cateterismo Cardíaco , Cardiología/normas , Ecocardiografía , Enfermedades de las Válvulas Cardíacas/epidemiología , Humanos , América Latina/epidemiología , Sociedades MédicasAsunto(s)
Humanos , Estenosis de la Válvula Pulmonar/etiología , Estenosis de la Válvula Pulmonar/patología , Estenosis de la Válvula Tricúspide/etiología , Estenosis de la Válvula Tricúspide/fisiopatología , Estenosis de la Válvula Tricúspide/patología , Ecocardiografía/métodos , Electrocardiografía/enfermeríaRESUMEN
OBJECTIVES: The objective was to analyze the diagnostic value of the echocardiographic methods used for quantification of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP) or rheumatic heart disease (RHD). METHODS: The study included 50 patients with MR (mean age of 46.1 years; 35 women), 27 (54%) with RHD and 23 (46%) with MVP. Quantification of the mitral valve regurgitation was obtained by regurgitant orifice area (ROA) and regurgitant volume (RV) by the flow convergence region (FCR) and two-dimensional Doppler echocardiographic methods, regurgitant fraction, jet area (JA), jet area/left atrial area ratio (JA/LAA), and vena contracta (VC). Patients were clinically followed to identify cardiovascular events. Data were analyzed by Pearson, kappa, and receiver operator characteristic curve tests; significance was defined as a P value less than .05. RESULTS: The correlation between the two methods for ROA and RV were r = 0.79 and r = 0.80, respectively, and between these parameters and regurgitant fraction, VC, JA, and JA/LAA varied from r = 0.54 to r = 0.94 (P lt; .05); the agreement varied from kappa = 0.19 to kappa = 0.83. The highest accuracy to identify patients with clinically significant MR (events at follow-up) was 96% for ROA by FCR, 94% for VC, 86% for RV by FCR, and 86% for JA. No method showed a significant difference between MVP and RHD. CONCLUSIONS: The methods analyzed had significant correlation and good agreement. ROA by FCR and VC had the best performance to identify severe MR; no significant difference between MVP and RHD was observed.
Asunto(s)
Velocidad del Flujo Sanguíneo/fisiología , Ecocardiografía Doppler en Color/métodos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/diagnóstico por imagen , Cardiopatía Reumática/diagnóstico por imagen , Adulto , Anciano , Diagnóstico Diferencial , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/fisiopatología , Prolapso de la Válvula Mitral/complicaciones , Prolapso de la Válvula Mitral/fisiopatología , Valor Predictivo de las Pruebas , Curva ROC , Reproducibilidad de los Resultados , Estudios Retrospectivos , Cardiopatía Reumática/fisiopatología , Índice de Severidad de la EnfermedadRESUMEN
Doença valvar cardíaca em idosos é um tema atual e relevante, constituindo-se em grande desafio na prática cardiológica. Atualmente, mais de 30% dos pacientes que necessitam de cirurgia cardíaca valvar têm mais de 70 anos, e espera-se que essa proporção de pacientes acima de 70 anos dobre em 10 anos. A estenose aórtica calcificada e a insuficiência mitral por prolapso de valva mitral são as lesões valvares mais freqüentes nos idosos. Neste artigo será discutido o manuseio desses pacientes, considerando-se os efeitos cardiovasculares e sistêmicos do processo de envelhecimento, o risco operatório e a seleção do tipo de prótese.
Valvular heart disease in the elderly is a relevant health issue and a great challenge in the medical practice. Today more than 30% of patients having valve surgery are more than 70 years old, and the proportion of patients aged more than 70 years has doubled over the past 10 years. Calcified aortic stenosis and mitral regurgitation due to mitral valve prolapse are the most frequent valvular lesions seen in the elderly. In this article the authors reviewed the management of these patients including cardiovascular and systemic effects in the process of aging, evaluation of operative risk and selection of the type of prostheses.
Asunto(s)
Humanos , Masculino , Femenino , Anciano , Estenosis de la Válvula Aórtica/complicaciones , Estenosis de la Válvula Aórtica/diagnóstico , Anciano/fisiología , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/diagnósticoRESUMEN
The inferior epigastric artery has been used as an alternative arterial conduit in coronary artery bypass graft surgery. Its harvesting requires a single or double, long abdominal paramedian incision that is technically difficult and does not yield a good cosmetic result. We describe an alternative new approach to one or both inferior epigastric arteries through a transverse suprapubic cosmetic incision.
Asunto(s)
Puente de Arteria Coronaria/métodos , Enfermedad Coronaria/cirugía , Arterias Epigástricas/trasplante , Recolección de Tejidos y Órganos/métodos , Adulto , Anciano , Anastomosis Quirúrgica , Estudios de Cohortes , Circulación Coronaria/fisiología , Enfermedad Coronaria/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Laparotomía/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Hueso Púbico , Medición de Riesgo , Sensibilidad y Especificidad , Resultado del TratamientoRESUMEN
Paciente de 14 anos, branco, sexo masculino, com diagnóstico de estenose subaórtica severa no pós-operatório tardio de correçäo total de um defeito do septo atrioventricular, forma completa. O diagnóstico clínico foi comprovado pelo estudo ecocardiográfico e cateterismo cardíaco, sendo o paciente submetido a reoperaçäo para tratamento da nova condiçäo, com ressecçäo do diafragma subaórtico. A via de saída do ventrículo esquerdo, estreita e deformada nos casos de defeito do septo atrioventricular, é suscetível de obstruçäo natural ou no pós-operatório, em decorrência do próprio ato cirúrgico ou das novas condiçöes estabelecidas. Torna-se, portanto, recomendável pesquisar possível obstruçäo tanto no pré-operatório como na sala de cirurgia após a correçäo,e no pós-operatório tardio
White male patient, 14 years old, who developed a severe subaortic stenosis in the late postoperative period of a total correction of atrioventricular septal defect. Clinical diagnosis was conf rmed by echocardiography and cardiac cathoterization. The patient underwent reoperation for treatment of the new condition, with ressection of subaortic stenosis. Atrioventricular septal defects show a narrow and deformed leit ventricle outflow tract, susceptible to obstruction before or after operation. It is, therefore, advisable to investigate a possible obstruction before the operation at the operation room and in the late postoperative period