RESUMEN
BACKGROUND: Multiple arterial grafts, in addition to the left internal thoracic artery, improve long-term survival after coronary artery bypass grafting (CABG); yet, the use of this procedure remains low for both the right internal thoracic artery (RITA) and the radial artery (RA). To identify the optimal arterial conduit to deploy for revascularization of diabetic patients, we compared the outcomes for RA and RITA grafts to the circumflex coronary. METHODS: From January 1, 1995, to December 31, 2011, 908 consecutive diabetic patients underwent first-time, isolated CABG (99% on-pump), 659 with the RA and 502 with the RITA, respectively, in two affiliated hospitals. Data were prospectively collected, and late mortality was determined from the Social Security Death Index. Propensity matching, based on preoperative and operative variables, identified 202 matched pairs from each group. RESULTS: Long-term survival was similar for matched patients. Mortality, myocardial infarction, reoperation for bleeding, stroke, sepsis, and renal failure were not significantly different between groups. However, deep sternal wound infection (p<0.035) and respiratory failure (p<0.048) favored the RA group, in which the total major adverse events were significantly fewer (p=0.002). CONCLUSIONS: In diabetic patients undergoing multivessel revascularization with either RA or RITA grafts to the circumflex coronary, long-term survival is similar. However, RA patients experienced significantly fewer respiratory or sternal wound adverse events. The RA is the preferred conduit to extend to more diabetic patients the recognized survival benefit of a multiple arterial graft strategy.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Circulación Coronaria/fisiología , Diabetes Mellitus/cirugía , Arterias Mamarias/trasplante , Complicaciones Posoperatorias/epidemiología , Arteria Radial/trasplante , Anciano , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/fisiopatología , Diabetes Mellitus/fisiopatología , Femenino , Estudios de Seguimiento , Humanos , Estimación de Kaplan-Meier , Masculino , Arterias Mamarias/fisiopatología , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Puntaje de Propensión , Arteria Radial/fisiopatología , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Liposarcoma occurs very rarely in the mediastinum. Patients often remain asymptomatic until it grows large enough to cause direct invasion or compression of adjacent organs. We report a case of a 77-year-old male presented with dyspnea of exertion and was found to have a large mediastinal mass which was eventually diagnosed as primary mediastinal well-differentiated liposarcoma. The limited respiratory function at the initial presentation prompted phrenic nerve preserving incomplete resection rather than radical removal of the adjacent mediastinal structures. After surgical removal, the recurrence for well-differentiated mediastinal liposarcomas in the mediastinum is unknown; therefore, close follow-up is crucial.
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Disnea/etiología , Liposarcoma/complicaciones , Neoplasias del Mediastino/complicaciones , Anciano , Diagnóstico Diferencial , Progresión de la Enfermedad , Disnea/diagnóstico , Disnea/cirugía , Humanos , Liposarcoma/diagnóstico , Liposarcoma/cirugía , Imagen por Resonancia Magnética , Masculino , Neoplasias del Mediastino/diagnóstico , Neoplasias del Mediastino/cirugía , Radiografía Torácica , Índice de Severidad de la Enfermedad , Esternotomía/métodos , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: A survival benefit of radial artery use versus saphenous vein grafting in coronary artery bypass grafting (CABG) has been reported. We aimed to elucidate the relative radial artery survival benefit as a function of time after surgery from two independent CABG series. METHODS: We compared 0- to 15-year survival with radial artery versus saphenous vein grafting in isolated, nonsalvage primary CABG with left internal thoracic artery to left anterior descending from two institutions: Ohio (radial artery [n=2,361; 61 years]; saphenous vein [n=2,547; 67 years]), and New York (radial artery [n=1,970; 58 years]; saphenous vein [n=2,974; 69 years]). Separate multivariate radial artery-use propensity models based on demographic, preoperative factors, intraoperative variables, and completeness of revascularization data were computed and used to derive propensity- and sex-matched CABG cohorts (1,799 [Ohio] and 995 [New York] pairs). A three-phase (early and late) mortality model was fit to Kaplan-Meier mortality estimates and used to derive relative radial artery versus saphenous vein hazard functions. RESULTS: Radial artery use patterns and patient risk profiles differed substantially for New York and Ohio, with the New York radial artery cohort significantly younger and more male. Within-institution matched graft-type cohorts were well matched. Cumulative mortality was significantly better for radial artery at both institutions (p < 0.001 both). All mortality-time data were well described by the three-phase model, and the derived relative hazard functions were qualitatively and quantitatively similar for New York and Ohio, exhibiting maximal benefit between 0.5 and 5 years. CONCLUSIONS: Despite substantial differences in radial artery use patterns during a 15-year period, our analysis in large propensity-matched radial artery and saphenous vein cohorts yielded remarkably similar, time-varying radial artery to saphenous vein survival benefit at both institutions. These converging findings based on two independent patient series extend currently available objective evidence in support of a radial artery survival advantage in CABG.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Arteria Radial/trasplante , Vena Safena/trasplante , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tasa de Supervivencia , Factores de TiempoRESUMEN
OBJECTIVE: We sought to determine if the radial artery (RA) or the free right internal thoracic artery (RITA) is the better conduit to bypass the circumflex coronary artery during coronary artery bypass grafting (CABG) using the left internal thoracic artery (LITA). METHODS: Propensity matching was performed on 2488 CABG-LITA patients from 2 affiliated centers, resulting in 528 pairs who received either a RA at one center or a free RITA at the other center to bypass the circumflex coronary artery from 1995 to 2009. RESULTS: Kaplan Meier estimated 1-, 5-, 10-, and 15-year survival rates were 99%, 95%, 85%, and 76% for RA patients, respectively, and 97%, 92%, 80%, and 71% for RITA patients, respectively (P = .060). Major adverse events (MAEs) were fewer in the RA group (7.6% vs 14.0%; P = .001) and use of the RA was a significant predictor of reduced MAEs (odds ratio [OR], 0.48; P = .002) in all patients and especially in diabetic (OR, 0.32; P = .003), older (OR, 0.40; P = .009), obese (OR, 0.15; P < .001), and chronic obstructive pulmonary disease (COPD) (OR, 0.05; P = .016) patients. However, survival was better with RA only in COPD (hazard ratio, 0.49; P = .045) and older (hazard ratio, 0.71; P = .050) patients. Overall RA patency (83.9%) was similar to RITA patency (87.4%) at a mean of 5.1 ± 3.8 years (P = .155). CONCLUSIONS: Long-term survival is similar in CABG-LITA patients using either a RA or free RITA graft to bypass the circumflex coronary artery. RA grafting has fewer MAEs, a similar patency to RITA, and improves survival in older and COPD patients. The choice of the second arterial conduit should be guided by patient profiles and surgeon preferences.
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Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Anastomosis Interna Mamario-Coronaria , Arteria Radial/trasplante , Factores de Edad , Anciano , Distribución de Chi-Cuadrado , Comorbilidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Diabetes Mellitus/mortalidad , Femenino , Humanos , Anastomosis Interna Mamario-Coronaria/efectos adversos , Anastomosis Interna Mamario-Coronaria/mortalidad , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York , Oportunidad Relativa , Selección de Paciente , Complicaciones Posoperatorias/mortalidad , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Arteria Radial/fisiopatología , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Off-pump coronary artery bypass (OPCAB) has gained increasing acceptance with potential benefits for high-risk elderly patients. We report a surgeon's operative outcomes in octogenarians with an OPCAB program. Retrospective, intention-to-treat analysis of 97 consecutive octogenarians who underwent coronary bypass by a single surgeon between 1997 and 2001 before and after initiation of a multi-vessel OPCAB program was performed. OPCAB was attempted in all octogenarians. The OPCAB cohort had higher serum creatinine (OPCAB vs. pre-OPCAB: 1.30 ± 0.79 mg/dl vs. 1.08 ± 0.27, p = 0.04) and ejection fractions (52 ± 14% vs. 45 ± 11%, p = 0.02) than the pre-OPCAB cohort. The OPCAB group was more likely to require urgent/emergency surgery (63 vs. 40%, p = 0.04) and to have chronic renal insufficiency (18 vs. 3%, p = 0.05). After programmatic change to OPCAB, significant postoperative improvements were observed in the length of hospital stay (17 ± 19 vs. 8 ± 4 days, p < 0.01), duration of inotropic requirement (47 ± 70 vs. 18 ± 39 h, p < 0.04), duration of ventilator support (51 ± 54 vs. 16 ± 27 h, p < 0.01) and incidence of tracheostomy (16 vs. 3%, p < 0.02). In-hospital mortalities (3.2 vs. 2.7%), strokes (3 per group) and 5-year survival did not differ significantly (57 vs. 67%, p = 0.50, NS). Despite some higher preoperative risks, the OPCAB program demonstrated clinical benefits in octogenarians but no advantage in hospital-mortality or long-term survival.
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Puente de Arteria Coronaria Off-Pump/mortalidad , Anciano de 80 o más Años , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Humanos , Masculino , New York/epidemiología , Periodo Perioperatorio , Estudios RetrospectivosRESUMEN
BACKGROUND: Left atrial dissection (LatD) is a rare entity most commonly associated with mitral valve surgery. We have reviewed our experience with 4 patients to better define the etiology and the treatment of LatD. METHODS: From 1991 to 2012, 4 patients experienced LatD after surgery (1 of 6,302, or 0.02%, of isolated coronary artery bypass grafting patients and 3 of 1,895, or 0.16%, of mitral valve patients). Patient and perioperative data and management were reviewed. RESULTS: Two patients were women, and ages ranged from 49 to 80 years. Three patients underwent mitral procedures (two replacements with coronary artery bypass grafting and one repair) for mitral regurgitation. One patient underwent emergent isolated coronary artery bypass grafting after cardiopulmonary resuscitation for a left main dissection during percutaneous coronary intervention. Three LatDs were found during surgery, and one LatD was found 12 days after mitral repair and was successfully treated nonoperatively. The LatD was located along the posterior atrial wall originating from the atrioventricular junction in all cases and obstructed mitral valve inflow. Operative repair focused on the evacuation of hematoma, obliteration of the false lumen, and repair of the entry injury. No mortality occurred. CONCLUSIONS: Left atrial dissection is a rare complication of cardiac surgery, probably related to a contained atrioventricular separation allowing pressurized blood to separate the layers of the posterior left atrium. Prompt intraoperative diagnosis, obliterating the false cavity, and addressing the entry point are essential. In contrast, a nonoperative approach in a stable patient with a delayed LatD suggests healing of the dissection, and atrial remodeling occurs.
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Procedimientos Quirúrgicos Cardíacos/efectos adversos , Rotura Cardíaca/etiología , Complicaciones Posoperatorias/etiología , Anciano , Anciano de 80 o más Años , Ecocardiografía Transesofágica , Femenino , Atrios Cardíacos , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugíaRESUMEN
BACKGROUND: Diabetes predicts worse outcomes after coronary artery bypass grafting (CABG) We hypothesized that a strategy using radial artery (RA) conduit(s) would improve outcomes and long term survival for diabetic patients undergoing CABG with Left Internal Thoracic Artery (LITA) and RA grafts, with or without additional saphenous vein (SV) when compared with outcomes for patients bypassed with LITA and SV but no RA. METHODS: A propensity matched study of long term survival in diabetic patients who had isolated first time CABG from January 1995 to June 2010 at an urban academic medical center in New York City. Our primary endpoint was all cause mortality determined from the Social Security Death Index in December 2010. RESULTS: We compared our 15 year outcomes in diabetic patients after isolated, primary CABG: 642 patients received LITA + RA +/- SV (RA group) vs. 1201 patients who had LITA + SV only (SV group). Propensity scoring for multiple preoperative and operative variables matched 409 patients from each group: 68% were male with an average age of 61 years and ejection fraction averaged 47%. Average grafts per patient was 3.7 for both groups with 2.3 arterial grafts per patient for the RA group. Operative (30 day) mortality was 0.1% RA vs. 1.9% SV, (p<0.0001) For propensity matched patients, mortality was 0.25 RA vs 0.5% SV. (p<0.001) The incidence of major complications was similar in both groups. Kaplan Meier actuarial survival at 1, 5, 10 and 12 years was 98%, 89%, 77 and 70% for RA vs. 96%, 87%, 64% and 59% for SV (p<0.006.) By Cox multivariate analysis significant predictors of mortality were: age, stroke, peripheral vascular disease, COPD, creatinine > 2.5mg/dl and low ejection fraction but only RA use predicted better survival [HR 0.683, CI 0.507- 0.920, p=0.0122]. CONCLUSION: For diabetic patients having CABG with LITA, use of radial artery conduit adds a substantial and sustained survival advantage compared to LITA and vein. Optimal revascularization for diabetics with multi vessel disease is redefined.
Asunto(s)
Puente de Arteria Coronaria/estadística & datos numéricos , Complicaciones de la Diabetes/epidemiología , Arteria Radial/cirugía , Anciano , Estudios de Cohortes , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/mortalidad , Complicaciones de la Diabetes/mortalidad , Complicaciones de la Diabetes/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Puntaje de Propensión , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: Radial artery (RA) grafting has a clear survival advantage after coronary artery bypass grafting (CABG) in studies with predominantly male populations, but the impact on women's long-term survival is unclear. We sought to determine if the reported long-term survival benefit of RA versus saphenous vein (SV) grafting in the general CABG population is valid for women. METHODS: Between 1995 and 2010, 1339 female patients were alive 30 days after primary, isolated CABG with left internal thoracic artery (LITA) and additional RA or SV conduits as needed. Patients were evaluated based on RA use: 332 patients had RA and 1007 patients had SV. Of these, 283 RA patients were matched to SV counterparts using a nonparsimonious propensity model based on 45 patient variables. RESULTS: Kaplan-Meier estimated survivals for the matched RA women at 1, 5, 10, and 15 years were 99%, 93%, 80%, and 70% versus 97%, 87%, 72%, and 58% for the SV women (log rank, P = .018). For symptomatic patients, overall RA patency was 80%, which was not different from the LITA patency rate of 84% but was superior to the SV conduits patency rate of 56% (P < .001). CONCLUSIONS: In women undergoing CABG with LITA grafting, use of an RA graft improves survival compared with use of an SV graft.
Asunto(s)
Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Arteria Radial/trasplante , Vena Safena/trasplante , Anciano , Distribución de Chi-Cuadrado , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Oclusión de Injerto Vascular/etiología , Oclusión de Injerto Vascular/mortalidad , Oclusión de Injerto Vascular/fisiopatología , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Análisis Multivariante , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Arteria Radial/fisiopatología , Factores de Riesgo , Vena Safena/fisiopatología , Factores Sexuales , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND/OBJECTIVES: Insufficient blood supply to the heart results in ischemic injury manifested clinically as myocardial infarction (MI). Following ischemia, inflammation is provoked and related to the clinical outcomes. A recent basic science study indicates that complement factor MASP-2 plays an important role in animal models of ischemia/reperfusion injury. We investigated the role of MASP-2 in human acute myocardial ischemia in two clinical settings: (1) Acute MI, and (2) Open heart surgery. METHODS: A total of 187 human subjects were enrolled in this study, including 50 healthy individuals, 27 patients who were diagnosed of coronary artery disease (CAD) but without acute MI, 29 patients with acute MI referred for coronary angiography, and 81 cardiac surgery patients with surgically-induced global heart ischemia. Circulating MASP-2 levels were measured by ELISA. RESULTS: MASP-2 levels in the peripheral circulation were significantly reduced in MI patients compared with those of healthy individuals or of CAD patients without acute MI. The hypothesis that MASP-2 was activated during acute myocardial ischemia was evaluated in cardiac patients undergoing surgically-induced global heart ischemia. MASP-2 was found to be significantly reduced in the coronary circulation of such patients, and the reduction of MASP-2 levels correlated independently with the increase of the myocardial necrosis marker, cardiac troponin I. CONCLUSIONS: These results indicate an involvement of MASP-2 in ischemia-related necrotic myocardial injury in humans.
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Serina Proteasas Asociadas a la Proteína de Unión a la Manosa/metabolismo , Isquemia Miocárdica/sangre , Isquemia Miocárdica/enzimología , Miocardio/enzimología , Miocardio/patología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Activación Enzimática/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/diagnóstico , Necrosis , Adulto JovenRESUMEN
BACKGROUND: During the past 2 decades, percutaneous coronary intervention (PCI) has increased dramatically compared with coronary artery bypass grafting (CABG) for patients with coronary artery disease. However, although the evidence available to all practitioners is similar, the relative distribution of PCI and CABG appears to differ among hospitals and regions. METHODS AND RESULTS: We reviewed the published data from the mandatory New York State Department of Health annual cardiac procedure reports issued from 1994 through 2008 to define trends in PCI and CABG utilization in New York and to compare the PCI/CABG ratios in the metropolitan area to the remainder of the State. During this 15-year interval, the procedure volume changes for CABG, for all cardiac surgeries, for non-CABG cardiac surgeries, and for PCI for New York State were -40%, -20%, +17.5%, and +253%, respectively; for the Manhattan programs, the changes were similar as follows: -61%, -23%, +14%, and +284%. The average PCI/CABG ratio in New York State increased from 1.12 in 1994 to 5.14 in 2008; however, in Manhattan, the average PCI/CABG ratio increased from 1.19 to 8.04 (2008 range: 3.78 to 16.2). The 2008 PCI/CABG ratios of the Manhattan programs were higher than the ratios for New York City programs outside Manhattan, in Long Island, in the northern counties contiguous to New York City, and in the rest of New York State; their averages were 5.84, 5.38, 3.31, and 3.24, respectively. In Manhattan, a patient had a 56% greater chance of receiving PCI than CABG as compared with the rest of New York State; in one Manhattan program, the likelihood was 215% higher. CONCLUSIONS: There are substantial regional and statewide differences in the utilization of PCI versus CABG among cardiac centers in New York, possibly related to patient characteristics, physician biases, and hospital culture. Understanding these disparities may facilitate the selection of the most appropriate, effective, and evidence-based revascularization strategy. (J Am Heart Assoc. 2012;1:e001446 doi: 10.1161/JAHA.112.001446.).
RESUMEN
BACKGROUND: Radial artery (RA) grafts are an attractive second arterial conduit after the left internal thoracic artery (LITA) for coronary artery bypass graft (CABG) surgery. However, long-term outcomes and the need for subsequent reintervention have not been defined. METHODS AND RESULTS: We performed a retrospective cohort study of our single institution's 16-year experience with 1851 consecutive patients (average age, 58 years; 82% men, 36% diabetic) undergoing primary, isolated CABG with the LITA, RA, and saphenous vein as needed. Average grafts per patient were 3.8, with 2.4 arterial grafts per patient. Survival was determined using the Social Security Death Index. Grafts were nonpatent if they had a >50% stenosis, a string sign, or were occluded. Five patients (0.3%) died in hospital and 0.8% had a myocardial infarction, 1.1% a stroke, and 0.6% renal failure. Kaplan-Meier-estimated 1-, 5-, 10-, and 15-year survival was 99%, 96%, 89%, and 75%, respectively. Of the cohort, 278 symptomatic patients underwent cardiac catheterization at our institution an average of 5.0±3.8 years (range, 0.1-12 years) after CABG. Overall RA (n=420 grafts) patency was 82% and SV (n=364 grafts) patency, 47% (P<0.0001). LITA (n=287 grafts including 9 sequential grafts) patency was 85% and right internal thoracic artery (n=15 grafts) patency was 80% (P=0.6). RA patency was not different from LITA patency (P=0.3). Overall freedom from catheterization, percutaneous coronary intervention, and CABG was 85%, 97%, and 99%, respectively. CONCLUSIONS: RA grafting is a highly effective revascularization strategy providing excellent short and long-term outcomes with very low rates of reintervention. RA patency is similar to LITA patency and is much better than SV patency. RA grafting should be more widely utilized in patients undergoing CABG.
Asunto(s)
Puente de Arteria Coronaria/métodos , Reestenosis Coronaria/cirugía , Arteria Radial/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco , Reestenosis Coronaria/epidemiología , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Vena Safena/cirugía , Accidente Cerebrovascular/epidemiología , Tasa de Supervivencia , Recolección de Tejidos y Órganos , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: We sought to examine the effect of different conduits on the progression of atherosclerosis in previously revascularized coronary territories. METHODS: Between 1995 and 2010, 4,960 patients were discharged alive after primary isolated coronary artery bypass grafting (CABG) with a left internal thoracic artery (LITA) conduit and additional conduits as needed: radial artery (RA) or saphenous vein graft (SVG), or both. Seven hundred seventy-two patients had coronary angiography for recurrent symptoms an average of 5.5±3.5 years after CABG (range, 0.1-16 years). Cumulative graft patency and disease progression in the native vessels was estimated by the Kaplan-Meier survival method. The log-rank test was used to assess differences of disease progression per territory between different types of conduits. RESULTS: Kaplan-Meier-estimated 1-, 5-, and 10-year overall disease progression in territories with patent LITAs was 0.01%, 4%, and 8%, respectively; with patent RA grafts, it was 0.01%, 6%, and 11%, respectively (log-rank test, p=0.157); and with patent SVGs it was 3%, 19%, and 43%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries in the anterior territory with patent LITA-to-left anterior descending (LAD) artery was 8%, and with patent RA grafts versus patent SVGs to the diagonal branches of LAD artery was 10% and 40%, respectively (log-rank test; p<0.0001). Disease progression in grafted native coronary arteries to the lateral territory with a patent RA graft was 11% versus 50% with a patent SVG (log-rank test; p<0.0001). CONCLUSIONS: RA and LITA grafting has a strong protective effect against progression of native coronary artery disease in previously grafted vessels. Multiple arterial grafting may improve long-term survival by preventing progression of atherosclerosis in the native coronary vessels.
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Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/prevención & control , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Anciano , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: The purpose of this study was to examine the effect of proton pump inhibitors (PPI) on the antiplatelet activity of clopidogrel in a consecutive series of Chinese patients after they had received coronary stents. METHODS: A sample of 51 consecutive Chinese patients treated with coronary stents and taking PPI and clopidogrel for more than 30 days were enrolled in this study. Mean values for platelet residual units and percentage inhibition before PPI (+PPI) and 14 days after discontinuation of PPI (-PPI) were compared using the paired t-test. RESULTS: There was no effect of concomitant use of esomeprazole and clopidogrel or omeprazole and clopidogrel on the inhibition assay, but platelet residual units and percentage inhibition showed statistically significant improvement after stopping lansoprazole in Chinese patients who were on chronic clopidogrel therapy. Clopidogrel resistance existed more frequently in the Chinese-American population examined, and was as high as 68% (+PPI) to 73% (-PPI). CONCLUSION: The clopidogrel resistance found is cause for concern, although its relationship with clinical events is currently unknown in this population. Further study with other thienopyridines or genetic variant analysis is suggested.
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2-Piridinilmetilsulfinilbencimidazoles/uso terapéutico , Angioplastia Coronaria con Balón , Pueblo Asiatico , Omeprazol/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de la Bomba de Protones/uso terapéutico , Trombosis/prevención & control , Ticlopidina/análogos & derivados , Anciano , Anciano de 80 o más Años , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/instrumentación , Asiático , Plaquetas/efectos de los fármacos , China/etnología , Clopidogrel , Resistencia a Medicamentos , Esomeprazol , Femenino , Humanos , Lansoprazol , Masculino , Persona de Mediana Edad , Ciudad de Nueva York/epidemiología , Pruebas de Función Plaquetaria , Estudios Prospectivos , Stents , Trombosis/sangre , Trombosis/etnología , Ticlopidina/uso terapéutico , Factores de TiempoRESUMEN
Previously we reported a case of abrupt change of postoperative mannan-binding-lectin (MBL) in a patient with preexisting MBL deficiency who expired shortly after cardiac surgery. Herein we report additional cases of 3 more patients with preexisting MBL deficiency who underwent cardiac surgery. Analysis of their blood samples from the perioperative period showed their MBL levels were abruptly increased at 24 hours after surgery. However, 2 patients had a subsequent drop of MBL at 48 hours, and both expired. These data indicated that the postoperative decrease of MBL may have been related with an unfavorable outcome after cardiac surgery.
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Procedimientos Quirúrgicos Cardíacos , Cardiopatías/sangre , Cardiopatías/cirugía , Lectina de Unión a Manosa/sangre , Lectina de Unión a Manosa/deficiencia , Anciano , Resultado Fatal , Femenino , Humanos , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
Compartment syndrome is a limb-threatening condition often associated with traumatic, crush, burn, and reperfusion injuries. It is characterized by the development of disproportionately severe pain, paresthesias, decreased range of motion, loss of pulse, and a tense, edematous limb. In addition, measured compartment pressures and creatine phosphokinase values are often elevated. The definitive treatment is a decompressive fasciotomy. Compartment syndrome after coronary artery bypass grafting, however, is rare. The few reported cases all occurred in the vein donor leg after open harvest. We present a patient with compartment syndrome after endoscopic harvest of the saphenous vein for coronary artery bypass grafting.
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Síndromes Compartimentales/etiología , Puente de Arteria Coronaria/métodos , Endoscopía/métodos , Infarto del Miocardio/cirugía , Vena Safena/trasplante , Recolección de Tejidos y Órganos/efectos adversos , Síndromes Compartimentales/terapia , Endoscopía/efectos adversos , Estudios de Seguimiento , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Modalidades de Fisioterapia , Medias de Compresión , Recolección de Tejidos y Órganos/métodosRESUMEN
Increasing evidence suggests that Mannan-binding lectin (MBL), the initial factor of the lectin pathway of complement, plays a role in cardiovascular diseases, i.e. inversely associated with risk of myocardial infarction (MI). In the present case, a patient with MBL deficiency underwent coronary artery bypass grafting (CABG) after an acute MI with underlining chronic lymphocytic leukemia (CLL). Post-operatively, the patient had a cerebral vascular accident and eventually expired. Analysis of his blood samples from pre-, intra-, and post-operative periods showed that MBL levels abruptly increased post-operatively. We hypothesize that the post-operative increase of MBL in the patient with pre-existing MBL deficiency may contribute to systemic inflammation, causing a detrimental effect after cardiac surgery.
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Leucemia Linfocítica Crónica de Células B/sangre , Leucemia Linfocítica Crónica de Células B/complicaciones , Lectina de Unión a Manosa/sangre , Lectina de Unión a Manosa/deficiencia , Infarto del Miocardio/complicaciones , Infarto del Miocardio/cirugía , Anciano , Lectina de Unión a Manosa de la Vía del Complemento/fisiología , Puente de Arteria Coronaria , Resultado Fatal , Humanos , Masculino , Complicaciones Posoperatorias/sangre , Complicaciones Posoperatorias/etiología , Accidente Cerebrovascular/sangre , Accidente Cerebrovascular/etiologíaRESUMEN
Oesophageal carcinosarcoma is a rare type of oesophageal cancer composed of both squamous cells and sarcomatous cells. We report a case of a 71 year old man presenting with dysphagia and weight loss. Oesophagogastroduodenoscopy revealed a bulky mass with a preliminary diagnosis of only oesophageal carcinoma, and the oesophageal mass was resected with a transhiatal oesophagectomy. On surgical pathology, it was discovered that the tumor had both squamous cell and sarcomatous cell components, and the final diagnosis was changed to oesophageal carcinosarcoma. We discuss the presentation, differential diagnosis, treatment, and prognosis of this unique entity.
RESUMEN
The efficacy of vein grafts used in coronary and peripheral artery bypass is limited by excessive hyperplasia and fibrosis that occur early after engraftment. In the present study, we sought to determine whether low-dose spironolactone alleviates maladaptive vein graft arterialization and alters intimal reaction to coronary artery stenting. Yorkshire pigs were randomized to treatment with oral spironolactone 25 mg daily or placebo. All animals underwent right carotid artery interposition grafting using a segment of external jugular vein and, 5 days later, underwent angiography of carotid and coronary arteries. At that time, a bare metal stent was placed in the left anterior descending artery and balloon angioplasty was performed on the circumflex coronary artery. Repeat carotid and coronary angiograms were performed before euthanasia and graft excision at 30 days. Angiography revealed that venous grafts of spironolactone-treated animals had lumen diameters twice the size of controls at 5 days, a finding that persisted at 30 days. However, neointima and total vessel wall areas also were 2- to 3-fold greater in spironolactone-treated animals, and there were no differences in vessel wall layer thicknesses or collagen and elastin densities. In the coronary circulation, there were no differences between treatment groups in any vessel wall parameters in either stented or unstented vessels. Taken together, these observations suggest that low-dose spironolactone may exert a novel protective effect on remodeling in venous arterial grafts that does not depend on the reduction of hyperplastic changes but may involve dilatation of the vessel wall.
Asunto(s)
Angioplastia Coronaria con Balón , Arterias Carótidas/cirugía , Venas Yugulares/trasplante , Espironolactona/uso terapéutico , Bloqueadores del Receptor Tipo 1 de Angiotensina II/farmacología , Inhibidores de la Enzima Convertidora de Angiotensina/farmacología , Animales , Arterias Carótidas/diagnóstico por imagen , Angiografía Coronaria , Vasos Coronarios/patología , Stents , PorcinosRESUMEN
BACKGROUND: Patients aged 90 years and older represent a rapidly growing subset of the population, many of whom are functionally limited by cardiovascular disease. Clinical decision making about cardiac surgical intervention in nonagenarians is hindered by a paucity of data examining survival outcomes in this population. METHODS: A consecutive series of nonagenarians who underwent cardiac operations between 1995 and 2004 were retrospectively reviewed. Data collection included baseline preoperative clinical status, intraoperative characteristics, and perioperative course. Area under the Kaplan-Meier survival estimate method was used to calculate mean survival. RESULTS: Cardiac surgical procedures were done in 49 patients (51% male); their mean age was 91.9 years (range, 90 to 97 years). Operative mortality was 8% (n = 4). Multivariate Cox proportional hazards models found preoperative chronic renal insufficiency (hazard ratio [HR], 4.88; 95% confidence interval [CI], 1.53 to 15.55; p = 0.007) and ejection fraction (HR, 0.96; 95% CI, 0.93 to 1.00; p = 0.033) were independently associated with death. Overall mean survival was 5.1 +/- 0.5 years (median, 5.2 years). Quality of life outcomes were similar to that of two related norm-based populations based on age and disease process. CONCLUSIONS: Cardiac surgical procedures can be performed safely and with therapeutic benefit in carefully selected nonagenarians. We consider physiologic indicators, social factors, and patient preferences to be the main determinants in the patient selection process. Our results support the need for more proactive intervention in symptomatic nonagenarian patients as it relates to earlier consideration of elective, rather than emergency cardiac operations.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Factores de Edad , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/mortalidad , Femenino , Humanos , Masculino , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
OBJECTIVES: To determine the prevalence and trends of antiretroviral drug resistance among HIV-1-infected Taiwanese patients who have been provided with free-of-charge antiretroviral therapy (ART) since 1990. METHODS: Blood samples collected from 786 HIV-1-infected patients from 1999 to 2006 were subjected to genotypic resistance assay. Antiretroviral resistance mutations were identified in accordance with the antiretroviral resistance mutation list of the International AIDS Society-USA Consensus Guidelines. Trends of resistance were studied in patients enrolled in two periods: before (period 1, January 1999 to December 2003) and after (period 2, January 2004 to December 2006) the CRF07_BC outbreak among injection drug users (IDUs). RESULTS: The frequency of HIV-1 isolates harbouring one or more primary mutations associated with antiretroviral resistance to reverse transcriptase inhibitors or protease inhibitors increased significantly from 6.6% in period 1 to 12.7% in period 2 (P = 0.003). A significant increase in prevalence of antiretroviral drug resistance was observed among men who have sex with men and patients infected with HIV subtype B. In multivariate analysis, hepatitis C virus (HCV) exposure, which exhibited collinearity with injection drug use and infection with CRF07_BC, represented a lower risk for infection with resistant viruses. CONCLUSIONS: Our findings suggest that the prevalence of antiretroviral resistance has increased in Taiwan over the past 8 years after the introduction of combination ART. IDUs who were HCV-seropositive and infected with CRF07_BC were at lower risk for infection with antiretroviral-resistant viruses.