RESUMEN
BACKGROUND: Common Achilles tendon ruptures are not usually fixed by bioabsorbable sutures due to limitations in their strength retention properties. Modern technology has made it possible to develop bioabsorbable sutures with prolonged strength retention. AIMS: To evaluate histologically tissue reactions of poly-L/D-lactide (PLDLA) sutures implanted in Achilles tendon of rabbits. MATERIAL AND METHODS: Fifteen rabbits were evaluated at 2, 6 and 12 weeks postoperatively, with five rabbits in each follow-up group. PLDLA monofilament sutures were implanted into the medial gastrocnemius tendon. Polyglyconate monofilament sutures with similar diameter (Maxon 4-0, Cyanamid of Great Britain Ltd., Gosport, UK) were implanted in the contralateral gastrocnemius tendon. The histology was studied in hard-resin embedded samples. The thickness of the formed fibrous tissue capsule was determined histomorphometrically. RESULTS: PLDLA led to formation of significantly thinner fibrous tissue capsule than Maxon sutures of the same diameter. Median thickness (PLDLA vs. Maxon) at two weeks was 5.26 vs.13.22 microm, at six weeks 11.66 vs. 80.97 microm, and at 12 weeks 10.63 vs. 17.59 microm (p<0.01). CONCLUSIONS: During the 12 week follow-up period, PLDLA sutures implanted intratendineously formed thinner fibrous capsule than Maxon sutures of the same diameter. The suture materials were not totally absorbed by 12 weeks.
Asunto(s)
Poliésteres , Suturas , Tendones/cirugía , Animales , ConejosRESUMEN
Various immunosuppressive and adjunctive pharmacological regimens exist for cardiac transplantation, though the associations between these regimens and long-term survival are unclear. We reviewed demographic, clinical, and pharmacological data from 220 consecutive adult heart transplant recipients between 1986 and 2003 who survived beyond 3 months. Immunosuppression was cyclosporine-based (n=94) or tacrolimus-based (n=126), and 104 patients were weaned off steroids (all receiving tacrolimus). Covariates of mortality were assessed in a Cox proportional hazards analysis. The mean age was 5.2+/-13 years. Survival was 96%, 88%, and 81% at 1, 3, and 5 years, respectively. Significant covariates associated with mortality included pretransplant diabetes mellitus (hazard ratio [HR] 2.83, 95% confidence interval [CI] 1.45 to 5.04), black race (HR 1.41, 95% CI 1.01 to 1.94), higher pretransplant creatinine clearance (HR 0.99, 95% CI 0.98 to 1.00), steroid withdrawal (HR 0.60, 95% CI 0.39 to 0.85), and exposure to a statin (HR 0.53, 95% CI 0.40 to 0.70) or an angiotensin receptor blocker (HR 0.50, 95% CI 0.20 to 0.95) after transplantation. Treatment with a statin, an angiotensin receptor blocker, and steroid withdrawal were each associated with improved survival in heart transplant recipients. These findings warrant prospective study, with specific emphasis on identifying the clinical effects of these medications in transplant recipients.
Asunto(s)
Antagonistas de Receptores de Angiotensina , Trasplante de Corazón/fisiología , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Corticoesteroides/administración & dosificación , Corticoesteroides/uso terapéutico , Adulto , Anciano , Bloqueadores del Receptor Tipo 1 de Angiotensina II/administración & dosificación , Bloqueadores del Receptor Tipo 1 de Angiotensina II/uso terapéutico , Causas de Muerte , Esquema de Medicación , Femenino , Trasplante de Corazón/mortalidad , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Retrospectivos , Análisis de Supervivencia , Sobrevivientes , Factores de Tiempo , Resultado del TratamientoRESUMEN
In eligible patients, cardiac transplantation has become the definitive treatment for end-stage heart failure. The initial posttransplantation course is marked by many potential difficulties, including renal insufficiency, hemodynamic instability, and perioperative bleeding. It is important to prevent early rejection; calcineurin inhibitors, such as tacrolimus or cyclosporine, are integral parts of such management. However, these drugs are associated with renal toxicity in some patients. Previous work suggests that limiting the increase in tacrolimus levels is associated with less renal insufficiency. The hypothesis of the current study was that a combination of clinical or laboratory variables could identify patients at risk for rapid changes in tacrolimus target levels. No single variable was strongly associated with high resultant trough levels following a standard 1-mg oral "test dose" of tacrolimus. However, the combination of 2 indices of liver metabolism (alanine aminotransferase and total bilirubin) along with serum creatinine did identify patients who tended toward elevated levels of tacrolimus (> or =4.5 ng/dL). Other variables, such as demographics, and even functional variables, such as right ventricular function by echocardiography, did not enhance the predictive value of this simple scoring system.
Asunto(s)
Trasplante de Corazón/inmunología , Inmunosupresores/farmacocinética , Tacrolimus/farmacocinética , Adulto , Anciano , Creatinina/sangre , Ecocardiografía , Femenino , Hematócrito , Humanos , Inmunosupresores/sangre , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tacrolimus/sangre , Resultado del TratamientoRESUMEN
Despite improvements in immunosuppression over the last two decades, the risk of allograft rejection is still high in the early postoperative period. Cellular rejection accounts for the majority of these episodes. However, humoral rejection is a distinct phenomenon that carries a high rate of graft loss and mortality. The currently available treatments for this serious clinical problem include anti-lymphocyte antibodies, immune globulin infusions, as well as plasmapheresis, all of which have limitations. We describe a case of refractory humoral cardiac rejection successfully treated with a single dose of rituximab (375 mg/m2). No further episodes occurred with 2 years of follow-up.
Asunto(s)
Anticuerpos Monoclonales/uso terapéutico , Rechazo de Injerto/tratamiento farmacológico , Trasplante de Corazón/inmunología , Adulto , Anticuerpos Monoclonales de Origen Murino , Formación de Anticuerpos/efectos de los fármacos , Suero Antilinfocítico/uso terapéutico , Cardiomiopatía Dilatada/cirugía , Rechazo de Injerto/patología , Trasplante de Corazón/patología , Humanos , Inmunosupresores/uso terapéutico , Masculino , Rituximab , Trasplante Homólogo , Resultado del TratamientoRESUMEN
BACKGROUND: Cardiac transplantation has become the established treatment of choice for eligible patients with end-stage congestive heart failure. Older recipients (over the age of 60) are sometimes regarded as too high risk for transplant. Because chronological age is frequently disparate from physiologic age, we hypothesized that with careful selection after a comprehensive screening evaluation we would be able to achieve comparable survival and quality of life in an older population. METHODS: Between January 1989 and December 2002, 240 de novo adult cardiac transplants were performed for 74 female and 176 male patients. Prior to listing for cardiac transplantation, the patients were evaluated to exclude significant comorbidities that would limit survival or functional capacity postsurgery. In patients over the age of 60, particularly rigorous testing was conducted to eliminate significant extracardiac disease. RESULTS: The patients are divided in this analysis into three groups based on age at transplant (age 18 to 45, 46 to 59, and 60 years or older). Older recipients experienced similar rates of moderately severe cellular rejection (ISHLT grade 3A/ B). Survival as derived by Kaplan-Meier analysis was equivalent for all groups by Mantel-Cox logrank test (P = NS). The survival for patients older than age 60 was 83.1%, 73.7%, 67.7%, 57.4%, and 43.1% at 1,3, 5, 7, and 10 years posttransplant, respectively. CONCLUSION: We conclude that chronological age over 60 years old should not exclude a patient from the potential long-term benefit of cardiac transplant, ensuring added longevity and excellent quality of life.
Asunto(s)
Trasplante de Corazón/estadística & datos numéricos , Adolescente , Adulto , Factores de Edad , Biopsia , Femenino , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/inmunología , Trasplante de Corazón/mortalidad , Humanos , Terapia de Inmunosupresión/métodos , Masculino , Persona de Mediana Edad , Selección de Paciente , Estudios Retrospectivos , Análisis de Supervivencia , SobrevivientesAsunto(s)
Diabetes Mellitus/inducido químicamente , Trasplante de Corazón/inmunología , Tacrolimus/efectos adversos , Adulto , Diabetes Mellitus/prevención & control , Esquema de Medicación , Trasplante de Corazón/efectos adversos , Humanos , Inmunosupresores/efectos adversos , Incidencia , Valor Predictivo de las Pruebas , Tacrolimus/administración & dosificaciónAsunto(s)
Trasplante de Corazón/fisiología , Inmunosupresores/uso terapéutico , Tacrolimus/uso terapéutico , Adulto , Peso Corporal , Relación Dosis-Respuesta a Droga , Femenino , Trasplante de Corazón/inmunología , Humanos , Inmunosupresores/administración & dosificación , Inmunosupresores/farmacocinética , Pruebas de Función Renal , Masculino , Grupos Raciales , Tacrolimus/administración & dosificación , Tacrolimus/farmacocinéticaAsunto(s)
Corticoesteroides/uso terapéutico , Rechazo de Injerto/epidemiología , Trasplante de Corazón/fisiología , Metilprednisolona/uso terapéutico , Tacrolimus/uso terapéutico , Adulto , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Cardiopatías/epidemiología , Trasplante de Corazón/mortalidad , Trasplante de Corazón/patología , Humanos , Inmunosupresores/uso terapéutico , Incidencia , Masculino , New York , Grupos Raciales , Análisis de SupervivenciaAsunto(s)
Trasplante de Corazón/efectos adversos , Inmunosupresores/uso terapéutico , Insuficiencia Renal/epidemiología , Tacrolimus/uso terapéutico , Adulto , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/epidemiología , Valor Predictivo de las Pruebas , Análisis de Regresión , Insuficiencia Renal/diagnósticoRESUMEN
BACKGROUND/PURPOSE: Pectus excavatum usually is corrected by thoracoplasty using metal plates. Recently bioabsorbabe polylactide plates have been developed. The aim of this study was to compare outcome after use of metal and bioasorbable plates in thoracoplasty performed for correction of pectus excavatum. METHODS: Eighty-three children (<16 years old) underwent thoracoplasty (Sulamaa's technique). In 75 patients, metallic plates, and in 8 patients, self-reinforced poly-L-lactide (SR-PLLA) plates, were used. Seven patients in the SR-PLLA group and 13 patients in the metal plate group were assessed 0.5 to 13 years postoperatively. RESULTS: The mean operating time was 121 minutes in the metal plate group, and 87 minutes in the SR-PLLA plate group. In the metal plate group, complications were pain caused by instability of the metal plates (n = 17), wound infection (n = 3), recurrence of deformity (n = 3), postoperative pain (n = 3), pneumothorax (n = 1), and nonspecific postoperative fever (n = 1). Thirteen patients underwent reoperation to refix the position of the metallic plates. In the SR-PLLA group, one case of pneumothorax occurred, and plate fragment palpability caused local pain in one patient. Cosmetic results and lung function values were similar. CONCLUSION: Our preliminary results show that bioabsorbable plates are a useful option in the treatment of pectus excavatum in children.
Asunto(s)
Implantes Absorbibles , Tórax en Embudo/cirugía , Poliésteres , Niño , Preescolar , Femenino , Estudios de Seguimiento , Tórax en Embudo/fisiopatología , Humanos , Masculino , Metales , Mecánica Respiratoria , Estudios Retrospectivos , Procedimientos Quirúrgicos Torácicos , Resultado del TratamientoRESUMEN
BACKGROUND: Concomitant surgical replacement of the aortic valve and ascending aorta is an ideal treatment for aortic root aneurysms, but there may be hesitation in its use in older patients, despite their known increased risk of rupture. This study was conducted to examine our results in 84 patients older than 65 years undergoing elective aortic root resection with composite valve-graft replacement. METHODS: Eighty-four patients older than 65 years were operated on between June 1987 and August 1998. Median age was 74 years (range, 66 to 89 years), and 57 patients were men. Seventeen patients were undergoing reoperation. Aortic insufficiency was present in 70 patients. Forty-seven patients received a conduit using a bioprosthesis, whereas in 37 a mechanical valved conduit (St. Jude) was used. The ascending aorta alone was replaced in 23 patients; 50 had hemi-arch replacement, and in 11 the entire aortic arch was replaced. RESULTS: Hospital mortality was 8.3% (7 of 84). Sixteen late deaths (19%) were noted during a median follow-up of 3.2 years (range, 0 to 10 years). Only one late death was aorta-related. The incidence of thrombotic or hemorrhagic complications was 2.1/100 patient-years, with equal frequency for both mechanical and bioprosthetic valves. CONCLUSIONS: We conclude that composite valve-graft replacement in elderly patients results in a low operative mortality, yields excellent long-term survival, and averts fatal aneurysm rupture in this high-risk population.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Válvula Aórtica/cirugía , Implantación de Prótesis Vascular , Implantación de Prótesis de Válvulas Cardíacas , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/mortalidad , Bioprótesis , Causas de Muerte , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Diseño de Prótesis , Tasa de SupervivenciaRESUMEN
OBJECTIVE: We sought to assess the optimal strategy for avoiding neurologic injury after aortic operations requiring hypothermic circulatory arrest. METHODS: All 717 patients who survived ascending aorta-aortic arch operations through a median sternotomy since 1986 were examined for factors influencing stroke. Temporary neurologic dysfunction was assessed in all patients who survived the operation without stroke since 1993. Multivariate analyses were carried out to determine independent risk factors for neurologic injury. RESULTS: Independent risk factors for stroke were as follows: age greater than 60 years (P <.001; odds ratio, 4.5); emergency operation (P =.02; odds ratio, 2.2); new preoperative neurologic symptoms (P =.05; odds ratio, 2.9); presence of clot or atheroma (P <.001; odds ratio, 4.4); mitral valve replacement or other concomitant procedures (P =.055; odds ratio, = 3.7); and total cerebral protection time, defined as the sum of hypothermic circulatory arrest and any retrograde or antegrade cerebral perfusion (P =.001; odds ratio, 1.02/min). In 453 patients surviving operations without stroke after 1993, independent risk factors for temporary neurologic dysfunction included age (P <.001; odds ratio, 1.06/y), dissection (P =.001; odds ratio, 2.2), need for coronary artery bypass grafting (P =.006; odds ratio, 2.1) or other procedures (P =.023; odds ratio, 3.4), and total cerebral protection time (P <.001; odds ratio, 1.02/min). When all patients with total cerebral protection times between 40 and 80 minutes were examined, the method of cerebral protection did not influence the occurrence of stroke, but antegrade cerebral perfusion resulted in a significant reduction in incidence on temporary neurologic dysfunction (P =.05; odds ratio, 0.3). CONCLUSIONS: The occurrence of stroke is principally determined by patient- and disease-related factors, but use of antegrade cerebral perfusion can significantly reduce the occurrence of temporary neurologic dysfunction.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Hipotermia Inducida/métodos , Complicaciones Posoperatorias/prevención & control , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/prevención & control , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/métodos , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Aneurisma de la Aorta Torácica/diagnóstico , Niño , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Probabilidad , Medición de Riesgo , Factores de Riesgo , Distribución por Sexo , Análisis de SupervivenciaRESUMEN
OBJECTIVE: This study was undertaken to analyze the risk of mortality and neurological complications after aortic surgery requiring hypothermic circulatory arrest (HCA) in octogenarians. METHODS: All patients of >80 years at the time of aortic surgery requiring HCA since 1988 were examined. Of 51 patients, 23 were male; the median age was 83. Twenty-six (51%) had proximal repair; the arch was replaced in eight (16%), and 17 (33%) had descending aorta repair. Eleven (22%) were emergencies. Multivariate analysis was carried out to determine the risk factors for in-hospital mortality and/or stroke (adverse outcome) using variables with P<0.1 after univariate analysis. RESULTS: The hospital mortality was 16%. Five patients suffered strokes (9.8%): only one survived >6 months, and three died before discharge. The overall adverse outcome was 22%, but elective operation was associated with much better results, with an adverse outcome of only 3.6% after operations via a median sternotomy. Adverse outcome was strikingly higher with more distal resections via a left thoracotomy: 47 vs. 8.8% for ascending aorta/arch resections (P=0.003). Emergency operation via a lateral thoracotomy was associated with a prohibitively high adverse outcome. Twenty-nine patients (73%) had temporary neurological dysfunction (TND). Multivariate analysis revealed emergency operation (P=0.01; odds ratio (OR), 10.6) and operations via a lateral thoracotomy (P=0.008; OR, 11) as independent preoperative predictors of adverse outcome. The overall survival was 66% at 2 years and 39% at 5 years, compared with 85 and 52% among age- and sex-matched controls. CONCLUSIONS: Aortic surgery utilizing HCA in octogenarians can be performed with an acceptable risk of mortality and stroke. From the evidence in this study, it seems that elective aneurysm repair via a median sternotomy can be undertaken for the usual indications, even in octogenarians. However, the enhanced vulnerability of the brain in the elderly is reflected by a high early mortality following stroke, and a high incidence of TND. Emergency operations increase the possibility of adverse outcome dramatically, and patients who require a lateral thoracotomy are at significantly higher risk than those operated via a median sternotomy.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Paro Cardíaco Inducido , Hipotermia Inducida , Anciano , Anciano de 80 o más Años , Disección Aórtica/cirugía , Comorbilidad , Procedimientos Quirúrgicos Electivos , Femenino , Humanos , Masculino , Complicaciones Posoperatorias , Estudios RetrospectivosRESUMEN
BACKGROUND: Tacrolimus (FK506) is a macrolide antibiotic that inhibits T-cell activation and proliferation. To date, all published trials have used tacrolimus and steroids in combination with either azathioprine or mycophenolate mofetil. Previous experience with pediatric cardiac transplant patients at our institution suggested that use of tacrolimus alone provides an adequate level of immunosuppression and that withdrawal of steroids is readily achieved in most recipients. Between January 1, 1996, and July 7, 1999, we performed 77 adult cardiac transplants. Forty-three of these patients received tacrolimus and prednisone as primary immunosuppression, without azathioprine or mycophenolate mofetil. Thirty-two of the 43 patients started on tacrolimus have been weaned off steroids and are maintained on monotherapy. These latter patients form the basis of this report. The mean time for achieving monotherapy was 246 +/- 127 days (range, 106 to 730). Grade > or = 2 rejection occurred at 0.40 episodes per patient in the first 90 days (a combination of Grades 2 and 3A/3B rejections). The freedom from treated rejection (includes all 3A/3B and Grade 2 rejection in the first 90 days) was 69% at 90 days and 52% at 1 year. One patient (of 32) had documented cytomegalovirus infection (gastritis) diagnosed at 8 months post-transplant. We observed 1 case of transplant vasculopathy and 1 case of post-transplant lymphoproliferative disorder during the follow-up period. Our results show that use of tacrolimus alone after steroid weaning provides effective immunosuppression with low incidence of rejection, cytomegalovirus infection, transplant arteriopathy, or post-transplant lymphoproliferative disease.
Asunto(s)
Rechazo de Injerto/prevención & control , Trasplante de Corazón , Inmunosupresores/uso terapéutico , Tacrolimus/uso terapéutico , Adulto , Biopsia , Análisis Costo-Beneficio , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Rechazo de Injerto/inmunología , Rechazo de Injerto/mortalidad , Rechazo de Injerto/patología , Supervivencia de Injerto , Trasplante de Corazón/inmunología , Trasplante de Corazón/mortalidad , Trasplante de Corazón/patología , Humanos , Inmunosupresores/economía , Masculino , Persona de Mediana Edad , Selección de Paciente , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia , Tacrolimus/economíaRESUMEN
BACKGROUND: Surgery for acute type A aortic dissection is associated with a high mortality rate and incidence of postoperative complications. This study was designed to explore perioperative risk factors for death in patients with acute type A aortic dissection. METHODS AND RESULTS: One hundred twenty-four consecutive patients with acute type A aortic dissection between 1984 and 1998 were reviewed. All underwent operation with resection of the intimal tear and open distal anastomosis: 107 patients had surgery within 24 hours and 17 patients had surgery within 72 hours of symptom onset. Median age was 62 years (23 to 89); 89 were men. Forty-three patients had ascending aortic replacement only, 72 had hemiarch repair, in 2 the entire arch was replaced, and in 7 replacement included the proximal descending aorta. The aortic valve was replaced in 54 patients, resuspended in 52, and untouched in 18. Hospital mortality rate was 15.3% (19 of 124): of these, 3 patients died during surgery, 4 had fatal rupture of the distal aorta before discharge, and 2 died of malperfusion-related complications. Multivariate analysis revealed age >60, hemodynamic compromise, and absence of hypertension as preoperative indicators of hospital death (P:<0.05); the presence of new neurological symptoms was a significant preoperative risk factor in univariate analysis. Ominous intraoperative factors included contained hematoma and a comparatively low esophageal temperature but not cerebral ischemic time (mean 32 minutes). The site of the intimal tear did not influence outcome, but mortality rate was higher with more extensive resection: 43% with resection including the descending aorta died versus 14% with only ascending aorta or hemiarch replacement. Overall 5- and 10-year survival was 71% and 54%, respectively; among discharged patients (median follow-up 41 months) survival was 84% and 64% versus expected US survival of 92% and 79%. CONCLUSIONS: Immediate surgical treatment of all acute type A dissections with resection of the intimal tear and use of hypothermic circulatory arrest for distal anastomosis results in acceptable early mortality rates and excellent long-term survival.
Asunto(s)
Aneurisma de la Aorta/mortalidad , Disección Aórtica/mortalidad , Procedimientos Quirúrgicos Cardíacos/mortalidad , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/cirugía , Aorta/patología , Aorta/cirugía , Aorta Torácica/patología , Aorta Torácica/cirugía , Aneurisma de la Aorta/cirugía , Válvula Aórtica/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Estudios de Cohortes , Femenino , Humanos , Hipotermia Inducida , Complicaciones Intraoperatorias/mortalidad , Masculino , Persona de Mediana Edad , Análisis Multivariante , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: This study was undertaken to determine predictors of adverse outcome and transient neurological dysfunction after replacement of the ascending aorta with an open distal anastomosis. METHODS: All 443 patients (300 male, median age 63) undergoing replacement of the ascending aorta with an open distal anastomosis between 1986 and 1998 were included in the analysis. The ascending aorta alone was replaced in 190 (42.9%); 253 (57.1%) also had proximal arch replacement. Median hypothermic circulatory arrest (HCA) time was 25 minutes (range 12 to 68). Either death or permanent neurological dysfunction were considered adverse outcome (AO). RESULTS: Adverse outcome occurred in 11.5% (51 of 443) of patients overall: in 7.4% of elective (20 of 269) or urgent (4 of 54) operations, but in 17% (19 of 113) of emergencies. Multivariate analysis of the group as a whole revealed that significant (p < 0.05) independent preoperative predictors of AO were age greater than 60 [odds ratio (OR) 2.2], hemodynamic instability (OR 2.7), and dissection (OR 1.9). For the 435 operative survivors, procedural variables predictive of AO were contained rupture (OR 2.8) and HCA time (OR 1.03/min). When only the 271 elective patients were analyzed separately, the need for a concomitant procedure (p = 0.009, OR 3.6) and HCA time (p = 0.002, OR 1.06/min) were the only predictors of AO in multivariate analysis. Transient neurological dysfunction (TND) occurred in 86 of 392 patients (22%). Significant predictors of TND for all patients without AO were age (OR 1.06/y), HCA time (OR 1.04/min), coronary artery disease (OR 2.2), hemodynamic instability (OR 3.4), and acute operation (OR 2.2). Survival of discharged patients was 93% at 1 year and 83% at 5 years. CONCLUSIONS: Early elective operation and shorter HCA time during ascending aorta/hemiarch surgery will reduce both AO and TND.
Asunto(s)
Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Rotura de la Aorta/cirugía , Ataque Isquémico Transitorio/etiología , Complicaciones Posoperatorias/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/mortalidad , Niño , Urgencias Médicas , Femenino , Paro Cardíaco Inducido , Mortalidad Hospitalaria , Humanos , Ataque Isquémico Transitorio/mortalidad , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Factores de Riesgo , Tasa de SupervivenciaRESUMEN
BACKGROUND: Postoperative dissection in some patients is related to manipulation of the aorta and accounts for 3% to 5% of deaths after cardiac surgery. METHODS: Between 1987 and 1999, 109 patients with previous cardiac operations were treated for chronic type A dissection. In 31 of the patients, the etiology was related to aortic manipulation. Twenty-one patients (17 men, 4 women; 67+/-13 years of age) had isolated coronary artery bypass grafting (CABG) as their first operation and were reviewed. The interval between operations was 52.9+/-47.3 months. RESULTS: Reoperation was elective in 11 patients, urgent in 10 patients. Median maximal aortic diameter was 6.8+/-2.1 cm; 9 patients had major aortic insufficiency. The intimal tear was at the partial occlusion clamp site in 12 patients (57.1%), at the cross-clamping site in 4 patients (19.1%), and at the proximal anastomosis in 1 patient (4.8%); 4 patients (19.1%) had multiple tears at several sites. Cystic media necrosis was present in 9.5% of the patients, severe atherosclerosis in 47.6% of the patients, and 42.9% of the patients had both. Nine patients (42.9%) underwent a modified Bentall procedure, 12 patients (57.1%) underwent a supracoronary anastomosis, and all had open distal anastomosis. There were two (9.5%) hospital deaths and three (14.3%) postoperative strokes. Freedom from cardiac or aorta-related mortality was 85.7% at a mean follow-up of 49.3 months. CONCLUSIONS: In patients who develop type A dissection of the aorta after previous CABG, the intimal tear most often is at partial occlusion clamp site. This complication is associated with morbidity and mortality. It remains to be seen whether the use of partial occlusion clamps on the pulsating and often diseased aorta during off-pump coronary artery bypass (OPCAB) will increase the risk of delayed iatrogenic dissections.
Asunto(s)
Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad Coronaria/cirugía , Anciano , Anciano de 80 o más Años , Aorta/patología , Aorta/cirugía , Puente Cardiopulmonar , Femenino , Paro Cardíaco Inducido , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Factores de TiempoRESUMEN
OBJECTIVES: The purpose of this prospective, randomized, double-blind, placebo-controlled study was to assess the efficacy of preoperatively and postoperatively administered oral d,l sotalol in preventing the occurrence of postoperative atrial fibrillation (AF). BACKGROUND: Atrial fibrillation is the most common arrhythmia following coronary artery bypass surgery (CABG). Its etiology, prevention and treatment remain highly controversial. Furthermore, its associated morbidity results in a prolongation of the length of hospital stay post-CABG. METHODS: A total of 85 patients, of which 73 were to undergo CABG and 12 CABG plus valvular surgery (ejection fraction > or = 28% and absence of clinical heart failure), were randomized to receive either sotalol (40 patients; mean dose = 190 +/- 43 mg/day) started 24 to 48 h before open heart surgery and continued for four days postoperatively, or placebo (45 patients, mean dose = 176 +/- 32 mg/day). RESULTS: Atrial fibrillation occurred in a total of 22/85 (26%) patients. The incidence of postoperative AF was significantly (p = 0.008) lower in patients on sotalol (12.5%) as compared with placebo (38%). Significant bradycardia/hypotension, necessitating drug withdrawal, occurred in 2 of 40 (5%) patients on sotalol and none in the placebo group (p = 0.2). None of the patients on sotalol developed Torsade de pointes or sustained ventricular arrhythmias. Postoperative mortality was not significantly different in sotalol versus placebo (0% vs. 2%, p = 1.0). Patients in the sotalol group had a nonsignificantly shorter length of hospital stay as compared with placebo (7 +/- 2 days vs. 8 +/- 4 days; p = 0.24). CONCLUSIONS: The administration of sotalol, in dosages ranging from 80 to 120 mg, was associated with a significant decrease (67%) in postoperative AF in patients undergoing CABG without appreciable side effects. Sotalol should be considered for the prevention of postoperative AF in patients undergoing CABG in the absence of heart failure and significant left ventricular dysfunction.
Asunto(s)
Antiarrítmicos/administración & dosificación , Fibrilación Atrial/prevención & control , Puente de Arteria Coronaria/efectos adversos , Sotalol/administración & dosificación , Administración Oral , Anciano , Antiarrítmicos/efectos adversos , Fibrilación Atrial/etiología , Método Doble Ciego , Femenino , Válvulas Cardíacas/cirugía , Humanos , Masculino , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos , Sotalol/efectos adversosRESUMEN
BACKGROUND: The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve. The dilated or aneurysmal ascending aorta is at risk for spontaneous rupture or dissection. The magnitude of this risk is closely related to the size of the aorta and the underlying pathology of the aortic wall. The occurrence of rupture or dissection adversely alters natural history and survival even after successful emergency surgical treatment. METHODS: In recommending elective surgery for the dilated ascending aorta, the patient's age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall have to be considered. The indications for replacement of the ascending aorta in patients with Marfan's syndrome, acute dissection, intramural hematoma, and endocarditis with annular destruction are supported by solid clinical information. Surgical guidelines for intervening in degenerative dilatation of the ascending aorta, however, especially when its discovery is incidental to other cardiac operations, remain mostly empiric because of lack of natural history studies. The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention. RESULTS: There are a number of current techniques for surgical restoration of the functional and anatomical integrity of the aortic root. The choice of procedure is influenced by careful consideration of multiple factors, such as the patient's age and anticipated survival time; underlying aortic pathology; anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sino-tubular ridge; the condition of the distal aorta; the likelihood of future distal operation; the risk of anticoagulation; and, of course, the surgeon's experience with the technique. Currently, elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described by Bentall, DeBono and Edwards (classic Bentall), or modified by Kouchoukos (button Bentall), remains the most versatile and widely applied method. Since 1989, the button modification of the Bentall procedure has been used in 250 patients at Mount Sinai Medical Center, with a hospital mortality of 4% and excellent long-term survival. In this group, age was the only predictor of operative risk (age > 60 years, mortality 7.3% [9/124] compared with age < 60, mortality 0.8% [1/126], p = 0.02). CONCLUSIONS: This modification of the Bentall procedure has set a standard for evaluating the more recently introduced methods of aortic root repair.
Asunto(s)
Aorta/patología , Aorta/cirugía , Aneurisma de la Aorta/cirugía , Adulto , Procedimientos Quirúrgicos Cardíacos/métodos , Dilatación Patológica , Supervivencia sin Enfermedad , Procedimientos Quirúrgicos Electivos , Humanos , Síndrome de Marfan/cirugía , Persona de Mediana EdadRESUMEN
BACKGROUND: With increasing clinical experience, it has become clear that two distinct forms of neurological injury occur after operations on the thoracic aorta that require temporary exclusion of the cerebral circulation. Traditionally, evaluation of neurological outcome was limited to reporting the incidence of postoperative stroke related to ischemic infarcts due to particulate embolization. More recently, the symptom complex defined as "temporary neurological dysfunction" (TND) was recognized as a functional manifestation of subtle and presumably transient brain injury, but whether this early postoperative syndrome is associated with long-term deficits of cognitive and intellectual functions has not been established. METHODS: With Institution Review Board approval, 105 patients undergoing elective thoracic aortic surgery were entered into a protocol involving neuropsychological evaluation with a battery of tests preoperatively, and 1 and 6 weeks postoperatively. Patients who could not be tested adequately or had documented strokes were eliminated from final analysis. Seventy-one patients completed the neuropsychological evaluation, which consisted of eight tests consolidated into five domains: attention, cognitive speed, memory, executive function, and fine motor function. Independent observers also determined whether temporary dysfunction was present, and graded its severity based on a fixed but subjective clinical scale, ranging from simple disorientation and lethargy or confusion (grade 1-2) to prolonged extreme agitation or psychotic behavior requiring treatment with psychotropic drugs (grade 3-5). Data were normalized to baseline values, and were analyzed using analysis of variance, analysis of covariance (ANCOVA), and chi2 as necessary. RESULTS: A previous analysis had shown that patients who could not be tested or had poor scores 1 week postoperatively were more likely to perform poorly at 6 weeks (odds ratio 5.27, p < 0.01). In the current study, in order to determine the clinical relevance of TND, patients were analyzed retrospectively according to their performance in neuropsychological testing: patients with no change or a decline of less than 50% in tests of memory, motor function, and attention 1 week postoperatively (group 1, n = 49) were compared with those with a negative change exceeding 50% in the same functions at 1 week (group 2, n = 22). The overall incidence of TND was 28.1% (20/71). The incidence of TND in group 2 (14/22, 63%) was significantly higher than in group 1 (6/49, 12%; p = 0.0006). Similarly, the severity of TND (as assessed by clinical score > 2) was also significantly higher in group 2 (11/14) compared with group 1 (0/6; p = 0.006.) CONCLUSIONS: The incidence and severity of clinically apparent temporary neurological dysfunction correlates significantly with poor performance on neuropsychological tests 1 week postoperatively. Such poor performance predicts continued deficits in memory and motor function at 6 weeks. Thus, TND may not be a benign self-limited condition as previously supposed, but rather a clinical marker for insidious but significant neurological injury associated with measurable long-term deficits in cerebral function. A concerted effort to reduce the incidence of this complication is therefore necessary.