RESUMEN
Secondary prevention, i.e. nonsmoking, exercise, weight control, correct nutrition and drugs affecting the prognosis, constitute the basis for the treatment of stable coronary artery disease. The most important drug affecting the prognosis is acetylsalicylic acid. Statin medication can be reduced on the basis of adverse effects only. Angiotensin convertase inhibitor medication is often forgotten in coronary artery disease patients who have undergone cardiac infarction or a temporary stage of cardiac insufficiency. Long-acting nitrate is not the first-line antianginal treatment, beta-blockers and calcium channel blockers being recommended instead.
Asunto(s)
Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/prevención & control , Prevención Secundaria , Antagonistas Adrenérgicos beta/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Aspirina/uso terapéutico , Bloqueadores de los Canales de Calcio/uso terapéutico , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Nitratos/uso terapéutico , PronósticoRESUMEN
Objective: Microwave ablation in conjunction with open heart surgery is effective in restoring sinus rhythm (SR) in patients with atrial fibrillation (AF). In patients assigned for isolated mitral valve surgery no prospective randomized trial has reported its efficacy. Methods: 70 patients with longlasting AF where included from 5 different centres. They were randomly assigned to mitral valve surgery and atrial microwave ablation or mitral valve surgery alone. Results: Out of 70 randomized, 66 and 64 patients were available for evaluation at 6 and 12 months. At 12 months SR was restored and preserved in 71.0 % in the ablation group vs 36.4 % in the control group (P=0.006), corresponding figures at 6 months was 62.5 % vs 26.5 % (P=0.003). The 30-day mortality rate was 1.4 %, with one death in the ablation group vs zero deaths in the control group. At 12 months the mortality rate was 7,1 % (Ablation n=3 vs Control n=2). No significant differences existed between the groups with regard to the overall rate of serious adverse events (SAE) during the perioperative period or at the end of the study. 16 % of patients randomized to ablation were on antiarrhytmic drugs compared to 6 % in the control group after 1 year (p=0.22). Conclusion: Microwave ablation of left and right atrium in conjunction with mitral valve surgery is safe and effectively restores sinus rhythm in patients with longlasting AF as compared to mitral valve surgery alone.
RESUMEN
OBJECTIVE: Patients on long-term warfarin treatment have an inherent high risk of stroke and here we aimed to identify the determinants of postoperative stroke after coronary artery bypass grafting (CABG) in these patients. METHODS: A consecutive series of 270 patients on long-term warfarin treatment who underwent isolated CABG in two university hospitals was assessed by logistic regression as well as classification and regression tree (CART) analysis. RESULTS: Postoperative stroke occurred in 10 patients during in-hospital stay (3.7%). Logistic regression showed that CHADS(2) > 2 (p = 0.036), recent thrombolysis (p < 0.0001) and history of deep vein thrombosis (p = 0.025) were independent predictors of postoperative stroke (area under the ROC curve 0.77). CART analysis showed that CHADS(2) > 2, history of stroke/TIA, no preoperative use of aspirin and preoperative use of low molecular weight heparins were associated with an increased risk of stroke (area under the ROC curve of 0.77). CONCLUSIONS: Both CART and logistic regression analyses showed that the patient characteristics included in CHADS(2) score are important also in the prediction of postoperative stroke risk. Preoperative antiplatelet treatment may be beneficial in the high risk patients and the preoperative bridging with low molecular weight heparins may even be harmful in this respect.
Asunto(s)
Anticoagulantes/administración & dosificación , Puente de Arteria Coronaria/efectos adversos , Accidente Cerebrovascular/prevención & control , Administración Oral , Anciano , Anticoagulantes/efectos adversos , Puente de Arteria Coronaria/mortalidad , Esquema de Medicación , Femenino , Finlandia , Mortalidad Hospitalaria , Hospitales Universitarios , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
The aim of the present study was to evaluate the changing risk of patients undergoing coronary artery bypass grafting (CABG). Residents of Oulu who underwent coronary angiography and/or revascularization from 1993 to 2006 formed the basis of this community-wide study. One thousand three hundred and forty-nine consecutive patients who underwent CABG have been included in the analysis on changing operative risk and results after CABG. A significant increase in the operative risk occurred in patients who underwent CABG (mean logistic EuroSCORE in 1278 patients: 1993-1997: 3.7%; 1998-2002: 4.6%; 2003-2006: 5.4%; P<0.0001). Thirty-day mortality decreased during the last period (1993-1997: 2.5%; 1998-2002: 3.0%; 2003-2006: 1.6%; P=0.49). The area under the ROC curve of logistic EuroSCORE (1993-1997: 0.86; 1998-2002: 0.78; 2003-2006: 0.99) for prediction of 30-day postoperative mortality markedly improved during the last study period. Despite the increased operative risk, off-pump coronary surgery was associated with lower immediate postoperative mortality rates. Contrary to on-pump surgery, immediate postoperative death occurred after off-pump surgery only in patients with additive EuroSCORE >or=6. The results of this study suggest that improved perioperative care as well as changes in operative strategy are positively faced with the increased burden of comorbidities and operative risk of patients currently undergoing CABG.
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Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Angiografía Coronaria , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria Off-Pump/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Finlandia/epidemiología , Encuestas de Atención de la Salud , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: We have evaluated the immediate and intermediate outcome after off-pump (OPCAB) and conventional on-pump coronary artery bypass surgery (CCAB) in patients with unstable angina pectoris requiring nitrates infusion until arrival in the operating room. METHODS: A consecutive series of 153 and 161 patients with unrelenting angina pectoris underwent CCAB and OPCAB, respectively. Conversion from OPCAB to beating heart surgery with perfusion occurred in 4 patients. RESULTS: The OPCAB patients had a significantly higher operative risk than CCAB patients (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 13.8 +/- 12.8% vs 10.5 +/- 10.0%, p = 0.005). In the overall series, a lower 30-day postoperative mortality was observed among OPCAB patients (1.9% vs 3.9%, p = 0.33), the difference increased along the logistic EuroSCORE tertiles (upper tertile: 3.2% vs 9.5%, p = 0.14), but failed to reach statistical significance. Similar results have been observed among one-to-one propensity score matched pairs. The results of three surgeons who treated most of their patients (96.9%) with OPCAB were compared with those of three surgeons who used, in most of cases (97.1%), the CCAB technique. When adjusted for logistic EuroSCORE, patients operated on by CCAB surgeons had a significantly higher 30-day postoperative mortality (7.1% vs 2.1%, p = 0.04; odds ratio [OR] 10.143; 95% confidence interval [CI] 1.084 to 94.945) as well as a higher risk of combined adverse events (47.1% vs. 35.1%, p = 0.009; OR 2.586; 95% CI 1.274 to 5.250). CONCLUSIONS: This study provided further evidence on the safety and efficacy of OPCAB in the treatment of high-risk patients. A dedicated approach to OPCAB seems to provide particularly good results. Such findings further support a more confident approach with OPCAB in these patients.
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Angina Inestable/mortalidad , Angina Inestable/cirugía , Puente de Arteria Coronaria Off-Pump/métodos , Mortalidad Hospitalaria/tendencias , Anciano , Análisis de Varianza , Angina Inestable/diagnóstico , Cateterismo Cardíaco , Estudios de Cohortes , Angiografía Coronaria , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Circulación Coronaria/fisiología , Femenino , Pruebas de Función Cardíaca , Hemodinámica/fisiología , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Pronóstico , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Estadísticas no Paramétricas , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The aim of the present study was to evaluate the impact of estimated glomerular filtration rate (eGFR) on the 15-year outcome after coronary artery bypass surgery (CABG) in a community-wide population study. METHODS: Eight hundred and eighty-two patients who underwent CABG were included in this study. eGFR was estimated by the modified Modification of Diet in Renal Disease study equation. RESULTS: Among 30-day operative survivors, patients with eGFR<60 ml/min/1.73 m(2) had significantly poorer overall survival (at 5, 10 and 15 year, 84.7%, 63.5% and 43.8% vs 92.8%, 77.6% and 58.3%, respectively, p<0.0001). eGFR (HR 0.989, 95% CI 0.981-0.997, as well as eGFR<60 ml/min/1.73 m(2): HR 1.470, 95% CI 1.092-1.979) was an independent predictor of late all-cause mortality only when patients' age was excluded from the regression model. This was probably due to strong impact of age on eGFR. eGFR (HR 0.987, 95% CI 0.975-0.998, as well as eGFR<60 ml/min/1.73 m(2); HR 1.612, 95% CI 1.086-2.395) was an independent predictor of cardiovascular mortality secondary to ischemic heart disease or ischemic stroke. eGFR (HR 0.991, 95% CI 0.983-0.999, as well as eGFR<60 ml/min/1.73 m(2): HR 1.396 95% CI 1.031-1.891) was an independent predictor of cardiovascular mortality and morbidity (myocardial infarction, stroke, need for redo CABG or PCI). When both preoperative serum creatinine and eGFR were included in the regression model, only eGFR was predictive of all-cause mortality, cardiovascular mortality and combined cardiovascular mortality and morbidity. CONCLUSIONS: This study showed that an eGFR<60 ml/min/1.73 m(2) is an important determinant of long-term outcome after isolated CABG. Since its predictive value seems to be superior to serum creatinine, eGFR may be useful to identify those patients undergoing CABG with subclinical chronic kidney disease.
Asunto(s)
Enfermedades Cardiovasculares/mortalidad , Puente de Arteria Coronaria/mortalidad , Tasa de Filtración Glomerular , Insuficiencia Renal Crónica/diagnóstico , Anciano , Enfermedades Cardiovasculares/complicaciones , Enfermedades Cardiovasculares/cirugía , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/mortalidad , Resultado del TratamientoRESUMEN
PURPOSE: The Spyder aortic connector (Medtronic, Minneapolis, MN) is a new, promising connector device and its safety and efficacy have been evaluated in this study. DESCRIPTION: Twenty-two patients were randomized to proximal vein graft anastomosis with the Spyder aortic connector (Medtronic) or hand-sewn technique. EVALUATION: Twenty patients underwent multi-detector computed tomographic scans of the chest 6 months after surgery to evaluate vein graft patency. We have failed to successfully deploy three Spyder connector devices. Thus in this study we have evaluated the graft patency of 19 hand-sewn grafts and of 19 vein grafts anastomosed with the Spyder anastomotic device. Three vein grafts whose proximal anastomosis was accomplished with the Spyder anastomotic connector were occluded and all hand-sewn vein grafts were patent (16% vs 0%; p = 0.23). Stenosis of the proximal anastomosis was observed in seven vein grafts (37%), accomplished with the Spyder anastomotic connector, and in one (5%) hand-sewn vein graft (p = 0.042). CONCLUSIONS: The results of this study suggest that the use of the Spyder aortic connector device is associated with suboptimal 6-month graft patency.
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Aorta/cirugía , Puente de Arteria Coronaria Off-Pump/instrumentación , Anciano , Anastomosis Quirúrgica/instrumentación , Puente de Arteria Coronaria Off-Pump/efectos adversos , Femenino , Oclusión de Injerto Vascular/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Vena Safena/trasplanteRESUMEN
BACKGROUND AND AIM OF THE STUDY: The European system for cardiac operative risk evaluation score (EuroSCORE) has been shown to be a valid tool for predicting immediate and late outcome after coronary artery bypass surgery. As evidence also suggests its value in heart valve surgery, this issue was investigated in a series of patients who underwent surgery for mitral valve regurgitation. METHODS: Data obtained from 180 patients who underwent mitral valve repair (MVRep) or mitral valve replacement (MVR) were reviewed, and the patients' additive and logistic EuroSCOREs calculated. RESULTS: The 30-day postoperative mortality rate was 10.0% (n = 18); rates were 7.1% after MVRep and 20.5% after MVR (p = 0.013). The additive EuroSCORE (p <0.0001, area under the ROC curve: 0.804, 95% CI 0.689-0.919, SE 0.059), as well as logistic EuroSCORE (p <0.0001, area under the ROC curve: 0.806, 95% CI 0.695-0.918, SE 0.057) were predictors of 30-day postoperative death. The 10-year overall survival rate from any cause of death was 74.7%. Additive and logistic EuroSCOREs were significantly higher in the MVR group compared to the MVRep group (p <0.0001 in both cases), and also among operative survivors. Patients who underwent MVR had a significantly poorer long-term survival than those with MVRep (p = 0.01). Both the additive EuroSCORE (p <0.0001) and logistic EuroSCORE (p = 0.003) were predictors of late, all-cause mortality. Both scores remained significant predictors of late outcome also when adjusted for type of surgery (MVRep versus MVR). Survival was particularly dismal in patients with an additive EuroSCORE >6 (at 10 years, 54.4% versus 86.6%, p <0.00001) or a logistic EuroSCORE >4% (at 10 years, 58.7% versus 86.6%, p <0.00001). CONCLUSION: EuroSCORE is an important predictor of immediate and late outcome after surgery for mitral valve regurgitation.
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Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Anciano , Femenino , Finlandia , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/mortalidad , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Proyectos de Investigación , Estudios Retrospectivos , Medición de Riesgo , Sensibilidad y Especificidad , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: The value of off-pump over conventional coronary artery bypass surgery in reducing the risk of postoperative stroke is controversial. This issue has been evaluated in light of our recent clinical experience. METHODS: Off-pump coronary artery bypass surgery was performed in 557 patients, and conventional coronary artery bypass surgery was performed in 445 patients. Preoperative stroke risk was calculated according to the Northern New England Cardiovascular Disease Study Group stroke risk-scoring method. RESULTS: Off-pump coronary artery bypass surgery was associated with a lower but not significant rate of postoperative stroke in the overall series (1.8% vs 2.5%, P = .45), a difference that slightly increased in the highest tertile of the Northern New England Cardiovascular Disease Study Group score (2.8% vs 4.2%, P = .75). The postoperative stroke rate was significantly lower when the operation was performed by off-pump coronary artery bypass surgeons using routinely epiaortic ultrasonographic scanning compared with conventional coronary artery bypass surgeons not using epiaortic ultrasonographic scanning (0.4% vs 3.9%, P = .015). The Northern New England Cardiovascular Disease Study Group score (mean, 4.6 +/- 2.1 vs 4.9 +/- 2.2; P = .189) was similar in these groups. Logistic regression showed that when adjusted for Northern New England Cardiovascular Disease Study Group stroke risk score and critical preoperative status, the treatment approach (off-pump coronary artery bypass surgery and routine epiaortic ultrasonographic scanning) was an independent predictor of postoperative stroke (P = .012; odds ratio, 34.1; 95% confidence interval, 2.2-533.7). CONCLUSIONS: The neuroprotective efficacy of off-pump coronary artery bypass surgery is marginal compared with that of conventional coronary artery bypass surgery. A decreased risk of postoperative stroke after off-pump coronary artery bypass surgery is expected, mostly in high-risk patients and when epiaortic ultrasonographic examination is routinely used for better planning of operative strategy, aiming to minimize the risk of intraoperative embolism.
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Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Accidente Cerebrovascular/etiología , Anciano , Femenino , Humanos , Masculino , Complicaciones Posoperatorias , Factores de RiesgoRESUMEN
OBJECTIVE: To identify the preoperative risk factors associated with increased prevalence of atherosclerotic lesions of the ascending aorta among patients undergoing off-pump coronary artery bypass surgery (OPCAB). MATERIAL AND METHODS: OPCAB was performed in 241 patients who were intraoperatively investigated by epiaortic ultrasound for the presence of atherosclerotic lesions of the ascending aorta. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) and the Multicenter Study of Perioperative Ischemia (McSPI) stroke risk scores were retrospectively calculated. RESULTS: A diseased ascending aorta was detected by intraoperative epiaortic ultrasound in 74 patients (30.7%). Patient's age (P = .002, odds ratio [OR] 1.067, 95% confidence interval [CI] 1.025-1.110), diabetes (P = .023; OR, 2.211; 95% CI, 1.117-4.378), extracardiac arteriopathy (P = .014; OR, 2.567; 95% CI, 1.214-5.428) and urgent/emergency operation (P < .0001; OR, 3.066; 95% CI, 1.685-5.580) were independent preoperative predictors of a diseased ascending aorta. The area under the ROC curve of the NNECVDSG score in predicting a diseased ascending aorta was 0.710 (95% CI, 0.642-0.778), and that of the McSPI score was 0.722 (95% CI, 0.655-0.788). The prevalence of a diseased ascending aorta was 11.2%, 34.7%, and 49.4% among the NNECVDSG score tertiles (P < .0001), and 11.3%, 31.7%, and 49.4% among the McSPI score tertiles (P < .0001). CONCLUSIONS: These findings confirm the reported high incidence of a diseased ascending aorta in patients undergoing coronary artery bypass surgery. Current stroke risk scores, particularly the simple NNECVDSG score, are valuable predictors of increased prevalence of a diseased ascending aorta.
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Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/epidemiología , Aterosclerosis/epidemiología , Aterosclerosis/cirugía , Puente de Arteria Coronaria Off-Pump/estadística & datos numéricos , Evaluación de Resultado en la Atención de Salud/métodos , Medición de Riesgo/métodos , Anciano , Aorta , Comorbilidad , Femenino , Finlandia/epidemiología , Indicadores de Salud , Humanos , Incidencia , Masculino , Cuidados Preoperatorios/métodos , Pronóstico , Reproducibilidad de los Resultados , Factores de Riesgo , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: The incidence of pulmonary embolism (PE) after coronary artery bypass surgery is ill defined. METHODS: Twenty-four patients undergoing off-pump coronary artery bypass surgery were enrolled in a prospective randomized study evaluating a new proximal aortic anastomotic device. Computed tomography was performed postoperatively about 1 week after surgery. RESULTS: Computed tomography showed signs of PE in 6 patients (25%), which were bilateral in 2 cases. None of these patients had symptoms or signs of PE or deep venous thrombosis. CONCLUSIONS: The present findings widen the controversial issue of thromboprophylaxis after cardiac surgery and suggest that low-dose heparin may be indicated after coronary artery bypass surgery.
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Puente de Arteria Coronaria Off-Pump/efectos adversos , Embolia Pulmonar/diagnóstico por imagen , Embolia Pulmonar/epidemiología , Anciano , Anastomosis Quirúrgica/instrumentación , Aorta/cirugía , Puente de Arteria Coronaria Off-Pump/instrumentación , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
BACKGROUND: Avoidance of manipulation of diseased ascending aorta has been shown to be associated with a reduced risk of postoperative stroke after off-pump coronary artery bypass surgery (OPCAB). The use of the Heartstring device (Guidant, Indianapolis, USA) to accomplish a proximal aortic anastomosis without aortic clamping has been suggested in such patients. PATIENTS AND METHODS: From April 2004 to December 2005, proximal aortic anastomoses have been accomplished employing the Heartstring device in 19 patients with calcified ascending aorta who underwent OPCAB. The diagnosis of diseased ascending aorta was made intraoperatively by epiaortic ultrasound scanning. RESULTS: Eighteen vein grafts and three radial artery grafts have been successfully anastomosed to the ascending aorta by employing the Heartstring device. Breaking of eight seals occurred during insertion. One patient (5.2%) had stroke two days after urgent OPCAB. CONCLUSION: The use of the Heartstring anastomotic device should be considered in high-risk patients with diseased ascending aorta requiring a prompt myocardial revascularization, whenever there is a place to safely insert this device into the ascending aorta.
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Anastomosis Quirúrgica/instrumentación , Enfermedades de la Aorta/cirugía , Prótesis Vascular , Puente de Arteria Coronaria Off-Pump/instrumentación , Anciano , Aorta/cirugía , Enfermedades de la Aorta/diagnóstico por imagen , Femenino , Humanos , Complicaciones Posoperatorias/prevención & control , Accidente Cerebrovascular/prevención & control , Ultrasonografía , Procedimientos Quirúrgicos Vasculares/instrumentaciónRESUMEN
BACKGROUND: The use of aortic connector devices for proximal vein graft anastomosis has been shown to be associated with a relevant rate of early graft complications. Cardica PAS-Port is a new aortic connector whose preliminary clinical results seem promising. The safety and efficacy of this aortic connector device have been evaluated in this prospective, randomized study. MATERIAL AND METHODS: Twenty-four patients were randomized to receive proximal aorta-vein graft anastomosis with either the Cardica PAS-port aortic connector or by the hand-sewn technique. Twenty-three patients underwent multidetector computed tomographic scan (MDCT) of the chest 6 months after surgery to evaluate graft patency. RESULTS: All aortic connector devices (18) were successfully deployed and 31 proximal anastomoses were performed by the hand-sewn technique. MDCT showed that 6-month freedom from vein graft complication was 22.2% in the PAS-Port group and 58.1% in the hand-sewn group (P = .04). Four vein grafts (22.2%) anastomosed with the PAS-Port and 2 hand-sewn vein grafts (6.5%) were occluded (P = .10). The use of the PAS-Port aortic connector was also predictive of any vein graft complication when adjusted for vein graft flow (P = .01; OR 8.64, 95% CI 1.66-45.00) and for peripheral resistance units (P = .02; OR 6.14, 95% CI 1.33-28.43). CONCLUSIONS: The results of this prematurely stopped, prospective, randomized study suggest that the use of PAS-Port aortic connector device is associated with a higher rate of early vein graft complications than the hand-sewn technique.
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Anastomosis Quirúrgica/instrumentación , Aorta/cirugía , Prótesis Vascular , Puente de Arteria Coronaria Off-Pump/instrumentación , Técnicas de Sutura/instrumentación , Anciano , Anastomosis Quirúrgica/métodos , Puente de Arteria Coronaria Off-Pump/métodos , Diseño de Equipo , Análisis de Falla de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM OF THE STUDY: Mitral valve repair for degenerative and ischemic mitral valve regurgitation has been shown to be a durable procedure. The study aim was to evaluate the quality of life of patients who had undergone mitral valve repair, and to compare it to that of an age- and gender-adjusted Finnish general population. METHODS: Among 130 late survivors after mitral valve repair, 109 (83.8%) answered the RAND-36 Health Survey questionnaire; these patients form the basis of the present study. RESULTS: The Wilcoxon test showed significantly higher mental health (p = 0.04) and pain scores (p = 0.015) and a lower role functioning/physical score (p = 0.008) in the study group. The scores of the other RAND-36 Health Survey variables of the study group were similar to those of the age- and gender-adjusted general population. The mean total score for the study group was 512 (median 532, IQR 360-678), compared to 522 (median 538, IQR 468-549) in the general population (p = 0.72) (only 95 patients were included in the analysis due to isolated missing scores). CONCLUSION: The quality of life of long-term survivors after mitral valve repair, as assessed by the RAND-36 Health Survey, is similar to that of an age- and gender-adjusted general Finnish population.
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Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Calidad de Vida , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/mortalidad , Reoperación , Encuestas y Cuestionarios , Tasa de SupervivenciaRESUMEN
BACKGROUND: Mitral valve repair (MVR) has been shown to achieve good long-term results. However, this procedure is associated with relevant immediate postoperative mortality. The aim of this study is to identify those preoperative variables associated with an increased risk of 30-d postoperative death. METHODS: One hundred and sixty-four patients underwent MVR at our institution from January 1993 to December 2000. RESULTS: Eleven patients (6.7%) died during the immediate postoperative outcome, a median of 14 d after surgery (range, 1-29 d). One patient (1.3%) out of 80 who underwent MVR as lone procedure died on postoperative day 14 of cardiac tamponade. The mortality rate in those who underwent MVR associated with other procedures was 11.9%. Multivariable analysis (154 patients included in the analysis) showed that patients' age (p = 0.006, for an increase of 10 units: OR 4.33, 95% CI 1.53-12.27), history of prior cardiac surgery (p = 0.006, OR 118.56, 95% CI 4.03-3491.14) and NYHA functional class (p = 0.011, OR 5.66, 95% CI 1.49-21.49) were significantly associated with an increased risk of postoperative death. The receiver operating characteristics (ROC) curve showed that patients' age had an area under the curve of 0.762 (95% CI 0.622-0.901, p = 0.004), its best cut-off value being 65 years (mortality, 13.4% vs 2.1%, p = 0.008, sensitivity 81.8%, specificity 62.1%, accuracy 63.4%). None of the patients older than 65 and with a history of prior cardiac surgery survived the operation. CONCLUSIONS: MVR is associated with a relevant 30-d mortality risk in patients older than 65 years, with advanced NYHA functional class and a history of prior cardiac surgery.
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Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Insuficiencia de la Válvula Mitral/mortalidad , Insuficiencia de la Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/mortalidad , Estenosis de la Válvula Mitral/cirugía , Complicaciones Posoperatorias/mortalidad , Distribución por Edad , Anciano , Estudios de Cohortes , Femenino , Finlandia , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico , Estenosis de la Válvula Mitral/diagnóstico , Análisis Multivariante , Atención Perioperativa , Valor Predictivo de las Pruebas , Probabilidad , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Distribución por Sexo , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Several studies reported excellent long-term results after mitral valve repair for regurgitation, however a number of patients still experience recurrent mitral valve regurgitation which requires reoperation. We have evaluated the long-term outcome of a consecutive series of patients who underwent mitral valve repair for regurgitation in an attempt to identify the risk factors associated with late failures. PATIENTS AND METHODS: One-hundred and sixty-four patients underwent mitral valve repair for ischemic and degenerative mitral valve regurgitation. Seventy-two patients underwent echocardiographic evaluation a median of 5.6 years after surgery. RESULTS: Ten-year survival freedom from any fatal cardiac event was 75.9% and survival freedom from redo mitral valve surgery was 93.8%. Multivariable analysis showed that residual mitral valve regurgitation grade>1 as assessed during the immediate postoperative period (at 10-year, 60.6% vs. 95.7%, p=0.001, RR 20.7, 95%C.I. 3.4-125.3) and chronic obstructive pulmonary disease/asthma (at 10-year 66.8% vs. 95.2%, p=0.013, RR 12.0, 95%C.I. 1.7-85.2) were predictors of redo mitral valve surgery. The same findings were observed also among patients with myxomatous degenerative disease. At echocardiographic follow-up, no significant improvement was detected in terms of left ventricular ejection fraction, whilst mitral valve regurgitation grade (median, 3 to 1), New York Heart Association class (median, 2 to 1) and left atrium diameter (median, 50 to 44 mm) decreased significantly. CONCLUSIONS: This study confirms the excellent clinical long-term results after mitral valve repair. An adequate repair technique is advocated in order to decrease the immediate postoperative rate of residual regurgitation>1 as this is a main determinant of late failures requiring redo mitral valve surgery. Further studies are required to better define the possible causative role of chronic obstructive pulmonary disease and any underlying connective tissue metabolic disorder in late failures after mitral valve repair.
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Insuficiencia de la Válvula Mitral/cirugía , Anciano , Supervivencia sin Enfermedad , Ecocardiografía , Femenino , Finlandia , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/epidemiología , Análisis Multivariante , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Valor Predictivo de las Pruebas , Reoperación , Factores de Riesgo , Tiempo , Resultado del TratamientoAsunto(s)
Fibrilación Atrial/diagnóstico , Fibrilación Atrial/terapia , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/normas , Calidad de Vida , Enfermedad Aguda , Anciano , Antiarrítmicos/uso terapéutico , Anticoagulantes/uso terapéutico , Fibrilación Atrial/mortalidad , Ablación por Catéter/métodos , Ablación por Catéter/normas , Enfermedad Crónica , Electrocardiografía , Femenino , Finlandia , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo , Tasa de SupervivenciaRESUMEN
OBJECTIVE: To evaluate whether pulmonary artery blood (PA) temperature on admission to the intensive care unit (ICU) is predictive of postoperative outcome after isolated on-pump coronary artery bypass grafting (CABG). DESIGN: A retrospective study on 1639 patients who underwent isolated on-pump CABG in whom PA temperature at admission to the ICU was available for review. RESULTS: Thirty-three patients (2.0%) died during the in-hospital stay and 87 patients (5.3%) developed low cardiac output syndrome. PA temperature at admission to the ICU was significantly associated with an increased risk of overall postoperative death (p = 0.002), cardiac death (p = 0.03), and low cardiac output syndrome (p < 0.0001), and was significantly correlated with prolonged length of ICU stay (p < 0.0001) and postoperative bleeding (p = 0.001). Patients with high PA temperature had significantly more severe comorbidities, and longer aortic cross-clamping and cardiopulmonary bypass time. The receiver operating characteristic curve showed that PA temperature at admission to the ICU in predicting postoperative death had an area under the curve of 0.660 (p = 0.002) and its best cut-off value was 36.4 degrees C (sensitivity: 63.6%, specificity: 65.2%). When the PA temperature at admission to the ICU was > or = 36.4 degrees C, the postoperative mortality and low cardiac output syndrome rates were 3.6 and 8.3%, whereas they were 1.1 and 3.7% when the PA temperature at admission to the ICU was < 36.4 degrees C (p = 0.001, p < 0.0001), respectively. CONCLUSION: Patients having a PA temperature > or =36.4 degrees C at admission to the ICU after CABG seem to be at higher risk of poor postoperative outcome.
Asunto(s)
Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/métodos , Enfermedad Coronaria/cirugía , Arteria Pulmonar , Temperatura , Anciano , Temperatura Corporal , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/métodos , Angiografía Coronaria/métodos , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/mortalidad , Femenino , Humanos , Incidencia , Unidades de Cuidados Intensivos , Modelos Lineales , Masculino , Persona de Mediana Edad , Análisis Multivariante , Cuidados Posoperatorios/métodos , Complicaciones Posoperatorias/epidemiología , Valor Predictivo de las Pruebas , Cuidados Preoperatorios/métodos , Probabilidad , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Atrial fibrillation, occurring after coronary artery bypass grafting (CABG), has been suggested to be associated with the development of postoperative stroke. However, it is not clear what is the incidence of atrial fibrillation-related postoperative stroke, the timing of its occurrence, and the outcome. These issues have been investigated in a consecutive series of patients who have undergone on-pump coronary artery bypass grafting (ONCAB). METHODS: Among 2,630 patients who underwent ONCAB, 52 patients (2.0%) experienced postoperative stroke and form the basis of the present study. RESULTS: Twelve patients (23.1%) died postoperatively. The ischemic cerebral event occurred after a mean of 3.7 days (range, 0 to 33). In 19 patients (36.5%), atrial fibrillation preceded the occurrence of neurologic complication. These patients experienced a mean of 2.5 episodes of atrial fibrillation before the occurrence of neurologic complication. The cerebrovascular event occurred after a mean of 6.0 days in patients in whom atrial fibrillation preceded it, after a mean of 1.2 days in those with calcified ascending aorta, and after a mean of 3.1 days in those without calcified ascending aorta or in whom atrial fibrillation did not precede the cerebrovascular complication (p < 0.0001). Stroke occurred a mean of 21.3 hours after atrial fibrillation. CONCLUSIONS: This study confirmed that atrial fibrillation, occurring after CABG, is a major determinant of postoperative stroke. Prevention of postoperative atrial fibrillation, and of formation of clots into the left atrium, may dramatically reduce the risk of postoperative stroke.