Asunto(s)

Accidentes por Caídas , Infarto del Miocardio , Anciano , Hospitalización , Humanos , Factores de Riesgo

RESUMEN

BACKGROUND: After hospitalization for acute myocardial infarction (AMI), older adults may be at increased risk for falls due to deconditioning, new medications, and worsening health status. Our primary objective was to identify risk factors for falls after AMI hospitalization among adults over age 75. METHODS: We used data from the Comprehensive Evaluation of Risk Factors in Older Patients with AMI (SILVER-AMI) study, a prospective cohort study of 3041 adults age 75 and older hospitalized with AMI at 94 community and academic medical centers across the United States. In-person interviews and physical assessments, as well as medical record review, were performed to collect demographic, clinical, functional, and psychosocial data. Falls were self-reported in telephone interviews and medically serious falls (those associated with emergency department use or hospitalization) were determined by medical record adjudication. Backward selection was used to identify predictors of fall risk in logistic regression analysis. RESULTS: A total of 554 (21.6%) participants reported a fall and 191 (6.4%) had a medically serious fall within 6 months of discharge. Factors independently associated with self-reported falls included impaired mobility, prior fall history, longer hospital stay, visual impairment, and weak grip. Factors independently associated with medically serious falls included older age, polypharmacy, impaired functional mobility, prior fall history, and living alone. CONCLUSIONS: Among older patients hospitalized for AMI, falls are common in the 6 months following discharge and associated with demographic, functional, and clinical factors that are readily identifiable. Fall risk should be considered in post-AMI clinical decision-making and interventions to prevent falls should be evaluated.

Asunto(s)

Accidentes por Caídas/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Infarto del Miocardio/complicaciones , Anciano , Anciano de 80 o más Años , Femenino , Estado de Salud , Humanos , Masculino , Estudios Prospectivos , Factores de Riesgo , Estados Unidos

Asunto(s)

Mediastinitis , Adaptación Fisiológica , Anciano , Centers for Medicare and Medicaid Services, U.S. , Genes Supresores de Tumor , Humanos , Mediastinitis/diagnóstico , Medicaid , Medicare , Proteínas de la Membrana , Estados Unidos

Asunto(s)

Procedimientos Quirúrgicos Cardíacos , Terapia de Presión Negativa para Heridas , Tórax

RESUMEN

Background In older adults undergoing cardiac surgery, prediction of downstream risk is critical. Our objective was to determine the association of 5-m gait speed with 1-year mortality and repeat hospitalization following cardiac surgery. Methods and Results In this prospective cohort of patients undergoing cardiac surgery at centers participating in the Society of Thoracic Surgeons Database with gait speed recorded, we examined all-cause mortality using a landmark analysis at 0 to 30, 30 to 365, and >365 days, as well as repeat hospitalization. The cohort consisted of 8287 patients (median age, 74 years; 32% females). At 1 year, survival was 90% in the slow (<0.83 m/s), 95% in the middle (0.83-1.00 m/s), and 97% in the fast (>1.00 m/s) gait speed tertiles, and risk of hospitalization was 45%, 33%, and 27%, respectively (both P<0.0001). After adjustment, gait speed remained predictive of mortality (hazard ratio, 2.16 per 0.1-m/s decrease in gait speed; 95% confidence interval, 1.59-2.93) and rehospitalization (hazard ratio, 1.71 per 0.1-m/s decrease in gait speed; 95% confidence interval, 1.45-2.0). In a landmark analysis, the effect of slow gait speed on mortality was most marked from 30 to 365 days after surgery, where each decline in 0.1 m/s of gait speed conferred a 2-fold increased risk of mortality. Conclusions Gait speed is a simple tool to screen for frailty and identify older adults at risk for adverse events in the early and midterm postoperative periods.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos/mortalidad , Velocidad al Caminar , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Bases de Datos como Asunto , Femenino , Fragilidad/diagnóstico , Humanos , Estimación de Kaplan-Meier , Masculino , Readmisión del Paciente/estadística & datos numéricos , Modelos de Riesgos Proporcionales , Factores de Riesgo , Sociedades Médicas , Análisis de Supervivencia , Estados Unidos

RESUMEN

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease (CVD) is the leading cause of death and major disability in adults aged 75 and older. Despite the effect of CVD on quality of life, morbidity, and mortality in older adults, individuals aged 75 and older have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older adults with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in nursing homes and assisted living facilities. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older adults typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision-making, and recommend future research to close existing knowledge gaps. To achieve these objectives, a detailed review was conducted of current American College of Cardiology/American Heart Association (ACC/AHA) and American Stroke Association (ASA) guidelines to identify content and recommendations that explicitly targeted older adults. A pervasive lack of evidence to guide clinical decision-making in older adults with CVD was found, as well as a paucity of data on the effect of diagnostic and therapeutic interventions on outcomes that are particularly important to older adults, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older adults representative of those seen in clinical practice and that incorporate relevant outcomes important to older adults in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older adults and enhance person-centered care of older individuals with CVD in the United States and around the world.

Asunto(s)

Cardiología , Enfermedades Cardiovasculares , Manejo de la Enfermedad , Geriatría , Guías de Práctica Clínica como Asunto , Factores de Edad , Anciano , American Heart Association , Cardiología/métodos , Cardiología/normas , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/terapia , Toma de Decisiones Clínicas , Medicina Basada en la Evidencia , Femenino , Geriatría/métodos , Geriatría/normas , Humanos , Masculino , Estados Unidos

RESUMEN

IMPORTANCE: Prediction of operative risk is a critical step in decision making for cardiac surgery. Existing risk models may be improved by integrating a measure of frailty, such as 5-m gait speed, to better capture the heterogeneity of the older adult population. OBJECTIVE: To determine the association of 5-m gait speed with operative mortality and morbidity in older adults undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study was conducted from July 1, 2011, to March 31, 2014, at 109 centers participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The 5-m gait speed test was performed in 15 171 patients aged 60 years or older undergoing coronary artery bypass graft, aortic valve surgery, mitral valve surgery, or combined procedures. MAIN OUTCOMES AND MEASURES: All-cause mortality during the first 30 days after surgery; secondarily, a composite outcome of mortality or major morbidity during the index hospitalization. RESULTS: Among the cohort of 15 171 patients undergoing cardiac surgery, the median age was 71 years and 4622 were female (30.5%). Compared with patients in the fastest gait speed tertile (>1.00 m/s), operative mortality was increased for those in the middle tertile (0.83-1.00 m/s; odds ratio [OR], 1.77; 95% CI, 1.34-2.34) and slowest tertile (<0.83 m/s; OR, 3.16; 95% CI, 2.31-4.33). After adjusting for the Society of Thoracic Surgeons predicted risk of mortality and the surgical procedure, gait speed remained independently predictive of operative mortality (OR, 1.11 per 0.1-m/s decrease in gait speed; 95% CI, 1.07-1.16). Gait speed was also predictive of the composite outcome of mortality or major morbidity (OR, 1.03 per 0.1-m/s decrease in gait speed; 95% CI, 1.00-1.05). Addition of gait speed to the Society of Thoracic Surgeons predicted risk resulted in a C statistic change of 0.005 and integrated discrimination improvement of 0.003. CONCLUSIONS AND RELEVANCE: Gait speed is an independent predictor of adverse outcomes after cardiac surgery, with each 0.1-m/s decrease conferring an 11% relative increase in mortality. Gait speed can be used to refine estimates of operative risk, to support decision-making and, since incremental value is modest when used as a sole criterion for frailty, to screen older adults who could benefit from further assessment.

Asunto(s)

Marcha , Anciano , Femenino , Fragilidad , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Periodo Posoperatorio , Cirugía Torácica

RESUMEN

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.

Asunto(s)

American Heart Association , Cardiología/normas , Enfermedades Cardiovasculares/terapia , Geriatría/normas , Atención al Paciente/normas , Sociedades Médicas/normas , Anciano , Anciano de 80 o más Años , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Femenino , Conocimientos, Actitudes y Práctica en Salud , Humanos , Masculino , Factores de Riesgo , Estados Unidos/epidemiología

RESUMEN

The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.

Asunto(s)

Anciano , Enfermedades Cardiovasculares/terapia , Guías de Práctica Clínica como Asunto , Ensayos Clínicos como Asunto , Muerte Súbita Cardíaca/prevención & control , Humanos , Esperanza de Vida , Evaluación de Necesidades , Atención Perioperativa , Pronóstico , Sujetos de Investigación , Medición de Riesgo

Asunto(s)

Comités Consultivos/normas , American Heart Association , Cardiología/normas , Competencia Clínica/normas , Intervención Coronaria Percutánea/normas , Médicos/normas , Cardiología/métodos , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/terapia , Fundaciones/normas , Humanos , Intervención Coronaria Percutánea/métodos , Informe de Investigación/normas , Estados Unidos

Asunto(s)

Angioplastia Coronaria con Balón/normas , Cateterismo Cardíaco/normas , Competencia Clínica/normas , Enfermedad de la Arteria Coronaria/terapia , Educación de Postgrado en Medicina/normas , Intervención Coronaria Percutánea/normas , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/educación , Cateterismo Cardíaco/efectos adversos , Consenso , Enfermedad de la Arteria Coronaria/diagnóstico , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/educación , Mejoramiento de la Calidad/normas , Indicadores de Calidad de la Atención de Salud/normas , Factores de Riesgo , Resultado del Tratamiento

Asunto(s)

Cardiología/normas , Competencia Clínica/normas , Enfermedad de la Arteria Coronaria/terapia , Reperfusión Miocárdica/normas , Médicos/normas , American Heart Association , Humanos , Estados Unidos

RESUMEN

OBJECTIVE: To compare long-term survival and incidence of ESRD between patients with and without preoperative renal dysfunction following heart transplantation. DESIGN: Fifty consecutive patients with preoperative estimated GFR < or = than 50 ml/min were compared with 50 age-matched patients with estimated GFR > or = than 80 ml/min who underwent heart transplantation between 1994 and 1998. We investigated two primary outcomes: death and development of ESRD. We also analyzed risk factors. RESULTS: Eight patients (16%) developed ESRD and 19 (38%) died in the control group whereas 10 patients (20%) developed ESRD and 26 (52%) died in the renal failure group during a mean follow-up period of 6.74 +/- 3.31 years. Survival and time to ESRD were not significantly different. In univariate and multivariate analysis, waiting time was the only risk factor found to predict mortality but not ESRD. High cyclosporine levels were only found to be associated with lower estimated GFR (p < 0.009). Among the control group, mortality was significantly higher in the subgroup of patients that developed > or = 50% reduction of estimated GFR at the end of the first post transplant year (p < 0.05). CONCLUSIONS: This study suggests that low pre-transplant estimated GFR may not accurately predict long-term development of ESRD.

Asunto(s)

Cardiopatías/cirugía , Trasplante de Corazón , Enfermedades Renales/complicaciones , Riñón/fisiopatología , Estudios de Casos y Controles , Femenino , Tasa de Filtración Glomerular , Cardiopatías/complicaciones , Cardiopatías/mortalidad , Cardiopatías/fisiopatología , Trasplante de Corazón/efectos adversos , Trasplante de Corazón/mortalidad , Humanos , Inmunosupresores/uso terapéutico , Incidencia , Estimación de Kaplan-Meier , Enfermedades Renales/mortalidad , Enfermedades Renales/fisiopatología , Fallo Renal Crónico/etiología , Fallo Renal Crónico/mortalidad , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Sobrevivientes , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

OBJECTIVE: Morbid obesity is increasingly observed in patients being evaluated for heart transplantation and represents a relative contraindication. We sought to evaluate the influence of pre-transplant obesity on morbidity and mortality after heart transplantation. DESIGN: We retrospectively reviewed 90 consecutive patients with preoperative obesity (BMI > or = 30) and 90 age matched patients with normal weight (BMI 19 - 26) who underwent heart transplantation at our institution between January 1997 and December 2005. RESULTS: Morbidly obese patients experienced higher rates of pre-transplant diabetes (29% vs 15%, p < 0.05) and prolonged waiting time before transplantation (191.4+/-136.1 vs 117.4+/-143.2 days, p < 0.001). There were no significant differences in post-operative complications including rejection and major and minor infections. There was no difference in actuarial survival between the obese and control groups after a mean follow-up of 4.26+/-2.95 years (p = 0.513, log-rank statistic 0.452). Causes of death did not differ. Cox proportional hazard analysis revealed increased association of peripheral vascular disease (HR 31.718, p = 0.001), and pre operative inotropic support (HR 33.725, p = 0.013) with increased mortality in the obese group. CONCLUSIONS: This study suggests morbid obesity does not affect survival or rates of infection and rejection after heart transplantation.

Asunto(s)

Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/efectos adversos , Obesidad Mórbida/complicaciones , Adulto , Anciano , Índice de Masa Corporal , Femenino , Rechazo de Injerto/etiología , Supervivencia de Injerto , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/mortalidad , Trasplante de Corazón/mortalidad , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Obesidad Mórbida/mortalidad , Philadelphia , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/etiología , Factores de Tiempo , Resultado del Tratamiento , Listas de Espera

RESUMEN

Previous reports have described penetrating cardiac injuries as the anatomic injury with the greatest opportunity for emergency department thoracotomy (EDT) survival. We hypothesize that actual survival rates are lower than that initially reported. A retrospective review of our EDT experience was performed. Data collected included injury mechanism and location, presence of measurable ED vital signs, initial ED cardiac rhythm, GCS, method of transportation, and survival. Logistic regression analysis identified predictors of survival. Ninety-four of 237 patients presented penetrating cardiac injuries after EDT. Eighty-nine patients (95%) were males. Measurable ED vital signs were present in 15 patients (16%). Cardiac injuries were caused by GSW in 82 patients (87%) and SW in 12 patients (13%). Fifteen patients (16%) survived EDT and were taken to the operating room, while eight patients (8%) survived their entire hospitalization. All survivors were neurologically intact. Survival rates were 5% for GSW and 33% for SW. Mechanism of injury (SW), prehospital transportation by police, higher GCS, sinus tachycardia, and measurable ED vital signs were associated with improved survival. In urban trauma centers where firearm injuries are much more common than stabbings, the presence of a penetrating cardiac injury may no longer be considered a predictor of survival after EDT.

Asunto(s)

Servicio de Urgencia en Hospital , Lesiones Cardíacas/cirugía , Toracotomía , Servicios Urbanos de Salud , Heridas Penetrantes/cirugía , Adolescente , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Lesiones Cardíacas/mortalidad , Humanos , Modelos Logísticos , Masculino , Inutilidad Médica , Selección de Paciente , Philadelphia/epidemiología , Estudios Retrospectivos , Medición de Riesgo , Toracotomía/mortalidad , Resultado del Tratamiento , Servicios Urbanos de Salud/estadística & datos numéricos , Heridas Penetrantes/mortalidad

RESUMEN

BACKGROUND: Listing status for heart transplantation (Tx) patients was changed in 1999 from Status 1 and 2 to Status 1A, 1B and 2. Because the selection process was modified in favor of seriously ill patients, it was not clear whether this change would affect survival or other aspects of transplant management. METHODS: We examined outcomes in 551 patients transplanted at our institution between 1986 and 2002 (pre-1999: n = 419; post-1999: n = 132) to determine the effects of change in listing protocol on transplant outcome. RESULTS: Using Cox proportional hazard analysis, survival was not different between pre-1999 (pre) and post-1999 (post). Overall waiting-list times were longer post-1999 (pre: 134 +/- 10.5 days, post: 172 +/- 15.6 days; p = 0.044), and were longer post-1999 for blood groups A (177 vs 123 days), B (96 vs 84 days) and O (229 vs 172 days), but were shorter post for blood group AB (42 vs 68 days). Survival was not affected by age (pre: 53.7 +/- 0.52 years, post: 53.1 +/- 1.04 years; hazard ratio [HR] 1.00; 95% confidence interval [CI] 0.996 to 1.023; p = 0.181), male gender (HR 1.132; 95% CI 0.822 to 1.56; p = 0.447) or waiting-list time. Serum creatinine was similar between the 2 groups (pre: 1.25 +/- 0.02, post: 1.26 +/- 0.04; p = 0.794), whereas pulmonary artery (PA) diastolic pressure was increased post-1999 (pre: 24.9 +/- 0.46, post: 27.0 +/- 0.74; p = 0.023). Survival was not affected by PA pressure (HR 1.00; 95% CI 0.986 to 1.014; p = 0.976), but an elevated pre-transplant creatinine reduced survival (HR 1.484; 95% CI 1.139 to 1.933; p = 0.003). CONCLUSIONS: The change in listing status implemented in 1999 caused an increase in wait times for patients with blood types A, B and O, and shortened wait time for type AB; however, no differences occurred in overall post-transplant survival after the change in listing protocol. Age, gender and PA pressure had no effect on survival in either time period, whereas pre-transplant serum creatinine decreased survival in both patient groups.

Asunto(s)

Trasplante de Corazón , Selección de Paciente , Listas de Espera , Antígenos de Grupos Sanguíneos , Estudios de Cohortes , Enfermedad Crítica , Determinación de la Elegibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Análisis de Supervivencia

RESUMEN

Myocardial bridging, the overlying of myocardial tissue onto epicardial coronary arteries, is an anatomic variant that is widely present in the general population. This condition can be associated with reduced forward coronary flow. Once these hearts are identified in potential donors by either visual inspection or coronary catheterization, they may no longer be considered suitable for transplantation. We present a case study that successfully utilized such a heart explanted from an older donor with "bench" myotomy repair before implantation.

Asunto(s)

Vasos Coronarios/anatomía & histología , Insuficiencia Cardíaca/terapia , Trasplante de Corazón , Miocardio , Donantes de Tejidos , Contraindicaciones , Vasos Coronarios/cirugía , Femenino , Trasplante de Corazón/métodos , Trasplante de Corazón/fisiología , Humanos , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana Edad

RESUMEN

This report describes a 62-year-old male diabetic patient with persistent chest wall osteomyelitis that developed after repeat coronary artery bypass grafting. The chronic infection was localized to the right anterior chest wall and refractory to medical and surgical treatment including long-term antiobiotics, five separate intraoperative debridements, and reconstruction with vascularized omentum over a two-year period at outside institutions. Aggressive surgical debridement with flap reconstruction resulted in definitive management. The organism isolated from multiple intraoperative bone, cartilage, and tissue cultures yielded Aspergillus fumigatus; therapy with itraconazole was utilized for 6 months. Surgical management of osteomyelitis and costochondritis is reviewed accompanied by a literature review on this uncommon cause of chronic chest wall infection.

Asunto(s)

Antifúngicos/uso terapéutico , Aspergilosis/tratamiento farmacológico , Aspergilosis/cirugía , Aspergillus fumigatus , Itraconazol/uso terapéutico , Osteomielitis/tratamiento farmacológico , Osteomielitis/cirugía , Pared Torácica , Puente de Arteria Coronaria/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Osteomielitis/microbiología , Inducción de Remisión

RESUMEN

BACKGROUND: Despite the increasingly common use of donor hearts at least 50 years of age, controversy still remains regarding long-term outcome. Our goal was to determine if older donor age is associated with an increased risk of mortality and specifically if the use of donor hearts at least 50 years of age reduces survival. METHODS: We retrospectively studied records of all primary heart transplants performed between January 1990 and July 2002. Fifty-six patients who had received donor hearts at least 50 years of age were compared with 611 recipients of donor hearts less than 50 years of age. Clinicopathologic parameters were analyzed for their effect on mortality using the Cox proportional hazard model with calculation of hazard ratios (HR). Cut-point analysis of donor age was used to determine which donor age is associated with the greatest risk of mortality after transplant. RESULTS: Recipients of donor hearts at least 50 years of age were older (58.5 years +/- 7.0 vs 53.2 +/- 11.6; mean +/- standard deviation [SD]; p < 0.0001), suffered more often from ischemic cardiomyopathy (69% vs 50%, p = 0.01), and experienced a longer waiting time (192.2 days +/- 301.0 vs 138.6 +/- 190.8, p < 0.0001). Donor hearts at least 50 years of age (age 54.1 +/- 3.5 years) were more often female (50% vs 34%, p = 0.03), died less often of "head trauma" (9% vs 42%, p < 0.0001), and exhibited fewer cytomegalovirus (CMV) mismatches (29% vs 39%, p = 0.04) than donor hearts less than 50 years of age (age 26.8 +/- 12.3 years). Multivariate predictors of mortality were rejection index (HR 1.90 per unit [rejections/100 survival days], p < 0.0001), donor age (HR 1.16 per 10-year increment, p = 0.002), and recipient age (HR 1.24 per 10-year increment, p = 0.04). Recipients of donor hearts at least 50 years of age had reduced 1-year and 5-year survival ([65.7% vs 81.7%, p < 0.05] and [48.3% vs 68.4%, p < 0.05], respectively), as well as a higher proportion of deaths occurring within 1 month of transplant (41% of total deaths vs 23%, p = 0.06). Cut-point analysis indicated the characteristic of donor age of at least 40 years (categorical variable) to predict mortality with the same degree of fit as age used as a continuous variable. CONCLUSIONS: Although we observed a substantial reduction in survival among patients who were allocated donor hearts at least 50 years of age, this difference was not solely attributable to the categorical variable of donor age 50 in this group. Donor age as a continuous variable, however, was determined to be a notable predictor of survival and use of the donor age cut-point of 40 years (categorical variable) allowed risk stratification with similar accuracy. The use of a donor age cut-point of 40 years may be a useful clinical criterion for graft-related risk assessment.

Asunto(s)

Causas de Muerte , Selección de Donante/métodos , Selección de Donante/estadística & datos numéricos , Trasplante de Corazón/mortalidad , Adulto , Factores de Edad , Rechazo de Injerto/epidemiología , Humanos , Persona de Mediana Edad , Philadelphia/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Análisis de Supervivencia , Tasa de Supervivencia

RESUMEN

We present a case of intractable high-volume (> 2L/d) chylothorax after transhiatal esophagectomy treated successfully with the simultaneous insertion of both Denver (Denver Biomedical, Golden, CO) and LeVeen (Becton-Dickinson, Rutherford, NJ) pleuroperitoneal shunts. The patient initially had chemoradiotherapy for a T4N1 squamous cell carcinoma of the thoracic esophagus. Re-staging showed a dramatic shrinkage of tumor, and a transhiatal esophagectomy was performed. Sequential bilateral thoracotomies were performed on postoperative days 19 and 26 for attempted control of high-volume chylothorax, but these were unsuccessful. Subsequent pleuroperitoneal shunt insertion was used, which immediately controlled the effusion. A shunt study was performed shortly after hospital discharge, which showed an occluded Denver shunt and a patent LeVeen shunt. The patient succumbed to metastatic carcinoma 18 months after discharge, but no pleural effusion had recurred.

Asunto(s)

Quilotórax/cirugía , Derivación Peritoneovenosa , Derrame Pleural/cirugía , Complicaciones Posoperatorias/cirugía , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carboplatino/administración & dosificación , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/radioterapia , Carcinoma de Células Escamosas/cirugía , Quilotórax/etiología , Quilotórax/terapia , Cisplatino/administración & dosificación , Terapia Combinada , Docetaxel , Neoplasias Esofágicas/complicaciones , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/radioterapia , Neoplasias Esofágicas/cirugía , Esofagectomía , Resultado Fatal , Fluorouracilo/administración & dosificación , Humanos , Ligadura , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Nutrición Parenteral Total , Derrame Pleural/etiología , Derrame Pleural/terapia , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Respiración Artificial , Taxoides/administración & dosificación , Toracostomía , Toracotomía , Adhesivos Tisulares/uso terapéutico