RESUMEN
BACKGROUND: Scimitar syndrome may be corrected using different techniques. Repair using an extracardiac conduit has rarely been performed. This study assessed the intermediate-term outcomes of this technique in adults. METHODS: From January 2000 to June 2011, 7 adult patients underwent correction with a ringed polytetrafluoroethylene conduit used to connect the scimitar vein (SV) to the left atrium, posterior to the inferior vena cava (IVC). Preoperative and perioperative data were reviewed retrospectively. RESULTS: All patients (32 ± 10.6 years old) were symptomatic (3 patients were New York Heart Association [NYHA] functional class II, 4 had recurrent pneumonia), with a ratio of pulmonary to systemic blood flow greater than 2, without significant pulmonary hypertension. In all patients, the SV drained the entire right lung venous return to the IVC below the diaphragm. Surgical repair was performed by sternotomy, normothermic cardiopulmonary bypass, and aortic cross-clamping. Four patients required additional closure of an atrial septal defect. Mean conduit diameter was 14 mm (range, 12 to 16 mm). Patients received long-term platelet suppression therapy with aspirin. There were no deaths and no reoperations. Mean follow-up time was 9.1 ± 3.6 years. Postoperative morbidity was nil. No evidence of subclinical stroke or embolization was found in postoperative magnetic resonance imaging of the brain. No thrombi on the prosthesis or in the left atria were detected at the latest echocardiogram, with laminar flow from the SV to the left atrium. At last follow-up, all patients were in NYHA class I. CONCLUSIONS: Correction of scimitar syndrome with an extracardiac conduit can be easily and safely performed in adults, with excellent intermediate-term durability, without graft thrombi or stenosis. This technique avoids deep hypothermic circulatory arrest when the SV is short or enters the IVC in an unusually caudad location.
Asunto(s)
Implantación de Prótesis Vascular/métodos , Politetrafluoroetileno , Síndrome de Cimitarra/cirugía , Adolescente , Adulto , Factores de Edad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: We analyzed the intermediate experience, survival, and prosthetic complications of patients who received the Biocor valve, a new-generation porcine valve, in the mitral position. METHODS: At the University of Padua, between May 1992 and January 2004, 154 consecutive patients (102 female and 52 male patients; mean age, 72.3 +/- 6 years; age range, 37-86 years) received 158 mitral Biocor prostheses (Biocor Industria e Pesguisa Ltda, Belo Horizonte, Brazil). Thirty-five percent of the patients had previous mitral operations, 24% had coronary artery bypass grafting, and 34.6% had other procedures. Median preoperative New York Heart Association class was III. Echocardiography was performed in 75% of the long-term survivors. Follow-up included 609.4 patient-years and was 100% complete, with a median time of 4 patient-years (range, 0.02-11.3 years). At 8 years, 20 (14%) of 142 operative survivors were still at risk. RESULTS: Early mortality was 13.6%. According to univariate analysis, New York Heart Association class III to IV, ejection fraction of less than 40%, urgency, male sex, and coronary artery bypass grafting were significant perioperative risk factors. Eight- and 10-year actuarial survival was 51.1% +/- 5.6% (40 deaths). Eight-year actuarial freedom from valve-related death, thromboembolism, anticoagulant-related hemorrhage, endocarditis, paravalvular leak, and valve-related complications were 85.2% +/- 5%, 85.7% +/- 4.4%, 92.6% +/- 3.7%, 94.1% +/- 3%, 91.8% +/- 3%, and 70.2% +/- 5.7%, respectively. Freedom from structural valve deterioration was 100%. Actual freedom from reoperation was 93.2% +/- 2.2%. By Doppler echocardiography, the peak and mean transprosthetic gradients were 15 +/- 5 mm Hg and 6.3 +/- 3 mm Hg, respectively (mean follow-up, 4.2 +/- 2.7 years). CONCLUSION: At intermediate follow-up, the Biocor prosthesis in the mitral position showed excellent results in terms of valve durability when compared with other second-generation tissue valves.
Asunto(s)
Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas , Válvula Mitral/cirugía , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Anticoagulantes/efectos adversos , Ecocardiografía , Endocarditis/etiología , Endocarditis/mortalidad , Endocarditis/cirugía , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Italia , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Hemorragia Posoperatoria/inducido químicamente , Hemorragia Posoperatoria/mortalidad , Diseño de Prótesis , Reoperación , Análisis de Supervivencia , Tromboembolia/etiología , Tromboembolia/mortalidad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The aim of this study was to analyze the 8-year experience, survival, prosthetic complications, and hemodynamics of patients who received the Biocor valve, a new-generation tissue valve, in the aortic position. METHODS: From May 1992 through May 2001, 257 consecutive patients (129 women and 128 men; mean age, 75 +/- 6 years; age range, 45-91 years) received 258 aortic Biocor porcine prostheses. One female patient who received 2 Biocor valves in the aortic position during 2 consecutive operations was entered twice in the statistical analysis. Twelve (4.6%) patients had previous aortic valve operations. Preoperatively, 82 (32%) patients were in New York Heart Association functional class III or IV. Associated surgical procedures included coronary artery bypass grafting in 56 (21.7%) patients, aortic annular enlargement or aortoplasty in 20 (8%) patients, and others in 8 (3%) patients. Echocardiography was performed in the majority of long-term survivors (91.6%). Follow-up included 1215 patient-years and was 100% complete, with a median time of 5 patient-years (range, 0.4-10.5 years). RESULTS: There were 16 (6.2%) early deaths. According to a univariate analysis, New York Heart Association functional class III or IV, concomitant procedures, ejection fractions of less than 40%, and urgent operations were identified as significant perioperative risk factors. At follow-up, 75 patients died; 8-year actuarial Kaplan-Meier survival was 48% +/- 5%. At 8 years, the actuarial freedom from valve-related death was 92% +/- 2.6%, the freedom from thromboembolism was 93% +/- 2%, the freedom from anticoagulant-related hemorrhage was 95% +/- 2%, the freedom from endocarditis was 99% +/- 0.6%, the freedom from paravalvular leak was 96% +/- 1.5%, the freedom from all valve-related complications was 78% +/- 4.5%, and the freedom from structural valve deterioration was 95% +/- 3.7%. At 8 years, the actuarial freedom from structural valve deterioration was 89% +/- 10% and 95.8% +/- 4% in patients younger and older than 65 years, respectively. At 10 years, in patients older than 65 years, the actual freedom from structural valve deterioration was 97.9% +/- 2.1%, and the freedom from reoperation was 97% +/- 1.3%. New York Heart Association status was I or II in 90% of patients at the end of follow-up. The mean echocardiographic follow-up time was 4.6 +/- 2 years. By using Doppler echocardiography, the peak and mean transprosthetic gradients were determined to be 30.8 +/- 9.3 mm Hg and 16.6 +/- 5.3 mm Hg, respectively. Mean mass/volume ratio and left ventricular end-diastolic volume were 1.37 +/- 0.17 g/mL and 63.4 +/- 22.6 mL/m(2), respectively. The majority of patients showed a persistent left ventricular hypertrophy. CONCLUSION: The Biocor is an effective bioprosthesis with a low incidence of valve-related complications comparable with that of other second-generation bioprostheses. This stented porcine prosthesis provides satisfactory results in terms of hemodynamics, valve durability, and freedom from reoperation.
Asunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Bioprótesis , Prótesis Valvulares Cardíacas , Hemodinámica/fisiología , Anciano , Anciano de 80 o más Años , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Estudios de Cohortes , Intervalos de Confianza , Ecocardiografía Doppler , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico/métodos , Complicaciones Posoperatorias/mortalidad , Probabilidad , Diseño de Prótesis , Falla de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Análisis de Supervivencia , Factores de TiempoRESUMEN
BACKGROUND: Tricuspid valve replacement (TVR) is an uncommon procedure. The use of biological vs mechanical prostheses in TVR has pros and cons. Therefore, we debate the choice between the different types of valves by means of a meta-analysis of studies of the last decade. METHODS: The heading "tricuspid valve replacement and (bio* or mec*)" was used to retrieve studies from Medline, Current Contents, and Embase. Eight out of 11 studies met the preset strict criteria: intra-institutional comparison of results of biological or mechanical TVR. Survival of hospital-discharged patients was recalculated to reduce the effect of unbalanced perioperative risk factors on overall survival. Hazard ratio was obtained from actuarial survival graphics comparison and at-risk groups, according to the method described by Parmar. If missing, the number of patients at risk was approximated assuming constant and noninformative censoring. Hazard pooling was done according to study heterogeneity. Bioprostheses were assumed as the gold standard and mechanical prostheses assumed as the challenging device. Therefore, a hazard more than 1 pointed to a higher risk of mechanical prostheses. Our 1998 study was updated for this analysis. RESULTS: In this study, 1,160 prostheses and 6,046 follow-up years were analyzed. The pooled survival hazard ratio of mechanical prostheses versus bioprostheses was 1.07 (0.84 to 1.35, p = 0.60). The pooled freedom from reoperation hazard ratio was 1.24 (0.67 to 2.31, p = 0.67). Pooled survival differences were trivial, favoring mechanical prostheses at 1 (-0.04%) and 15 years (-1.1%) and favoring bioprostheses (+1.8%) at 10 years. CONCLUSIONS: There is not a gold standard in tricuspid prostheses replacement. Prosthetic choice is left to the surgeon's clinical judgment, taking into consideration each patient's characteristics and needs.
Asunto(s)
Bioprótesis , Prótesis Valvulares Cardíacas , Válvula Tricúspide/cirugía , Femenino , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Reoperación , Análisis de SupervivenciaRESUMEN
We prospectively compared, according to their preoperative clinical profiles, the in-hospital outcomes of patients operated on consecutively (but without randomization) for isolated coronary artery disease with on-pump or off-pump techniques. During 2001, 324 patients underwent coronary artery bypass grafting: 216 patients (mean age, 66.7 +/- 8.9 years; range, 41-85 years) underwent on-pump revascularization, and 108 patients (mean age, 676 +/- 10 years; range, 37-90 years) underwent full-sternotomy off-pump revascularization. The 2 groups were homogeneous with regard to female sex (22.6% vs 26.8%), previous cardiac operation (2.8% vs 4.6%), cardiogenic shock (1.3% vs 1.9%), diabetes (30% vs 33%), and chronic renal failure that required hemodialysis (3% vs 3.5%). Postoperative complications, including bleeding, myocardial infarction, acute renal failure, mediastinitis with sternal dehiscence, cerebrovascular events, and prolonged respiratory assistance were more frequent in on-pump patients (P = 0.004). The total number of grafts and the grafts per patient ratio were significantly higher in on-pump patients (P = 0.0001), whereas the total number of full arterial revascularizations was higher in off-pump patients (P = 0.0001). Off-pump patients showed a significantly shorter intensive care unit stay (P = 0.02), and less need for intra-aortic balloon pump insertion (P = 0.04). In-hospital mortality was 2.8% in on-pump patients and 2.7% in off-pump patients (P = NS). Although the hospital mortality rate was comparable for the 2 techniques, the in-hospital comparison between the 2 groups showed how the avoidance of cardiopulmonary bypass can significantly reduce the cumulative postoperative incidence of complications in patients undergoing coronary artery bypass grafting.