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Introduction: Acute kidney injury (AKI) is common in hospitalized patients and associated with poor outcomes. Current methods for identifying AKI (rise in serum creatinine [sCr] or fall in urine output [UO]) are inadequate and delay detection. Early detection of AKI with easily measurable biomarkers might improve outcomes by facilitating early implementation of AKI care pathways. Methods: From a porcine model of AKI, we identified trace elements (TEs) in urine that were associated with subsequent development of AKI. We tested these putative biomarkers in 2 observational cohort studies of patients at high risk of AKI: 151 patients undergoing cardiac surgery and 150 patients admitted to a general adult intensive care unit (ICU). Results: In adults admitted to the ICU, urinary cadmium (Cd) (adjusted for urinary creatinine) had area under the receiver operating characteristic curve (AUROC) 0.70 and negative predictive value (NPV) 89%; copper (Cu) had AUROC 0.76 and NPV 91%. In humans (but not pigs), urinary zinc (Zn) was also associated with AKI and, in the ICU study, had AUROC 0.67 and NPV 80%. In patients undergoing cardiac surgery, Zn had AUROC 0.77 and NPV 91%; urinary Cd and Cu had poor AUROC but NPV of 93% and 95%, respectively. In control studies, we found that the urinary biomarkers are stable at room temperature for at least 14 days and are not affected by other confounding factors, such as chronic kidney disease (CKD). Conclusion: Urinary Cd, Cu, and Zn are novel biomarkers for early detection of AKI. Urinary trace metals have advantages over proteins as AKI biomarkers because they are stable at room temperature and have potential for cheap point-of-care testing using electrochemistry.
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OBJECTIVES: Despite the 10-year results of the Arterial Revascularization Trial, the controversy regarding the survival benefit of multiarterial grafting (MAG) remains. Our goal was to present our long-term survival data in this propensity-matched observational study. METHODS: A primary unmatched population of 4303 patients with first-time isolated coronary artery bypass grafts operated on between 2000 and 2018 were included. A total of 1187 post-matched patients were compared with matched controls. Multivariate logistic regression and Cox proportional hazard analyses were undertaken to assess the contribution of MAG and other covariates to the long-term survival of unmatched and propensity-matched populations. RESULTS: MAG was associated with increased median survival in both the unmatched and the matched groups; difference: 962 and 1459 days, log-rank tests; P = 0.029 and 0.0004, respectively. MAG was associated with a reduced hazard of death in the unmatched as well as in the matched groups: hazard ratio [95% confidence interval (CI)]: 0.72 (0.62-0.83); P < 0.0001 and 0.75 (0.64-0.88); P ≤ 0.0001, respectively. In the matched group, the prosurvival factors were low logistic EuroSCORE, obesity, no intra-aortic balloon pump, an ejection fraction >30%, age 50-69 years, operation by an experienced surgeon, with and without diabetes, on-pump surgery and 3 distal anastomoses. In a cohort of 242 late-presenting patients with reinfarction or recurrent angina, both MAG and control populations were associated with reduced median survival; median (95% CI): MAG: 3026 (1138-3503); control: 3035 (2134-3991), log-rank P = 0.217 with superior patency of the left internal mammary artery but no difference between radial artery and saphenous vein grafts. CONCLUSIONS: Multiarterial revascularization, especially using the radial artery as a second arterial conduit, is associated with a significant survival benefit and a lack of in-hospital morbidity.
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Enfermedad de la Arteria Coronaria , Arterias Mamarias , Anciano , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Arterias Mamarias/trasplante , Persona de Mediana Edad , Puntaje de Propensión , Arteria Radial/trasplante , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM OF THE STUDY: To determine whether the type of atrial access to the mitral valve (left atriotomy, superior trans-septal, or limited trans-septal) influenced postoperative permanent pacemaker implantation and to investigate the effect of the sinoatrial (SA) node artery origin (right coronary or circumflex arteries) on the rate of pacemaker insertion. METHODS: We retrospectively reviewed consecutive cases of patients who had mitral valve surgery at the Trent Cardiac Centre (2008-2016). The primary outcome was the incidence of permanent pacemaker insertion. The data were analyzed using univariate then binary multivariate regression analysis. RESULT: Four hundred sixty nine patients had mitral valve surgery. The mean age was 66.5 ± 12.3 years and 47.5% were female. One hundred fifty patients (32%) had mitral valve surgery via the standard left atriotomy approach, while 226 (48.2%) and 93 (19.8%) cases were performed using the limited trans-septal and superior trans-septal approaches, respectively. Concomitant tricuspid valve surgery was carried out in 33 cases (7%). The overall rate of pacemaker implantation was 5.3%. On univariate analysis, only age (≥70 years old) and concomitant tricuspid valve surgery were significant predictors of postoperative pacemaker insertion, while on multivariate analysis only age (≥70 years old) remained as a predictor. The type of atrial incision and the origin of the SA node artery did not affect the rate of pacemaker implantation. CONCLUSION: The type of atrial approach to the mitral valve and the origin of the SA node artery did not influence the incidence of postoperative permanent pacemaker insertion.
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Procedimientos Quirúrgicos Cardíacos/métodos , Válvula Mitral/cirugía , Marcapaso Artificial , Nodo Sinoatrial/cirugía , Anciano , Femenino , Atrios Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Válvula Tricúspide/cirugíaRESUMEN
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether there was a difference in postoperative outcomes [namely permanent pacemaker (PPM) insertion, rhythm disturbance, reoperation for bleeding, hospital stay and in-hospital mortality] between trans-septal or superior (extended) trans-septal (STS) approaches in comparison with the conventional left atriotomy (LA) used in mitral valve surgery. Using the reported search strategy, 353 papers were found of which 11 represented the best evidence to answer the clinical question. The authors, journal, year and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Two papers compared all 3 atrial incisions with neither showing a difference in PPM implantation rate, whereas 2 papers compared just the trans-septal with the LA approach, again both finding no significant difference in PPM implantation. Seven studies compared the STS approach with the LA approach with regard to PPM implantation; 1 study showed that the STS approach was an independent risk factor for PPM implantation, PPM insertion was not necessary in 2 studies and there was no difference in PPM insertion in 4 studies. Postoperative junctional rhythm was studied in 5 papers that compared the STS approach with the LA approach; junctional rhythm was more prevalent in the STS approach in 2 studies, albeit transient, whereas 3 papers did not show a significant difference. Mortality, hospital stay and re-exploration for bleeding did not differ among the 3 groups.
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Arritmias Cardíacas/etiología , Atrios Cardíacos/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Válvula Mitral/cirugía , Marcapaso Artificial , Complicaciones Posoperatorias , Anciano , Arritmias Cardíacas/fisiopatología , Arritmias Cardíacas/terapia , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Válvula Mitral/diagnóstico por imagen , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
We report the case of a 44-year-old pregnant woman who was diagnosed with symptomatic severe mitral stenosis that did not respond to optimal medical therapy and balloon valvuloplasty. After a multidisciplinary team discussion on the timing and risks of interventions and postoperative optimization of peripartum anticoagulation, the patient underwent mechanical mitral valve replacement during the 2nd trimester of pregnancy. The outcome was excellent for the mother and the infant. This case emphasizes the importance of a multidisciplinary approach in managing unusual cases.
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Valvuloplastia con Balón/métodos , Estenosis de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Complicaciones Cardiovasculares del Embarazo/cirugía , Segundo Trimestre del Embarazo , Adulto , Femenino , Humanos , Recién Nacido , Embarazo , Resultado del EmbarazoRESUMEN
OBJECTIVES: Aortic valve replacement (AVR) using sutureless technology is a feasible alternative in surgical patients. Comparative evidence against established strategies such as conventional AVR and transcatheter AVR is lacking, limiting the assessment of safety and efficacy. METHODS: Medline search for available evidence was undertaken. The outcomes analysed were 30-day mortality, risk for stroke, myocardial infarction, renal failure, paravalvular leak and need for permanent pacemaker. Odds ratios were pooled using fixed- and random-effect models. A trial sequential analysis was undertaken to assess the statistical reliability of cumulative evidence. RESULTS: Twelve studies of moderate methodological quality were included. Sutureless AVR was associated with at least 30% reduction in 30-day mortality versus transcatheter AVR [odds ratio (95% confidence interval) 0.40 (0.25, 0.62); P < 0.001] primarily in the low- and intermediate-risk population and a similar reduction in the risk for paravalvular leak [0.13 (0.09, 0.17); P < 0.001]. There was no reduction in the risk for 30-day mortality versus conventional AVR [1.03 (0.56, 1.88); P = 0.93]. There was evidence in favour of conventional AVR with at least 50% risk reduction in pacemaker implantation against sutureless technology. There was absence of either benefit or harm vis-à-vis risk for renal injury or stroke due to lack of required information size. CONCLUSIONS: Current evidence suggests risk reduction in 30-day mortality with sutureless AVR versus transcatheter AVR but is inconclusive versus standard AVR in matched patients. Robust randomized evidence is lacking to lend support to any potential recommendation.
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Procedimientos Quirúrgicos sin Sutura , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/cirugía , Humanos , Complicaciones Posoperatorias/epidemiología , Factores de Riesgo , Procedimientos Quirúrgicos sin Sutura/efectos adversos , Procedimientos Quirúrgicos sin Sutura/mortalidad , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del TratamientoRESUMEN
BACKGROUND: Optimal management of diffuse malignant pleural mesothelioma (DMPM) remains unclear. We report our 30-year surgical experience with DMPM with emphasis on surgical procedure and post-operative adjuvant therapy. METHODS: During the period of the study, 217 patients with DMPM were referred for surgical opinion. Patients who only had pleural biopsies were excluded (n=78). Consecutive patients who underwent surgical treatment were included (n=139). Surgical options were extra-pleural pneumonectomy (EPP) for Butchart stage I disease in clinically fit patients (n=49) or pleurectomy/decortication in patients who were either not fit for EPP or had advanced disease (Butchart stage II and III) or both (n=90). Post-operative adjuvant therapy included either chemotherapy, radiotherapy, both or none. RESULTS: The median follow-up was 10.0 months. The longest survival (median 26.0 months, IQR: 11.14-40.9 months) occurred in the pleurectomy/decortication group who received both post-operative chemotherapy and radiotherapy (n=24) (p<0.001). EPP whether or not combined with adjuvant therapy provided no significant survival advantage in comparison to pleurectomy/decortication (overall median survival 10.3 months vs 10.1 months, p=0.09). On univariate analysis, pleurectomy/decortication combined with chemotherapy and radiotherapy was the strongest predictor of prolonged survival (Hazard Ratio=3.6). Multivariate analysis with the inclusion of histological type, surgical procedure and type of adjuvant therapy, EPP without adjuvant therapy was an independent risk-factor for decreased survival (Hazard Ratio=9.2). CONCLUSIONS: In this series, cytoreductive surgery combined with post-operative adjuvant therapy provided better survival despite either advanced disease or surgically less fit patients. Thus, pleurectomy/decortication may be the procedure of choice, given that neither surgical procedure (EPP or PD) is not curative.
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Mesotelioma/cirugía , Neoplasias Pleurales/cirugía , Neumonectomía/métodos , Anciano , Quimioterapia Adyuvante , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Mesotelioma/patología , Mesotelioma/terapia , Persona de Mediana Edad , Neoplasias Pleurales/patología , Neoplasias Pleurales/terapia , Radioterapia Adyuvante , Resultado del TratamientoRESUMEN
A case of recurrent severe mitral regurgitation following blunt chest trauma with deceleration injury in a 61-year-old woman is presented. The patient had undergone previous CABG and mitral annuloplasty with the use of a flexible (Duran) ring. At reoperation, partial dehiscence of the annuloplasty ring, which had become rigid, was found. This was successfully repaired.
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Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/etiología , Válvula Mitral/lesiones , Válvula Mitral/cirugía , Traumatismos Torácicos , Procedimientos Quirúrgicos Cardíacos , Femenino , Humanos , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/cirugía , Falla de Prótesis , Reoperación , Resultado del Tratamiento , Heridas no PenetrantesAsunto(s)
Cuerpos Extraños/complicaciones , Derrame Pericárdico/etiología , Pericardio , Proteínas/efectos adversos , Toracoscopía , Anciano , Puente de Arteria Coronaria/efectos adversos , Cuerpos Extraños/diagnóstico por imagen , Humanos , Masculino , Derrame Pericárdico/terapia , Técnicas de Ventana Pericárdica , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in patients with a small aortic root involves the occurrence of patient-prosthesis mismatch (PPM). Recent reports have shown that a reduced effective orifice area index (EOAI) may not be the sole factor responsible for this complication. The study aim was to analyze the activity of atrial natriuretic peptide (ANP)/renin-angiotensin-aldosterone (RAA) after implantation of stented or stentless valves. METHODS: Between 2001 and 2003, a total of 30 patients operated on at the authors' institution received either a stentless Freestyle bioprosthesis (group A; n = 15) or a stented Mosaic bioprosthesis (group B; n = 15). The demographics of both groups were similar, and all patients underwent echocardiography preoperatively, and at one, six and 12 months postoperatively. The activity of the RAA system and plasma ANP level were measured in all patients preoperatively and at one and six months postoperatively. RESULTS: At one month after AVR, statistically significant inter-group differences were noted in plasma renin activity (group A, 3.7 +/- 2.1 ng/ml/h; group B, 5.6 +/- 0.8 ng/ml/h; p <0.05; control value 0.3-5.3 ng/ml/h). For ANP, statistically significant differences were present at one month after surgery (group A, 36.3 +/- 5.1 pg/ml; group B, 62.9 +/- 9.2 pg/ml; p <0.005; control value 27.3-37.2 pg/ml). On echocardiography, the ejection fraction, aortic valve gradient, EOAI and left ventricular mass index (LVMI) were assessed. A statistically significant difference was identified for the LVMI at 12 months postoperatively (group A, 216 +/- 13 g/m2; group B, 240 +/- 18 g/m2; p <0.05). In terms of other parameters both groups were similar. CONCLUSION: The implantation of an aortic valve prosthesis affects the hemodynamics of the entire circulatory system, and thus the activity of natriuretic systems. Whilst stentless valves allowed much more rapid normalization of circulatory system hemodynamics (one month), no difference compared to preoperative was identified after six months. Natriuretic peptides appear to provide more sensitive (long-term) but less specific (short-term) assessment of circulatory system behavior than echocardiography.
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Estenosis de la Válvula Aórtica/sangre , Estenosis de la Válvula Aórtica/cirugía , Factor Natriurético Atrial/sangre , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Sistema Renina-Angiotensina , Stents , Anciano , Aldosterona/sangre , Angiotensinas/sangre , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Biomarcadores/sangre , Bioprótesis , Ecocardiografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Renina/sangre , Volumen Sistólico , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/cirugía , Isquemia Miocárdica/complicaciones , Adulto , Anciano , Ecocardiografía , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Estudios Prospectivos , Resultado del TratamientoAsunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Anciano , Anciano de 80 o más Años , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diseño de Prótesis , Stents , Resultado del TratamientoRESUMEN
The authors report the case of 70-year-old female who underwent urgent CABG for unstable angina. The post-operative course was complicated by Staphylococcal mediastinitis, which was treated with chest irrigation system and antibiotics. Because of extensive tissue destruction caused by the infection, the steel sternal wires were not placed. Interestingly, one year after surgery the sternal wound was completely healed and there were no paradoxical respiratory movements.
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Antiinfecciosos/uso terapéutico , Mediastinitis/tratamiento farmacológico , Mediastinitis/microbiología , Infecciones Estafilocócicas/tratamiento farmacológico , Infecciones Estafilocócicas/microbiología , Esternón/microbiología , Dehiscencia de la Herida Operatoria/tratamiento farmacológico , Dehiscencia de la Herida Operatoria/microbiología , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/microbiología , Anciano , Puente de Arteria Coronaria , Femenino , Humanos , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: Currently, Shelhigh Stentless Composite Valve (SSCV) is the only complete biological conduit available on the market for this purpose. SSCV has been used to avoid anticoagulation with the advantage of established haemodynamic benefits of stentless valves as well as for its surgeon-friendly surgical implantation. METHODS: Between August 1999 and January 2001, 11 patients (8 women, 3 men, mean age 71.5+/-9.3 years) underwent first time aortic root and ascending aorta replacement with SSCV in Leicester. Aortic regurgitation was found in seven patients and aortic stenosis was predominant in three. Mean preoperative NYHA functional class was 24+/-0.7 and mean Parsonnet score was 25.1+/-1.1. Mean preoperative aortic root diameter was 5.34+/-1.2 cm, left ventricular (LV) end-systolic diameter was 4.3+/-0.5, and end-diastolic diameter was 6.5+/-0.6 cm. Preoperative LV ejection fraction was less than 30% in 6 (55%) patients. One patient had additional aortic arch replacement and three patients had concomitant myocardial revascularisation. Seven patients received size 25 mm SSVC, and four patients received size 27 mm SSCV. All patients had Doppler echocardiographic studies before discharge from the hospital and current follow-up data are available for all patients. RESULTS: All patients survived the early postoperative period, however, one patient developed transient stroke. While no biological glue or teflon were used during surgery, no patient required re-operation for bleeding and there was no significant blood loss recorded postoperatively. Mean postoperative intensive care stay was 1.5+/-0.7 and hospital stay was 11.3+/-4.9 days. Postoperative mean gradients were 9.7+/-3.05 mmHg for 25 mm grafts, and 8.6+/-4.3 mmHg for 27 mm composite grafts. CONCLUSIONS: Early experience with the SSCV used for the replacement of ascending aorta is encouraging. Practical benefits include improved haemostatic suture line, established haemodynamic advantages of a stentless valve and surgeon-friendly implantation while avoiding long-term anticoagulation.
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Aorta/cirugía , Aneurisma de la Aorta/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis Vascular , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Torácica/cirugía , Válvula Aórtica/patología , Insuficiencia de la Válvula Aórtica/cirugía , Materiales Biocompatibles , Prótesis Vascular , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Conventional coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB) carries higher mortality and morbidity for patients undergoing surgery during acute coronary syndrome (ACS). The aim of this retrospective study was to evaluate potential benefits of avoiding CPB by instead performing off-pump CAB (OPCAB) during surgery on patients in ACS. METHODS: Among 624 patients who underwent OPCAB between January 1999 and June 2001, 143 underwent surgery during ACS (group 1). The ACS patients in group 1 were divided into 2 subgroups: 66 underwent surgery during acute myocardial infarction (AMI group) and 77 during unstable angina classified as class III or IV according to the Braumwald classification (unstable coronary artery disease [CAD] group). Group 2 (the elective CAD group) consisted of 481 patients who underwent isolated elective OPCAB during the same time period. RESULTS: Overall 30-day mortality was 4.9% (n = 7) for the ACS group and 0.83% (n = 4) for the elective CAD group (P < .0001). Differences between groups were found in use of inotropes, intraaortic balloon pump, and subsequent conversion of OPCAB to CPB (P < .0001, P < .01, and P < .03, respectively), as well as use of blood transfusion (P < .0003). Multivariate logistic regression analysis for 641 patients revealed ACS (P < .015), AMI (P < .019), renal failure (P < .017), and left ventricle aneurysm (P < .028) as independent risk factors for 30-day mortality in ACS reoperation (P = .02), whereas in AMI renal failure (P = .02) appeared to be an independent risk factor. CONCLUSIONS: OPCAB is a valuable treatment strategy in ACS patients; however, it carries significant mortality and morbidity. Careful preselection and timing of intervention are required in order for patients to fully benefit from the OPCAB strategy.
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Puente de Arteria Coronaria/métodos , Enfermedad Coronaria/cirugía , Infarto del Miocardio/cirugía , Análisis de Varianza , Puente Cardiopulmonar , Puente de Arteria Coronaria/mortalidad , Enfermedad Coronaria/mortalidad , Femenino , Humanos , Complicaciones Intraoperatorias , Masculino , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Oportunidad Relativa , Análisis de Regresión , Estudios Retrospectivos , SíndromeRESUMEN
BACKGROUND: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass carries significant risk for patients with severe left ventricular (LV) dysfunction. METHODS: Between 1997 and 2000, 240 patients underwent OPCAB. The patients were retrospectively divided into 2 groups with regard to LV function. Group 1 consisted of 90 patients with ejection fraction (EF) <35% and grou p 2 of 150 patients without severe LV impairment and EF >35%. Patients were compared for preoperative risk factors, perioperative mortality, and postoperative complications. RESULTS: Preoperative expected mortality according to EuroSCORE was higher in group 1, 5.95, compared with group 2, 2.66 (P =.0005). A few preoperative risk factors were more common in group 1: urgent operation (P =.00001), unstable angina (P =.0018), Canadian Cardiovascular Society class (P =.001), myocardial infarction (P =.0001), and peripheral arteriopathy (P =.0006). Mean number of grafts was 1.51 in group 1 and 1.55 in group 2 with the same internal thoracic artery utilization. Perioperative drainage, anesthesia and intubation time, transfusion rate, and use of inotropes were comparable. Actual, nonadjusted mortality was 2.5% in group 1 and 1.4% in group 2 (P = not significant). Overall rates of postoperative complications were comparable; only use of an intraoperative balloon pump was more frequent in group 1 (P =.006). Postoperative stay was shorter in group 1 (P equals). CONCLUSIONS: Off-pump CABG for patients with LV impairment is associated with surgical outcome similar to that among patients with normal LV function, in spite of the presence of unfavorable risk factors. Off-pump surgery with selective anterior (including right main) arterial revascularization can be indicated in the presence of poor LV function.
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Puente de Arteria Coronaria/métodos , Disfunción Ventricular Izquierda/cirugía , Anciano , Puente Cardiopulmonar , Puente de Arteria Coronaria/mortalidad , Femenino , Humanos , Masculino , Estudios Retrospectivos , Factores de Riesgo , Volumen Sistólico , Disfunción Ventricular Izquierda/mortalidadRESUMEN
BACKGROUND AND AIMS OF THE STUDY: Surgery for ischemic mitral regurgitation (IMR) is required in 4-5% of patients subjected to coronary artery surgery, and may be challenging. The study aim was to determine outcome following mitral valve repair and myocardial revascularization for moderate-to-severe IMR. METHODS: A total of 102 patients (mean age 68+/-7 years) underwent mitral valve repair for IMR between 1998 and 2001 at the authors' unit. Among patients, 28 had acute and 74 chronic mitral regurgitation (MR). Valve repair was achieved with an annuloplasty ring in all 102 patients, while 99 underwent concomitant myocardial revascularization. Preoperatively, 69 patients had MR grade III-IV, 62 had CCS angina class III-IV, 59 were in NYHA class II-IV, 81 had impaired left ventricular function, and 10 were in cardiogenic shock. Follow up was 100% complete (mean 14+/-7 months; range: 0-38 months). RESULTS: Overall operative mortality was 8.8% (n = 9) (17.8% for acute IMR, 5.4% for chronic, p = 0.048). On multiple logistic regression analysis, cardiogenic shock (p = 0.028) was the only significant risk factor for operative death. There were 11 late deaths. Kaplan-Meier survival at one and three years was 82+/-4% and 79+/-4%, respectively. On Cox proportional hazards regression model, preoperative left ventricular end-systolic diameter (LVESD) >4.5 cm (p = 0.01) and NYHA class III-IV (p = 0.02) were independent adverse predictors of survival. Three patients required reoperation. Kaplan-Meier three-year freedom from reoperation was 97+/-2%. CONCLUSION: Surgery for IMR carries a considerable, but acceptable, operative risk and provides satisfactory freedom from reoperation and mid-term survival. Cardiogenic shock before surgery is the major determinant of an unfavorable in-hospital outcome. LVESD >4.5 cm and poor preoperative NYHA status limit the probability of late survival. The study results support early surgical intervention for IMR, before ventricular dilatation occurs.
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Puente de Arteria Coronaria , Implantación de Prótesis de Válvulas Cardíacas , Isquemia/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Anciano , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antiarrítmicos/uso terapéutico , Anticoagulantes/uso terapéutico , Causas de Muerte , Puente de Arteria Coronaria/mortalidad , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Hipolipemiantes/uso terapéutico , Contrapulsador Intraaórtico/mortalidad , Isquemia/tratamiento farmacológico , Isquemia/epidemiología , Tiempo de Internación , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/tratamiento farmacológico , Insuficiencia de la Válvula Mitral/epidemiología , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Valor Predictivo de las Pruebas , Reoperación , Factores de Riesgo , Índice de Severidad de la Enfermedad , Volumen Sistólico/fisiología , Factores de Tiempo , Resultado del Tratamiento , Reino Unido/epidemiologíaRESUMEN
BACKGROUND: Whether to perform a stentless aortic valve replacement (AVR) is not well established. Our aim was to determine the outcome after AVR with stentless xenograft valves. METHODS: Between 1996 and 2001, a total of 404 patients (mean age 70.4 years) underwent a stentless AVR by one surgeon in our unit. Concomitant procedures were performed in 132 patients (33%). Twenty patients (6.4%) had undergone previous AVR. Eleven types of stentless xenograft valves were implanted: Medtronic Freestyle in 221 patients (55%), Shelhigh in 55 (14%), Shelhigh composite conduit in 33 (8%), Sorin in 26 (6%), Cryolife O'Brien in 25 (6%), Aortech-Elan in 17 (4%), Edwards Prima in 14 (4%), Toronto SPV in 7 (2%), and other valves in 6 (1%). A subcoronary implantation technique was used in 302 cases (76%), complete root replacement in 62 (15%), and a modified Bentall-De Bono procedure in 33 (8%). Mean follow-up was 19.4 months (range, 1.2 to 60.6 months). RESULTS: Overall hospital mortality was 4.2%. This was 2.4% for isolated AVR, 3.6% for AVR and coronary artery bypass grafting, 5.5% for replacement of two or more valves, and 12% for the modified Bentall procedure. On multiple logistic regression redo cardiac operation (p = 0.0006), cardiogenic shock (p = 0.001), left ventricular ejection fraction less than 0.30 (p = 0.01), modified Bentall procedure (p = 0.03), and endocarditis (p = 0.04) were predictors of in-hospital death. Five-year freedom from thromboembolism, hemorrhage, prosthetic endocarditis, structural valve deterioration, and reoperation was 97%, 99%, 99%, 98%, and 96%, respectively. Kaplan-Meier survival at 5 years was 88%. On Cox regression, cardiogenic shock (p = 0.001) and older age (p = 0.03) were adverse predictors of survival. At echocardiographic examination within 6 months from the operation, mean aortic valve gradients were 15 +/- 6 mm Hg, 12.8 +/- 3 mm Hg, 10.8 +/- 4 mm Hg, 9.3 +/- 3 mm Hg, 9.1 +/- 4 mm Hg, and 8.2 +/- 3 mm Hg for valve sizes of 19, 21, 23, 25, 27, and 29 mm, respectively. CONCLUSIONS: The availability of several stentless valve designs facilitates the surgical treatment of diverse aortic valve or root diseases with encouraging early and mid-term results. Patients requiring concomitant procedures may also benefit from the excellent hemodynamic characteristics of a stentless valve. We consider stentless AVR the treatment of choice for patients older than 60 years and those having small aortic roots.