RESUMEN
In the last decades, minimally invasive procedures have been developed in the therapy of aortic valve disorders. Recently, a novel concept of minimally invasive coronary revascularization in multivessel disease via left anterior mini-thoracotomy demonstrated promising results. Full median sternotomy, as a very invasive procedure, is the standard approach in concomitant surgical aortic valve replacement (sAVR) and coronary bypass grafting (CABG). The aim of our study was to show that the combination of minimal invasive aortic valve replacement via upper mini-sternotomy and coronary artery bypass grafting via left anterior mini-thoracotomy is feasible to avoid full median sternotomy. From 07/2022 to 09/2022, concomitant sAVR via upper partial sternotomy and CABG via left anterior mini-thoractomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in six consecutive patients (6 males; 69.8 ± 7.4 [60-79] years). All patients had severe aortic stenosis (MPG 45.5 ± 17.3 mmHg) and a significant coronary artery disease (three-vessel: 33%, two-vessel: 33%, one-vessel: 33%) with indication to cardiac surgery. Mean EuroScore2 was 3.2. All patients underwent successful less invasive concomitant biological sAVR and CABG. 67% of patients received a 25 mm, 33% received a 23 mm biological aortic valve replacement (Edwards Lifesciences Perimount). A total of 11 distal anastomoses (1.8 ± 1.0 [1-3] per patient) were performed by using left internal artery mammary (50%), radial artery (17%) and saphenous venous graft (67%) for grafting the left anterior descending (83%), circumflex (67%) and right (33%) coronary artery. Hospital mortality was 0%, stroke rate was 0%, myocardial infarction was 0% and repeat revascularization rate was 0%, ICU stay was 1 day in 83% of all patients and 50% left hospital within 8 days after surgery. Less invasive concomitant surgical aortic valve replacement and coronary artery bypass grafting using upper mini-sternotomy and left anterior mini-thoracotomy is feasible without compromises in surgical principles and complete coronary revascularization while maintaining thoracic stability by avoiding full median sternotomy.
Asunto(s)
Enfermedad de la Arteria Coronaria , Esternotomía , Masculino , Humanos , Esternotomía/efectos adversos , Esternotomía/métodos , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Resultado del Tratamiento , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugíaRESUMEN
BACKGROUND: Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported. METHODS: From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%). RESULTS: Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%. CONCLUSION: This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.
Asunto(s)
Enfermedad de la Arteria Coronaria , Toracotomía , Masculino , Humanos , Anciano de 80 o más Años , Toracotomía/métodos , Resultado del Tratamiento , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , EsternotomíaRESUMEN
BACKGROUND: Calcineurin-inhibitor-(CNI)-induced renal failure is one major cause of morbidity in cardiac transplantation (HTx). In this prospective, randomized, multicenter trial, the impact of immunosuppressive conversion toward CNI-free (mycophenolate mofetil [MMF] and sirolimus) or a CNI-reduced immunosuppressive regimen on renal function, efficacy, and safety was evaluated. METHODS: Since 2004, 63 HTx-patients (0.5-18.4 years after HTx) with CNI-based immunosuppression and reduced creatinine clearance less than 60 mL/min (39+/-15 mL/min) were included in this trial. Patients in the CNI-free-Group (group 1) were converted to sirolimus that was started with 2 mg/day until target trough levels (8-14 ng/mL) were achieved. Subsequently, CNIs were withdrawn. In CNI-reduction-Group (group 2), CNI target trough levels were reduced by 40%. In both groups MMF was continued and trough level adjusted (1.5-4 microg/mL). RESULTS: Patients demographics and survival (mean follow-up time: 16.7+/-9 months) was equal (100%). Renal function improved significantly after complete CNI withdrawal while remaining unchanged with CNI-reduction (Creatinine clearance after 12 months: 53+/-24 mg/dL [group 1] vs. 38+/-20 mg/dL [group 2], P=0.01). End-stage renal failure (hemodialysis) was avoided by CNI-withdrawal and occurred only after CNI reduction (n=6; P=0.01). Acute rejection episodes were more common in group 2 (4 vs. 2). Graft function remained stable (echocardiography) within both groups. Adverse events were more common in group 1 (65%) than in group 2 (n=40%) and were responsible for discontinuation in 4 and 0 cases, respectively. CONCLUSIONS: Conversion toward a CNI-free immunosuppression (Mycophenolate, sirolimus) is superior to CNI-reduced immunosuppression in improving renal failure in late HTx-recipients. However, this benefit is relativized by the increased incidence and severity of sirolimus/MMF-associated side effects.
Asunto(s)
Trasplante de Corazón/inmunología , Inmunosupresores/uso terapéutico , Fallo Renal Crónico/inmunología , Riñón/inmunología , Ácido Micofenólico/análogos & derivados , Sirolimus/uso terapéutico , Adulto , Anciano , Inhibidores de la Calcineurina , Femenino , Humanos , Riñón/efectos de los fármacos , Fallo Renal Crónico/complicaciones , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Ácido Micofenólico/uso terapéutico , Selección de PacienteRESUMEN
Migrating cells like coronary smooth muscle cells in restenosis change their cell shape and form cellular protrusions called filopodia. A prerequisite for filopodia formation is the rearrangement of the actin cytoskeleton. An essential role of the 78-kDa protein Moesin is described for Rho- and Rac-dependent assembly of actin filaments. In vivo Moesin is not observed in mature smooth muscle cells. The objective of this study was to demonstrate that Moesin is upregulated in migrating coronary smooth muscle cells during restenosis development. In vivo expression of Moesin was upregulated in neointimal coronary smooth muscle cells of dilated porcine coronary arteries compared to the undilated left circumflex coronary artery of the same swine. Concordant to these results Moesin expression was upregulated in migrating and invading human arterial smooth muscle cells in vitro analyzed by FACS, Western blotting and RT-PCR. In addition, the invasive potential of Moesin-positive Mel Im cells transfected with Moesin sense DNA increased by 28% as compared to mock-transfected control, whereas antisense transfected cells had a decreased invasive potential of 32%. Transfection of Moesin-negative HepG2 with Moesin sense cDNA increased the invasive potential by 43%. Finally, transfection of human arterial smooth muscle cells with Moesin sense cDNA caused an increased invasive potential of 30%. Transfection of haSMCs with antisense cDNA decreased the invasive potential by 37% in comparison to mock-transfected control. These results demonstrate for the first time an upregulation of Moesin expression in coronary smooth muscle cells of the neointima after arterial injury. The increased migrative and invasive potential of cells transfected with Moesin confirmed the functional role of Moesin in cell migration. This indicates an important role of Moesin during restenosis development.
Asunto(s)
Angioplastia Coronaria con Balón , Estenosis Coronaria/metabolismo , Proteínas de Microfilamentos/análisis , Túnica Íntima/metabolismo , Actinas/análisis , Animales , Biomarcadores/análisis , Movimiento Celular , Células Cultivadas , Estenosis Coronaria/patología , Vasos Coronarios , Citometría de Flujo , Proteínas de Microfilamentos/genética , Proteínas de Microfilamentos/metabolismo , Modelos Animales , Músculo Liso Vascular/patología , Porcinos , TransfecciónRESUMEN
Introducción y objetivos. Identificar los factores que afectan precoz y tardíamente en el resultado de esta cirugía combinada, considerada de alto riesgo. Pacientes y método. Entre 1984 y 1997 fueron operados 264 pacientes (edad media 63 ñ 7,3 años) con cirugía valvular mitral (199 pacientes, 75 por ciento remplazo valvular, 25 por ciento reconstrucción) en combinación con revascularización miocárdica (media 2,4 ñ 1,3 bypass). El seguimiento medio fue de 69 ñ 42 meses, con un cumplimiento del 98,3 por ciento. Resultados. La mortalidad hospitalaria fue del 10,6 por ciento (28/264). La cirugía de urgencia en pacientes con etiología mitral isquémica, la reducción moderada a severa de la función ventricular izquierda y la edad avanzada (> 60 años) se asociaron de manera independiente con la mortalidad hospitalaria (p < 0,05). La etiologia isquémica de la patología mitral (cirugía programada y de urgencia), el grado de severidad de la insuficiencia mitral y la clase IV de la NYHA se asociaron con la mortalidad hospitalaria solamente en el análisis estadístico univariante. La supervivencia actuarial fue del 86, 69 y 48 por ciento a 1, 5, y 10 años, respectivamente. La clase preoperatoria de la NYHA fue la única variable independiente relacionada con la supervivencia total. El 85 por ciento de los supervivientes se encontraban postoperatoriamente en clases I o II de la NYHA. Conclusiones. La cirugía mitral combinada con revascularización miocárdica está asociada con una alta mortalidad hospitalaria. Factores de riesgo independientes de la mortalidad hospitalaria son la cirugía de urgencia en pacientes con etiología mitral isquémica, la función ventricular izquierda reducida y la edad vanzada. La mortalidad total se encuentra influida, de manera independiente, por la clase funcional IV preoperatoria de la NYHA (AU)