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OBJECTIVE: The main goal of this study was to assess the potential clinical impact of an outpatient administration of available antivirals including SOT, N/R, and MOL to COVID-19 patients at high risk for disease progression. METHODS: We conducted a retrospective analysis on 2606 outpatient individuals with mild to moderate COVID-19 at risk for disease progression, hospitalization, or death. After receiving either SOT (420/2606), MOL (1788/2606), or N/R (398/2606), patients were followed-up with regarding primary (hospitalization rate) and secondary (treatment and side effects) outcomes by phone. RESULT: A total of 2606 patients were treated at the outpatient clinic (SOT: 420; N/R: 398; MOL: 1788). 3.2% of the SOT patients (1 ICU admission), 0.8% of the MOL patients (2 ICU admissions), and none of the N/R patients were hospitalized. 14.3% of the N/R patients reported strong to severe side effects, exceeding SOT (2.6%) and MOL (5%) patients. A reduction in COVID symptoms after the treatment was experienced by 43% of patients in both the SOT and MOL groups and by 67% of patients in the N/R group, respectively. Women had a higher chance of symptom improvement with MOL (OR 1.2, 95%CI 1.0-1.5). CONCLUSION: All antiviral treatment options effectively prevented hospitalization in high-risk COVID-19 patients and were well tolerated. Side effects were pronounced in patients with N/R.
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COVID-19 , Efectos Colaterales y Reacciones Adversas Relacionados con Medicamentos , Humanos , Femenino , Pacientes Ambulatorios , Estudios Retrospectivos , Antivirales/efectos adversos , Progresión de la Enfermedad , Lactamas , LeucinaRESUMEN
BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become the standard therapy for high-risk and non-operable patients with severe aortic stenosis. However, the procedure involves several adverse effects, such as rhythm and conduction disturbances. Patients with postprocedural left bundle branch block may have an increased mortality risk, whereas patients with preprocedural right bundle branch block display a higher rate of postinterventional bradyarrhythmias. OBJECTIVE: The purpose of this study was to investigate the occurrence of high-degree atrioventricular block (AVB) in patients with preexisting bundle branch block (BBB) or BBB occurring during TAVI. METHODS: In this prospective single-center study, 50 consecutive patients undergoing TAVI with the Medtronic CoreValve Revalving System were included. Of these patients, 17 with preexisting BBB or BBB occurring during TAVI received a primary prophylactic permanent DDD pacemaker, programmed to the SafeR-mode and featuring dual-channel event counters as well as stored intracardiac electrograms. Pacemaker readouts and intracardiac electrograms were analyzed for the occurrence of high-degree AVB. RESULTS: Ten of 17 patients (58.8%) with preexisting BBB or BBB occurring during TAVI developed episodes of high-degree AVB that were immediately terminated due to switch into DDD backup pacing. In 5 of the cases (29.4%), the first documented episode of high-degree AVB occurred after hospital discharge. Mean follow-up period was 578.1 ± 294.9 days. CONCLUSION: Development of high-degree AVB is a common complication in patients with preexisting BBB or BBB occurring during TAVI. Accordingly, intensified monitoring might be reasonable, especially in patients treated with the self-expandable Medtronic CoreValve Revalving System.
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Estenosis de la Válvula Aórtica/cirugía , Bloqueo Atrioventricular/epidemiología , Bloqueo de Rama/epidemiología , Complicaciones Intraoperatorias/epidemiología , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Distribución por Edad , Anciano , Anciano de 80 o más Años , Animales , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/mortalidad , Bloqueo Atrioventricular/diagnóstico , Bloqueo Atrioventricular/terapia , Bloqueo de Rama/diagnóstico , Bloqueo de Rama/terapia , Estudios de Cohortes , Electrocardiografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Complicaciones Intraoperatorias/diagnóstico , Masculino , Marcapaso Artificial , Cobertura de Afecciones Preexistentes , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Distribución por Sexo , Estadísticas no Paramétricas , Análisis de Supervivencia , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Resultado del Tratamiento , UltrasonografíaRESUMEN
A 57-year-old man was admitted to our department with recent onset of chest pain. Computed tomography (CT) scans revealed an acute aortic syndrome manifested by a penetrating atherosclerotic ulcer and contained rupture at the level of origin of an aberrant right subclavian artery. A combined vascular and endovascular approach was selected. The entire arch was rerouted, a reversed bifurcated Dacron prosthesis was placed, and a bypass was created between the right common carotid artery and the lusorian artery, followed by thoracic endovascular aortic repair. The clinical course was uneventful. The CT scan obtained after the procedure revealed regular supra-aortic perfusion and complete exclusion of the complex lesion.
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Aneurisma/cirugía , Enfermedades de la Aorta/cirugía , Rotura de la Aorta/cirugía , Aterosclerosis/cirugía , Implantación de Prótesis Vascular , Anomalías Cardiovasculares/cirugía , Trastornos de Deglución/cirugía , Procedimientos Endovasculares , Arteria Subclavia/anomalías , Úlcera/cirugía , Aneurisma/complicaciones , Aneurisma/diagnóstico , Aneurisma/fisiopatología , Enfermedades de la Aorta/complicaciones , Enfermedades de la Aorta/diagnóstico , Enfermedades de la Aorta/fisiopatología , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/etiología , Rotura de la Aorta/fisiopatología , Aortografía/métodos , Aterosclerosis/complicaciones , Aterosclerosis/diagnóstico , Aterosclerosis/fisiopatología , Anomalías Cardiovasculares/complicaciones , Anomalías Cardiovasculares/diagnóstico , Anomalías Cardiovasculares/fisiopatología , Arteria Carótida Común/cirugía , Dolor en el Pecho/etiología , Trastornos de Deglución/complicaciones , Trastornos de Deglución/diagnóstico , Trastornos de Deglución/fisiopatología , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional , Arteria Subclavia/fisiopatología , Arteria Subclavia/cirugía , Síndrome , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Úlcera/complicaciones , Úlcera/diagnóstico , Úlcera/fisiopatologíaRESUMEN
OBJECTIVES: Stent graft-induced retrograde type A dissection is a life-threatening complication after endovascular treatment of acute aortic type B dissections. METHODS: From August 2005 to February 2011, retrograde aortic dissection occurred in 4 of 29 patients (13.8%) undergoing thoracic endovascular aortic repair (TEVAR) for acute complicated aortic type B dissection. Three patients underwent emergent surgical conversion immediately after TEVAR. The operative strategy was a combined surgical and endovascular approach (frozen elephant trunk technique) using a specially designed hybrid prosthesis (Jotec E-vita open). All operations were performed under moderate hypothermia (25-28°C) and selective bilateral antegrade cerebral perfusion. The mean duration of circulatory arrest was 56 ± 7 min. Operative data and the outcome of surgery were analysed retrospectively. Data were analysed retrospectively in the limited number of patients. RESULTS: All patients survived the surgical procedure. No stroke, paraplegia, renal failure or other major complications occurred. Postoperative CT scans revealed perigraft thrombus formation and stable aortic dimensions in all patients after 6 months. In one patient, the retrograde dissection remained primarily undetected and untreated. The patient died suddenly, with no clinical signs, within 7 days after stent graft implantation. Autopsy revealed cardiac tamponade due to retrograde type A aortic dissection. CONCLUSIONS: Retrograde aortic dissection type A is a serious complication of thoracic endovascular repair of acute aortic type B dissection. Despite the small number of patients investigated in this study, the frozen elephant trunk technique appears to be a feasible bail-out strategy for the treatment of these acute aortic events.
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Angioplastia/efectos adversos , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Muerte Súbita Cardíaca/etiología , Mortalidad Hospitalaria/tendencias , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Angioplastia/métodos , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Aortografía/métodos , Prótesis Vascular , Implantación de Prótesis Vascular/métodos , Causas de Muerte , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Reoperación/métodos , Reoperación/mortalidad , Estudios Retrospectivos , Medición de Riesgo , Stents/efectos adversos , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Cardiovascular disease, preceded by vascular endothelial dysfunction, is a prominent cause of death in dogs. L-carnitine and taurine, well known for their antioxidative capacity, beneficially affect cardiovascular disease as well as certain dog cardiomyopathies. It is well established that vascular endothelial dysfunction precedes cardiovascular disease and that "vasoprotective factors" (NO and antioxidants) prevent apoptosis, whereas "risk factors" such as oxidized LDL, hyperglycemia, and free fatty acids trigger it in cultured human vascular endothelial cells. Whereas human vascular cell in vitro models are widely established and used for the characterisation of potential vasoprotective substances, such models are not available for canine endothelial cells. In the present study we therefore developed an in vitro model, which allows the testing of the effects of different substances on proliferation and apoptosis in canine aortic endothelial cells. This model was used to test L-carnitine, taurine, pomegranate extract, and Soy Isoflavones in comparison to reference substances (glutathione and pioglitazone) previously shown to modulate human endothelial cell function. L-carnitine and taurine neither exhibited antiproliferative nor antiapoptotic activities in the context of this study. However extracts from pomegranate and soy isoflavones dramatically reduced proliferation and apoptosis in a dose dependent fashion, being in line with a vasoprotective activity in dogs.
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We present a case of a 59-year old male with a Stanford type A aortic dissection (DeBakey type I) extending from the sinotubular junction to the abdominal aorta. The patient was treated by a combined surgical and endovascular repair (frozen elephant trunk technique) using a specially designed hybrid prosthesis (E-vita open, Jotec GmbH). This onstage hybrid procedure enables simultaneous treatment of the ascending aorta, the aortic arch and the descending aorta.
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OBJECTIVE: Near-infrared spectroscopy (NIRS) complements online monitoring of cerebral oxygenation during aortic arch surgery. Its addition targets at an increase of safety of a complex procedure employing bilateral antegrade cerebral perfusion (BACP) and circulatory arrest under tepid blood temperatures. We report the outcome of NIRS-guided aortic arch surgery using BACP with moderate hypothermic circulatory arrest (MHCA). METHODS: Between December 2006 and December 2008, NIRS was used in 13 patients (mean age: 67.5 ± 11.3 years) undergoing aortic arch repair using BACP combined with MHCA. The diagnosis was atherosclerotic thoracic aneurysms in eight and acute aortic dissection in five patients. Seven patients had a hemi-arch replacement, six underwent frozen stent-graft arch replacement and four patients had concomitant procedures such as coronary artery bypass grafting (CABG) or aortic valve surgery. Our regimen of employing an algorithm for adaptation of perfusion modalities included the threshold of the drop in regional cerebral oxygen saturation <55% and/or a drop in the total oxygen index (TOI) of 15-20% assessed by the means of NIRS. RESULTS: The mean MHCA was 35 ± 16min and lowest bladder temperature was 26 ± 1.2°C. The mean TOI pre-MHCA was 66 ± 6.5%. Twelve out of 13 patients underwent bilateral perfusion because of unilateral drops below the threshold level of TOI (mean: 44±7.9%). In three patients, an organic psychosyndrome was observed. No patient developed permanent neurological dysfunction. CONCLUSION: NIRS-guided BACP during MHCA allows a safe approach to complex aortic arch surgery. The drop of brain oxygenation values in the contralateral hemisphere during unilateral ACP strongly suggests the routine use of BACP, when circulatory arrest under tepid temperatures is used.
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Aorta Torácica/cirugía , Circulación Cerebrovascular , Monitoreo Intraoperatorio/métodos , Anciano , Disección Aórtica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/métodos , Isquemia Encefálica/prevención & control , Paro Circulatorio Inducido por Hipotermia Profunda/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Perfusión/métodos , Espectroscopía Infrarroja Corta/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: The purpose of this study was to evaluate the alterations of the aorta by using a new combined surgical and endovascular technique for the treatment of aortic type A dissections. The diameter of the descending aorta, the implanted stent graft, and the false lumen were evaluated. METHODS: Between August 2005 and February 2009, 14 patients (aged 49 +/- 13 years; 11 men, 3 women) with type A dissection in the aorta were operated on the thoracic aorta by the frozen elephant trunk technique. The size dynamics of the false lumen were analyzed by deducting the diameter of the stent graft obtained on computed tomography from the maximum dimension of the aorta. RESULTS: The technical success rate was 100%. All patients survived during the follow-up period. The mean follow-up period was 21.4 months. No redisection or aortic rupture occurred during the follow-up period. Postoperative computed tomography scans showed complete thrombus formation of the false lumen in the perigraft space within the entire zone of the stented segment of the hybrid prosthesis during the first 2 weeks after surgery in 12 patients (86%), whereas all patients showed complete obliteration of the false lumen at the 3-month control. The follow-up computed tomography scan obtained after 12 months revealed shrinkage of the false lumen in 9 patients (64%). CONCLUSIONS: The combined surgical and endovascular technique described in this report proved effective for the treatment of extended aortic lesions. The perigraft space thrombosed completely and had shrunken after successful placement of the stent graft.
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Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Stents , Disección Aórtica/diagnóstico por imagen , Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
Atrial fibrillation (AF) following cardiac surgery is an important factor contributing to postoperative morbidity. Transvenous, intracardial cardioversion (TIC) has been shown to be effective in the treatment of chronic AF, but is an invasive and cost-intensive procedure. However, TIC would definitely be a beneficial approach if recurrence of AF following TIC is low and pharmacological treatment could be avoided. Thus, we hypothesised that TIC would be superior to conventional treatment with amiodarone with respect to the conversion rate and recurrence of AF. We compared TIC and conventional amiodarone therapy in a prospective, randomised and controlled trial in patients who developed AF following cardiac surgery. Twenty-three patients developed AF out of a total of 76 patients who gave written informed consent. Eighteen of these AF patients could be randomised into two equally sized groups to receive either an ALERT pulmonary artery catheter and TIC, or a standard pulmonary artery catheter and treatment with amiodarone. Haemodynamic parameters were registered before intervention to exclude pulmonary hypertension or fluid overload. Rates of cardioversion were compared by a Likelyhood ratio test. Out of the nine ALERT patients, AF in five cases converted to sinus rhythm (SR) with a median of two shocks (6 J). After 24 hours however, only two patients remained in sinus rhythm. On the other hand, six of the nine patients treated with amiodarone were still in SR after 24 hours. Whereas no difference was detectable in the conversion rate, persistence of SR following TIC was low. Thus, TIC without antiarrhythmic treatment is not recommendable for the treatment of postoperative AF.
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Fibrilación Atrial/etiología , Fibrilación Atrial/terapia , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Cardioversión Eléctrica/métodos , Anciano , Anciano de 80 o más Años , Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Cateterismo de Swan-Ganz , Cardioversión Eléctrica/estadística & datos numéricos , Femenino , Humanos , Funciones de Verosimilitud , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Resultado del TratamientoRESUMEN
The management of open chest with the vacuum assisted closure (VAC) system was evaluated in terms of impact on cardiac hemodynamics, respiratory parameters, complications, incidence of wound infection, overall handling and outcome in 22 patients during 2005 and 2008 after cardiac surgery. The decision to leave the sternum open was made electively in all patients at the time of primary operation or reexploration. In four patients the VAC was implanted during the primary operation. In the remainder the VAC was implanted after a mean of five days after the primary operation. The overall mortality rate was 45% (10/22). None of the patients developed a sternal wound infection, nor were there any VAC related complications. Management of open chest with the VAC system can be considered as an alternative to sterile draping. The VAC has no negative impact on cardiac hemodynamics as well as respiratory mechanics. The feared complication of right ventricular rupture and massive bleeding can be effectively prevented. Through the stabilizing of the thoracic cage, the patient can be easily moved and mobilized for nursing reasons and pneumonia prevention. Furthermore, the VAC effectively prevents the contamination of the wound and the mediastinum with potential subsequent infection.
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Procedimientos Quirúrgicos Cardíacos , Terapia de Presión Negativa para Heridas , Esternón/cirugía , Cicatrización de Heridas , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Niño , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Terapia de Presión Negativa para Heridas/efectos adversos , Terapia de Presión Negativa para Heridas/mortalidad , Proyectos Piloto , Mecánica Respiratoria , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & control , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: We evaluated the application of a new combined surgical and endovascular technique for the treatment of thoracic aortic aneurysms and dissections. The technique is used to treat extensive aortic disease by a single-stage procedure. Surgical outcomes and follow-up data are summarized and analyzed. METHODS: Between August 2005 and December 2006, 7 patients (2 women), aged 62 +/- 11 years, with aortic pathologies (5 dissections, 2 aneurysms) underwent replacement of the ascending aorta and the aortic arch and simultaneous stent graft implantation into the descending aorta. The stent graft used was the E-vita open endoluminal stent graft (Jotec Inc, Hechingen, Germany), which was implanted using the technique of circulatory arrest and moderate hypothermia with selective antegrade cerebral perfusion. The stent graft was deployed under visual guidance through the open aortic arch into the true lumen. RESULTS: Intraoperative antegrade stenting of the descending aorta combined with the distal ascending aorta and aortic arch repair was performed successfully in all patients. The survival rate was 100%. One patient had a postoperative neurologic deficit but recovered completely. Four patients had fully thrombosed perigraft spaces within 11 days, whereas 1 patient showed complete obliteration of the false lumen at the 3-month control. CONCLUSIONS: The combined surgical and endovascular technique described in this report proved feasible for the treatment of extended aortic lesions. It serves as an additional option for aortic repair in a single-stage method and is associated with no elevated risk for the patient.
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Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular/métodos , Stents , Adulto , Anciano , Disección Aórtica/mortalidad , Aneurisma de la Aorta Torácica/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Tasa de SupervivenciaRESUMEN
BACKGROUND: Descending necrotizing mediastinitis (DNM) is a life-threatening emergency after oropharyngeal infection. The diagnosis must be established rapidly. DNM is associated with septic shock and respiratory insufficiency. Because mortality rates may be as high as 60%, aggressive surgical treatment is indicated. METHODS: Between December 2001 and December 2005, 5 patients (3 men, 2 women) with DNM, average age of 69 years (range, 24 to 72 years), were treated at our department. Surgical treatment consisted of one or more cervical drainages and drainage of the mediastinum through sternotomy after mediastinitis had been confirmed by computed tomography. The latter investigation also revealed mediastinal abscess and empyema. After radical debridement, a vacuum-assisted closure device was inserted. RESULTS: The outcome was favorable in 4 patients. A 72-year-old woman died of prolonged septic shock and subsequent multiple organ failure. Tracheotomy was performed in all patients to create an airway. The duration of the intensive care unit stay was 51 +/- 24.2 days. CONCLUSIONS: Rapid and extensive cervical and mediastinal debridement is mandatory in patients with DNM. A vacuum-assisted closure device is useful because it promotes tissue approximation and stimulates the ingrowth of granulation tissue.
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Drenaje , Mediastinitis/patología , Mediastinitis/cirugía , Esternón/cirugía , Dispositivos de Fijación Quirúrgicos , Vacio , Absceso/diagnóstico por imagen , Absceso/microbiología , Absceso/cirugía , Adulto , Anciano , Infecciones Bacterianas , Desbridamiento , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación , Masculino , Mediastinitis/diagnóstico por imagen , Mediastinitis/microbiología , Persona de Mediana Edad , Necrosis , Orofaringe/microbiología , Tomografía Computarizada por Rayos X , TraqueotomíaRESUMEN
A group of international experts met in May 2006 to develop clinical guidelines on the practical application of vacuum assisted closure (V.A.C.)+ therapy in deep sternal wound infections. Group discussion and an anonymous interactive voting system were used to develop content. The recommendations are based on current evidence or, where this was not available, the majority consensus of the international group. The principles of treatment for deep sternal wound infections include early recognition and treatment of infection. V.A.C. therapy should be instigated early, following thorough wound irrigation and surgical debridement. V.A.C. therapy in deep sternal wound infections requires specialist surgical supervision and should only be undertaken by clinicians with adequate experience and training in the use of the technique.
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Esternón/cirugía , Infección de la Herida Quirúrgica/terapia , Cicatrización de Heridas , Humanos , Cuidados Posoperatorios , Resultado del Tratamiento , Vacio , Cicatrización de Heridas/fisiologíaRESUMEN
OBJECTIVE: This study investigated the predictive value of a decrease in monocyte HLA-DR expression as an early marker for postoperative SIRS and septic complications. We hypothesized that decreased HLA-DR levels in the first 24 h after cardiac surgery is not related to postoperative SIRS/sepsis. We also compared HLA-DR levels of patients with postoperative complications to those with an uncomplicated course. DESIGN AND SETTING: Prospective observational study in a tertiary care postoperative intensive care unit. PATIENTS: Eighty five consecutive patients undergoing cardiac surgery. MEASUREMENTS AND RESULTS: Expression of HLA-DR on monocytes was analyzed by flow cytometry using a new quantitative and well standardized technique. Arterial blood samples were collected before induction of anesthesia, immediately after admission to the ICU, and on the first postoperative day. Postoperative HLA-DR expression was significantly decreased in all patients. There were no significant differences in HLA-DR expression during the first 24 h after surgery in patients with uncomplicated course and those developing SIRS or septic complications. CONCLUSIONS: In patients undergoing cardiac surgery the monitoring of pre- and immediate postoperative HLA-DR levels during the first 24 h does not help to predict increased risk for postoperative SIRS/sepsis or infectious complications.