RESUMEN
PRINCIPAUX CONSTATS: STRUCTURE ORGANISATIONNELLE: Le nombre d'interventions TAVI réalisées au Québec a augmenté de 294 en 2013- 2014 à 526 en 2017-2018, pour atteindre 30 % de tous les remplacements valvulaires aortiques (TAVI et RVA ± PAC); Le taux d'interventions TAVI, de 49 par million d'habitants en 2017-2018, suit la moyenne canadienne, mais demeure inférieur à celui observé en Ontario et en Colombie-Britannique; Depuis 2014-2015, tous les centres pratiquant des TAVI atteignent le volume minimal annuel recommandé en 2017 de 30 interventions [INESSS, 2017a]; La moitié des cardiologues interventionnistes pratiquant des TAVI au Québec ont effectué moins de 20 interventions par année, soit le volume minimal d'opérateur actuellement recommandé [INESSS, 2017a]. CARACTÉRISTIQUES DES PATIENTS: Une proportion importante des patients sélectionnés pour être traités par TAVI au Québec étaient âgés de plus de 85 ans et souffraient de comorbidités importantes et de symptômes limitant significativement l'activité physique (classes III et IV de la NYHA). PROCESSUS DE SÉLECTION DES PATIENTS ET DÉLAIS D'ATTENTE: Les processus de documentation se sont améliorés, notamment en ce qui a trait à: o la documentation du score de la STS (Society of Thoracic Surgery, mesure du risque prédit de mortalité opératoire) qui s'est améliorée d'une proportion de 50 % des patients en 2013-2014 à 72 % en 2017-2018; o la documentation d'une décision thérapeutique prise par une équipe multidisciplinaire qui est passée d'une proportion de 0 % des patients en 2013-2014 à 92 % en 2017-2018; o la documentation des dates nécessaires à la mesure des délais d'attente. En 2017-2018, la date de référence et la date de la décision thérapeutique par l'équipe multidisciplinaire étaient documentées chez plus de 9 patients sur 10. Délais d'attente: Depuis 2015-2016, le délai médian d'évaluation du patient (entre la référence et la décision thérapeutique) est d'environ 60 jours et suit la médiane canadienne. Le délai médian entre la décision relative au traitement et l'intervention a diminué depuis 2015-2016 à 32 jours en 2017-2018, ce qui est en deçà de la médiane canadienne de 56 jours. PROCESSUS DE SOINS LIÉS À L'INTERVENTION TAVI: À l'échelle provinciale, l'approche TAVI par voie d'accès transfémorale est la plus fréquemment utilisée (79 % des interventions en 2017-2018); Actuellement, deux grandes catégories de valves sont utilisées au Québec chez plus de 95 % des patients, c'est-à-dire le « balloon-expandable ¼ et le « selfexpandable ¼. Toutefois, ces deux catégories de valves sont en évolution technique constante et d'autres types de valves continuent d'émerger; Au moins deux opérateurs étaient présents dans la salle d'hémodynamie ou hybride durant l'intervention dans 88 % des interventions TAVI, en 2017-2018. Dans la majorité de ces cas, au moins un chirurgien cardiaque jouait le rôle de professionnel responsable ou de soutien pour la réalisation de l'intervention. PRINCIPAUX ÉVÈNEMENTS INDÉSIRABLES ET DURÉE DU SÉJOUR: De façon générale, l'incidence d'évènements indésirables péri et post-intervention a diminué avec le temps au Québec; L'incidence de conversion urgente vers un RVA est passée de 3 % en 2013-2014 à 0,2 % en 2017-2018, et la proportion de patients ayant plus d'une valve déployée a diminué de 7 % à 1 %; La proportion des patients ayant eu un saignement majeur a diminué de 13 % en 2013-2014 à 6 % en 2017-2018 (p < 0,05), avec une diminution de la variabilité des résultats entre les six programmes TAVI. La fréquence de transfusion pendant le séjour hospitalier (avant ou après l'intervention) a également diminué de 30 % en 2013-2014 à 16 % en 2017-2018 (p < 0,05); La fréquence d'implantation d'un nouveau stimulateur cardiaque permanent s'est maintenue au fil des années au niveau provincial, représentant 17 % des cas en 2017-2018, avec une variabilité observée selon les centres et les différents types de valves; L'incidence d'accidents vasculaires cérébraux (AVC) intrahospitaliers s'est maintenue entre 2,2 % et 4,4 %; La durée médiane du séjour hospitalier au centre d'interventions TAVI a diminué de 5 à 3 jours entre 2013-2014 et 2017-2018. La durée médiane pour la dernière année d'observation était de 2 jours chez les patients traités par voie transfémorale, la voie la plus fréquemment utilisée, et de 5 jours pour ceux traités par une autre voie d'accès. RÉSULTATS CLINIQUES: La proportion de patients de retour au domicile suivant le congé hospitalier a augmenté, passant de 74 % en 2013-2014 à environ 80 % en 2017-2018. Parallèlement, on observe une diminution de la proportion de patients décédés à l'établissement de l'intervention TAVI (de 6,5 % à 1,9 %), ou transférés vers un centre de soins de longue durée (de 5 % à 2 %). La proportion des patients orientés dans un autre centre hospitalier de soins de courte durée est demeurée relativement stable au fil des années (13 % en 2013-2014 et 14 % en 2017-2018). ⢠L'incidence de mortalité à 30 jours a diminué, passant de 6,5 % en 2013-2014 à 2,7 % en 2017-2018 (p = 0,008), alors que l'incidence de mortalité à 1 an a diminué du tiers, soit de 14,6 % en 2013-2014 à 9,0 %, en 2017-2018 (p = 0,01).
MAIN FINDINGS: ORGANIZATIONAL STRUCTURE: The number of TAVIs performed in Québec increased from 294 in 2013-2014 to 526 in 2017-2018, at which time it accounted for 30% of all aortic valve replacements (TAVIs and SAVRs, with or without CABG, combined); The TAVI utilization rate of 49 per million population in 2017-2018 is similar to the Canadian average but is below that observed in Ontario and British Columbia; Since 2014-2015, all facilities performing TAVI have met the minimum annual volume of 30 procedures recommended in 2017 [INESSS, 2017a]; Half of interventional cardiologists performing TAVI in Québec carried out fewer than 20 procedures per year, which is the minimum operator volume currently recommended [INESSS, 2017a]. PATIENT CHARACTERISTICS: Many of the patients selected for treatment with TAVI in Québec were over 85 years of age and had major comorbidities and suffered symptoms that substantially limited their physical activity (NYHA classes III and IV). PATIENT SELECTION PROCESS AND WAIT TIMES: The documentation of processes has improved, particularly with regards to: documentation of the Society of Thoracic Surgery (STS) score, a measure of the predicted risk of surgical mortality, which improved from being present for 50% of patients in 2013-2014 to 72% in 2017-2018; the proportion of patients who had documentation that the treatment decision was made by a multidisciplinary team, which increased from 0% in 2013- 2014 to 92% in 2017-2018; the documentation of dates necessary for measuring wait times: in 2017- 2018, the date of referral and the date of the treatment decision by the multidisciplinary team were documented for more than 9 out of every 10 patients. WAIT TIMES: Since 2015-2016, the median time for patient assessment (from referral to treatment decision) has been maintained at approximately 60 days and is in line with the Canadian median. The median time from the treatment decision to the actual procedure has decreased since 2015-2016 to 32 days in 2017-2018, which is shorter than the Canadian median delay of 56 days. TAVI CARE PROCESSES: At the provincial level, the transfemoral access route was the most frequently used TAVI approach (in 79% of all interventions in 2017-2018); In Québec, two main categories of valves are currently used in more than 95% of patients, namely, balloon-expandable and self-expandable devices. However, these two categories of valves are in constant technical evolution, and other types of valves continue to emerge; In 2017-2018, at least two operators were present in the catheterization laboratory or hybrid room during 88% of the TAVI procedures. In most of these cases, a cardiac surgeon was either responsible for the treatment or had a supportive role. MAJOR ADVERSE EVENTS AND LENGTH OF HOSPITAL STAY: Overall, the incidence of peri- and post-procedural adverse events has decreased over time in Québec; The incidence of urgent conversion to SAVR decreased from 3% in 2013-2014 to 0.2% in 2017-2018, and the proportion of patients for whom more than one valve was deployed decreased from 7% to 1%; The frequency of implantation of a new permanent pacemaker has remained relatively unchanged over the years at the provincial level, accounting for 17% of the cases in 2017-2018, with variability being observed between the facilities and the different types of valves; The incidence of intrahospital stroke has remained between 2.2% and 4.4%; The median length of stay at TAVI centres decreased from 5 to 3 days between 2013-2014 and 2017-2018. The median length of stay in the most recent year of observation was 2 days for patients treated via the transfemoral approach (the most frequently used), and 5 days for those treated via alternative approaches. CLINICAL OUTCOMES: The proportion of patients who returned home at hospital discharge increased from 74% in 2013-2014 to approximately 80% in 2017-2018. During the same time period, there was a decrease in the proportion of patients who died at a TAVI facility (from 6.5% to 1.9%), or who were sent to a long-term care facility (from 5% to 2%). The proportion of patients transferred to another acute care hospital has remained relatively stable over the years (13% in 2013-2014 and 14% in 2017- 2018). The incidence of 30-day mortality decreased from 6.5% in 2013-2014 to 2.7% in 2017-2018 (p=0.008), while 1-year mortality decreased by a third, from 14.6% in 2013-2014 to 9.0% in 2017-2018 (p=0.01).
Asunto(s)
Perfil de Salud , Enfermedades Cardiovasculares/cirugía , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Eficacia , Análisis Costo-BeneficioRESUMEN
ANTECEDENTES: El reemplazo protésico de la válvula tricúspide es un procedimiento infrecuente, con elevada mortalidad y morbilidad operatoria, independientemente de la etiología de la insuficiencia tricuspídea. Persiste aún una discusión respecto al tipo de prótesis a utilizar, mecánica o biológica. OBJETIVO: Analizar nuestros resultados perioperatorios y alejados en el reemplazo valvular tricuspídeo, comparando ambos tipos de prótesis. MÉTODO: Revisión de la Base de Datos de nuestro Servicio de Cirugía Cardiovascular para el periodo enero 1991 - diciembre 2017. Identificados los pacientes con reemplazo valvular tricuspídeo (RVT); se revisaron los protocolos operatorios y los ecocardiogramas. La supervivencia se certificó a través del Registro Civil e Identificación de Chile. RESULTADOS: Se identificaron 83 pacientes con RVT (76% mujeres), los que representaron el 0,7% del total de las cirugías con circulación extracorpórea y el 2,1% de las cirugías valvulares para el periodo en estudio. La edad promedio fue 49±16,5 años. Cuarenta y nueve casos (59%) correspondieron a reoperaciones y otros 49 tuvieron un procedimiento asociado. En 40 pacientes (48%) se utilizó una prótesis mecánica y en 43 (52%) una biológica. La mortalidad operatoria global fue 9,6% (8 pacientes, 4 con una prótesis mecánica y 4 con una biológica). El seguimiento se completó en el 100%, con un promedio de 7,1 años. Veintiocho pacientes fallecieron durante el seguimiento; la principal causa fue insuficiencia cardiaca. Así, la supervivencia a 5 años fue 70,3 ± 5,3% y a 10 años 58 ± 6,3%, sin diferencia significativa entre ambos tipos de prótesis. Siete pacientes se reoperaron durante el seguimiento (5 casos con prótesis biológica y 2 mecánica). CONCLUSIÓN: El RVT continúa siendo un procedimiento infrecuente, con mayor incidencia en mujeres, en la quinta década de la vida. La mayoría de los pacientes presentaba comorbilidad y había tenido cirugía cardiovascular previa. La mitad de estos recibió una prótesis mecánica y la otra, biológica. No hubo diferencias significativas entre ambos tipos de prótesis en cuanto a mortalidad operatoria, supervivencia alejada o reoperación.
BACKGROUND: Tricuspid valve replacement (TVR) is an uncommon surgical procedure, associated with high mortality and morbidity. The use of biological or mechanical prostheses in TVR has advantages and disadvantages and, therefore, there persists a debate regarding the choice of one or other type of prostheses. AIM: To analyze our operative and long-term surgical results, comparing both types of prosthetic valves. METHODS: The Data Base of the Cardiovascular Surgery Service was reviewed for the period between January 1991 and December 2017. 83 patients with TVR were identified, the operative notes and echocardiogram reports were analyzed. Survival was obtained from the Chilean Civil Identification Service. RESULTS: 83 patients (76% women) had TVR. They represented 0.7% of the total cases operated on with extracorporeal circulation and 2.1% of all valve disease cases, for the study period. Mean age was 49±16.5 years. 49 cases (59%) were reoperations and another 49 had an associated procedure. In 40 patients (48%) a mechanical prosthesis was used and in 43 (52%) a biological one was implanted. Operative mortality rate was 9.6% (8 patients, had a mechanical valve and the other 8, a biological one). Follow-up was 100% completed, with an average of 7.1 years. 28 patients died during follow-up; the main cause of death was heart failure. Five-year survival rate was 70.3 ± 5.3% and at 10 years it was 58 ± 6.3%, without significant difference the type of prostheses. Seven patients were re-operated during follow-up (5 cases corresponded to a biological prostheses and 2 to a mechanical one). CONCLUSION: TVR is still an infrequent surgical procedure, more commonly performed in women, on the fifth decade of life. Most patients presented comorbidities and had a previous cardiovascular surgical operation. Half of them received a mechanical prosthesis and half a biological one. There was no significant difference between both types of prostheses related to surgical mortality, long-term survival or reoperation.
Asunto(s)
Humanos , Masculino , Femenino , Adolescente , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Adulto Joven , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/cirugía , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/métodos , Circulación Extracorporea , Reoperación , Insuficiencia de la Válvula Tricúspide/etiología , Insuficiencia de la Válvula Tricúspide/mortalidad , Bioprótesis , Comorbilidad , Análisis de Supervivencia , Estudios de Seguimiento , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricosRESUMEN
BACKGROUND: Recent evidence has showed us that quality of mitral valve repair is strongly related to volume. However, this study shows how low-volume centers can achieve results in mitral valve repair surgery comparable to those reported by referral centers. It compares outcomes of mitral valve repair using resection versus noresection techniques, tendencies, and rates of repair. METHODS: Between 2004 and 2017, 200 patients underwent mitral valve repair for degenerative mitral valve disease at Fundación Cardioinfantil-Institute of Cardiology. Fifty-eight (29%) patients underwent resection and 142 (71%) noresection. RESULTS: Follow-up was 94% complete, mean follow-up time was 2.3 years. There was no 30-day mortality. Five patients required mitral valve replacement after an average of 5.3 years (Resection = 2; Noresection = 3). Freedom from severe mitral regurgitation was 98% at 6.6 years of follow-up for the noresection group, and 92.5% at 7 years for the resection group (log rank: 0.888). At last follow-up, two patients died of cardiovascular disease related to mitral valve, 181 patients (86%) showed no or grade I mitral regurgitation. Patients with previous myocardial infarction had increased risk of recurrent mitral regurgitation (p = 0,030). Within four years, we inverted the proportion of mitral valve replacement and repair, and in 2016 we achieved a mitral valve repair rate of 96%. CONCLUSION: This study suggests that resection and noresection techniques are safe and effective. Recurrence of severe mitral regurgitation and need for mitral valve replacement are rare. We show that low-volume centers can achieve results comparable to those reported worldwide by establishing a mitral valve repair team. We encourage hospitals to follow this model of mitral valve repair program to decrease the proportion of mitral valve replacement, while increasing mitral valve repair.
Asunto(s)
Hospitales de Bajo Volumen/normas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Adulto , Anciano , Colombia , Femenino , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Hospitales de Bajo Volumen/estadística & datos numéricos , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Anuloplastia de la Válvula Mitral/métodos , Recurrencia , Estudios Retrospectivos , Medición de Riesgo/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: To analyse hospital mortality in patients subjected to cardiac surgery in Mexico during the year 2015, and identify the mortality risks factors, and its correlation with days of hospital stay in the cardiovascular intensive care unit. METHOD: The database of Cardiovascular Intensive Care of the National Institute of Cardiology was examined for this cases and controls study that included only adult patients subjected to cardiac surgery during the year 2015. RESULTS: A total of 571 patients were subjected to a surgical procedure. The predominant indication was single or multiple valve replacement surgery, followed by coronary revascularisation surgery, and correction of adult congenital heart disease. Overall mortality was 9.2, and 8% died in intensive care. The main risk factors for death were preoperative organ failure or pulmonary hypertension, and prolonged time with extracorporeal circulation. The primary cause of death was secondary to cardiogenic shock. The hospital mortality observed in this population was higher for patients undergoing pulmonary thromboendarterectomy, complex aortic disease surgery, and valvular surgery. CONCLUSIONS: The mortality of patients undergoing cardiac surgery in Mexico differs slightly from that reported in the world literature, primarily because there were more multivalvular surgeries and mixed complex procedures performed.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Mortalidad Hospitalaria , Tiempo de Internación/estadística & datos numéricos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Bases de Datos Factuales , Endarterectomía/métodos , Endarterectomía/mortalidad , Femenino , Cardiopatías Congénitas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Unidades de Cuidados Intensivos , Masculino , México/epidemiología , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Choque Cardiogénico/epidemiología , Choque Cardiogénico/mortalidadRESUMEN
Objective: To validate a nursing care protocol by specialist nurses, contributing to the care delivered to patients undergoing percutaneous valve replacement. Methods: This cross-sectional, prospective, quantitative study adopted the Content Validity Index (CVI) to verify level of agreement regarding this protocol's total set of items. Results: The CVI obtained for each item of the protocol, verified using a validation instrument, was greater than the minimum required that is 0.80, on average. Conclusion: The development of a protocol intended to guide care provided to patients who have undergone TAVI, improves patient safety and minimizes health problems, so that the implementation of specific strategies for the development of actions performed by nurses is essential.
Objetivo: Validar un protocolo de cuidados de enfermería por enfermeros especialistas, contribuyendo para la práctica asistencial del paciente sometido al cambio de válvula percutánea. Métodos: Se trata de un estudio metodológico, transversal y prospectivo, con abordaje cuantitativo, que empleó el Índice de Validez de Contenido (CVI) para verificar el nivel de concordancia en el conjunto total de ítems del instrumento del protocolo. Resultados: Después de la verificación con el CVI para cada ítem del instrumento de validación del protocolo, los valores obtenidos en relación a todos los ítems del protocolo, quedaron con los valores, en media, mayores que el mínimo para el CVI, que es arriba de 0,80. Conclusión: El desarrollo de un protocolo de cuidados dirigido para los pacientes sometidos a TAVI, posibilita el aumento de la seguridad del paciente minimiza los daños a la salud, siendo un factor esencial en la implementación de estrategias específicas para el desarrollo de acciones desempeñadas por el enfermero.
Objetivo: Validar um protocolo de cuidados de enfermagem realizado por enfermeiros especialistas, contribuindo para a prática assistencial do paciente submetido à troca valvar percutânea. Métodos: Trata-se de um estudo metodológico, transversal e prospectivo, com abordagem quantitativa, que empregou o Índice de Validade de Conteúdo (IVC) para verificar o nível de concordância no conjunto total de itens do instrumento do protocolo. Resultados: Após a verificação com o IVC, para cada item do instrumento de validação do protocolo, os valores obtidos em relação a todos os itens ficaram, em média, maiores que o mínimo para o IVC, que é acima de 0,80. Conclusão: O desenvolvimento de um protocolo de cuidados, voltado para os pacientes submetidos ao TAVI, possibilita o aumento da segurança destes e minimização dos agravos à saúde, sendo um fator essencial na implementação de estratégias específicas nas ações desempenhadas pelo enfermeiro.
Asunto(s)
Humanos , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/enfermería , Investigación Metodológica en Enfermería/estadística & datos numéricos , Implantación de Prótesis de Válvulas Cardíacas/enfermería , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Atención de EnfermeríaRESUMEN
Resumen Objetivo: Analizar las causas de mortalidad hospitalaria de pacientes operados de cirugía cardiaca en México en el año 2015. Identificar los factores de riesgo de mortalidad y realizar una correlación con el tiempo de estancia hospitalaria en terapia intensiva cardiovascular. Método: Estudio de casos y controles. Se estudió la base de datos de la Terapia Intensiva Cardiovascular del Instituto Nacional de Cardiología. Se incluyeron todos los pacientes adultos operados de cirugía cardiaca en el año 2015. Resultados: Se operaron 571 pacientes. La indicación quirúrgica predominante fue la cirugía de cambio valvular único o múltiple, seguida de la cirugía de revascularización coronaria y corrección de cardiopatías congénitas del adulto. La mortalidad global fue de un 9.2% y el 8% falleció en terapia intensiva. Los principales factores de riesgo de muerte fueron la presencia de falla orgánica o hipertensión pulmonar prequirúrgica, y el tiempo prolongado de circulación extracorpórea. La principal causa de muerte fue el choque cardiogénico. La mortalidad hospitalaria observada en esta población fue mayor para los operados de tromboendarterectomía pulmonar, cirugía de enfermedad aórtica compleja y cirugía valvular. Conclusiones: La mortalidad de los pacientes operados de cirugía cardiaca en México difiere levemente de la reportada en la literatura mundial porque se trata mayormente de cirugía multivalvular y de procedimientos quirúrgicos mixtos complejos.
Abstract Objective: To analyse hospital mortality in patients subjected to cardiac surgery in Mexico during the year 2015, and identify the mortality risks factors, and its correlation with days of hospital stay in the cardiovascular intensive care unit. Method: The database of Cardiovascular Intensive Care of the National Institute of Cardiology was examined for this cases and controls study that included only adult patients subjected to cardiac surgery during the year 2015. Results: A total of 571 patients were subjected to a surgical procedure. The predominant indication was single or multiple valve replacement surgery, followed by coronary revascularisation surgery, and correction of adult congenital heart disease. Overall mortality was 9.2, and 8% died in intensive care. The main risk factors for death were preoperative organ failure or pulmo- nary hypertension, and prolonged time with extracorporeal circulation. The primary cause of death was secondary to cardiogenic shock. The hospital mortality observed in this population was higher for patients undergoing pulmonary thromboendarterectomy, complex aortic disease surgery, and valvular surgery. Conclusions: The mortality of patients undergoing cardiac surgery in Mexico differs slightly from that reported in the world literature, primarily because there were more multivalvular surgeries and mixed complex procedures performed.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Mortalidad Hospitalaria , Procedimientos Quirúrgicos Cardíacos/métodos , Tiempo de Internación/estadística & datos numéricos , Choque Cardiogénico/mortalidad , Choque Cardiogénico/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Bases de Datos Factuales , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Endarterectomía/métodos , Endarterectomía/mortalidad , Cardiopatías Congénitas/cirugía , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Unidades de Cuidados Intensivos , México/epidemiologíaRESUMEN
BACKGROUND: There is no consensus regarding which risk factors influence the outcome of mitral valve replacement. AIM: To study the effects of the referring health care system and other factors on the results of mitral replacement. PATIENTS AND METHODS: We included 632 patients operated between 1990 and 2010 receiving the St Jude prosthesis. Patients were divided into three groups, group 1 composed by 180 patients coming from the Public System, group 2 composed by 182 patients coming from the University System and group 3 composed by 270 patients coming from the Private System. RESULTS: Overall operative mortality was 4.3%. There was no difference between groups in mortality. Factors responsible for operative mortality were: emergency operation (Odds Patio (OR): 5.6 P < 0.01) and left ventricular function (according to ejection fraction) grade III to IV (OR: 2.5 p = 0.048). Actuarial survival rates at 1, 5, 10, 15 and 20 years were 95%, 87%, 76%, 61% and 41%, respectively. Risk factors for long-term mortality were diabetes (OR: 3.3 p < 0.01), left ventricular function grades III-IV (OR: 2.6 p < 0.01), New York Heart Association functional class III to PV (OR: 2.1 p < 0.005) and male sex (OR: 1.5 p < 0.032). CONCLUSIONS: Referring health care system and type of surgery do not constitute a risk factor for mitral replacement. Risk factors were: emergency surgery, ventricular function grades III-IV, diabetes, functional capacity class III-IV and male sex. Integration of public and private health care systems in a university hospital setting achieves excellent outcomes for complex pathology.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Mortalidad Hospitalaria , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Enfermedades de las Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
Background: There is no consensus regarding which risk factors influence the outcome of mitral valve replacement. Aim: To study the effects ofthe referring health care system and other factors on the results of mitral replacement. Patients and Methods: We included 632 patients operated between 1990 and 2010 receiving the St Jude prosthesis. Patients were divided into three groups, group 1 composed by 180 patients coming from the Public System, group 2 composed by 182 patients coming from the University System and group 3 composed by 270 patients coming from the Private System. Results: Overall operative mortality was 4.3%. There was no difference between groups in mortality. Factors responsible for operative mortality were: emergency operation (Odds Patio (OR): 5.6 P < 0.01) and left ventricular function (according to ejection fraction) grade III to IV (OR: 2.5 p = 0.048). Actuarial survival rates at 1, 5, 10, 15 and 20 years were 95%, 87%, 76%, 61% and 41%, respectively. Risk factors for long-term mortality were diabetes (OR: 3.3 p < 0.01), left ventricular function grades III-IV (OR: 2.6 p < 0.01), New York Heart Association functional class III to PV (OR: 2.1 p < 0.005) and male sex (OR: 1.5 p < 0.032). Conclusions: Referring health care system and type of surgery do not constitute a risk factor for mitral replacement. Risk factors were: emergency surgery, ventricular function grades III-IV, diabetes, functional capacity class III-IV and male sex. Integration of public and private health care systems in a university hospital setting achieves excellent outcomes for complex pathology.
Asunto(s)
Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Mortalidad Hospitalaria , Hospitales Privados/estadística & datos numéricos , Hospitales Públicos/estadística & datos numéricos , Hospitales Universitarios/estadística & datos numéricos , Enfermedades de las Válvulas Cardíacas/mortalidad , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
O Contegra, um enxerto de veia jugular bovina, tem sido amplamente utilizado como biomaterial de preferência no tratamento cirúrgico das cardiopatias congênitas, especialmente como um conduto para a reconstrução da via de saída ventricular direita. Este artigo tem como objetivo fazer uma revisão abrangente sobre os desfechos clínicos do Contegra. Foram recuperados, coletados e analisados, relatos de Contegra publicados desde 2002. Havia 1.718 Contegra, aplicados em 1.705 pacientes. Os tamanhos dos condutos foram de 8-22 mm. As idades dos pacientes foram de recém-nascidos até 74,5 anos, com prevalência de pacientes pediátricos. O diagnóstico primário foi cardiopatia congênita em todos os casos, sendo os três diagnósticos principais: tetralogia de Fallot, tronco arterioso e atresia pulmonar, que representaram 25,6%, 16,7% e 13,1%, respectivamente. O Contegra foi utilizado como enxerto tubular na posição pulmonar em 1635 (95,9%) pacientes, como remendo monocúspide em 12 (0,7%), como enxerto na posição da valva pulmonar ou monocúspide em 40 (2,3%), e, como conduto artéria pulmonar-veia cava inferior na operação de Fontan, em 18 (1,1%) pacientes, respectivamente. O reimplante de conduto foi realizado em 141 (8,3%) pacientes, 33,8 ± 37 (8,6-106,8) meses após a inserção do conduto inicial. A plástica do conduto foi necessária em seis (0,4%) e a reintervenção em 83 (4,9%) dos pacientes. As indicações do reimplante do conduto incluíram estenose importante da anastomose distal, pseudoaneurisma da anastomose proximal e regurgitação importante do conduto. Quanto ao bom desempenho, disponibilidade e longevidade, o Contegra é um biomaterial adequado para a reconstrução da via de saída ventricular direita e como remendo para reparo de comunicação interventricular, mas não é apto para a operação de Fontan.
Contegra, a bovine jugular vein graft, has been widely used as a preferable biomaterial in the surgical treatment of congenital heart defects, especially as a conduit for the right ventricular outflow tract reconstruction. This article aims to make a comprehensive review on the clinical outcomes of Contegra. Reports of Contegra published since 2002 were comprehensively retrieved, collected and analyzed. There were 1718 Contegra, applied in 1705 patients. The sizes of the conduits were 8-22 mm. The patients aged from newborn to 74.5 years, prevailed by pediatrics. The primary diagnosis was congenital heart defects in all cases, with Tetralogy of Fallot, truncus arteriosus and pulmonary atresia being the first three diagnoses, representing 25.6%, 16.7%, and 13.1%, respectively. Contegra was used as a tube graft in the pulmonary position in 1635 (95.9%) patients, as a monocuspid patch in 12 (0.7%), as a graft in the position of the pulmonary valve or a monocusps in 40 (2.3%), and as an inferior vena cava-pulmonary artery conduit in the Fontan procedure in 18 (1.1%) patients, respectively. Conduit reimplantation was performed in 141 (8.3%) patients 33.8 ± 37 (8.6-106.8) months after the initial conduit insertion. Conduit plasty was necessary in 6 (0.4%), and reintervention in 83 (4.9%) patients. Indications for conduit reimplantation included severe stenosis of the distal anastomosis, pseudoaneurysm of the proximal anastomosis and severe conduit regurgitation. As for the good performance, availability and longevity, Contegra is a biomaterial suitable for the right ventricular outflow tract reconstruction and for patch repair for ventricular septal defect, but not apt for Fontan procedure.
Asunto(s)
Adolescente , Adulto , Anciano , Niño , Preescolar , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Adulto Joven , Bioprótesis , Materiales Biocompatibles/uso terapéutico , Prótesis Valvulares Cardíacas , Cardiopatías Congénitas/cirugía , Factores de Edad , Materiales Biocompatibles/efectos adversos , Bioprótesis/efectos adversos , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Prótesis Valvulares Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas , Venas Yugulares/trasplante , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
Contegra, a bovine jugular vein graft, has been widely used as a preferable biomaterial in the surgical treatment of congenital heart defects, especially as a conduit for the right ventricular outflow tract reconstruction. This article aims to make a comprehensive review on the clinical outcomes of Contegra. Reports of Contegra published since 2002 were comprehensively retrieved, collected and analyzed. There were 1718 Contegra, applied in 1705 patients. The sizes of the conduits were 8-22 mm. The patients aged from newborn to 74.5 years, prevailed by pediatrics. The primary diagnosis was congenital heart defects in all cases, with Tetralogy of Fallot, truncus arteriosus and pulmonary atresia being the first three diagnoses, representing 25.6%, 16.7%, and 13.1%, respectively. Contegra was used as a tube graft in the pulmonary position in 1635 (95.9%) patients, as a monocuspid patch in 12 (0.7%), as a graft in the position of the pulmonary valve or a monocusps in 40 (2.3%), and as an inferior vena cava-pulmonary artery conduit in the Fontan procedure in 18 (1.1%) patients, respectively. Conduit reimplantation was performed in 141 (8.3%) patients 33.8 ± 37 (8.6-106.8) months after the initial conduit insertion. Conduit plasty was necessary in 6 (0.4%), and reintervention in 83 (4.9%) patients. Indications for conduit reimplantation included severe stenosis of the distal anastomosis, pseudoaneurysm of the proximal anastomosis and severe conduit regurgitation. As for the good performance, availability and longevity, Contegra is a biomaterial suitable for the right ventricular outflow tract reconstruction and for patch repair for ventricular septal defect, but not apt for Fontan procedure.
Asunto(s)
Materiales Biocompatibles/uso terapéutico , Bioprótesis , Cardiopatías Congénitas/cirugía , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Factores de Edad , Anciano , Materiales Biocompatibles/efectos adversos , Bioprótesis/efectos adversos , Bioprótesis/estadística & datos numéricos , Niño , Preescolar , Femenino , Prótesis Valvulares Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas/estadística & datos numéricos , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Venas Yugulares/trasplante , Masculino , Persona de Mediana Edad , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Valvar heart disease is an important public health problem, more common in developing countries, especially in younger. OBJECTIVE: To evaluate the epidemiological features of patients and its influence on the prosthesis type choice used on patients who underwent valve surgery. METHODS: Cross-sectional. Data such as age, sex, provenance, surgery procedure and prosthesis type were retrospectively analyzed. We reviewed 366 charts of all patients submitted to heart valve surgery during three years in a public health cardiovascular treatment center. RESULTS: 52% of patients were female. The age range was from 5 to 82, the median was 41 years old. In regards 37.7% of patients came from Salvador (Bahia, Brazil) and 62.3% from countryside. Valve replacement was performed in 73% of patients, whereas 7.38% underwent valvuloplasty and 18.3% underwent valve repair and replacement. Regarding type of prosthesis, 70.0% received bioprosthesis and 30.0% received metal prosthesis. On note bioprosthesis were more used in younger (P<0,001). CONCLUSION: Biological prostheses were used predominantly in younger. This might be possible due to a low social-economic status, avoiding metal valve implantation and the consequent anticoagulation therapy.
Asunto(s)
Bioprótesis , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Bioprótesis/estadística & datos numéricos , Brasil , Niño , Preescolar , Métodos Epidemiológicos , Femenino , Prótesis Valvulares Cardíacas/estadística & datos numéricos , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Factores de Riesgo , Factores Sexuales , Factores Socioeconómicos , Adulto JovenRESUMEN
INTRODUÇÃO: A doença cardíaca valvar é um grave problema de saúde pública, mais frequente em países em desenvolvimento, acometendo indivíduos em idade laboralmente produtiva. OBJETIVO: Avaliar o perfil socioeconômico e epidemiológico dos pacientes submetidos a cirurgia valvar e a sua relação com os tipos de próteses utilizadas em um centro de referência público de Salvador, BA, Brasil. MÉTODOS: Estudo de corte transversal descritivo de prevalência, no qual foram analisados retrospectivamente idade, sexo, procedência, tipo de valvopatia, cirurgia a qual o paciente foi submetido e o tipo de prótese utilizada em casos de trocas, em centro de referência público de cardiologia. RESULTADOS: Foram revisados 366 prontuários, de todos os pacientes submetidos a cirurgia de valva cardíaca, de janeiro de 2007 a dezembro de 2009. Em relação ao sexo, 52% dos pacientes eram do sexo feminino. A idade média ± DP foi de 41,70 ± 17,85 anos. Dentre os pacientes, 37,7% eram procedentes da capital e 62,3%, do interior do estado da Bahia (Brasil). A troca valvar foi realizada em 73% dos pacientes, enquanto que 7,38% realizaram plastia valvar e 18,3% realizaram tanto plastia quanto troca. Dos pacientes que realizaram troca valvar, 70% receberam bioprótese e 30% do tipo metálica, com predominância do uso bioprótese nas faixas etárias jovens (P<0,001). CONCLUSÃO: Próteses biológicas foram predominantemente usadas em jovens. Esse fato, possivelmente, pode ser atribuído ao baixo nível socioeconômico da população em questão, distância de centros urbanos, dificuldade de realização de exames para controle da anticoagulação e nível educacional ruim, inviabilizando o uso de valva metálica e a consequente terapia anticoagulante.
BACKGROUND: Valvar heart disease is an important public health problem, more common in developing countries, especially in younger. OBJECTIVE: To evaluate the epidemiological features of patients and its influence on the prosthesis type choice used on patients who underwent valve surgery. METHODS: Cross-sectional. Data such as age, sex, provenance, surgery procedure and prosthesis type were retrospectively analyzed. We reviewed 366 charts of all patients submitted to heart valve surgery during three years in a public health cardiovascular treatment center. RESULTS: 52% of patients were female. The age range was from 5 to 82, the median was 41 years old. In regards 37.7% of patients came from Salvador (Bahia, Brazil) and 62.3% from countryside. Valve replacement was performed in 73% of patients, whereas 7.38% underwent valvuloplasty and 18.3% underwent valve repair and replacement. Regarding type of prosthesis, 70.0% received bioprosthesis and 30.0% received metal prosthesis. On note bioprosthesis were more used in younger (P<0,001). CONCLUSION: Biological prostheses were used predominantly in younger. This might be possible due to a low social-economic status, avoiding metal valve implantation and the consequent anticoagulation therapy.
Asunto(s)
Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Bioprótesis , Prótesis Valvulares Cardíacas , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Factores de Edad , Brasil , Bioprótesis , Métodos Epidemiológicos , Prótesis Valvulares Cardíacas , Diseño de Prótesis , Factores de Riesgo , Factores Sexuales , Factores SocioeconómicosRESUMEN
BACKGROUND: the combined heart valve surgery and coronary artery bypass graft surgery has increased in frequency. The combined procedures have an increased risk of perioperative complications and mortality and usually is realized in older patients. We present our experience with this combined procedure. METHODS: we analyzed the files of patients treated with combined valve surgery and coronary artery bypass graft surgery, between June 1, 2008 and June 30, 2011. We evaluated risk factors, surgical time, morbidity and mortality. RESULTS: in the analyzed period, we included 74 patients. There were 51 male patients (69%) and 23 female patients (31%). The mean age was 63 ± 7.3 years. The most frequent procedure was aortic valve replacement with one or two coronary artery bypass grafts. The main complications were postoperative bleeding (18.9%), mediastinitis (8.1%) and cardiac rhythm disturbances (2.7%). The mortality was 2.7%. CONCLUSION: it was concluded that combined valve surgery with myocardial revascularization has similar results to that reported by other authors and on this basis this procedure is safe and useful.
Asunto(s)
Puente de Arteria Coronaria/estadística & datos numéricos , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Arritmias Cardíacas/epidemiología , Arritmias Cardíacas/etiología , Comorbilidad , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/mortalidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Hospitales Generales/estadística & datos numéricos , Hospitales Urbanos/estadística & datos numéricos , Humanos , Masculino , Mediastinitis/epidemiología , Mediastinitis/etiología , México , Persona de Mediana Edad , Hemorragia Posoperatoria/epidemiología , Estudios Retrospectivos , Factores de Riesgo , Servicio de Cirugía en Hospital/estadística & datos numéricos , Infección de la Herida Quirúrgica/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUCTION: Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES: This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS: Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS: Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P = 0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P = 0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P < 0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P = 0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P = 0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P < 0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS: Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined.
Asunto(s)
Válvula Aórtica/cirugía , Bloqueo Atrioventricular/epidemiología , Estimulación Cardíaca Artificial/estadística & datos numéricos , Puente de Arteria Coronaria/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Válvula Mitral/cirugía , Anciano , Bloqueo Atrioventricular/etiología , Puente de Arteria Coronaria/métodos , Métodos Epidemiológicos , Femenino , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Atención PerioperativaRESUMEN
INTRODUÇÃO: Distúrbios do sistema de condução cardíaco são complicações potenciais e conhecidas dos procedimentos de cirurgia cardíaca valvar. OBJETIVOS: Investigar a associação entre fatores peri-operatórios com bloqueio atrioventricular (BAV) e a necessidade de estimulação cardíaca artificial temporária (ECAT) e, se necessário, implante de marcapasso definitivo no pós-operatório de cirurgia cardíaca (POCC) valvar. MÉTODOS: Coorte histórica de pacientes submetidos a cirurgia cardíaca valvar, sendo realizada análise de banco de dados por regressão logística. RESULTADOS: No período de janeiro de 1996 a dezembro de 2008, foram realizadas 1102 cirurgias cardíacas valvares: 718 (65,2%) na valva aórtica e 407 (36,9%) na valva mitral; destas, 190 (17,2%) cirurgias de revascularização miocárdica associadas à cirurgia valvar e 23 (2,1%) cirurgias valvares combinadas (aórtica+mitral). Cento e oitenta e sete (17%) pacientes apresentaram quadro clínico e eletrocardiográfico de BAV durante o POCC valvar, necessitando de ECAT. Quatorze (7,5%) pacientes evoluíram para implante de marcapasso definitivo (1,27% do total da amostra). A análise multivariada evidenciou associação significativa de BAV com cirurgia de valva mitral (OR=1,76; IC 95% 1,08-2,37; P=0,002), implante de prótese biológica (OR=1,59; IC 95% 1,02-3,91; P= 0,039), idade maior que 60 anos (OR = 1,99; IC 95% 1,35-2,85; P<0,001), uso prévio de medicações antiarrítmicas (propafenona e amiodarona) (OR = 1,86; IC 95% 1,04-3,14; P=0,026) e uso prévio de betabloqueador (OR = 1,76; IC 95% 1,25-2,54; P=0,002). Embora a presença do BAV e necessidade de ECAT não tenham se associado a aumento de mortalidade, prolongaram a permanência hospitalar significativamente (P<0,0001) e, portanto, o consumo de recursos hospitalares. CONCLUSÃO: Esse estudo evidencia um conjunto de fatores preditivos potenciais a um perfil de pacientes que determinam alto risco de bloqueio atrioventricular e necessidade de estimulação ...
INTRODUCTION: Disturbances of the cardiac conduction system are potential complications after cardiac valve surgery. OBJECTIVES: This study was designed to investigate the association between perioperative factors and atrio-ventricular block, the need for temporary cardiac artificial pacing and, if necessary, permanent pacemaker implantation after cardiac valve surgery. METHODS: Retrospective analysis of the Cardiac Surgery Database - Hospital São Lucas/PUCRS. The data are collected prospectively and analyzed retrospectively. RESULTS: Between January 1996 and December 2008 were included 1102 valve surgical procedures: 718 aortic valves (65.2%), 407 (36.9%) mitral valve and 190 (17.2%) coronar artery bypass grafting combined with valve repair and 23 (2.1%) aortic and mitral combined surgery. 187 patients (17%) showed clinical and electrocardiographic pattern of atrio-ventricular block requiring artificial temporary pacing. Of these, 14 patients (7.5%) required permanent pacemaker implantation (1.27% of the total valve surgery patients). Multivariate analysis showed association of the incidence of atrio-ventricular block and temporary pacing with mitral valve surgery (OR 1,76; CI 95% 1.08-2.37; P=0.002), implantation of bioprosthetic devices (OR 1.59; CI 95% 1.02-3.91; P=0,039), age over 60 years (OR 1.99; CI 95% 1.352.85; P<0.001), prior use of anti-arrhythmic drugs (OR 1.86; CI 95% 1.04-3.14; P=0.026) and previous use of b-blocker (OR 1.76; CI 95% 1.25-2.54; P=0.002). Remarkably the presence of atrio-ventricular block did not significantly show association with increased mortality, but significantly prolonged (P<0.0001) hospital length-of-stay and, therefore, hospital costs. CONCLUSIONS: Our study presents a group of predictive factors referring to a specific patient profile by which high risk of atrio-ventricular block and the need of temporary cardiac pacing after cardiac valve surgery it is determined.
Asunto(s)
Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Válvula Aórtica/cirugía , Bloqueo Atrioventricular/epidemiología , Estimulación Cardíaca Artificial/estadística & datos numéricos , Puente de Arteria Coronaria/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Válvula Mitral/cirugía , Bloqueo Atrioventricular/etiología , Puente de Arteria Coronaria/métodos , Métodos Epidemiológicos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Atención PerioperativaRESUMEN
OBJETIVO: Pacientes septuagenários ou mais idosos necessitando de cirurgia cardíaca vêm crescendo em todo mundo. O objetivo do estudo é conhecer melhor esse grupo de pacientes e determinar fatores de risco para morbidade operatória. MÉTODOS: Revisamos 783 pacientes submetidos a operações cardíacas valvares e de revascularização do miocárdio isoladas ou associadas no período de 2002 a 2007. Tais pacientes foram divididos em "grupo <70 anos de idade" e "grupo >70 anos de idade". RESULTADOS: Cento e noventa e sete pacientes tinham 70 anos ou mais de idade (idade média 74,1 ± 3,9) e 61 por cento eram do sexo masculino. No grupo > 70 anos, foi significativamente maior o número de pacientes portadores de doença vascular periférica (9 por cento versus 5 por cento, P= 0,019), doença carotídea (5 por cento versus 2 por cento, P= 0,026) e angina instável (17 por cento versus 9 por cento, P= 0,018). Em ambos os grupos, a revascularização do miocárdio foi mais freqüente. No grupo > 70 anos, 41 por cento dos pacientes tiveram ao menos um efeito adverso, versus 22 por cento do grupo <70 anos (P<0,001). Aincidência de sangramento pós-operatório, complicações pulmonares, mediastinite, necessidade de vasopressores, disfunção renal e acidente vascular cerebral foi significativamente maior no grupo > 70 anos. A mortalidade foi maior no grupo > 70 anos (19 por cento versus 8,5 por cento, P<0,001). A regressão logística revelou que DPOC (OR: 8,6), FE (OR: 7,1), operação não eletiva (OR: 17,2) e tempo de circulação extracorpórea > 120 min (OR: 3,4) são preditores de mortalidade hospitalar no grupo estudado. CONCLUSÕES: A mortalidade hospitalar em septuagenários ou mais idosos nas operações de revascularização miocárdica e valvares isoladas ou associadas é maior que nos pacientes mais jovens.
OBJECTIVES: Septuagenarians or older patients needing heart surgery has increased in whole world. The objective of study is to know the characteristics of this group of patients and determine the risk factors for operative morbidity. METHODS: We revised the medical records of 783 patients undergone heart valve surgery, myocardial revascularization or both between 2002 and 2007. The patients were divided in "control group" (<70 years) "septuagenarian group" (70 years old or more). RESULTS: One hundred ninety seven patients were at least 70 years old (mean age 74.1±3.9) and 61 percent were male. In the control group the mean age was 52.1±11.7 and 54 percent were male. In the septuagenarians group it was significantly higher the proportion of patients suffering from peripheral vascular disease (9 percent versus 5 percent, P=0.019), carotid artery obstruction (5 percent versus 2 percent, P=0.026), unstable angina (17 percent versus 9 percent, P=0.018). In both groups coronary artery bypass surgery prevailed. In the septuagenarian group 41 percent of the patients had a least one morbid event, versus 22 percent of the patients in the control group (P<0.001). Postoperative bleeding, pulmonary complications, mediastinitis, need of vasopressors, renal dysfunction and strokes were significantly higher in the septuagenarian group. The mortality was higher in the septuagenarian (19 percent versus 8.5 percent, P<0.001). The logistic regression revealed that COPD (OR: 8.6), EF < 35 percent (OR: 7,1), non-elective operation (OR: 17,2) and cardiopulmonary bypass time >120 min (OR: 3,4) were predictive of hospital mortality in septuagenarian or older patients. CONCLUSIONS: The hospital mortality of septuagenarians or elderly is significantly higher than younger patients.
Asunto(s)
Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Revascularización Miocárdica/mortalidad , Factores de Edad , Estudios de Casos y Controles , Circulación Extracorporea , Mortalidad Hospitalaria , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Modelos Logísticos , Revascularización Miocárdica/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Factores de Riesgo , Factores de TiempoRESUMEN
OBJECTIVES: Septuagenarians or older patients needing heart surgery has increased in whole world. The objective of study is to know the characteristics of this group of patients and determine the risk factors for operative morbidity. METHODS: We revised the medical records of 783 patients undergone heart valve surgery, myocardial revascularization or both between 2002 and 2007. The patients were divided in 'control group' (<70 years) 'septuagenarian group' (70 years old or more). RESULTS: One hundred ninety seven patients were at least 70 years old (mean age 74.1+/-3.9) and 61% were male. In the control group the mean age was 52.1+/-11.7 and 54% were male. In the septuagenarians group it was significantly higher the proportion of patients suffering from peripheral vascular disease (9% versus 5%, P=0.019), carotid artery obstruction (5% versus 2%, P=0.026), unstable angina (17% versus 9%, P=0.018). In both groups coronary artery bypass surgery prevailed. In the septuagenarian group 41% of the patients had a least one morbid event, versus 22% of the patients in the control group (P<0.001). Postoperative bleeding, pulmonary complications, mediastinitis, need of vasopressors, renal dysfunction and strokes were significantly higher in the septuagenarian group. The mortality was higher in the septuagenarian (19% versus 8.5%, P<0.001). The logistic regression revealed that COPD (OR: 8.6), EF < 35% (OR: 7,1), non-elective operation (OR: 17,2) and cardiopulmonary bypass time >120 min (OR: 3,4) were predictive of hospital mortality in septuagenarian or older patients. CONCLUSIONS: The hospital mortality of septuagenarians or elderly is significantly higher than younger patients.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Revascularización Miocárdica/mortalidad , Adulto , Factores de Edad , Anciano , Estudios de Casos y Controles , Circulación Extracorporea , Femenino , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Mortalidad Hospitalaria , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Factores de Riesgo , Factores de TiempoRESUMEN
In the Heart Institute of University of São Paulo Medical School, between 1980 and 2000, were performed 712 mitral valve repair procedures, 39 aortic valve repairs and 469 tricuspid valve repairs. In our experience with mitral valve repair, the most performed techniques were quadrangular resection of the posterior leaflet, posterior annuloplasty with bovine pericardial sling and Carpentier ring annuloplasty. Quadrangular resection of the posterior leaflet is the technique of choice in mitral regurgitation due to degenerative disease, and repair is possible in 90% of the cases. Since 1994, we perform the quadrangular resection without ring annuloplasty, a modification in the technique called "Double Teflon" technique, with good results. Aortic valve repair is performed in specific situations. In congenital aortic insufficiency, we perform the suspention of the prolapsed leaflets in the comissures. In rheumatic aortic insufficiency, when we found leaflet retraction, we elongate the leaflets with bovine pericardial patchs. Our experience of aortic valve repair, between 1980 and 2000, consists of a small group of 39 patients. The results are satisfactory, but these techniques are feasible only in selected cases. Tricuspid insufficiency is generally a consequence of annular enlargement in patients with mitral valve disease and we prefer the De Vega annuloplasty in these cases. In cases with large annulus dilatation, we prefer to use the "Revuelta" or the "bicuspidization" techniques. In patients with previous tricuspid repair and annulus distortion, we prefer to use bovine pericardial sling or Carpentier ring annuloplasty.
Asunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Academias e Institutos , Válvula Aórtica/cirugía , Brasil , Femenino , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Humanos , Masculino , Válvula Mitral/cirugía , Procedimientos de Cirugía Plástica/métodos , Sensibilidad y Especificidad , Resultado del Tratamiento , Válvula Tricúspide/cirugíaRESUMEN
Os autores fazem uma análise do desempenho de diversos tipos de próteses, demonstram os fatos mais relevantes que devem orientar a escolha da prótese (mecânica ou biológica) e apresentam os resultados a médio e longo prazos de 239 pacientes submetidos a troca valvar. Verificam que a prevalência de disfunção das próteses, acidentes tromboembólicos, hemorrágicos e infecciosos foram pouco significativos durante o período de acompanhamento, que variou de 3 a 118 meses