124 research outputs found
Long Term Clinical Follow-up and Graft Patency of Offpump vs On-pump Coronary Artery Surgery in Patients with ST-Segment Elevation Myocardial Infarction
The role of minimal access valve surgery in the elderly. A meta-analysis of observational studies
Background Minimal access valve surgery, both mitral and aortic, may be related to improvement in specific post-operative outcomes, therefore may be beneficial for the subgroup of the elderly referred for valve surgery. Methods A systematic literature review identified several different studies, of which 6 fulfilled criteria for meta-analysis. Outcomes for a total of 1347 patients (675 conventional standard sternotomy and 672 minimally invasive valve surgery) were assessed with a meta-analysis using random effects modeling. Heterogeneity, subgroup analysis with quality scoring were also assessed. The primary endpoint was early mortality. Secondary endpoints included intra and post-operative outcomes. Results In the context of elderly patients, minimal access valve surgery conferred comparable early mortality to standard sternotomy (odd ratio (OR) 0.79, CI [0.40,1.56], p\ua0=\ua00.50) with no heterogeneity (p\ua0=\ua00.13); it was also associated with reduced mechanical intubation time (OR 0.48, CI [0.30,0.78], p\ua0=\ua00.003) and reduced post-operative length of stay (weighted mean difference (WMD)\ua0 122.91, CI [ 123.09,\ua0 122.74] p\ua0<\ua00.00001), however both cardio-pulmonary bypass time and cross clamp time were longer (WMD 24.29, CI [22.97, 25.61] p\ua0<\ua00.00001 and WMD 8.61, CI [7.61, 9.61], p\ua0<\ua00.00001, respectively); subgroup analysis demonstrated statistically significant reduced post-operative length of stay for both minimally invasive aortic and mitral surgery (WMD\ua0 122.84, CI [ 123.07,\ua0 122.60] p\ua0<\ua00.00001 and WMD\ua0 122.98, CI [ 123.25,\ua0 122.71] p\ua0<\ua00.00001 respectively). Conclusions Despite a prolonged cardiopulmonary bypass and cross clamp time, minimally invasive valve surgery is a safe alternative to standard sternotomy in the elderly, with similar early mortality, and improvements in intubation time as well as length of stay
Patent foramen ovale and thromboembolic complications
The foramen ovale, an atrial septal defect which is essential in the fetal circulation, remains patent through adulthood in approximately 25% of the general population and so it represents the most common persistent abnormality of fetal origin. Patent foramen ovale (PFO) allows interatrial right-to-left blood shunting during those periods of the cardiac cycle in which the right atrial pressure exceeds the left one. An increasing number of pathological manifestations of PFO has been recently identified; among these, paradoxical systemic embolism, refractory hypoxemia in patients with right ventricular myocardium infarction or severe pulmonary disease, orthostatic oxygen desaturation in the rare platypnea-orthodeoxia syndrome, neurological decompression illness in divers, high altitude pilots and astronauts, and finally, migraine headache with aura. Nowadays many techniques allow to detect a PFO. In this study we investigated each of them, assessing their potential diagnostic role even in comparison with the main features of the other method
Non-sutureless minimally invasive aortic valve replacement: mini-sternotomy versus mini-thoracotomy: a series of 1130 patients
OBJECTIVES: Aortic valve replacement through conventional sternotomy still represents the gold-standard surgical approach for aortic valve disease. However, given the increasing number of patients with comorbidities, strategies that can improve operative results are always sought. Minimally invasive aortic valve surgery, although related to a steep learning curve, might be associated with improved post- operative outcomes. The main aim of this study was to assess whether significant differences exist in terms of operative and early results between a mini-sternotomy and a right mini-thoracotomy approach for isolated aortic valve replacement without sutureless technologies.
METHODS: This is an observational retrospective multicentre study from nine Italian cardiac centres that analyses prospectively collected data of patients who underwent isolated minimally invasive aortic valve replacement between January 2010 and December 2014. Two approaches are considered (mini-sternotomy and mini-thoracotomy) and compared in terms of operative and early outcomes.
RESULTS: After interrogation of the centralized database, a total of 1130 patients were retrieved (854 mini-sternotomy and 276 mini-thoracotomy). Patients in the mini-sternotomy group had a higher risk profile. There was no difference in terms of early mortality; cardiopulmonary bypass and cross-clamp time did not differ significantly between the groups; and a significantly higher number of reoperations for bleeding was observed in the right mini-thoracotomy group.
CONCLUSIONS: Both mini-sternotomy and mini-thoracotomy could be performed safely, with low mortality and postoperative morbidity. The mini-thoracotomy approach was associated with a significantly higher rate of reoperation for bleeding. Uptake among cardiac centres was low. Sutureless technologies could potentially increase surgical volume by simplifying the mini-thoracotomy procedure
Treatment of pulmonary hypertension in patients undergoing cardiac surgery with cardiopulmonary bypass: a randomized, prospective, double-blind study.
OBJECTIVE: Pulmonary hypertension can already be present in patients undergoing cardiac surgery or can be exacerbated by cardiopulmonary bypass. Postoperative treatment is still a challenge for physicians. The aim of this study was to evaluate the effects of inhaled prostacyclin (iPGI2) and nitric oxide (iNO) compared with those of intravenous vasodilators.
METHODS: This prospective, randomized, double-blind study included 58 patients affected by severe mitral valve stenosis and pulmonary hypertension with high pulmonary vascular resistance (> 250 dynes x s x cm(-5)) and a mean pulmonary artery pressure > 25 mmHg. All patients were monitored by central venous, radial arterial and Swan-Ganz catheters. Data were recorded at six different time points, before induction of anaesthesia, during and after surgery. Prostacyclin and nitric oxide were administered by inhalation 5 min before weaning from cardiopulmonary bypass and continued in the intensive care unit. Right ventricular function was evaluated by transoesophageal echocardiography.
RESULTS: Hospital mortality was 3.4%. After drug administration, the mean pulmonary artery pressure and pulmonary vascular resistance were significantly decreased in the iNO and iPGI2 groups with respect to the baseline values (P < 0.05) and such a decrease was maintained throughout the study; this was not observed in the control group. In the iNO and iPGI2 groups we demonstrated a significant increase in cardiac indices and right ventricular ejection fraction after drug administration with respect to baseline. Furthermore, patients in the inhaled drug groups were weaned easily from cardiopulmonary bypass (P = 0.04) and had a shorter intubation time (P = 0.03) and intensive care unit stay (P = 0.02) than the control group.
CONCLUSIONS: Our data suggest that both iNO and iPGI2 are effective in the treatment of pulmonary hypertension. iPGI2 has a number of advantages over iNO, including its easy administration and lower cost. Intravenous vasodilator treatment, on the other hand, is effective in terms of mortality but has a higher morbidity rate
Designing a new scoring system (QualyP Score) correlating the management of cardiopulmonary bypass to postoperative outcomes.
Aim: The aim of this study was to ascertain if a score, directly derived from CPB records, could correlate to major postoperative outcomes. Methods: An additive score (QualyP Score) was created from 10 parameters: peak lactate value during CPB, peak VCO2i, lowest DO2i/VCO2i, peak respiratory quotient, CPB time, cross-clamp time, lowest CPB temperature, circulatory arrest, ultrafiltration during CPB, number of packed red cells transfused intraoperatively. The PerfSCORE was calculated, as well. Multivariable logistic regression models were built to detect the independent predictors of: peak lactate >3 mmol/L during the first three postoperative days; the incidence of acute kidney injury network (AKIN) 1-2-3; respiratory insufficiency; mortality. Results: The mean score was 4.8±2.6 (0-10). A QualyP Score ≥1 was predictive of postoperative acidosis (OR=1.595). A score ≥2 was predictive of AKIN 2 (OR=1.268) and respiratory insufficiency (OR=1.526). A score ≥5 was predictive of AKIN 3 (OR=1.848) and mortality (OR=1.497). Conclusions: QualyP Score may help to provide a quality marker of perfusion, emphasizing the need for goal-directed perfusion strategies. </jats:sec
Therapeutic decision-making for patients with fluctuating mitral regurgitation
Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve)
Uncertainties and challenges in surgical and transcatheter tricuspid valve therapy: a state-of-the-art expert review
Tricuspid regurgitation (TR) is a frequent and complex problem, commonly combined with left-sided heart disease, such as mitral regurgitation. Significant TR is associated with increased mortality if left untreated or recurrent after therapy. Tricuspid regurgitation was historically often disregarded and remained undertreated. Surgery is currently the only Class I Guideline recommended therapy for TR, in the
form of annuloplasty, leaflet repair, or valve replacement. As growing experience of transcatheter therapy in structural heart disease,
many dedicated transcatheter tricuspid repair or replacement devices, which mimic well-established surgical techniques, are currently
under development. Nevertheless, many aspects of TR are little understood, including the disease process, surgical or interventional risk
stratification, and predictors of successful therapy. The optimal treatment timing and the choice of proper surgical or interventional technique for significant TR remain to be elucidated. In this context, we aim to highlight the current evidence, underline major controversial
issues in this field and present a future roadmap for TR therapy
Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography
Purpose: A number of parameters recorded during dobutamine stress echocardiography (DSE) are associated with worse outcome. However, the relative importance of baseline mitral regurgitation (MR) is unknown. The aim of this study was to assess the prevalence and associated implications of functional MR with long-term mortality in a large cohort of patients referred for DSE.
Methods: 6745 patients (mean age 64.9±12.2 years) were studied. Demographic, baseline and peak DSE data were collected. All-cause mortality was retrospectively analyzed. DSE was successfully completed in all patients with no adverse outcomes.
Results: MR was present in 1019 (15.1%) patients. During a mean follow up of 5.1±1.8 years, 1642 (24.3%) patients died and MR was significantly associated with increased all-cause mortality (p<0.001). With Kaplan-Meier analysis, survival was significantly worse for patients with moderate and severe MR (p<0.001). With multivariate Cox regression analysis, moderate and severe MR (HR 2.78; 95% CI 2.17 - 3.57; and HR 3.62; 95% CI 2.89 - 4.53, respectively) were independently associated with all-cause mortality. The addition of MR to C statistic models significantly improved discrimination.
Conclusions: MR is associated with all-cause mortality and adds incremental prognostic information among patients referred for DSE. The presence of MR should be taken into account when evaluating the prognostic significance of DSE results
Outcomes of Patients with Asymptomatic Aortic Stenosis Followed Up in Heart Valve Clinics
Importance: The natural history and the management of patients with asymptomatic aortic stenosis (AS) have not been fully examined in the current era. Objective: To determine the clinical outcomes of patients with asymptomatic AS using data from the Heart Valve Clinic International Database. Design, Setting, and Participants: This registry was assembled by merging data from prospectively gathered institutional databases from 10 heart valve clinics in Europe, Canada, and the United States. Asymptomatic patients with an aortic valve area of 1.5 cm2 or less and preserved left ventricular ejection fraction (LVEF) greater than 50% at entry were considered for the present analysis. Data were collected from January 2001 to December 2014, and data were analyzed from January 2017 to July 2018. Main Outcomes and Measures: Natural history, need for aortic valve replacement (AVR), and survival of asymptomatic patients with moderate or severe AS at entry followed up in a heart valve clinic. Indications for AVR were based on current guideline recommendations. Results: Of the 1375 patients included in this analysis, 834 (60.7%) were male, and the mean (SD) age was 71 (13) years. A total of 861 patients (62.6%) had severe AS (aortic valve area less than 1.0 cm2). The mean (SD) overall survival during medical management (mean [SD] follow up, 27 [24] months) was 93% (1%), 86% (2%), and 75% (4%) at 2, 4, and 8 years, respectively. A total of 104 patients (7.6%) died under observation, including 57 patients (54.8%) from cardiovascular causes. The crude rate of sudden death was 0.65% over the duration of the study. A total of 542 patients (39.4%) underwent AVR, including 388 patients (71.6%) with severe AS at study entry and 154 (28.4%) with moderate AS at entry who progressed to severe AS. Those with severe AS at entry who underwent AVR did so at a mean (SD) of 14.4 (16.6) months and a median of 8.7 months. The mean (SD) 2-year and 4-year AVR-free survival rates for asymptomatic patients with severe AS at baseline were 54% (2%) and 32% (3%), respectively. In those undergoing AVR, the 30-day postprocedural mortality was 0.9%. In patients with severe AS at entry, peak aortic jet velocity (greater than 5 m/s) and LVEF (less than 60%) were associated with all-cause and cardiovascular mortality without AVR; these factors were also associated with postprocedural mortality in those patients with severe AS at baseline who underwent AVR (surgical AVR in 310 patients; transcatheter AVR in 78 patients). Conclusions and Relevance: In patients with asymptomatic AS followed up in heart valve centers, the risk of sudden death is low, and rates of overall survival are similar to those reported from previous series. Patients with severe AS at baseline and peak aortic jet velocity of 5.0 m/s or greater or LVEF less than 60% have increased risks of all-cause and cardiovascular mortality even after AVR. The potential benefit of early intervention should be considered in these high-risk patients
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