High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery

OBJECTIVE: The failure to wean from mechanical ventilation is related to worse outcomes after cardiac surgery. The aim of this study was to evaluate whether the serum level of B-type natriuretic peptide is a predictor of weaning failure from mechanical ventilation after cardiac surgery. METHODS: We conducted a prospective, observational cohort study of 101 patients who underwent on-pump coronary artery bypass grafting. B-type natriuretic peptide was measured postoperatively after intensive care unit admission and at the end of a 60-min spontaneous breathing test. The demographic data, hemodynamic and respiratory parameters, fluid balance, need for vasopressor or inotropic support, and length of the intensive care unit and hospital stays were recorded. Weaning failure was considered as either the inability to sustain spontaneous breathing after 60 min or the need for reintubation within 48 h. RESULTS: Of the 101 patients studied, 12 patients failed the weaning trial. There were no differences between the groups in the baseline or intraoperative characteristics, including left ventricular function, EuroSCORE and lengths of the cardiac procedure and cardiopulmonary bypass. The B-type natriuretic peptide levels were significantly higher at intensive care unit admission and at the end of the breathing test in the patients with weaning failure compared with the patients who were successfully weaned. In a multivariate model, a high B-type natriuretic peptide level at the end of a spontaneous breathing trial was the only independent predictor of weaning failure from mechanical ventilation. CONCLUSIONS: A high B-type natriuretic peptide level is a predictive factor for the failure to wean from mechanical ventilation after cardiac surgery. These findings suggest that optimizing ventricular function should be a goal during the perioperative period

Drug-coated balloon angioplasty versus nitinol stent in the superficial femoral artery

A superioridade da angioplastia com implante de stent autoexpansível de nitinol sobre a angioplastia com balão convencional para o tratamento das lesões oclusivas fêmoro-poplíteas está bem definida. Por outro lado, o uso de balões farmacológicos se mostrou seguro e eficaz quando comparado aos resultados da angioplastia com balão convencional. O propósito deste estudo foi avaliar se os resultados do tratamento percutâneo com balão farmacológico são não inferiores em relação ao implante de stent autoexpansível de nitinol, no território fêmoro-poplíteo, analisando a taxa de perviedade primária ao longo de um ano, por meio do ultrassom com doppler colorido. Trata-se de um ensaio clínico randomizado, unicêntrico, simples-cego, de não-inferioridade realizado em centro de referência para doenças cardiovasculares no Estado de São Paulo. Foram randomizados 85 pacientes portadores doença arterial obstrutiva periférica (DAOP) sintomática Classificação de Rutherford Categoria 3 ou superior com documentação angiográfica de obstrução superior a 70% ou oclusão, localizada nas artérias femoral superficial e/ ou poplítea proximal de até 15 cm de extensão, distribuídos aleatoriamente em dois grupos, numa proporção de 1:1 para o tratamento endovascular através de angioplastia com stent de nitinol ou balão farmacológico. O objetivo primário do estudo foi avaliar a taxa de perviedade primária, definida como a ausência combinada de revascularização da lesão-alvo (Target Lesion Revascularization), reestenose > 50% ao ultrassom com Doppler. A prevalência de oclusão observada na amostra foi de 71,4% e o implante de stent de resgate pós angioplastia foi necessário em 16,7% desses casos. Para o estudo estabelecemos uma margem de não inferioridade de -10%, ao final de 12 meses a taxa de perviedade foi de 89,7% no grupo balão farmacológico e 80,0% no grupo stent de nitinol (diferença entre os grupos de 9,7%, intervalo de confiança de 95%, para teste unicaudal: -8.42% a 27.91%; p=0,007) ou seja, não-inferioridade demonstrada. A taxa de mortalidade geral e de amputações maiores foram baixas, sendo respectivamente de 4,7% de 1,17%. O uso do balão farmacológico com Paclitaxel demonstrou ser não inferior ao implante de stent autoexpansível em nitinol para intervenções fêmoro-poplíteas nas lesões obstrutivas de até 15 cm de comprimento.The superiority of angioplasty with bare nitinol stents over plain old balloon angioplasty for the treatment of occlusive femoropopliteal lesions is well documented. On the other hand, the use of drug-coated balloons proved to be safe and effective when compared to plain old balloon angioplasty. The purpose of this study was to evaluate the results of percutaneous treatment with drug-eluting balloon is non-inferior to implantation of a bare nitinol stents in the femoropopliteal territory, analyzing the rate of primary patency over a year on color Doppler ultrasound. This is a randomized, single-centre, singleblind, non-inferiority clinical trial carried out at a referral center for cardiovascular disease in the State of São Paulo. Eighty-five patients with symptomatic peripheral artery disease - Rutherford classification Category 3 or higher - with angiographic documentation of greater than 70% obstruction or total occlusion located in the superficial femoral artery and / or proximal popliteal, up to 15 cm in length, were randomly divided into two groups, in a 1:1 ratio for endovascular treatment through angioplasty with nitinol stent or drug-coated balloon. The primary efficacy endpoint comprised the patency rate, defined as the combined absence of target lesion revascularization (TLR) and restenosis above 50% at postoperative duplex scanning. Total occlusion was observed in 71.4% of the treated lesions, and provisional stenting was performed in 16.7% of those cases. We evaluated the hypothesis of drug-coated balloon non-inferiority in relation to bare nitinol stent, with a margin of -10% at 12 months. Primary patency was 80% in the bare nitinol stent group and 89.7% in the drug-coated balloon group (difference: 9.7% [one-sided lower bound of the 95% CI: - 8.42% to 27.91%]; non-inferiority P value of 0.007). The overall death rate was 4.7%, and the major amputation rate was 1.17%. The use of drug-coated balloons was demonstrated to be non-inferior to the implantation of bare nitinol stents for femoropopliteal interventions in lesions up to 15 cm in length

Tratamento endovascular de aneurisma de aorta abdominal com fístula aorto-cava utilizando oclusor vascular concomitante a endoprótese bifurcada: relato de caso

Resumo As fístulas aorto-cava são entidades raras e de etiologia variada, estando frequentemente associadas a significativa morbimortalidade. Acredita-se que o aumento da tensão da parede nos grandes aneurismas resulte em reação inflamatória e aderência à veia adjacente, culminando na erosão das camadas aderidas e na formação da fístula. O tratamento cirúrgico convencional tem altas taxas de mortalidade. Embolia pulmonar paradoxal e o vazamento são complicações temidas do tratamento endovascular. O uso de oclusor vascular associado a endoprótese bifurcada é boa opção no tratamento do aneurisma de aorta abdominal com fístula aorto-cava

Computed Tomograpy Venography diagnosis of iliocaval venous obstruction in advanced chronic venous insufficiency

Objective:Iliocaval obstruction is associated with venous hypertension symptoms and may predispose to deep venous thrombosis (DVT). Ultrasonography may fail to achieve noninvasive diagnosis of these obstructions. The possibility of using Computed Tomography Venography (CTV) for these diagnoses is under investigation.Methods:Patients with CVI graded at CEAP clinical classes 3 to 6 and previous treatment failure underwent evaluation with CTV. Percentage obstruction was rated by two independent examiners. Obstruction prevalence and its associations with risk factors and CEAP classification were analyzed.Results:A total of 112 limbs were prospectively evaluated. Mean patient age was 55.8 years and 75.4% were women. Obstructions involved the left lower limb in 71.8% of cases and 35.8% of patients reported a medical history of deep venous thrombosis. Overall, 57.1% of imaging studies demonstrated venous obstruction of at least 50% and 10.7% showed obstruction of >80%. The only risk factor that was found to be independently associated with a significantly higher incidence of >50% venous obstruction was a medical history of DVT (p=0.035) (Fisher's exact test). There was a positive relationship between clinical classification (CEAP) and degree of venous obstruction in the limbs studied (Chi-square test for linear trend; p=0.011).Conclusion:Patients with advanced CVI are often affected by obstructions in the iliocaval venous territory and CTV is able to diagnose the degree of obstruction. There is a positive association between degree of obstruction and both previous history of DVT and severity of symptoms of CVI