The current investigation aimed to study the efficacy of hemostatic therapy guided either by conventional coagulation analyses or point-of-care (POC) testing in coagulopathic cardiac surgery ...patients.
Patients undergoing complex cardiac surgery were assessed for eligibility. Those patients in whom diffuse bleeding was diagnosed after heparin reversal or increased blood loss during the first 24 postoperative hours were enrolled and randomized to the conventional or POC group. Thromboelastometry and whole blood impedance aggregometry have been performed in the POC group. The primary outcome variable was the number of transfused units of packed erythrocytes during the first 24 h after inclusion. Secondary outcome variables included postoperative blood loss, use and costs of hemostatic therapy, and clinical outcome parameters. Sample size analysis revealed a sample size of at least 100 patients per group.
There were 152 patients who were screened for eligibility and 100 patients were enrolled in the study. After randomization of 50 patients to each group, a planned interim analysis revealed a significant difference in erythrocyte transfusion rate in the conventional compared with the POC group 5 (4;9) versus 3 (2;6) units median (25 and 75 percentile), P<0.001. The study was terminated early. The secondary outcome parameters of fresh frozen plasma and platelet transfusion rates, postoperative mechanical ventilation time, length of intensive care unit stay, composite adverse events rate, costs of hemostatic therapy, and 6-month mortality were lower in the POC group.
Hemostatic therapy based on POC testing reduced patient exposure to allogenic blood products and provided significant benefits with respect to clinical outcomes.
Minimally-Invasive Valve Surgery Schmitto, Jan D., MD, PhD; Mokashi, Suyog A., MD; Cohn, Lawrence H., MD
Journal of the American College of Cardiology,
08/2010, Letnik:
56, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Minimally-invasive approaches have become increasingly important in cardiac valve surgery. Smaller incisions have become commonplace in many major centers. We reviewed the existing literature and ...present the current state-of-the-art of minimally-invasive valve operations in this paper.
Background Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ...ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period. Methods Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients. Results Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE ( p = 0.018). Conclusions This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.
Objective The present study assessed the clinical and echocardiographic outcomes for 1000 patients undergoing minimally invasive mitral valve surgery. Methods The Brigham Cardiac Valve database was ...reviewed. From August 1996 to November 2011, 1000 patients had undergone minimally invasive mitral valve surgery (median follow-up, 7 years). Data on the surgical approach, complications, reoperations, and late survival were tabulated. Late echocardiographic data on the recurrence of mitral regurgitation after mitral repair in myxomatous disease were also collected. Survival, freedom from reoperation and recurrent mitral regurgitation (grade ≥ 3+) were evaluated with life tables and Kaplan-Meier analyses. Results The mean patient age was 57 years. Of the 1000 patients, 41% were women. Myxomatous degenerative disease was the predominant pathologic entity (86%). A lower hemisternotomy was the predominant surgical approach (75%). Mitral repair was performed in 923 patients and replacement in 77. Eight operative deaths (0.8%) occurred. A total of 44 patients with failed mitral repairs underwent reoperation, with 1 mitral valve replaced again on the same operative day for atrioventricular groove disruption. Nine failed repairs were repaired again (9/44 20%). A total of 106 late deaths occurred. The overall survival at 15 years was 79% ± 3%. Freedom from reoperation at 15 years was 90% ± 3% for repairs and 100% for replacements. Late echocardiograms were acquired for 615 of 815 eligible mitral repair patients with myxomatous disease (75%). Freedom from recurrent mitral regurgitation (grade ≥ 3+) at 1, 5, and 10 years was 99% ± 1%, 87% ± 2%, and 69% ± 4%, respectively. Conclusions Minimally invasive mitral valve surgery is effective, with excellent late results. The durability of minimally invasive mitral valve repair compared favorably with conventional full sternotomy methods at late follow-up.
Abstract Background Surgical dogma suggests that homografts should be used preferentially, compared with conventional xenograft or mechanical prostheses, in the setting of infective endocarditis ...(IE), because they have greater resistance to infection. However, comparative data that support this notion are limited. Methods From the prospective databases of 2 tertiary academic centers, we identified 304 consecutive adult patients (age ≥17 years) who underwent surgery for active IE involving the aortic valve (AV), in the period 2002 to 2014. Short- and long-term outcomes were evaluated using propensity scores and inverse-probability weighting to adjust for selection bias. Results Homografts, and xenograft and mechanical prostheses, were used in 86 (28.3%), 139 (45.7%), and 79 (26.0%) patients, respectively. Homografts were more often used in the setting of prosthetic valve endocarditis (58.1% vs 28.8%, P = .002) and methicillin-resistant Staphylococcus (25.6% vs 12.1%, P = .002), compared with conventional prostheses. Early mortality occurred in 17 (19.8%) in the homograft group, and 20 (9.2%) in the conventional group ( P = .019). During follow-up (median: 29.4 months; interquartile-range: 4.7-72.6 months), 60 (19.7%) patients died, and 23 (7.7%) experienced reinfection, with no significant differences in survival ( P = .23) or freedom from reinfection rates ( P = .65) according to the types of prostheses implanted. After adjustments for baseline characteristics, using propensity-score analyses, use of a homograft did not significantly affect early death (odds ratio 1.61; 95% confidence interval CI, 0.73-3.40, P = .23), overall death (hazard ratio 1.10; 95% CI, 0.62-1.94, P = .75), or reinfection (hazard ratio 1.04; 95% CI, 0.49-2.18, P = .93). Conclusions No significant benefit to use of homografts was demonstrable with regard to resistance to reinfection in the setting of IE. The choice among prosthetic options should be based on technical and patient-specific factors. Lack of availability of homografts should not impede appropriate surgical intervention.
Abstract Objective We hypothesized that increased postgraduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures. Methods ...Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated coronary artery bypass grafting (CABG) (n = 3726), aortic valve replacement (AVR) (n = 1626), mitral valve repair (n = 731), mitral valve replacement (MVR) (n = 324), and MVR + AVR (n = 184) from January 2002 through June 2012. After adjusting for patient risk and surgeon variability, we evaluated the influence of surgeon experience on cardiopulmonary bypass and crossclamp times, and long-term survival. Results Mean surgeon experience after fellowship graduation was 16.0 ± 11.7 years (range, 1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and crossclamp times with increased surgeon experience. There was marginal improvement in the predictability ( R2 value) of cardiopulmonary bypass and crossclamp time for CABG with the addition of surgeon experience; however, all other procedures had marked increases in the R2 following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (hazard ratio HR, 0.85; P < .0001), mitral valve repair (HR, 0.73; P < .0001), and MVR + AVR (HR, 0.95; P = .006) but not in CABG (HR, 0.80; P = .15), and a trend toward significance in MVR (HR, 0.87; P = .09). Conclusions In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival.
Abstract Background With increasing prevalence of injected drug use in the United States, a growing number of intravenous drug users (IVDUs) are at risk for infective endocarditis (IE) that may ...require surgical intervention; however, few data exist about clinical outcomes of these individuals. Methods We evaluated consecutive adult patients undergoing surgery for active IE between 2002 and 2014 pooled from 2 prospective institutional databases. Death and valve-related events, including reinfection or heart valve reoperation, thromboembolism, and anticoagulation-related hemorrhage were evaluated. Results Of the 436 patients identified, 78 (17.9%) were current IVDUs. The proportion of IVDUs increased from 14.8% in 2002 to 2004 to 26.1% in 2012 to 2014. IVDUs were younger (aged 35.9 ± 9.9 years vs 59.3 ± 14.1 years) and had fewer cardiovascular risk factors than non-IVDUs. During follow-up (median, 29.4 months; quartile 1-3, 4.7-72.6 months), adverse events among all patients included death in 92, reinfection in 42, valve-reoperation in 35, thromboembolism in 17, and hemorrhage in 16. Operative mortality was lower among IVDUs (odds ratio, 0.25; 95% confidence interval CI, 0.06-0.71), but overall mortality was not significantly different (hazard ratio HR, 0.78; 95% CI, 0.44-1.37). When baseline profiles were adjusted by propensity score, IVDUs had higher risk of valve-related complications (HR, 3.82; 95% CI, 1.95-7.49; P < .001) principally attributable to higher rates of reinfection (HR, 6.20; 95% CI, 2.56-15.00; P < .001). Conclusions The proportion of IVDUs among surgically treated IE patients is increasing. Although IVDUs have lower operative risk, long-term outcomes are compromised by reinfection.
Objectives Both partial and complete annuloplasty rings are used for mitral valve repair for patients with functional mitral regurgitation (FMR). We sought to determine if recurrence of mitral ...regurgitation (MR) is affected by the type of ring used. Methods Five hundred forty-eight patients diagnosed with FMR underwent mitral valve repair with ring annuloplasty between 1998 and 2008 in our institution. Medical records were reviewed retrospectively for clinical and echocardiographic data to determine the presence of recurrent MR (defined as moderate or severe). Results Among 479 patients for whom postoperative echocardiographic data were available, recurrent MR occurred less frequently in the complete versus partial ring group (20 of 209 10% vs 56 of 270 21% patients; P = .001), despite lower preoperative ejection fractions in the complete ring group (median, 35%; interquartile range, 25%-45% vs median, 40%; interquartile range, 30%-55%; P < .001). Kaplan-Meier analysis demonstrated greater freedom from recurrent MR in the complete ring group (108 vs 103 months; P = .001). Risk-matched propensity analysis of 102 patients per group (area under the curve, 0.824; 95% confidence interval, 0.788-0.861; P < .001) also demonstrated that complete ring recipients had greater freedom from recurrent MR than partial ring recipients by univariate analysis (7 7% vs 17 17% patients; P = .049), and a trend toward greater freedom by Kaplan-Meier analysis (110 vs 104 months; P = .068). Conclusions The use of complete mitral annuloplasty rings provides improved freedom from recurrent MR in patients with FMR.
Objective Risk-stratifying algorithms are currently used to determine which patients may be at prohibitive risk for surgical aortic valve replacement, and thus candidates for transcatheter aortic ...valve implantation. Minimally invasive surgical approaches have been successful in reducing morbidity and improving survival after aortic valve replacement, especially in octogenarians. We documented outcomes after minimally invasive aortic valve replacement in high-risk octogenarians who may be considered candidates for percutaneous/transapical aortic valve replacement. Methods From 1996 to 2009, minimally invasive aortic valve replacement was performed in 249 consecutive octogenarians. We used the modified European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons score to risk-stratify patients and characterize all early and late results. Results The mean age at operation was 84 ± 3 (range 80–95) years, and 111 patients (45%) were male. Twenty-one percent (n = 52) had previous cardiac surgery. Operative mortality was 3% (n = 8/249). The median modified European System for Cardiac Operative Risk Evaluation (11%; interquartile range, 6–14) and Society of Thoracic Surgeons score (10.5%; interquartile range, 7–17) were not predictive of 30-day mortality in this cohort of patients (European System for Cardiac Operative Risk Evaluation c-index = 0.527, P = .74, Society of Thoracic Surgeons score c-index = 0.67, P = .18). Despite their poor predictive power, the Society of Thoracic Surgeons score and European System for Cardiac Operative Risk Evaluation were correlated with each other ( r = 0.40, P < .0001). Postoperative complications included stroke in 10 patients (4%), pneumonia in 3 patients (1%), renal failure requiring dialysis in 2 patients (1%), cardiac arrest in 2 patients (1%), pulmonary embolism in 1 patient (1%), and sepsis in 1 patient (1%). Follow-up was available for 238 patients (96%) and extended up to 12 years. Overall, long-term survival after minimally invasive aortic valve replacement at 1, 5, and 10 years was 93%, 77%, and 56%, respectively. There was no significant difference in long-term survival compared with that of a US age- and gender-matched population (standardized mortality ratio, 1.01; 95% confidence interval, 0.76–1.37; P = .88). A multivariate Cox-proportional hazards model indicated that increasing age (hazard ratio, 1.10; P = .008) and severe chronic obstructive pulmonary disease (hazard ratio, 2.52; P < .007) were significant predictors of survival. By using these factors, a clinical prediction model ( P = .02) was developed and demonstrated that low-risk patients (first quartile prediction score) had 1-, 5-, and 8-year survival of 94%, 84%, and 67%, whereas high-risk patients (third quartile prediction score) had 1-, 5-, and 8-year survival of 89%, 74%, and 49%, respectively. Conclusions Patients thought to be high-risk candidates for surgical aortic valve replacement have excellent outcomes after minimally invasive surgery with long-term survival that is no different than that of an age- and gender-matched US population. These data provide a benchmark against which outcomes of transcatheter aortic valve implantation could be compared.
Mitral Valve Repair Kaneko, Tsuyoshi; Cohn, Lawrence H
Circulation Journal,
2014, Letnik:
78, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Mitral valve repair is the gold standard treatment for mitral regurgitation. The history of mitral valve repair and its refinement in terms of the technique used will show the evolution of this ...surgical technique. The standard technique we use for mitral valve repair is described, and the outcomes we have observed over the past 4 decades are presented. (Circ J 2014; 78: 560–566)
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