1,721,014 research outputs found
Implante transapical sin bomba de neocuerdas tras recurrencia de regurgitación mitral
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New echocardiographic screening tool for left ventricular tract obstruction risk assessment in TMVR
No full textBackground: Transcatheter mitral valve replacement (TMVR) is an alternative to conventional surgery to treat severe mitral disease but its use is limited by the risk of left ventricular outflow tract obstruction (LVOTO). Screening depends on ECG-gated computed tomography (CT) that is not widely available and requires contrast. We developed and validated a transthoracic echocardiographic (TTE) method to assess the risk of LVOTO after TMVR with the Tendyne System. Methods: We measured the LVOT longitudinal area on preoperative TTE dataset of patients screened for TMVR. The LVOT was measured as the box-area included by the aortic valve annulus, the anterior mitral leaflet (AML), the c-septum distance line, and the respective length of the AML on the interventricular septum. We analyzed the correlation between the TTE LVOT-box and the CT-measured neoLVOT area. Prediction performance for eligible patients was tested with ROC curves. Results: Thirty-nine patients were screened, out of 14 patients (36%) not eligible for TMVR, 8 had risk of LVOTO. We found a linear correlation between the TTE LVOT-box and the CT-measured Neo-LVOT (r = 0.6, p = 0.002). ROC curve showed that the method is specific and sensitive and the cut-off value of the measure LVOT-box is 350 mm2. Conclusions: The proposed method is reliable to evaluate the risk of LVOTO after TMR with the Tendyne System. It is quick and easy and can be used as a first-line assessment in the outpatient clinic. Patients with LVOT-box <350 mm2 should not be further screened with ECG-gated cardiac CT
Minimally invasive left atrial appendage occlusion plus reduced dose direct oral anticoagulant to prevent stroke in patients with atrial fibrillation-the LAAO-PlusRE
No full text: The onset of atrial fibrillation (AF) has a direct association with left atrial appendage (LAA) function, as demonstrated by recent studies demonstrating the link between left atrial (LA) wall fibrosis, impaired contractility, and the development of AF. Non-valvular AF (NVAF) affects almost 30 million people worldwide, with this number expected to increase in the next 20 years. It is the main cause of ischemic stroke, with significant subsequent economic and social impact. Currently, the mainstay of stroke prevention in patients with NVAF is oral anticoagulation (OAC), which reduces the incidence of ischemic events at the stake of increased hemorrhagic events. Despite the introduction and widespread use of direct oral anticoagulants (DOACs), which almost completely replaced vitamin K antagonists (VKAs), the adherence to OAC is still low, hindering the efficacy of stroke prevention. Percutaneous LAA occlusion (LAAO) is now indicated (class IIB) in patients with NVAF at increased ischemic risk who cannot undergo OAC. Recently published data demonstrated that a reduced dose of DOAC after percutaneous LAAO is superior to long-term dual antiplatelet therapy (DAPT) for stroke prevention in the mid-term. One of the possible pitfalls of percutaneous LAAO is postprocedural peri-device leaks (PDLs) that have been associated with increased thromboembolic events. According to LAAOS III results, surgical LAAO during cardiac surgery brings a 33% reduction in risk of stroke at five years, independently from the OAC regimen with a high rate of complete appendage occlusion. The combination of surgical LAAO and reduced dose DOAC might ensure adequate embolic prevention, lowering the hemorrhagic risk. The present manuscript aims to describe the rationale and design of the Minimally Invasive Left Atrial Appendage Occlusion Plus REduced Dose DOAC To Prevent Stroke In Patients With Atrial Fibrillation Randomized Clinical Trial (LAAO-PlusRE)
Risk stratification of severe aortic stenosis according to new guidelines: Long term outcomes
Full text linkBackground: Current ESC and ACC/AHA guidelines for the management of valvular heart disease assign a class Ia indication for aortic valve replacement (AVR) only to patients with symptomatic severe aortic valve stenosis and asymptomatic patients with depressed left ventricular ejection fraction (LVEF <50%) or positive exercise test. We examined the long-term outcomes for patients undergoing AVR for aortic stenosis over a 11-year period at our institution compared to current international guidelines for AVR. Methods: Patients who had undergone isolated AVR for severe aortic valve stenosis between January 2001 and December 2012 were selected. The population was divided into subgroups based on preoperative LVEF (< or ≥50%) and on presence/absence of symptoms (NYHA =I or ≥II, respectively). Results: We identified 607 patients with a median follow-up (FU) time of 5.75 years (IQR 3.24–8.00 years). The presence of symptoms did not have a significant impact on cardiovascular mortality (P=0.201). Patients with LVEF <50% displayed a higher long-term cardiovascular mortality rate (P=0.015). Multivariate analysis showed that preserved LVEF was a protective factor for asymptomatic patients (P=0.021), while preoperative LVEF did not affect the mortality rate in symptomatic patients (HR 0.88; 95% CI, 0.54–1.44). Correspondingly, asymptomatic patients with reduced LVEF were found to be at a higher risk of long-term mortality compared to the other groups (P=0.011). The only other independent risk factor for death was age (HR 6.46; 95% CI, 2.22–18.76). Conclusions: According to our data, current international class I indications for symptomatic patients ensure good long-term survival, while class I indications for asymptomatic patients with reduced LVEF are associated with poor long-term survival. Our results suggest that early surgery should also be considered also for asymptomatic patients with preserved LVEF, particularly in cases of very low operative risk. © Journal of Thoracic Disease. All rights reserved
A simple in silico model as a support in the clinical practice: automatic setting of a VA-ECMO system
No full textThe use of peripheral VA-ECMO remains controversial despite its increased use in clinical practice. Complications are still very common, and their underlying causes, possibly related to CS (Cardiogenic Shock) etiology and VA-ECMO setting, are not comprehensively understood yet.
A mathematical model of the complete native circulation supported by VA-ECMO is proposed, which can help in automatic setting the mechanical pump and monitoring patient’s hemodynamics. The real system is represented as a combination of functional compartments (e.g. the heart chambers, described by the time-varying elastance), where pressure and flow rate (or volume) waves are calculated. The CS condition is simulated by reducing the maximum elastance of the left ventricle of an appropriate grade of impairment, k. Different criteria for CS identification i.e., thresholds on SBP, MAP UO, EF and CI, are adopted.
Depending on the CS criterion the impairment k ranges from 50% up to 84%, and the VA-ECMO pressure head that guarantees a flow of 3.6 l/min falls in the range 100-80 mmHg. Hemodynamics in the supported patient changes accordingly, with respect to both the positive (e.g., perfusion increase) and negative (e.g. LV distension) effects of ECMO.
According to the model, the setting of the VA-ECMO pump depends on the CS hemodynamic criterion and the selected pump flow rate. This could lead to different management of the patient and different outcomes. The model proves its potential as a bed-side tool for the automatic control of the mechanical circuit
The prophylactic use of negative pressure wound therapy after cardiac surgery: a meta-analysis
No full textBackground: Surgical site infections (SSi) pose a frequent complication in cardiac surgery patients and lead to increased patient discomfort and extended hospitalization. Aim: This meta-analysis evaluates the protective role of single-use-negative-pressure-wound-therapy (sNPWT) devices on closed surgical wounds after cardiac surgery, and explores their potential preventive application across all cardiac surgery patients. Methods: A comprehensive literature search was conducted on PubMed and Elsevier, focusing on studies related to "negative pressure wound therapy" or "PICO negative pressure wound therapy" combined with "cardiac surgery" or "sternotomy," published between 2000 and 2022. Inclusion criteria encompassed case-control studies comparing sNPWT with traditional dressing on closed cardiac surgical incisions in adult patients undergoing median sternotomy without immediate postoperative infective complications, with available details on SSIs. A retrospective analysis of cases treated with sNPWT in our Center was also performed. Findings: The meta-analysis revealed a protective role of sNPWT, indicating a 44% risk reduction in overall SSIs (OR 0.56) and a 40% risk reduction in deep wound infections (OR 0.60). Superficial wound infections, however, showed non-significant protective effects. A single-center study aligned with the meta-analysis findings, confirming the efficacy of sNPWT and was included in the meta-analysis. Conclusion: The meta-analysis and the single-centre study collectively support the protective role of negative pressure wound therapy against overall and deep surgical site infections, suggesting its potential prophylactic use on all cardiac surgery population
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