1,721,294 research outputs found
Results of atrial fibrillation ablation during mitral surgery in patients with poor electro-anatomical substrate
No full textBACKGROUND AND AIM OF THE STUDY: Enlarged (> 50 mm) atria, longstanding (> 5 years) persistent atrial fibrillation (AF) and age > 70 years are considered predictive of recurrent AF following surgical ablation. The electrophysiological and clinical outcome after AF-ablation was evaluated in high-risk patients undergoing concomitant procedures. METHODS: Between January 2005 and January 2009, a total of 45 patients who complied with the three major predictors of failure, but who had undergone AF ablation ('left + right bipolar radiofrequency Maze') during concomitant mitral surgery were followed up. Freedom from AF, atrial flutter (AFL) and atrial tachycardia (AT), without anti-arrhythmic therapy (discontinued at the sixth month) was the primary endpoint. Survival, freedom from AF/AFL/AT with anti-arrhythmic therapy, early events during post-ablation blanking period, freedom from congestive heart failure (CHF) and from re-hospitalization, and changes in NYHA functional class were registered. RESULTS: Postoperatively, 18 patients (40%) showed sinus rhythm (SR) at admission to the intensive care unit, while 16 (26%) showed junctional rhythm and five (11%) required definitive pacemaker. Eleven of the 40 patients (28%) were discharged without a pacemaker, and experienced early events during the post-ablation blanking period. After a mean of 21 +/- 14 months' follow up, the actuarial survival was 88 +/- 7%. The prevalence of SR at six, 12, and 18 months was 74%, 64%, and 64% respectively. Freedom from AF/AFL/AT was 54 +/- 10% without anti-arrhythmic medications, and 51 +/- 9% with such drugs. Freedom from CHF was 85 +/- 6%, and significantly better in SR patients (94 +/- 6%) than in AF patients (69 +/- 13%; p = 0.018). Freedom from rehospitalization was 75 +/- 8%, and better in SR patients (94 +/- 6%) than in AF patients (37 +/- 14%; p = 0.0001). Accordingly, when compared to AF patients, the NYHA class was significantly ameliorated in SR patients at both six months (1.4 +/- 0.6 versus 2.7 +/- 0.9) and at the final follow up control (1.2 +/- 0.5 versus 1.9 +/- 0.7; p < 0.0001). The E/A wave recovered in 22 (85%) of the SR patients. CONCLUSION: AF ablation during mitral valve surgery achieves good electrophysiological results, even in patients traditionally considered as poor candidates. SR recovery allows a higher freedom from CHF and rehospitalization, with a better functional recovery when compared to AF
PULSATILE CARDIOPULMONARY BYPASS IN ELDERLY PATIENTS WITH INCREASED PULSE PRESSURE (REPLY)
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Informazioni fornite dalle diverse matrici da testare con i saggi biologici: applicabilità di Vibrio fischeri
No full textSafety and efficacy of a novel temporary sternal spreader in the management of severe postcardiotomy cardiogenic shock: A preliminary report study
No full textOpen chest management (OCM) with delayed sternal
closure (DSC) is a valuable tool to manage patients with
postcardiotomy hemodynamic instability related to cardiogenic
shock with myocardial and lung edema and/or severe
coagulopathy.1-4
OCM traditionally involves the use of plastic material
(generally a syringe) acting as a stent between the 2 hemisternal
halves, with the purposes to maintain the chest
open to prevent compression and to avoid traumatic
injuries on the underlying mediastinal structures.1-4 The
use of these ‘‘passive’’ plastic stents, however, is linked
to the ‘‘all or nothing’’ rule, which makes the decision
on stent removal and chest closure tricky and
potentially associated with a renewed hemodynamic
instability.4 The risk for passive stent dislocation with potential
sternal fracture or mediastinal injury has also been
reported.1-5
We tested a new device for temporary sternal stenting,
the Temporary Sternal Spreader (TSS; Futura Engineering,
Cerbara, PG, Italy), which allows ‘‘closed’’
remote spreading variations over time until complete reapproximation
of the sternal halves is accomplished,
while keeping the wound continuously covered by
a sterile elastic membrane. The trial was coupled
with continuous hemodynamic monitoring to titrate
sternal reapproximation on objective hemodynamic
improvements
Hemostasis during cardiopulmonary bypass
No full textCardiopulmonary bypass (CPB) extensively activates the hemostatic system. When blood comes into contact with nonendothelial surfaces, it activates platelets and factor XII triggering the coagulation intrinsic pathway. At the same time, cardiac surgery itself is responsible for mechanical tissue damage, tissue factor exposure, and activation of the extrinsic pathway. Laminar flow induces proinflammatory cytokines release. Hemodilution, together with hypothermia, significantly reduces concentration of fibrinogen and coagulation factors. Longer CPB runs decrease postoperative platelets count and function. Moreover, medications affecting the coagulation system are commonly used by patients undergoing cardiac surgery. Thus careful anticoagulation management during CPB is required to avoid life-threatening thromboembolic and bleeding complications. Unfractionated heparin (UFH) is the gold-standard anticoagulant used with extracorporeal circulation and it is monitored with the point-of-care activated clotting time test. Careful attention should be paid in case of antithrombin deficiency due to increased risk of heparin resistance. Furthermore, inadequate heparin reversal with protamine may lead to postoperative heparin rebound. In the event of specific clinical conditions such as active heparin-induced thrombocytopenia, heparin allergy, and protamine allergy, alternatives to UFH must be considered
The determinants of functional capacity in left ventricular assist device patients: many actors with not well defined roles
No full textImprovement in hemodynamic parameters is routinely demonstrated in patients implanted with continuous-flow left ventricular assist devices (CF-LVADs). However, functional capacity assessed by cardiopulmonary exercise test (CPET), following LVAD implantation, remains considerably restricted. In this review, we analyzed the current knowledge on the causes of the persistent limitation in exercise capacity in CF-LVAD patients. Limitation to exercise is multifactorial and involves: LVAD factors (fixed CF-LVAD pump speed), native cardiac factors (residual function of native left ventricle, right ventricular dysfunction, aortic valve abnormalities), comorbidities (abnormal skeletal muscle metabolism, low skeletal muscle mass, anemia), patient's characteristics (age, physical deconditioning). In addition, we emphasize the role of some potential therapeutic strategies like the increase in CF-LVAD pump speed according to the patient's activity, the echo-optimization of the device (paying attention to right ventricular function and aortic valve opening), the implementation of physical rehabilitation and the treatment of potentially reversible extracardiac factors (anemia, muscle deconditioning, obesity)
Mitral valvuloplasty complicated by catheter perforation of the right atrium and the aortic root
No full textAccording to latest guidelines, percutaneous mitral commissurotomy (PMC) represents the first-line treatment for symptomatic severe mitral valve stenosis with favorable morphology. We report successful surgical treatment of a potential life-threatening complication occurred during PMC. Heart-team discussion and closed collaboration with centers are crucial for decision-making and cardiac surgery onsite should be ensured for high-risk procedures
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