Cardiovascular surgery (London, England)最新文献

Abdominal aortic aneurysm (AAA) repair is a complex surgical procedure and is commonly performed in a variety of practice settings across the United States. The quality of surgical care is neither ideal nor uniform across medical centers with documented variation in both utilization and outcomes. Recent data document that screening, though effective in reducing AAA-related deaths, may have only small contributions to population mortality. Large randomized trials have provided evidence regarding the timing of AAA repair and provide strong evidence for the development of appropriateness criteria. In general, lower mortality rates have been consistently associated with higher provider volume (surgeon and hospital) and specialization in vascular surgery. Current health policy initiatives suggest referral of several complex procedures to high volume centers based on minimum volume standards. Processes of care of high-volume providers and vascular surgeons should be studied and used to guide quality improvement efforts for lower volume providers and surgeons of other specialties performing AAA repair.

Purpose: Recurrent carotid stenosis following standard longitudinal carotid endarterectomy (s- CEA), with and without patch angioplasty, effects the durability of the procedure and can lead to reintervention. The purpose of this study is to evaluate the incidence of restenosis following eversion carotid endarterectomy (e-CEA) in women.

Methods: The records of all patients undergoing elective carotid endarterectomy (CEA) for symptomatic and asymptomatic high-grade carotid stenosis over a 5-year period from July 1994 to June 1999 were reviewed. Eversion endarterectomy was performed preferentially under regional anesthesia in awake patients. Postoperatively, patients were routinely evaluated by duplex scans at 3 months, 6 months, 12 months, and yearly thereafter. Hemodynamically significant restenosis (>70%) via duplex scans was confirmed by standard or magnetic resonance angiography. Student’s t-test and Chi square analysis were used to assess statistical significance and assumed for P<0.05.

Results: Over this 5-year period, 3429 eversion carotid endarterectomies were done for symptomatic (female: 375, male: 573) and asymptomatic (female: 1091, male: 1390) high grade carotid stenosis. In the postoperative period 18 (0.9%) male and 12 (0.8%) female patients developed a permanent stroke (P = NS). Operative mortality was 0.6% (n = 12) in males and 0.5% (n = 8) in females (P = NS). Cranial nerve injuries, wound infections, and neck hematoma occurred in 7 (0.4%), 2 (0.1%), and 26 (1.3%) male and in 3 (0.2%), 3 (0.2%), and 15 (1.0%) female patients, respectively. Recurrent carotid stenosis greater than 70% via duplex scan (PSV >125 cm/s and EDV >100 cm/s) developed in 12 (1.0%) males and 15 (1.5%) females (P = NS).

Conclusion: The eversion technique for CEA requires both the transection and anastomosis of the internal carotid artery at the carotid bulb, and appears to result in a low incidence of restenosis in women. This is a straightforward technique and obviates the need for primary closure of distal smaller caliber internal carotid artery that can lead to narrowing, and the use of patch closure that has its attendant risks.

Purpose: Several investigators have suggested a dismal prognosis of ruptured abdominal aortic aneurysm (rAAA) repair in the elderly. The purpose of this study is to evaluate the morbidity and mortality of rAAA repair in octogenarians and compare it to that of a younger population.

Methods: From 1980 to 2000, all patients undergoing emergent rAAA repair were divided into two groups based on their age; Group I: age <80, Group II: ≥80 years. Outcomes were evaluated based on a Chi-square test and a P-value <0.05 indicated statistical significance.

Results: Over a 20-year period, 323 patients underwent rAAA repair through a left retroperitoneal (74%) or standard transperitoneal (26%) approach. In Group I (age <80 years) and II (≥80 years), the overall 30-day mortality was 25 and 41% (P<0.05), respectively. Furthermore, the elderly population had a higher incidence of death due to myocardial infarction (15 vs. 7%), as well as non-fatal cardiac and cerebrovascular events (17 vs. 4%) when compared to the younger patients.

Conclusion: Although the elderly patients have an increased risk of having cardiac and cerebrovascular events in the postoperative period, the treatment of rAAAs in these patients should not be any different than that of a younger population. The left retroperitoneal approach is feasible and beneficial for rAAA repair and is associated with a limited morbidity and mortality.

The aim of this study is to determine if surgical repair of coarctation in adults improves systemic hypertension.

The charts of 23 consecutive patients (age range 13–36 years, mean 23.6±7) who underwent repair of aortic coarctation at the Atatürk University, Aziziye Hospital, between 1986 and 2000 were reviewed. There were 16 (70%) men and seven (30%) women. All patients had preoperative hypertension. Systolic blood pressure (BP) ranged between 150 and 200 mmHg, with a mean of 176±15 mmHg. Peak systolic gradient across the coarctation was 52±20 mmHg (range from 30 to 112 mmHg).

There were no early or late deaths. Mean systolic BP values at the first postoperative evaluation were 176±15 mmHg (p<0.001 from preoperative values). Exercise testing revealed hypertensive response to exercise in three of 10 patients who had borderline hypertension at rest and without medication.

Repair of coarctation of aorta even in adults is safe and improves systemic hypertension. To identify patients with potential hypertension, exercise testing should be performed. Impaired arterial dilatation may be an important contributor to exercise-related hypertension and late morbidity or mortality.

Objective: (1) To evaluate the quality of life (QoL) scores, assessed with SF36 and EuroQol (EQ-5D), of long term survivors after mechanical aortic valve replacement (mAVR); (2) to study the association of QoL with NYHA score, number of major bleeding and thrombo-embolic events and follow-up time; (3) to compare QoL scores of long term mAVR survivors with QoL scores of other populations.

Methods: In total 312 patients had a mAVR between 1964 and 1974 at St. Antonius Hospital Nieuwegein (NL). Mean age at operation was 41 (sd=12). Mean postoperative NYHA class at 1-year follow-up was 1.7 (sd=0.7). In 2001 the survivors (n=78; 25%) were followed-up for late events, NYHA class and QoL scores. 69 patients (93%) returned completed questionnaires.

Results: Mean duration of follow-up was 30 years (sd=1.8). Mean age of responders was 65 years (sd=10, range 47–93). In 2001, NYHA class of responders was 2 (sd=0.9). The mean (sd) SF36 scores for responders were: 64 (29) for physical function, 64 (29) for role-physical, 80 (30) for bodily pain, 55 (25) for general health, 63 (23) for vitality, 73 (29) for social functioning, 70 (38) for role-emotional, 76 (18) for mental health. The mean EQ-5D score of responders was: 61 (13). These SF36 and EQ-5D scores are comparable to those of other populations (e.g. cancer, diabetes type-2, migraine, chronic liver disease and iliac artery occlusive disease and Dutch general population). For responders a moderate to high association of SF36 and EQ-5D scores and their NYHA scores(R²=0.36) was found. The number of major bleeding events, age, sex and survival time were not related to QoL.

Conclusion: At long term follow-up (mean 30 years) of patients who had mAVR, QoL was relatively high; it was moderately to highly associated with their NYHA class; bleeding and thromboembolic events seem to be of little importance for the QoL at long term follow-up. QoL at long term follow-up of patients who had mAVR is comparable to other cross sectional designed studies with short term follow-up and other population.

Purpose. To study early changes in venous hemodynamics in stripping operation with preservation of the calf saphenous veins.

Patients and methods. From October 1999 to December 2000, 110 extremities of 73 patients were treated for primary varicose veins. Based on preoperative ascending venography, 40 extremities underwent the groin-to-knee stripping of the GSV, 20 underwent the proximal division of the LSV, and 50 received combinations of both surgeries. To evaluate venous hemodynamic changes, air plethysmography was performed before operation and 7–14 days after operation.

Results. The venous volume, venous filling index and residual volume fraction were improved after surgery, but the ejection fraction did not change. The overall incidence of nerve injury was 4.5% (five limbs).

Conclusions. In stripping operations, the preservation of the calf saphenous veins, which is shown to be advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement.

Patients with significant risk factors are at increased risk of higher mortality and morbidity (9–16%) after CABG-procedures with cardiopulmonary bypass (CPB). When catheter interventions are not applicable and conventional CABG with CPB are considered to have an unacceptable perioperative risk, these patients (n=35) were scheduled for minimally invasive coronary artery bypass grafting (MIDCAB).

Patients and methods: The risks leading to exclusion of conventional CABG procedures were: extremely impaired LV-function (EF<20%), severe pulmonary diseases, malignant carcinoma, compromised coagulation system, age >80 years with impaired physical constitution, redo-procedures after complicated initial operation, symptomatic descending thoracic aortic aneurysm, ongoing long-term intensive care treatment with unclear prognosis. All patients received the LIMA as a single graft to the LAD. One year follow-up was performed using transthoracic Doppler echocardiography at rest and during exercise.

Results: In 20 patients incomplete revascularization was accepted. There was no mortality, while signs for myocardial infarction were seen in two patients. Twenty-nine patients (82%) showed clear improvement of clinical symptoms, one patient needed further conventional CABG.

Nine to thirteen months postoperatively (mean 10.8±1.6 months), there were two deaths due to noncardiac reasons. Three of the survivors (n=33) had symptoms of angina pectoris. Exercise tests revealed an improved stress tolerance (NYHA class improved from preop. III–IV to postop. I–II). The IMA graft flow increased significantly with exercise in all patients. Flow patterns in both flow velocity and volume changed to diastolic-dominant, and the ratio of diastolic to systolic time–velocity integral of >1.5 excluded a graft stenosis.

Conclusions: In high-risk patients, with an increased likelihood of perioperative morbidity and mortality, the MIDCAB procedure can be performed accurately and safely. Even after incomplete revascularization of some high-risk patients, exercise tolerance was improved. Transthoracic Doppler echocardiography proved to be a clinically useful noninvasive method of assessing IMA graft function at rest and during exercise. Despite the small patient population, our late follow-up results suggest the potential benefit of MIDCAB for patients with otherwise inoperable heart disease.