RESUMO
OBJECTIVE: This study aims to investigate the ability of the six-minute walk distance (6MWD) as a prognostic marker for midterm clinical outcomes three months after coronary artery bypass grafting (CABG), to identify possible predictors of fall in 6MWD in the early postoperative period, and to establish the percentage fall in early postoperative 6MWD, considering the preoperative baseline as 100%. METHODS: A prospective cohort of patients undergoing elective CABG were included. The percentage fall in 6MWD was assessed by the difference between preoperative and postoperative day (POD) five. Clinical outcomes were evaluated three months after hospital discharge. RESULTS: There was a significant decrease in 6MWD on POD5 compared with preoperative baseline values (percentage fall of 32.5±16.5%, P<0.0001). Linear regression analysis showed an independent association of the percentage fall of 6MWD with cardiopulmonary bypass (CPB) and preoperative inspiratory muscle strength. Receiver operating characteristic curve analysis revealed that the best cutoff value of percentage fall in 6MWD to predict poorer clinical outcomes at three months was 34.6% (area under the curve = 0.82, sensitivity = 78.95%, specificity = 76.19%, P=0.0001). CONCLUSION: This study indicates that a cutoff value of 34.6% in percentage fall of 6MWD on POD5 was able to predict poorer clinical outcomes at three months of follow-up after CABG. Use of CPB and preoperative inspiratory muscle strength were independent predictors of percentage fall of 6MWD in the postoperative period. These findings further support the clinical application of 6MWD and propose an inpatient preventive strategy to guide clinical management over time.
Assuntos
Ponte de Artéria Coronária , Humanos , Teste de Caminhada , Estudos Prospectivos , Curva ROC , Análise de RegressãoRESUMO
ABSTRACT Objective: This study aims to investigate the ability of the six-minute walk distance (6MWD) as a prognostic marker for midterm clinical outcomes three months after coronary artery bypass grafting (CABG), to identify possible predictors of fall in 6MWD in the early postoperative period, and to establish the percentage fall in early postoperative 6MWD, considering the preoperative baseline as 100%. Methods: A prospective cohort of patients undergoing elective CABG were included. The percentage fall in 6MWD was assessed by the difference between preoperative and postoperative day (POD) five. Clinical outcomes were evaluated three months after hospital discharge. Results: There was a significant decrease in 6MWD on POD5 compared with preoperative baseline values (percentage fall of 32.5±16.5%, P<0.0001). Linear regression analysis showed an independent association of the percentage fall of 6MWD with cardiopulmonary bypass (CPB) and preoperative inspiratory muscle strength. Receiver operating characteristic curve analysis revealed that the best cutoff value of percentage fall in 6MWD to predict poorer clinical outcomes at three months was 34.6% (area under the curve = 0.82, sensitivity = 78.95%, specificity = 76.19%, P=0.0001). Conclusion: This study indicates that a cutoff value of 34.6% in percentage fall of 6MWD on POD5 was able to predict poorer clinical outcomes at three months of follow-up after CABG. Use of CPB and preoperative inspiratory muscle strength were independent predictors of percentage fall of 6MWD in the postoperative period. These findings further support the clinical application of 6MWD and propose an inpatient preventive strategy to guide clinical management over time.
RESUMO
Abstract Background: Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients. Objectives: To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization. Methods: Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014. Results: Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups. Conclusion: Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.
Resumo Fundamento: A revascularização cirúrgica do miocárdio é o melhor tratamento para o paciente dialítico com doença coronariana multiarterial. Contudo, o procedimento ainda apresenta elevada morbimortalidade. O uso da circulação extracorpórea (CEC) pode impactar de maneira negativa na evolução intra-hospitalar desses pacientes. Objetivos: Avaliar a diferença entre as técnicas com ou sem CEC na evolução intra-hospitalar de pacientes dialíticos submetidos a cirurgia de revascularização do miocárdio. Métodos: Estudo unicêntrico de 102 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização cirúrgica do miocárdio em um hospital terciário universitário no período de 2007 a 2014. Resultados: 63 pacientes foram operados com CEC e 39 sem o uso de CEC. Foi observada alta prevalência de fatores de risco cardiovascular em ambos grupos, porém sem diferença estatisticamente significante entre eles. O grupo "com CEC" apresentou maior número de coronárias revascularizadas (2,4 vs 1,7; p <0,0001), maior necessidade de hemocomponentes (77,7% vs 25,6%; p <0,0001) e apoio inotrópico (82,5% vs 35,8%; p <0,0001). Na evolução pós-operatória, o grupo "sem CEC" apresentou menor necessidade de drogas vasoativas (61,5% vs 82,5%; p = 0,0340), maior taxa de extubação em sala cirúrgica (58,9% vs 23,8%, p = 0,0006), menor tempo de ventilação mecânica (13,0 horas vs 36,3 horas, p = 0,0217), menor taxa de infecções (7,6% vs 28,5%; p = 0,0120) e menor tempo de internação em UTI (5,2 dias vs 8,1 dias; p = 0,0054) em comparação ao grupo "com CEC". Não houve diferença de mortalidade entre os grupos. Conclusão: O uso da CEC na revascularização do miocárdio em pacientes dialíticos resultou em maior morbidade no período perioperatório em comparação ao procedimento realizado sem CEC, contudo, sem diferença de mortalidade.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Diálise Renal/métodos , Circulação Extracorpórea/métodos , Falência Renal Crônica/fisiopatologia , Falência Renal Crônica/mortalidade , Revascularização Miocárdica/métodos , Complicações Pós-Operatórias , Fatores de Tempo , Doença da Artéria Coronariana/cirurgia , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/mortalidade , Reprodutibilidade dos Testes , Fatores de Risco , Diálise Renal/mortalidade , Resultado do Tratamento , Mortalidade Hospitalar , Estatísticas não Paramétricas , Circulação Extracorpórea/mortalidade , Centros de Atenção Terciária , Hospitais Universitários , Unidades de Terapia Intensiva , Tempo de Internação , Revascularização Miocárdica/mortalidadeRESUMO
BACKGROUND: Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients. OBJECTIVES: To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization. METHODS: Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014. RESULTS: Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups. CONCLUSION: Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.
Assuntos
Circulação Extracorpórea/métodos , Falência Renal Crônica/fisiopatologia , Falência Renal Crônica/terapia , Revascularização Miocárdica/métodos , Diálise Renal/métodos , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Doença da Artéria Coronariana/cirurgia , Circulação Extracorpórea/mortalidade , Feminino , Mortalidade Hospitalar , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva , Falência Renal Crônica/mortalidade , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/mortalidade , Complicações Pós-Operatórias , Diálise Renal/mortalidade , Reprodutibilidade dos Testes , Fatores de Risco , Estatísticas não Paramétricas , Centros de Atenção Terciária , Fatores de Tempo , Resultado do TratamentoRESUMO
AbstractObjective:Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group.Methods:A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately.Results:There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences.Conclusion:Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.
ResumoObjetivo:O melhor tratamento atual para os pacientes dialíticos com acometimento coronariano multiarterial é a revascularização cirúrgica do miocárdio. Dentre as complicações pós-operatórias, a síndrome vasoplégica de etiopatogenia inflamatória torna-se importante pelo impacto altamente negativo no prognóstico. Considerando que esses pacientes possuem uma exacerbação intrínseca da resposta inflamatória, nosso objetivo foi avaliar a incidência e a mortalidade da síndrome vasoplégica no pós-operatório de revascularização miocárdica nesse grupo.Métodos:Estudo retrospectivo, unicêntrico, de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização miocárdica, em um hospital terciário universitário, no período de 2007 a 2012. Esses pacientes foram divididos em 2 grupos, de acordo com o emprego ou não da circulação extracorpórea. A incidência e a mortalidade da vasoplegia foram analisadas nos grupos. Após a identificação dos pacientes quanto à presença de vasoplegia, este subgrupo foi estudado separadamente.Resultados:Não houve diferenças demográficas pré-operatórias entre os grupos com circulação extracorpórea (n=20) e sem circulação extracorpórea (n=30). Dados intraoperatórios demonstraram maior número de artérias coronárias revascularizadas (2,8 vs. 1,8; P<0,0001) e maior necessidade de transfusão (65% vs. 23%; P=0,008) no grupo circulação extracorpórea. A incidência de vasoplegia foi estatisticamente maior (P=0,0124) no grupo circulação extracorpórea (30%) em comparação ao grupo sem circulação extracorpórea (3%). A mortalidade dos pacientes com vasoplegia foi 50% no grupo circulação extracorpórea e 0% no grupo sem circulação extracorpórea. A análise do subgrupo vasoplégico não demonstrou diferenças clínicas estatisticamente significantes.Conclusão:O emprego da circulação extracorpórea na revascularização cirúrgica do miocárdio em pacientes com insuficiência renal crônica dialítica aumentou o risco para desenvolvimento de síndrome vasoplégica pós-operatória.
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Vasoplegia/mortalidade , Anastomose Cirúrgica/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Incidência , Revascularização Miocárdica/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Vasoplegia/etiologiaRESUMO
OBJECTIVE: Coronary artery bypass grafting is currently the best treatment for dialysis patients with multivessel coronary artery involvement. Vasoplegic syndrome of inflammatory etiology constitutes an important postoperative complication, with highly negative impact on prognosis. Considering that these patients have an intrinsic inflammatory response exacerbation, our goal was to evaluate the incidence and mortality of vasoplegic syndrome after myocardial revascularization in this group. METHODS: A retrospective, single-center study of 50 consecutive and non-selected dialysis patients who underwent myocardial revascularization in a tertiary university hospital, from 2007 to 2012. The patients were divided into 2 groups, according to the use of cardiopulmonary bypass or not (off-pump coronary artery bypass). The incidence and mortality of vasoplegic syndrome were analyzed. The subgroup of vasoplegic patients was studied separately. RESULTS: There were no preoperative demographic differences between the cardiopulmonary bypass (n=20) and off-pump coronary artery bypass (n=30) group. Intraoperative data showed a greater number of distal coronary arteries anastomosis (2.8 vs. 1.8, P<0.0001) and higher transfusion rates (65% vs. 23%, P=0.008) in the cardiopulmonary bypass group. Vasoplegia incidence was statistically higher (P=0.0124) in the cardiopulmonary bypass group (30%) compared to the off-pump coronary artery bypass group (3%). Vasoplegia mortality was 50% in the cardiopulmonary bypass group and 0% in the off-pump coronary artery bypass group. The vasoplegic subgroup analysis showed no statistically significant clinical differences. CONCLUSION: Cardiopulmonary bypass increased the risk for developing postoperative vasoplegic syndrome after coronary artery bypass grafting in patients with dialysis-dependent chronic renal failure.
Assuntos
Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Vasoplegia/mortalidade , Anastomose Cirúrgica/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Vasoplegia/etiologiaRESUMO
Fundamentos: Atualmente, a revascularização cirúrgica do miocárdio é o melhor tratamento para o paciente dialítico com lesão coronariana multiarterial, contudo a mortalidade e a morbidade hospitalar do procedimento ainda permanecem altas. Objetivos: Avaliar os resultados e a evolução intra-hospitalar da revascularização cirúrgica do miocárdio isolada em pacientes dialíticos. Métodos: Estudo retrospectivo unicêntrico de 50 pacientes dialíticos consecutivos e não selecionados, submetidos à revascularização cirúrgica do miocárdio em um hospital terciário universitário no período de 2007 a 2012. Resultados: A casuística apresentou alta prevalência de fatores de risco cardiovasculares (100% hipertensos, 68% diabéticos e 40% dislipidêmicos). Não houve óbito intraoperatório, e 60% dos procedimentos foram feitos sem circulação extracorpórea. Houve sete (14%) óbitos intra-hospitalares. Infecção pós-operatória, insuficiência cardíaca prévia, uso de circulação extracorpórea, função ventricular anormal e reexploração cirúrgica foram os fatores associados a maior mortalidade. Conclusão: A revascularização cirúrgica do miocárdio é um procedimento factível para essa classe de pacientes, contudo com alta morbidade e mortalidade intra-hospitalar. É necessário melhor entendimento das particularidades metabólicas desses pacientes para o planejamento adequado das condutas. .
Background: Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high. Objective: Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients. Methods: Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012. Results: High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality. Conclusion: Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions. .
Assuntos
Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/mortalidade , Mortalidade Hospitalar , Falência Renal Crônica/mortalidade , Diálise Renal/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Hospitalização , Hospitais Universitários/estatística & dados numéricos , Complicações Intraoperatórias , Falência Renal Crônica/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Centros de Atenção Terciária/estatística & dados numéricosRESUMO
BACKGROUND: Coronary artery bypass grafting currently is the best treatment for dialytic patients with multivessel coronary disease, but hospital morbidity and mortality related to procedure is still high. OBJECTIVE: Evaluate results and in-hospital outcomes of coronary artery bypass grafting in dialytic patients. METHODS: Retrospective unicentric study including 50 consecutive and not selected dialytic patients, who underwent coronary artery bypass grafting in a tertiary university hospital from 2007 to 2012. RESULTS: High prevalence of cardiovascular risk factors was observed (100% hypertensive, 68% diabetic and 40% dyslipidemic). There was no intra-operative death and 60% of the procedures were performed off-pump. There were seven (14%) in-hospital deaths. Postoperative infection, previous heart failure, cardiopulmonary bypass, abnormal ventricular function and surgical re-exploration were associated with increased mortality. CONCLUSION: Coronary artery bypass grafting is feasible to dialytic patients although high in-hospital morbidity and mortality. It is necessary better understanding about metabolic aspects to plan adequate interventions.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/mortalidade , Mortalidade Hospitalar , Falência Renal Crônica/mortalidade , Diálise Renal/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Feminino , Hospitalização , Hospitais Universitários/estatística & dados numéricos , Humanos , Complicações Intraoperatórias , Falência Renal Crônica/cirurgia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária/estatística & dados numéricos , Fatores de TempoRESUMO
OBJECTIVE: To present the immediate results and assess the clinical and hemodynamic performance of stentless bovine pericardial bioprostheses in aortic position. METHODS: Twenty patients were operated who were indicated for surgery for valve replacement with biological prosthesis. Eleven patients were male; sixteen had aortic stenosis; four, insufficiency; the mean age was 66.3 +/- 8.8 years. The surgical technique used was subcoronary implant. Associated procedures were performed in five patients. Postoperative morbidity, mortality and hemodynamic performance were assessed on transthoracic echocardiogram. RESULTS: Mean time of cardiopulmonary bypass was 136.5 +/- 24.41 minutes and mean anoxic time was 105.2 +/- 21.62 minutes. Hospital mortality was 5% (one patient). Mean time of intensive care unit stay was 3.65 +/- 3.23 days. Mean postoperatively transvalvular gradient was was 25.39 +/- 7.82 mmHg. Left ventricle ejection fraction was 67 +/- 13.49% preoperatively and 63.24 +/- 16.06% postoperatively (p = 0.45). Eleven patients did not present any degree of valve regurgitation, eight presented mild regurgitation and one ,mild to moderate regurgitation. CONCLUSION: Stentless prostheses can be used for the surgical treatment of aortic valve diseases, with in hospital mortality and morbidity similar to the mortality and morbidity described in the literature for similar procedures, with satisfactory hemodynamic performance.