Biomedical subjects
Publications and source records attributed to Pedro E Antunes.
Isolated involvement of the left heart chambers by metastases of malignant tumors is extremely rare. We report a case of an 8-year-old child, with a left atrial metastasis of a Wilms' tumor detected in a control nuclear magnetic resonance 1 year after left inferior lobectomy for metastatic extension of the kidney tumor, which was diagnosed 4 years earlier. The metastasis was excised en bloc with a disc of the posterior left atrial wall.
OBJECTIVE: Controversy still exists regarding the optimal surgical technique for postinfarction left ventricular (LV) aneurysm repair. We analyze the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LV aneurysms. METHODS: Between May 1988 and December 2001, 110 consecutive patients underwent repair of LV aneurysms. These represent 2.0% of a total group of 5429 patients who underwent isolated CABG during the period. Seventy-six (69.1%) patients were submitted to linear repair and 34 (30.9%) to patch remodelling. There were 94 (84.5%) men and 17 women, with a mean age of 59.2+/-9.2 years. Coronary surgery was performed in all patients (mean no. of grafts/patient, 2.7+/-0.8) and 14 (12.7%) had associated coronary endarterectomy. Forty-four (40.0%) patients had angina CCS class III/IV (linear 43.4%, patch 32.4%, NS) and the majority was in NYHA class I/II (88.2% in both groups). Left ventricular dysfunction (EF>40%) was present in 72 (65.5%) patients (linear 61.8%, patch 73.5%, NS). RESULTS: There was no perioperative mortality, and major morbidity was not significantly different between linear repair and patch repair groups. During a mean follow-up of 7.3+/-3.4 years (range 4-182 months) 14 patients (14.3%) had died, 12 (85.7%) of possible cardiac-related cause. Actual global survival rate was 85.7%. Actuarial survival rates at 5, 10 and 15 years were 91.3, 81.4 and 74%, respectively. There was no significant difference in late survival between the patch and the linear groups. At late follow-up the mean angina and NYHA class were, 1.3 (preoperative 2.4, P<0.001) and 1.5 (preoperative 1.7, NS), respectively, with no difference between the groups. There was no significant difference in hospital readmissions for cardiac causes (linear 22.8% and patch 37.0%). CONCLUSIONS: The technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Both techniques achieved good results with respect to perioperative mortality, late functional status and survival.
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Myocardial infarction may be complicated by the formation of a left-ventricular aneurysm that distorts the normal elliptical geometry of the ventricle to produce a dilated spherical ventricle with limited contractile and filling capacities. One of the consequences is congestive heart failure, which may be refractory to medical therapy and require surgical treatment. Surgical methods to restore the volume and shape of the left ventricle have evolved over the years. Nevertheless, although surgery for left-ventricular aneurysms has been performed for almost 50 years, the most appropriate approach is still controversial. This review gives an overview of the postinfarction left-ventricular aneurysm, tackling issues from the disease itself to surgical and other techniques of ventricular remodeling.
OBJECTIVES: In this study, we evaluate the incidence of and analyse the pre and intraoperative risk factors for the development of postoperative renal dysfunction (PRD), and the impact of such an event on perioperative mortality and on hospital length of stay. In addition, we sought to investigate the influence of a mildly increased serum creatinine (1.3-2.0 mg/dl) on perioperative mortality and morbidity. METHODS: The study included 2445 consecutive patients who had no pre-existing renal disease (creatinine or=2.1 mg/dl with a preoperative-to-postoperative increase >or=0.9 mg/dl. Univariate and multivariate analyses were performed where appropriate. RESULTS: Global 30-day mortality was 0.7%. The incidence of PRD was 5.6% (136 patients). Mortality for patients who experienced PRD was 8.8 vs. 0.1% for patients who did not (P<0.001). PRD increased the length of hospital stay by 3.4 days (7.6 vs. 11.0 days; P<0.001), and patients who needed haemodialysis (11%) had a perioperative mortality of 33.3% and a mean hospital length of stay of 16 days. Multivariable logistic regression identified the following variables as independent predictors of PRD: age (P=0.017; odds ratio (OR) 1.3 per 10 years), angina class III/IV (P=0.003; OR 1.7); cardiopulmonary bypass time (P=0.007; OR 1.01 per minute); preoperative serum creatinine levels: group 1 (1.3-1.6 mg/dl (P<0.001; OR 5.5)) and group 2 (1.7-2.0 mg/dl (P<0.001; OR 14.2)). Finally, a mild elevation of the preoperative creatinine level (1.3-2.0 mg/dl) increased significantly the probability of perioperative mortality, low cardiac output, haemodialysis and prolonged hospital stay. CONCLUSIONS: Although the likelihood of PRD in patients without pre-existing renal dysfunction is relatively low, it dramatically increases mortality, morbidity and length of stay after CABG. Mildly elevated (>1.2 mg/dl) preoperative serum creatinine level significantly increases the perioperative mortality and morbidity.
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OBJECTIVE: Stroke is a major complication after coronary surgery, occurring in 1-4% of the patients. In this study, we evaluate the incidence and pre- and intraoperative risk factors for the development of a cerebrovascular accident (CVA) and the impact of such an event on perioperative mortality and on hospital length of stay. METHODS: Data from 4567 patients submitted to isolated coronary artery bypass grafting (CABG) with hypothermic ventricular fibrillation between 1992 and 2001 were entered prospectively into a dedicated computerized database and analyzed retrospectively at this time. Univariate and multivariate analyses were performed where appropriate. RESULTS: The incidence of postoperative CVA was 2.5% (116 patients). Multivariable logistic regression identified the following variables to be independent predictors of a postoperative CVA: cerebrovascular disease (P<0.001; odds ratio (OR), 2.66), peripheral vascular disease (P<0.001; OR, 2.33), number of periods of aortic cross-clamping (P=0.019; OR, 1.31 per each period of aortic cross-clamping), LV dysfunction (P=0.012; OR, 1.82) and age (P=0.008; OR, 1.28 per each 10 years). Non-elective surgery showed a marginal significance (P=0.08; OR 1.83). The 30-day mortality for patients who experienced a CVA was 16.4% versus 0.6% for patients who did not (P<0.001). Postoperative CVA increased the length of hospital stay threefold to 20.3+/-28.3 days as compared with patients who did not have a postoperative CVA (7.6+/-4.2 days; P<0.001). CONCLUSIONS: Postoperative CVA dramatically increases the mortality and length of stay after CABG. Identification of predisposing factors permits preoperative risk stratification and may facilitate improved patient selection or optimization. Our study adds evidence to the superiority of the fibrillation technique over intermittent cross-clamping of the aorta, among non-cardioplegic techniques, in terms of neurological protection.
OBJECTIVE: To demonstrate that staged, consecutive, carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) are safe, perhaps preferable, alternative for the treatment of patients with severe carotid and coronary artery disease. METHODS: During an 8-year period ending December 1999, 77 (2.1%) of 3633 consecutive patients who were referred for isolated coronary surgery were found to have significant carotid disease and underwent CEA, and subsequently, CABG. The mean age was 65.2 +/- 5.9 years and 66 (85.7%) were males. The majority (84.4%) had triple vessel and 19.4% had left main disease. Carotid disease was unilateral in 71 patients (92.2%) and bilateral in six (7.8%), and 57 (74.0%) were neurologically asymptomatic. Only obstructions >70% were considered for endarterectomy. RESULTS: Eighty-three isolated CEAs were performed with direct clamping of the artery (mean 20.1 +/- 5.9 min) in all but one. There were no deaths. There were two strokes (2.4%) and three (3.6%) myocardial infarctions (MI). The mean admission time was 6.0 +/- 3.5 days. The staging interval was 32.4 days. During coronary surgery, a mean of 2.9 coronary grafts/patient was performed and all but one patient received at least one IMA graft. One patient (1.3%) died. There were two cases (2.6%) of MI and three patients (3.9%) had a stroke. Hence, the overall rates of perioperative mortality, MI and stroke were 1.3, 6.3 and 6.3%, respectively. The mean admission time was 8.3 +/- 6.0 days. CONCLUSIONS: Staging of carotid and coronary operations resulted in low global perioperative mortality and morbidity rates in these high-risk patients and is a good alternative therapeutic option.