Texas Heart Institute journal
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Cardiovascular adaptations during pregnancy are normally well tolerated in healthy women. However, 2% to 4% of women of childbearing age have some degree of concomitant heart disease, and these changes may compromise cardiac function. Of these, a few who do not respond to medical treatment may require surgical correction. ⋯ Modulation of the fetoplacental response to cardiopulmonary bypass may prevent placental dysfunction and sustained uterine contractions, which underlie fetal hypoxia and acidosis. In this article, we review cardiovascular adaptations to pregnancy and the pathophysiologic effects of cardiopulmonary bypass on the mother, fetus, and fetoplacental unit, and we talk about whether manipulation of these responses can help in improving fetal outcome. Finally, approaches regarding perfusion management and off-pump cardiac surgical techniques in pregnancy are discussed.
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Controlled Clinical Trial
Diagnostic accuracy of N-terminal pro-brain natriuretic peptide in the evaluation of postoperative left ventricular diastolic dysfunction.
We compared the diagnostic accuracy of N-terminal prohormone brain natriuretic peptide (NT-proBNP) with that of echocardiography in the evaluation of left ventricular diastolic dysfunction after coronary artery bypass grafting. Thirty patients were studied prospectively. Patients who had recent myocardial infarction, unstable angina pectoris, or low ejection fraction with systolic dysfunction were excluded. ⋯ The NT-proBNP had 87.5% sensitivity and 55% specificity, whereas E/Ea had 87.5% sensitivity and 86.4% specificity. Plasma NT-proBNP levels are significantly related to mitral E/Ea ratio, which is a predictor of diastolic stage. Therefore, elevated NT-proBNP levels may indicate the time for a Doppler echocardiographic evaluation and identify a subgroup of patients at high risk who need closer monitoring during the early postoperative period.
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Herein, we report a successful bridge to heart transplantation by use of the TandemHeart percutaneous ventricular assist device (pVAD) in a chronic aortic dissection patient who was experiencing postcardiotomy shock. The patient had undergone an aortocoronary bypass to treat an acute, extensive myocardial infarction that had resulted from severe stenosis of a Cabrol-like graft to the left main coronary artery. ⋯ The outcome shows that, in critically ill cardiogenic shock patients, a permissive approach to pVAD use is valuable in screening candidates for long-term ventricular assist device support or for heart transplantation. This case also reveals the validity of direct bridging to transplantation from a pVAD in carefully selected patients.
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Comparative Study
Cardiovascular spectrum in Williams-Beuren syndrome: the Mexican experience in 40 patients.
In this study, we have identified and evaluated the cardiovascular anomalies associated with Williams-Beuren syndrome in children. In a retrospective, lineal, and observational study, we reviewed the files of children who were seen from 1980 through 2005 (25 years) after a clinical diagnosis of Williams-Beuren syndrome. Forty children were diagnosed with this syndrome at the National Institute of Pediatrics in Mexico City. ⋯ Five patients showed combined lesions, the most frequent being supravalvular aortic stenosis in combination with pulmonary artery brachial stenosis, or with atrial and ventricular defects. Patients with incomplete atrioventricular defect and bicuspid aortic valve, as were seen at our hospital, have not to our knowledge been reported in other studies. One of the patients was scheduled for balloon dilation; another was scheduled for surgery; a 3rd patient was operated on twice for the placement of an aorto-aortic bridge; another underwent ventricular septal defect closure; and yet another underwent aortoplasty, this last dying shortly after surgery.
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End-stage heart-failure patients in acute refractory cardiogenic shock with multi-organ dysfunction require aggressive medical therapy that includes inotropic support. Historically, the intra-aortic balloon pump was the last option for patients who were dying of acute cardiogenic shock. Short-term extracorporeal pulsatile or nonpulsatile cardiac assist devices or extracorporeal membrane oxygenation offered further treatment options; however, these therapies required invasive surgical procedures. ⋯ The mean cardiac index before support, 1.02 L/(min.m2) (range, 0.0-1.8 L/[min.m2]) (0.0 L/[min.m2] implies active cardiopulmonary resuscitation), improved to 2.97 L/(min.m2) (range, 2.2-4.0 L/[min.m2]) during support. Three patients underwent successful cardiac transplantation; 5 are currently supported by axial-flow pumps; and 1 died of complications unrelated to the axial-flow pump, after 587 days. End-organ function and overall condition improved uniformly in our patients, thus decreasing the preoperative risk factors for implantation of the long-term device.