High Operative Risk Patients Research Articles

Technical Nuances in the Perioperative Management of Chronic Subdural Hematoma by Twin Burr Hole Craniostomy: Tips, Tricks, and Tactics

AbstractChronic subdural hematoma (CSDH) remains to be the most common neurosurgical entity usually encountered in the elderly population. With an increasing life expectancy and associated comorbidities, the incidence of CSDH is ever increasing. There is a lack of uniformity among neurosurgeons regarding management of CSDH, but surgical evacuation using twin burr hole craniostomy remains to be the most preferred modality. Other options available are twist drill craniostomy and craniotomy. A conservative approach may be preferred in a thin subdural hematoma with no or minimal neurological deficit or in high operative risk patients. Complications such as pneumocephalus, recollection, or rebleeding may be seen following surgical evacuation of CSDH. Herein we aimed to address the technical nuances associated with twin burr hole evacuation of CSDH to reduce the complications and the overall associated morbidity and mortality.

Early and mid-term outcomes of minimally invasive mitral valve surgery in high operative risk patients at University Medical Center, Ho Chi Minh City

Introduction: Minimally invasive mitral valve surgery (MIMVS) has seen significant advancement in the past decades, offering numerous benefits to patients. However, there remain cohorts of patients with mitral valve pathologies, deemed at higher surgical risk, who may face rejection for MIMVS due to concerns regarding potential postoperative complications associated with this approach. Objective: To assess early and midterm outcomes of MIMVS in higher-operative-risk patients at the University Medical Center of Ho Chi Minh City. Methods: A retrospective descriptive study of the patients meeting our high operative risk criteria, who underwent mitral valve surgery at the University Medical Center of Ho Chi Minh City from January 2017 to March 2023. Results: A total of 68 eligible cases were included in our study. The male-to-female ratio was 0.6:1. Among these cases, 21 patients underwent valve repair and 47 others underwent mitral valve replacement. 30.9% of cases presented with NYHA class III or above heart failure. The mean cardiopulmonary circulation time and aortic cross-clamp time were 157.4 ± 38.8 minutes and 102.7 ± 26.3 minutes, respectively. Three cases experienced minimally invasive surgery related complications, including one case of limb ischemia requiring fasciotomy, one case of femoral wound seroma, and one case of postoperative wound infection necessitating debridement. No instances of conversion to sternotomy or in-hospital mortality were observed. The mean ICU stay and postoperative length of stay at ward were 4.6 ± 3.5 days and 10.8 ± 5.9 days, respectively. Patients showed rapid recovery during the postoperative period. During ICU care, one patient suffered a non-disabling cerebrovascular accident, one case required continuous renal replacement therapy, three cases necessitated intra-aortic balloon pump placement, and three cases required reoperation due to hemorrhagic pleural effusion. During follow-up period, three patients died within 6 months, and another patient died after their surgery one year. Other patients had favorable outcomes at the time of discharge and at subsequent follow-up. Conclusion: Minimally invasive mitral valve surgeries highlight the feasibility and safety of minimally mitral valve surgery in higher-operative-risk patients.

Near-infrared spectroscopy-intravascular ultrasound to improve assessment of coronary artery disease severity in patients referred for transcatheter aortic valve implantation (The IMPACTavi registry): Design and rationale

Transcatheter aortic valve implantation (TAVI) was established as a standard treatment for high-operative risk patients with severe aortic stenosis (AS). Although coronary artery disease (CAD) often co-exists with AS, clinical and angiographic evaluations of stenosis severity are unreliable in this specific setting. To provide precise risk stratification of coronary lesions, combined near-infrared spectroscopy and intravascular ultrasound (NIRS-IVUS) was developed to integrate morphological and molecular information on plaque composition. However, there is a lack of evidence on the association between NIRS-IVUS derived findings such as maximum 4mm lipid core burden index (maxLCBI4mm) and clinical outcomes in AS patients undergoing TAVI. This registry aims to assess feasibility and safety of NIRS-IVUS imaging in the setting of routine pre-TAVI coronary angiography to improve assessment of CAD severity. The registry is designed as a non-randomized, prospective, observational, multi-center cohort registry. Patients referred for TAVI with angiographic evidence of CAD receive NIRS-IVUS imaging and are followed up to 24 months. Enrolled patients are classified as NIRS-IVUS positive and NIRS-IVUS negative, respectively, based on their maxLCBI4mm to compare their clinical outcomes. The primary endpoint of the registry is major adverse cardiovascular events over a 24-month follow-up period. Identification of patients likely or unlikely to benefit from revascularization prior to TAVI represents an important unmet clinical need. This registry is designed to investigate whether NIRS-IVUS-derived atherosclerotic plaque characteristics can identify patients and lesions at risk for future adverse cardiovascular events after TAVI, in order to refine interventional decision-making in this challenging patient population.

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

BackgroundEarly treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve.MethodsSURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected.ResultsThe study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study.ConclusionsThese results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

Surgical Therapy for Patients with Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement.

Aortic stenosis (AS) is the most common valvular heart disease and is most frequently recognized among elderly people. Surgical aortic valve replacement (SAVR) is the most effective therapy, but its indication is sometimes difficult, and is impossible for high operative risk patients. Transcatheter aortic valve replacement (TAVR) was recently approved in Japan for high risk and inoperable patients with severe AS. TAVR is a less invasive method because it does not require a cardiopulmonary bypass and is associated with excellent surgical outcomes. In Western countries, the indication of TAVR has already been extended to moderate operative risk patients with severe AS, and is going to be further extended to low risk patients. The number of patients undergoing TAVR is increasing progressively, and there are effective alternative therapies for patients with severe AS. Selection of these surgical methods will be important in the near future. In regard to low operative risk patients especially, not only operative mortality, but also long-tern mortality and morbidity and quality of life should be taken into consideration. It is considered that some comorbidities in AS patients will be revealed to have an impact on surgical outcomes at the time when these surgical methods are selected. In this review, we examine end-stage renal disease on hemodialysis, functional tricuspid regurgitation, and sigmoid septum, and give an outline of what influence SAVR and TAVR have on the surgical outcomes of severe AS patients.

Predictors of survival in patients with acute coronary syndrome undergoing percutaneous coronary intervention of unprotected left main coronary artery stenosis.

Aim of this study was to investigate predictors of survival in unstable patients with high SYNTAX-1-score. In significant unprotected left main coronary artery (ULMCA) stenosis, treatment options include percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). While CABG is recommended for stable patients with ULMCA stenosis and a SYNTAX-1-score > 32, PCI may be preferable in unstable or high operative risk patients. Retrospective single-center all-comers registry study. A total of 142 patients underwent ULMCA-PCI (~72.9 years, 23.2% females, 54.2% survival in 2-year follow-up), 84 of whom had a SYNTAX-1 > 32 (37.4 ± 12.8). Patients in the high-SYNTAX-1-group (score > 32) were more often in an acute condition compared to low-SYNTAX-2-group (score ≤ 32) including acute myocardial infarction (76.2% vs. 57.4%, p = .024), cardiogenic shock (48.2% vs. 14.8%, p = .001), or need for mechanical support (36.1% vs. 11.1%, p = .001). Survival was predicted by the acute condition including cardiogenic shock (OR 0.06 and 0.05) and myocardial infarction (OR 0.03 and 0.34) in both groups. Performance of the SYNTAX-1-score was limited in our patient collective in both groups (c-index 0.65 vs. 0.63) while SYNTAX-2-PCI-score performed better (c-index 0.67 vs. 0.67). EuroScore II had the best discriminative ability (c-index 0.87 vs. 0.78). The majority of patients undergoing ULMCA-PCI presented in acute conditions with high SYNTAX-1-score, and is therefore underrepresented in clinical trials. Prognosis was best predicted by the acute condition and the EuroScore II. These data suggest that therapy in unstable patients should be guided by clinical condition over the anatomical SYNTAX-1-score.

Self-expanding CENTERA valve for the treatment of severe, symptomatic aortic stenosis.

Transcatheter aortic valve implantation (TAVI) is now an established treatment option for both high and intermediate operative risk patients with severe symptomatic aortic stenosis. The number of patients undergoing TAVI has increased over the last decade warranting continued technological improvements in transcatheter heart valve (THV) systems. The novel CENTERA self-expanding THV (Edwards Lifesciences, CA, USA) received CE approval this year. It is deliverable through a 14Fr sheath and has a unique motorized delivery system. The CENTERA-2 study results demonstrated a favorable survival rate at 30 days (99%), as well as a low need for new permanent pacemaker implantation (4.9%). 1-year outcomes reported a low incidence of >moderate paravalvular leak (0.6%) and consistently favorable THV hemodynamics making this a competitive THV for patients with severe aortic stenosis.

Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer: American Society of Clinical Oncology Endorsement of the American Society for Radiation Oncology Evidence-Based Guideline.

Purpose The American Society for Radiation Oncology (ASTRO) produced an evidence-based guideline on treatment with stereotactic body radiotherapy (SBRT) for patients with early-stage non-small-cell lung cancer. ASCO has a policy and set of procedures for endorsing and/or adapting clinical practice guidelines that have been developed by other professional organizations. Methods The ASTRO Evidence-Based Guideline for Stereotactic Body Radiotherapy for Early-Stage Non-Small-Cell Lung Cancer was reviewed for developmental rigor by methodologists. An ASCO Expert Panel updated the literature search and reviewed the guideline content and recommendations. Results The ASCO Expert Panel determined that the recommendations from the ASTRO guideline, published in 2017, are clear, thorough, and based on the most relevant scientific evidence. ASCO statements and minor modifications were added to enhance the applicability of the ASTRO guideline for the broader ASCO audience. Recommendations For standard operative risk patients with stage I NSCLC, SBRT is not recommended outside of a clinical trial. Lobectomy with systematic lymph node evaluation remains the recommended treatment, although a sublobar resection may be considered in select clinical scenarios. Recommendations are provided regarding the use of SBRT in high operative risk patients and for inoperative patients, including in challenging scenarios where tumors are: centrally located, > 5 cm in diameter, lacking tissue diagnosis, synchronous primary or multifocal, second primary after pneumonectomy, proximal to or involved with mediastinal structures, abutting the chest wall, or recurring after previous treatment. Qualifying statements are included to provide further guidance for implementation, and the importance of a discussion of treatment options among members of the multidisciplinary cancer care team is emphasized. Additional information is available at: www.asco.org/thoracic-cancer-guidelines and www.asco.org/guidelineswiki .

Long-term outcomes and propensity score matching analysis: rectal cancer resection for patients with elevated preoperative risk.

BACKGROUNDIt is still controversial about the treatment strategy for rectal cancer patients with elevated operative risk and elder rectal cancer patients.METHODSThis study presented a retrospective single center experience in rectal cancer proctectomy for high operative risk patients. High operative risk patient was defined as Cr-POSSUM > 5% combined with associated risk factors. 220 in 1477 consecutive patients met the inclusion criteria.RESULTS132 patients were selected (66:66) after propensity score matching. The total complication rate between conventional open rectal resection (71 %) and laparoscopic surgery (41%) was significantly different (p = 0.0005). There is a significantly positive correlation between open surgery and advanced Dindo Classification (p = 0.02). Cr-POSSUM is positively correlated with Dindo Classification (p = 0.01). There was no significant difference in survival rate among stage I∼II, different age groups or different Cr-POSSUM score sub-groups. However, stage III-IV tumor patients in laparoscopic group experienced improved overall survival rate. (p < 0.0001). For patients with preoperative pulmonary or renal disease, patients in laparoscopic group also had better long term prognosis (p = 0.03, p = 0.049).CONCLUSIONSThe results demonstrate the potential advantages of laparoscopic rectal cancer resection for high operative risk patients, especially for the patients with preoperative respiratory or renal disease and stage III cancer.

Early Endocarditis and Delayed Left Ventricular Pseudoaneurysm Complicating a Transapical Transcatheter Mitral Valve-in-Valve Implantation: Percutaneous Closure Under Local Anesthesia and Echocardiographic Guidance.

A 72-year-old man was referred because of suspected infective endocarditis. Fifteen years earlier, he had undergone mitral valve replacement with a 33-mm Hancock valve for severe mitral regurgitation. Three months ago, he presented with a first episode of congestive heart failure caused by severe mitral regurgitation reflecting degeneration of the bioprosthetic valve without sign of endocarditis. Because of a high surgical risk based on an estimated Euroscore I of 42.96% and The Society of Thoracic Surgeons (STS) score of 29% (main comorbidity is an advanced Parkinson disease), valve-in-valve implantation was planned. A 29-mm Edwards Sapien 3 (S3) balloon-expandable valve was successfully implanted through transapical puncture of the left ventricle (LV) after direct surgical exposure by mini thoracotomy. Patient was discharged 10 days after the procedure without complications. On his admission, the patient was febrile and examination revealed a purulent discharge at the site of thoracotomy. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed a 15-mm mobile vegetation on the leaflet of the S3 (Movie I in the Data Supplement) and a pseudoaneurysm at the apex of the left ventricle (LVPA) flowing by a large apical defect (Figure 1; Movie II in the Data Supplement). Computed tomographic (CT) scanning confirmed the LVPA free from any thrombus and identified the surgical suture tip in its deep (Figures 1 and 2; Movie III in the Data Supplement). 18F positron-emission tomography demonstrated an uptake on the S3 and LVPA (Figure 2). Blood cultures were positive for Staphylococcus aureus . Antibiotherapy with co-trimoxazole for 6 weeks and clindamycin for 1 week was started, and a quick clinical and biological …

Laparoscopic gastropexy relieves symptoms of obstructed gastric volvulus in highoperative risk patients

BackgroundOperative repair of obstructive gastric volvulus is challenging. In high-operative risk patients with obstructive gastric volvulus, we perform laparoscopic reduction of gastric volvulus and anterior abdominal wall sutured gastropexy. This case series reports our experience with this operation. MethodsWe reviewed the charts of all patients who presented with obstructive gastric volvulus and underwent laparoscopic gastropexy between 2007 and 2013. ResultsEleven patients underwent laparoscopic gastropexy. Median age was 83 years (50 to 92). Six patients presented with chronic obstruction; 5 presented with acute obstruction. Median postoperative hospitalization was 2 days (1 to 39). Two patients required reoperation for displaced gastrostomy tubes. At median follow-up of 3 months (2 weeks to 57 months), all patients remained free of gastric obstructive symptoms and recurrent episodes of volvulus. Only 1 patient received nutrition via gastrostomy tube. ConclusionsLaparoscopic gastropexy can treat obstructed gastric volvulus in highoperative risk patients. Because of associated morbidity, gastrostomy tubes should be placed selectively.

Depth of valve implantation, conduction disturbances and pacemaker implantation with CoreValve and CoreValve Accutrak system for Transcatheter Aortic Valve Implantation, a multi-center study

BackgroundTranscatheter Aortic Valve Implantation (TAVI) is now considered an indispensable treatment strategy in high operative risk patients with severe, symptomatic aortic stenosis. However, conduction disturbances and the need for Permanent Pacemaker (PPM) implantation after TAVI with the CoreValve prosthesis still remain frequent. Methods and resultsWe aimed to evaluate the implantation depth, the incidence and predictors of new conduction disturbances, and the need for PPM implantation within the first month after TAVI, using the new Accutrak CoreValve delivery system (ACV), compared to the previous generation CoreValve (non-ACV). In 5 experienced TAVI-centers, a total of 120 consecutive non-ACV and 112 consecutive ACV patients were included (n=232). The mean depth of valve implantation (DVI) was 8.4±4.0mm in the non-ACV group and 7.1±4.0mm in the ACV group (p=0.034). The combined incidence of new PPM implantation and new LBBB was 71.2% in the non-ACV group compared to 50.5% in the ACV group (p=0.014). DVI (p=0.002), first degree AV block (p=0.018) and RBBB (p<0.001) were independent predictors of PPM implantation. DVI (p<0.001) and pre-existing first degree AV-block (p=0.021) were identified as significant predictors of new LBBB. ConclusionDVI is an independent predictor of TAVI-related conduction disturbances and can be reduced by using the newer CoreValve Accutrak delivery system, resulting in a significantly lower incidence of new LBBB and new PPM implantation.

The Ibero-American transcatheter aortic valve implantation registry with the CoreValve prosthesis. Early and long-term results

BackgroundTranscatheter aortic valve implantation (TAVI) is the recommended therapy for patients with severe aortic stenosis who are not suitable candidates for surgery. The aim of this study was to describe early experience and long-term follow-up with the CoreValve self-expanding aortic prosthesis at 42 Ibero-American hospitals. MethodsMultiple centre observational study including 1220 consecutive patients with symptomatic severe aortic stenosis who are not suitable candidates for surgery and underwent transcatheter aortic valve implantation with the self-expanding Medtronic CoreValve System between December 2007 and May 2012. ResultsThe registry included 1220 consecutive patients with a mean age of 80.8±6.3years and a mean logistic euroSCORE of 17.8%±13%. The procedural success rate was 96.1%. Hospital mortality was 7.3% and combined end-point was 21.3%. Aortic regurgitation after TAVI was present in 24.5% (Sellers grade≥2). The estimated 1-year and 2-year survival rates were 82.1% and 73.4% respectively. The following issues were significant independent risk factors for hospital mortality: acute kidney failure (odds ratio 3.55); stroke (odds ratio 5.72); major bleeding (odds ratio 2.64) and euroSCORE (odds ratio 1.02). Long-term predictors of mortality were diabetes mellitus (hazard ratio 1.59, 95% confidence interval 1.09–2.31), severe chronic obstructive pulmonary disease (hazard ratio 1.85, 95% confidence interval 1.85–2.88), and functional classes NYHA III–IV (hazard ratio 1.31, 95% confidence interval 1.01–1.70). ConclusionsTranscatheter aortic valve implantation constitutes a safe and viable therapeutic option for high operative risk patients with severe aortic stenosis. Long-term prognosis is conditioned by associate comorbidities.

Totally Intracorporeal Laparoscopic Colectomy (TILC) Is Associated With Similar Surgical Outcomes in High and Low Operative Risk Patients

Patients undergoing laparoscopic-assisted colectomy with obesity, high American Society of Anesthesiologists (ASA) grade, and left-sided colon tumors are at high risk for operative conversion and complications. We hypothesized that a completely intracorporeal laparoscopic colectomy would be beneficial for high-risk patients compared with healthy, low-risk patients. We conducted a retrospective study of 136 consecutive patients undergoing a standardized totally intracorporeal laparoscopic colectomy for neoplasms from February 2004 to September 2011. Patients were stratified into a high-risk group with 1 or more factors: body mass index >30, ASA grade ≥ 3, and left-sided tumors or a low-risk group with no factors. Variables compared were case frequency during the learning curve, body mass index, estimated blood loss, operative time, conversion, 30-day complications, and length of stay. Comparisons between groups were made by χ2 analysis or t test where appropriate. Data are expressed as median ± SD, odds ratio, and significance defined as P<0.05. Laparoscopic colectomy was performed in 136 patients with a conversion rate of 4%. There were 86 high-risk patients and 50 low-risk patients. High-risk patients had a significantly (P<0.005) longer operative time (225 ± 66 vs. 186 ± 55 min) but no significant difference in estimated blood loss, conversion rates, learning curve, complications, or length of stay compared with low-risk patients. When laparoscopic colectomy is performed totally intracorporeally, surgical outcomes in high-risk patients with obesity, high ASA grade, and left-sided tumors are equally successful to results achieved for low-risk patients that are thin, healthy, with right-sided lesions.

Endovascular Treatment of Totally Occluded Superior Mesenteric Artery by Retrograde Crossing via the Villemin Arcade

Chronic mesenteric ischemia (CMI) is a rare disorder that is commonly caused by progressive atherosclerotic stenosis or occlusion of one or more mesenteric arteries. Endovascular treatment for symptomatic CMI represents a viable option, especially in high-operative risk patients. We report a case of acute symptomatic CMI with chronic totally occlusion of the superior mesenteric artery (SMA) associated with significant stenosis of celiac trunk (CT) and inferior mesenteric artery (IMA) that underwent endovascular treatment of all the three mesenteric arteries: stenting of CT and IMA stenosis, and recanalization of the SMA occlusion by retrograde crossing via the Villemin arcade.

Role of computed tomography imaging for transcatheter valvular repair/insertion

During the last decade, the development of transcatheter based therapies has provided feasible therapeutic options for patients with symptomatic severe valvular heart disease who are deemed inoperable. The promising results of many nonrandomized series and recent landmark trials have increased the number of percutaneous transcatheter valve procedures in high operative risk patients. Pre-procedural imaging of the anatomy of the aortic or mitral valve and their spatial relationships is crucial to select the most appropriate device or prosthesis and to plan the percutaneous procedure. Multidetector row computed tomography provides 3-dimensional volumetric data sets allowing unlimited plane reconstructions and plays an important role in pre-procedural screening and procedural planning. This review will describe the evolving role of multidetector row computed tomography in patient selection and strategy planning of transcatheter aortic and mitral valve procedures.

Percutaneous femoral artery access with Prostar device for innovative mitral and aortic interventions

The potential advantages of percutaneous femoral access over a surgical approach are easier recovery and lower inguinal complications rate. This technique can be an asset in disabled patients with high risk of decubitus complications or in surgically challenging patients (obesity). We describe percutaneous access for mitral and aortic minimally invasive valvular interventions in 156 patients (transcatheter aortic valve implantation, n=40; and minimally invasive cardiac surgery, n=116). Severe complications, in two transcatheter aortic valve implantation (TAVI) patients (one retroperitoneal bleeding and one massive superficial bleeding) and in three minimally invasive patients (two retroperitoneal bleeding and one arteriovenous fistula), occurred during first 50 patients versus 0 among 106 following patients (p=0.01). Percutaneous access is possible for innovative cardiac interventions, but severe complications can occur, especially during the learning curve, with serious consequences in high operative risk patients, urging highest caution when initiating this innovative approach.

Endovascular Aortic Aneurysm Repair (EVAR) Has Significantly Lower Perioperative Mortality in Comparison to Open Repair: A Systematic Review

Objective The objective of this meta-analysis was to evaluate the effectiveness of endovascular abdominal aortic aneurysm repair (EVAR) in reducing inhospital mortality against open graft replace-ment for aortic aneurysm. Methods Generic terms including EVAR, endovascular aneurysm repair and aortic endografting were used to search a variety of electronic databases. Based on selection criteria, decisions regarding inclusion and exclusion of primary studies were made. Results A total of three randomized controlled trials on 1,468 patients were included. In the EVAR group, 12 of 759 (1.5%) patients died, compared to 33 of 709 (4.6%) patients who died in the open surgery group. In both the fixed and random effect models, EVAR was associated with statistically significantly lower perioperative mortality when compared to open surgical repair of aortic aneurysm. The risk ratio of 0.33 indicates that mortality is 3.3 times more likely in the open surgery group compared to the EVAR group. Conclusion EVAR carries a threefold lower risk of perioperative death in comparison to open repair of abdominal aortic aneurysm. This early advantage must be offset against the increased need for later re-intervention and probable equivalence of long-term outcome. In older and high operative risk patients, EVAR should be the treatment of choice.

Annular reconstruction for mitral valve replacement in a destroyed or calcified mitral annulus

Mitral valve replacement in the presence of severe annular calcification and an infectious lesion may be complicated by atrioventricular rupture, left circumflex coronary artery injury, and recurrence of infective endocarditis. Confronted with these circumstances, we have developed a technique of annular reconstruction for mitral valve replacement. The prosthetic valve is made by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. This technique has been employed in five patients: three had extensive annular calcification, and two had acute valve endocarditis with destruction of mitral annulus. In all cases, the circumferential or partial annular reconstruction permitted secure implantation of the prosthetic valve. The one postoperative death was related to hemodialysis due to chronic renal failure. There were no other fatalities during the postoperative course, and the valves functioned normally. Our results suggest that this technique can be performed in high operative risk patients when mitral valve replacement is impossible using conventional techniques.

Gallstone cholangitis: a 10-year experience of combined endoscopic and laparoscopic treatment.

To date, no procedure has yet been identified as the gold standard for the treatment of gallstone cholangitis in the laparoscopic era. The data of 109 consecutive patients with acute cholangitis were prospectively entered into a computerized database. All patients were managed according to a standard protocol. The main treatments were endoscopic retrograde cholangiography (ERC) combined with endoscopic sphincterotomy (ES), followed by interval laparoscopic cholecystectomy (LC). Patients in whom ERC or endoscopic stone clearance failed were managed by emergency open common bile duct exploration. LC was performed with a standardized four-cannula technique. The mean duration of surgery, conversion rate, and postoperative outcome of these patients were evaluated. ERC was successful in 103 patients (94.5%). In five of these patients (4.8%), no bile duct stones were found. The 98 patients (95.2%) with common bile duct stones were referred for ES. The bile duct stones were successfully removed after ES in 93 cases (94.9%). The overall failure rate of ERC and ES for choledocholithiasis was 10.1%. Self-limiting pancreatitis occurred in four patients (4.3%). Overall, two of the 109 patients died (1.8%). After ES, 81 patients underwent LC. LC was performed successfully in 74 patients (91.3%). Conversion to open surgery was required in seven patients (8.7%). The morbidity rate after cholecystectomy was 7.4%; the morbidity rate after open bile duct exploration was 36.4% (p<0.05). Fifteen patients were managed conservatively after initial endoscopic management of their cholangitis. The overall incidence of recurrent biliary symptoms was significantly higher among patients with gallbladder in place than for patients who underwent cholecystectomy (38.5% vs 1.5%, p<0.001). ES followed by LC is a safe and effective approach for the management of gallstone cholangitis; cholecystectomy should be performed in patients with gallstone cholangitis unless the operative risk is extremely high. These high operative risk patients and those who refuse surgery after ES should be warned that they are at high risk for recurrent biliary symptoms.