Medium-term Outcomes Of Patients Research Articles

Lung Transplantation and Coronary Artery Disease

Coronary artery disease (CAD) remains a relative contraindication to lung transplantation. We have offered lung transplantation and coronary revascularization to selected patients with discrete CAD and preserved left ventricular function. The purpose of this report is the following: (1) to examine the short-term and medium-term outcome of patients after coronary revascularization and lung transplantation; and (2) to compare the short-term and medium-term outcome of this cohort to a matched group of lung transplant recipients without CAD. From January 2000 to March 2010, 27 patients with CAD underwent coronary revascularization and lung transplantation. The control group was matched based on age, diagnosis, lung allocation score, and type of procedure. Lung transplant recipients with CAD and the control group had similar incidence of primary graft dysfunction (grade III). The duration of mechanical ventilation, intensive care unit stay, and hospital stay were the same. At a mean follow-up of 3 years, the incidence of composite adverse cardiac events was similar in the 2 groups. Lung transplant recipients with CAD and the control group also had similar medium-term survival. Lung transplantation can be considered in patients with preexistent CAD with acceptable early and medium-term outcomes.

Fenestrated Aortic Endografts for Juxtarenal Aortic Aneurysm: Medium Term Outcomes

Aims The utility of fenestrated-endovascular aneurysm repair (FEVAR) remains uncertain. This study examines the medium term outcomes of patients undergoing FEVAR for asymptomatic juxtarenal abdominal aortic aneurysm (AAA). Methods Consecutive patients undergoing elective FEVAR for juxtarenal AAA at a single tertiary centre were studied between October 2005 and March 2010. Patients were followed up for at least six-months within a protocol including clinical examination, laboratory studies, CT and duplex imaging, and abdominal radiographs. Outcomes were assessed in terms of survival, target vessel patency and graft related complications. Results Twenty-nine patients were analysed on an intention to treat basis. There were 27 men and two women of median (range) age 74 (54–86) years. Mean (SD) aneurysm diameter was 68 (7) mm. Median (range) ASA score was 3 (2–4). No procedures required conversion to an open procedure, but one procedure was abandoned. Seventy-nine visceral vessels were perfused through a fabric fenestration or scallop. All vessels remained patent at completion angiography. No patients died within 30-days of surgery. During follow up there were four (14%) deaths at a median (range) of 17 (8–21) months after aneurysm repair. None of these deaths were aneurysm related. Eighteen (62%) patients suffered one or more graft related complications, of whom 11 (38%) required one or more early or late reintervention. Conclusions Fenestrated aortic endografts can be utilized safely in the management of juxtarenal AAA in patients at high-risk for open surgery. However, the rate of graft related complication and reintervention is high at medium term follow up.

Endoscopic treatment of dysplasia in ulcerative colitis – medium term outcome

IntroductionUntil recently a finding of low grade dysplasia within a segment of colitis was an indication for colectomy. However, recent literature suggests that well-circumscribed lesions could be managed by endoscopic...

Cost benefits of intraoperative cell salvage in radical cystectomy

Objective:We have looked into the clinical and financial benefits of using intra-operative cell salvage (ICS) as a method to reduce the amount of autologous blood transfusion (ABT) requirement for our radical cystectomy (RC) patients.Materials and Methods:Fifteen consecutive patients undergoing radical cystectomy received cell salvaged blood (ICS), while 15 did not (NCS). The cost of using the cell saver, number of homologous transfusions, survival, and recurrences were recorded and compared using paired t-test and chi-square test between the two groups. A Dideco Electa® (Sorin Group, Electa, Italy) cell saver machine was used for all the patients in the ICS group and leukocyte filters were used on the salvaged blood before the autologous transfusion.Results:The mean age was 63 years (53–72 years), 66 years (46–79 years) in ICS and NCS groups, respectively (P = 0.368). All 15 (100%) patients in the NCS group required an allogenic transfusion compared to 9/15 (60%) in the ICS group (P = 0.08). There was a significant reduction in the mean volume of allogenic blood transfused with the use of cell saver. Median follow-up was 23 and 21 months in the ICS and NCS group with 10 and 4 patients alive at last follow-up, respectively. There was a saving of 355 pounds per patient in the ICS group compared to the NCS group.Conclusion:Our initial study shows that cell savage is feasible and safe in patients undergoing radical cystectomy. It does not adversely affect the medium term outcome of patients undergoing RC and is also cost effective.

Peri-mitral atrial flutter in patients with atrial fibrillation ablation

Peri-mitral atrial flutter (PMFL) is commonly encountered in patients undergoing atrial fibrillation (AF) ablation. The purpose of this study was to determine the electrophysiologic characteristics, procedural success, and medium-term outcomes in patients with PMFL. The study consisted of 50 consecutive patients (45 men and 5 women, age 57 +/- 12 years) with PMFL following or during AF ablation. Of the 50 PMFLs, 24 occurred during AF ablation (16 at index ablation and 8 at repeat procedure for recurrent AF), and 26 developed during follow-up. Ablation of PMFL was performed by creating a linear lesion joining the mitral annulus to the left inferior pulmonary vein. The incidence of PMFL was higher in patients with mitral isthmus (MI) ablation performed during AF ablation, prior to the development of PMFL, than in those in whom MI ablation was not performed (23% vs 8%, P = .04). Following the procedure, PMFL was more frequent in patients with prior MI ablation than in those without (41% vs 15%, P <.01). Seventy percent (35/50) were terminated by ablation with 6.4 +/- 6.9 minutes of radiofrequency application. Among patients in whom PMFL terminated, supplemental ablation was required for bidirectional conduction block in 66% (23/35). MI block was achieved in 92% (46/50) using 13.6 +/- 7.4 minutes of ablation. At mean follow-up of 19 +/- 4 months, 96% of patients were free from PMFL. PMFL can be terminated by MI ablation, but the procedure is proarrhythmic. Supplemental ablation is necessary to establish bidirectional block of the line despite termination of PMFL in the majority of patients.

Transcatheter closure of atrial septal defects with multiple devices in adults: Procedural and clinical outcomes

Objective This study reports the procedural, short and medium term outcomes in patients receiving multiple implants for device closure of secundum atrial septal defects (ASD). Design and setting From the database of the Toronto Congenital Cardiac Centre, 36 consecutive patients (mean age 46 ± 15 years; 23 females) received > 1 implant for closure of an interatrial communication. Short term (mean 97 ± 77 days) and medium term (mean 2.5 ± 1.4 years) follow-up data were analyzed. Procedures were performed under intracardiac echo (ICE) and fluoroscopic guidance. Results The Amplatzer Septal Occluder (ASO™) was implanted in all except one. Thirty-one patients had 2, and 4 patients, 3 ASO™ devices. There were no major adverse events at implantation or on follow-up. Patients with > NYHA class I symptoms fell from 44% to 6% ( p < 0.05) at 3 months. Right ventricular (RV) systolic pressure fell from 39 ± 7 to 32 ± 4 mm Hg in the short term ( p < 0.05), and to 30 ± 4 mm Hg in the medium term ( p < 0.05, compared to baseline) and RV diameters fell from 48 ± 5 to 40 ± 5 ( p < 0.05) in the short term and to 38 ± 8 mm ( p = ns) in the medium term. Small residual leaks were present in 22% at 3 months and 12% ( p < 0.05) at 1 year. Conclusion Multiple ASD device implants can be safely employed with excellent outcomes. Significant reductions in RV pressure and diameter occur in the short term with a continued trend to benefit.

Results of Percutaneous Coronary Intervention of the Unprotected Left Main Coronary Artery in 143 Patients and Comparison of 30-Day Mortality to Results of Coronary Artery Bypass Grafting

Percutaneous coronary intervention (PCI) of the unprotected left main coronary artery (LMCA) is controversial. In 143 patients who underwent PCI of the unprotected LMCA, 30-day mortality was compared with predicted cumulative risk-adjusted perioperative surgical mortality based on logistic European System for Cardiac Operative Risk Evaluation. One-year clinical follow-up was completed in all patients. The overall major adverse cardiac event rate at 1 year was 34.3%, reflecting the high-risk profile of the patient population. Twelve patients (8%) experienced an acute myocardial infarction and 16 (11%) underwent target lesion revascularization. In 31 patients (22%) who died during the first year, median logistic European System for Cardiac Operative Risk Evaluation was 30%. Calculated RRs showed significantly lower 30-day mortality using PCI compared with predicted surgical mortality (RR 0.54, 95% confidence interval 0.31 to 0.86). Angiographic follow-up in 90 of the 118 patients alive at 6 months showed binary restenosis of 6% in patients treated with drug-eluting stents versus 29% in patients receiving bare-metal stents (p < or =0.01). In conclusion, PCI for unprotected LMCA disease was associated with acceptable short- and medium-term outcomes in patients at low to intermediate risk of bypass surgery. Mortality remains high in very high-risk patients unsuitable for surgery. However, in selected indications, PCI of the LMCA can offer an alternative to surgery, especially when using drug-eluting stents.

Strokes after cardiac surgery: mostly right hemispheric ischemic with mild residual damage

Since cardiac surgery is now performed on patients with high risk for cerebrovascular disease, we studied the clinical findings and medium term outcome of patients with acute stroke/transient ischemic attack (TIA) after cardiac surgery. All consecutive patients with acute stroke/TIA after cardiac surgery were prospectively observed during a 19 month period. Follow-up was between 3 months and 21 months. Risk factors, type of stroke, anatomic localization, initial neurological deficit and followup outcome were evaluated, using standard assessment scores. Among 406 patients operated (mean age 64.3 +/- 12.7 years, 284 males), 18 developed stroke and 2 TIAs (mean age 65.7 years, 13 males). There were no cases of intracerebral hemorrhage. Most of the strokes happened shortly after valve surgery (mean 1.3 days post operatively) and were right hemispheric (right = 11, left = 3; p = 0.034). Vertebrobasilar stroke appearance was delayed (mean: 8.25 days post operatively); they were attributed mostly to cardiac arrhythmias. Stroke/TIA patients did not have a higher preoperative risk than those without, but their cardiac functional score was worse (p = 0.01), and the average cardiopulmonary bypass time during surgery was longer (p = 0.009). Two patients died in hospital, both with vertebrobasilar stroke. Most of the hemispheric stroke patients became functionally independent (mean modified Rankin Scale < 2), even those with initial severe deficit. Strokes after cardiac surgery are mostly right hemispheric and exclusively ischemic. Outcome is relatively fair. We suggest an embolic injury to the right hemisphere, procedure related, as a possible mechanism.

Rifampin levels, interferon-gamma release and outcome in complicated pulmonary tuberculosis

Factors that relate to medium-term outcome in patients with pulmonary tuberculosis (PTB) who have completed the 2-month intensive phase of treatment are incompletely understood. The relationship between in vitro production of interferon-gamma (IFN-gamma), interleukins (ILs)-5 and -10 and drug levels determined after 2 months of drug therapy, to outcome at 24 months was studied prospectively. Cytokine concentrations were determined from culture supernatants after stimulation of whole blood with purified protein derivative (PPD) of Mycobacterium tuberculosis. Plasma concentrations of rifampin, isoniazid, pyrazinamide and ethambutol were determined by high-performance liquid chromatography. The treatment failure and relapse free survival probability was 0.54 (95% CI: 0.40-0.67) at 24 months. In multivariate analysis of parameters at 2 months the strongest positive associations with disease free survival were IFN-gamma response to PPD (p=0.002) and serum creatinine (p=0.001). Drug concentrations were not associated with outcome although rifampin exposure correlated with IFN-gamma response to PPD (p=0.0132). These data suggest that the ability to mount a recall immune response to M. tuberculosis may influence treatment outcome. The data support the idea to identify persons at risk of a poor treatment outcome by monitoring of the in vitro response to tuberculosis antigens.

Clearance of Irretrievable Bile Duct and Pancreatic Duct Stones by Extracorporeal Shockwave Lithotripsy, Using a Transportable Device

Extracorporeal shockwave lithotripsy (ESWL) is an established treatment of irretrievable biliary and pancreatic stones, but the cost of the shockwave generators limits its widespread use. We revised data about the effectiveness of our treatment for refractory stones using a transportable shockwave generator. We retrospectively evaluated the short and medium-term outcomes of patients who underwent ESWL using a transportable electromagnetic shockwave generator between 1998 and 2003 at our unit, for the treatment of irretrievable bile duct or pancreatic duct stones. All patients received intravenous conscious sedation and antibiotic prophylaxis. Complete stone clearance was achieved in 70/82 patients (85.4%), in 66 of the patients (94.2%) with 1 session of ESWL. Despite the insertion of a stent in the bile duct, 2 patients had moderate cholangitis, while they waited for the next ESWL session. We did not record any moderate-severe complication of ESWL, but 2 patients underwent surgery owing to perforation/bleeding during endoscopic removal of residual fragments. A symptomatic recurrence of stones was recorded in 10/69 (14.5%) patients, who had been previously cleared and whose follow-up data (median follow-up 29 mo; range 7 to 66) were available. We obtained satisfactory stone clearance by using a transportable shockwave generator. Most patients required 1 session. Our experience confirmed the safety of the treatment, even though patients may experience cholangitis while awaiting definitive treatment. The use of a transportable ESWL generator may be a valuable option in centers, while ensuring a sufficient proficiency in biliary endoscopy.

Effect of the Left Internal Mammary Artery to the Left Anterior Descending Artery on Mortality and Morbidity After Combined Coronary and Valve Operations

The effect of using the left internal mammary artery in combined coronary and valve operations have not been fully investigated. We aimed to quantify the impact of the left internal mammary artery to the left anterior descending artery on early and mid-term outcomes in these patients. Data was collected prospectively on 630 consecutive patients who underwent revascularization of the left anterior descending artery with concomitant valve operations between April 1997 and March 2003. Multivariate logistic regression and Cox proportional hazards analyses were used to adjust in-hospital outcomes and Kaplan-Meier survival curves. A propensity score for left internal mammary artery use was constructed to control for selection bias. The left internal mammary artery was used in 478 (75.9%) patients. Univariate analyses found left internal mammary artery patients had significantly lower in-hospital mortality (6.3% versus 13.2%; p < 0.01) and postoperative renal failure (8.2% versus 13.8%; p = 0.038). After adjusting for treatment selection bias, in-hospital mortality (adjusted odds ratio, 0.77; p = 0.45) and renal failure (adjusted odds ratio, 0.94; p = 0.86) were no longer significantly different. A total of 171 (27.1%) deaths occurred during the follow-up, with a total follow-up of 2,325 patient-years. The crude relative risk for the left internal mammary artery was 0.67 (p = 0.015). After adjusting for the propensity score, the adjusted relative risk was 0.91 (p = 0.62). The left internal mammary artery does not adversely affect the short-term and medium-term outcomes in patients undergoing concomitant coronary and valve operations. Survival at 7 years was similar with or without the use of the left internal mammary artery.

Audit of short and medium term outcome of patients with decompensated alcoholic liver disease (ALD): Dominic Ray-Chaudhuri, Elaine McFarlane, Martin Bradley, Dermot Gleeson, Liver Unit, Sheffield Teaching Hospitals Trust, Sheffield Uk

Audit of short and medium term outcome of patients with decompensated alcoholic liver disease (ALD): Dominic Ray-Chaudhuri, Elaine McFarlane, Martin Bradley, Dermot Gleeson, Liver Unit, Sheffield Teaching Hospitals Trust, Sheffield Uk

Presentation, outcome, and cause of septic arthritis after anterior cruciate ligament reconstruction: a case control study

Purpose: The objective of this study was to examine clinical presentation and medium-term outcome of patients with septic arthritis of the knee after anterior cruciate ligament (ACL) reconstruction. Type of Study: Matched case control study. Methods: From a consecutive case series of 575 patients who underwent ACL reconstruction from 1996 through 1999, we report on 10 patients (1.7%) with postoperative septic arthritis. These patients were compared with individually matched patients without infection, on average, 3 years after surgery. The examination included physical and radiographic evaluation, functional testing, KT-1000, Lysholm and Tegner scales, and the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) form. Results: The predominant clinical presentation among patients with septic arthritis was modest classic signs of local infection. However, all had fever and elevated sedimentation rate or high C-reactive protein. Bacterial cultures showed coagulase-negative Staphylococcus species in 6, Staphylococcus aureus in 1, and Propionibacteriaceae species in 1 patient. The diagnosis was established with a delay of approximately 5 days. All patients underwent arthroscopic debridement and lavage (2 cases) or continuous irrigation (8 cases), as well as antibiotic treatment. One experienced graft rupture caused by the infection. At the end of the follow-up evaluation, the infected patients reported significantly lower activity levels than the control subjects (mean Tegner score, 5.3 v 7.2, P = .03). No statistically significant differences were noted in mean Lysholm, IKDC, or KOOS scores, or in KT-1000 difference. Two infected patients scored lower on the Tegner and Lysholm scales postoperatively than they did preoperatively. When examining the causes of infection, we found contamination by coagulase-negative Staphylococcus on supposedly sterile suture clamps on 3 graft preparation boards. Conclusions: In cases of suspected septic arthritis after ACL reconstruction, laboratory studies and aspiration followed by culture testing should be performed liberally to avoid the otherwise frequently delayed diagnosis. The inferior postoperative activity level noted in infected patients appeared not to be secondary to graft failure but may be related to arthrofibrosis, cartilage damage, or recurring postinfectious meniscal tears.

Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis.

The purpose of this study was to describe our minimally invasive technique and outline perioperative and medium-term outcomes in patients undergoing laparoscopic ileal pouch-anal anastomosis (LIPAA) for ulcerative colitis. Data were obtained from a prospectively collected database of 13 LIPPA procedures performed for ulcerative colitis between May 1994 and November 2000. Medium-term quality-of-life follow-up was obtained by telephone interview. Eight males and five females had an LIPAA performed, all of whom had previously undergone total abdominal colectomy with ileostomy. Median operative time was 255 minutes (range, 200-398 minutes) with one conversion (8%) due to adhesions. There were no deaths or intraoperative complications; however, six patients experienced seven postoperative complications within 30 days of final closure of defunctioning ileostomy (two leaks, two wound infections, one pulmonary embolus, and two reoperations for small bowel obstruction). Median length of stay was 7 days (range, 5-13 days). Median follow-up was 24 months (range, 6-66 months). The median number of day and night bowel movements was 6.0 (range, 3-10) and 1.0 (range, 0-3), respectively, with five patients requiring medication to control frequency. None had incontinence of stool or retrograde ejaculation; however, one had occasional incontinence of gas, three had occasional nocturnal soiling, and one was impotent. Three patients (23%) had pouchitis, all treated successfully with oral antibiotics. All patients were satisfied with the outcome of their operation and all preferred their pouch to previous ileostomy. Patients reported their overall social, emotional, and physical well being to be satisfactory to excellent. Results of the SF-36, a generic quality-of-life survey, were similar to those from studies of patients following an open pelvic pouch procedure. The LIPAA is technically feasible in experienced centers. We believe that the technique is still evolving and that more time and experience is required to refine the procedure.

Prediction of medium-term outcome by cortisol response to the combined dexamethasone-CRH test in patients with remitted depression.

Current hypotheses hold that mechanisms underlying abnormal hypothalamic-pituitary-adrenocortical (HPA) function are causal factors in the precipitation of depression. If this is the case, then normalization of initially disturbed HPA regulation should indicate a good prognosis and persistent HPA dysregulation should be associated with a greater likelihood of relapse or chronicity. The combined dexamethasone/corticotropin-releasing hormone test was administered twice to inpatients with major depression (N = 40), once after initiation of treatment and once after remission, shortly before discharge. Patients with a high cortisol response on both occasions or with a substantially increased cortisol response at discharge were at much higher risk for relapse within the next 6 months than those with low cortisol responses. An easy-to-administer neuroendocrine test allows the prediction of medium-term outcome in patients with remitted depression.

Abciximab in primary coronary angioplasty for acute myocardial infarction improves short- and medium-term outcomes.

The purpose of this study was to compare the outcome of primary percutaneous transluminal coronary angioplasty for acute myocardial infarction (MI) when performed with or without the platelet glycoprotein IIb/IIIa antibody, abciximab. Abciximab improves the outcome of angioplasty but the effect of abciximab in primary angioplasty has not been investigated. Data were collected from a computerized database. Follow-up was by telephone or review of outpatient or hospital readmission records. A total of 182 consecutive patients were included; 103 received abciximab and 79 did not. The procedural success rate was 95% in the two groups. At 30-day follow-up, the composite event rate of unstable angina, reinfarction, target vessel revascularization and death from all causes was 13.5% in the group of patients who did not receive abciximab, 4% (p < 0.05) in the abciximab group and 2.4% (p < 0.05) in the subgroup of patients (n = 87) who completed the 12-h abciximab infusion. At the end of follow-up (mean 7+/-4 months), the composite event rate was 32.4%, 17% (p < 0.05) and 13.1% (p < 0.01) in these three categories respectively. Abciximab bolus followed by a 12-h infusion was an independent predictor of event-free survival, in a Cox proportional hazards model (relative risk 0.49; 95% confidence interval 0.24 to 0.99; p < 0.05). Abciximab given at the time of primary angioplasty may improve the short- and medium-term outcome of patients with acute MI, especially when a 12-h infusion is completed.

Short and medium term outcomes after rollerball endometrial ablation for menorrhagia.

To review prospectively the intraoperative, short and medium term outcomes of patients treated by rollerball endometrial ablation during the learning curve for this relatively new procedure. Seventy-seven women with menorrhagia (71 with dysfunctional bleeding; six with additional small intramural myomas) underwent hysteroscopic rollerball endometrial ablation by coagulation diathermy during 1.5% glycine irrigation, after a two-month period of hormonal suppression. OPERATIVE AND SHORT-TERM EFFECTS: These were recorded at operation and six-week follow-up. No serious short-term complications were recorded. Objective measurement of intraoperative blood loss was always less than 20 mL. One woman experienced uterine perforation with a narrow cervical dilator which did not interfere with the ablation, and two patients had mild postoperative uterine infections. One patient experienced persistent postoperative pain. MEDIUM-TERM OUTCOME: This was recorded at each visit, or by telephone, and confirmed by questionnaire at one year. Twenty-five per cent achieved complete amenorrhoea, 29% staining only, 30% light periods, 10% "normal" or erratic periods and 6% were unchanged. Five patients underwent a second ablation, and three of these later underwent hysterectomy. Measured menstrual blood loss fell from 104 +/- 19 mL (mean +/- standard error of mean) to 1.7 +/- 1.1 mL at six months in 18 women. Other menstrual symptoms were also often dramatically reduced. Of those women with dysmenorrhoea, 33% were cured and 43% markedly improved; of those with midcycle pain, 28% were cured and 53% markedly improved; of those with significant premenstrual symptoms, 13% were cured, 47% markedly improved, 11% unchanged, and 6% were worse. This new procedure is a safe and effective treatment for menorrhagia caused by dysfunctional uterine bleeding, with impressive ancillary benefits for dysmenorrhoea, midcycle pain and premenstrual tension. It is often called minimally invasive surgery, but it must be recognised that it is not minor surgery.