Poor Cardiac Status Research Articles

Perioperative Outcomes of Open Surgical Repair for Juxtarenal and Infrarenal Aortoiliac Occlusive Disease in Patients with Poor Cardiac Status

Purpose: The most common cause of mortality in patients undergoing open surgical repair for aortoiliac disease is from cardiac complications. As there is a paucity of literature about the surgical outcomes in patients with compromised cardiac status, this study was undertaken to study the perioperative outcomes of open surgical repair for aortoiliac occlusive disease in patients with poor cardiac status. Methodology: A retrospective study was carried out from January 2017 to December 2020. Patients with aortoiliac occlusive disease based on computed tomography angiographic findings with poor cardiac reserve (ejection fraction ≤40% on echocardiography) were included in the study. The primary endpoints were perioperative complications which included intraoperative hemodynamic complications and early postoperative complications. Results: During 2017–2020, a total of 44 patients with aortoiliac occlusive disease (AIOD) with erectile function ≤40% underwent open surgical repair. Of these, 25 (57%) patients had infrarenal aortoiliac involvement and 19 (43%) had juxtarenal aortoiliac involvement. In our study of open surgical repair for juxtarenal and infrarenal aortoiliac occlusive disease in patients with poor cardiac status, intraoperative hemodynamic complications were noted in 26 (59%) patients, early postoperative complications were noted in 11 (25%), and mortality rate was 4.5%. Conclusion: Even though AIOD patients with poor cardiac status are at high operative risk than patients with normal cardiac status, open surgical repair with in-line bypass can be considered as a suitable option in these patients, especially where facilities for appropriate intraoperative monitoring and management are available.

Chagas Cardiomyopathy: Usefulness of EKG and Echocardiogram in a Non-Endemic Country.

BackgroundChagas disease (CD) is a major cause of cardiomyopathy in Latin America, and migration movements have now spread the disease worldwide. However, data regarding Chagas cardiomyopathy (CC) and the usefulness of echocardiography in non endemic countries are still scarce.Methods and resultsWe selected 485 patients in the chronic phase of CD from two Spanish settings. Data from physical examination, electrocardiogram (EKG), x-ray, and two dimensional transthoracic echocardiogram were recorded. Trypanosoma cruzi DNA was assessed by PCR in peripheral blood. Patients were stratified according to the Kuschnir classification and a combination of echocardiogram and electrocardiogram findings. Patients mainly came from Bolivia (459; 94.6%). One hundred and forty three patients (31.5%) had at least one electrocardiogram abnormality. Twenty seven patients (5.3%) had an abnormal echocardiography. Patients with abnormal echocardiography were older (47 (IQR 38–57) years vs 41 (IQR 38–57) years); p = 0.019) and there was a greater proportion of males (66.7% vs 29.7%); p<0.001). Among echocardiographic variables, diastolic dysfunction was associated with poor cardiac status. In the multivariate analysis, abnormal EKG and gender were associated with abnormal echocardiography. Echocardiography may be spared for males under 30 and females under 45 years old with normal EKG as the likelihood of having an abnormal echocardiography is minimal. Association between T. cruzi DNA in the peripheral blood and cardiac involvement was not observed.ConclusionCC rates in the studied population are low. Age and sex are important determinants for the development of CC, and with the EKG should guide echocardiogram performance.

De Novo Treatment of Diffuse Large B-Cell Lymphoma With Rituximab, Cyclophosphamide, Vincristine, Gemcitabine, and Prednisolone in Patients With Cardiac Comorbidity: A United Kingdom National Cancer Research Institute Trial

The treatment of patients with diffuse large B-cell lymphoma (DLBCL) with cardiac comorbidity is problematic, because this group may not be able to receive anthracycline-containing chemoimmunotherapy. We designed a single-arm phase II multicenter trial of rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisolone (R-GCVP) in patients considered unfit for anthracycline-containing chemoimmunotherapy because of cardiac comorbidity. Sixty-one of 62 patients received R-GCVP, administered on day 1 with gemcitabine repeated on day 8 of a 21-day cycle. Median age was 76.5 years. All patients had advanced disease; 27 (43.5%) had left ventricular ejection fraction of ≤ 50%, and 35 (56.5%) had an ejection fraction of > 50% and comorbid cardiac risk factors such as ischemic heart disease, diabetes mellitus, or hypertension [Corrected]. Primary end point was overall response rate at the end of treatment. Thirty-eight patients (61.3%; 95% CI, 49.2 to 73.4) achieved disease response (complete response [CR], n = 18; undocumented/unconfirmed CR, n = 6; partial response, n = 14). Two-year progression-free survival for all patients was 49.8% (95% CI, 37.3 to 62.3), and 2-year overall survival was 55.8% (95% CI, 43.3 to 68.4). Thirty-four patients experienced grade ≥ 3 hematologic toxicity. There were 15 cardiac events, of which seven were grade 1 to 2, five were grade 3 to 4, and three were fatal, reflecting the poor cardiac status of the study population. Our phase II multicenter trial showed that the R-GCVP regimen is an active, reasonably well-tolerated treatment for patients with DLBCL for whom anthracycline-containing immunochemotherapy was considered unsuitable because of coexisting cardiac disease.

Adult Atypical Sporadic Burkitt Lymphoma Successfully Treated with Bendamustine and Rituximab

Sporadic Burkitt lymphoma (BL) accounts for 1% to 2% of lymphomas in adults. The abdomen is the most common site of involvement. The 2008 World Health Organization Classification of Tumors of Haematopoietic and Lymphoid Tissues introduced a new category of high-grade B-cell lymphomas: an entity with overlapping features of both diffuse large B-cell lymphoma and Burkitt lymphoma (DLBCL/BL). These lymphomas reportedly have poor overall survival rates. We present a case of an elderly adult atypical sporadic BL with jaw and bone marrow involvement. The tumor had the typical characteristic of BL including atypical monotonous lymphoid infiltrate with a starry-sky appearance and a high Ki67 proliferate index of 95%. MYC/IgH rearrangement was seen in 93.5% of the cells with 92% of cells also positive for IgH/Bcl-2, a feature of double-hit lymphoma. This atypical case of adult sporadic BL had features as classified of DLBCL/BL. Though high intensity regimen is used in BL and atypical BL, elderly patients tend to not tolerate these regimens well. Our patient was treated with bendamustine and bituximab given herelderly age and poor cardiac status. The patient responded well to chemotherapy and remains in complete remission two years after diagnosis up to the date of this report. The atypical presentation and excellent response to bendamustine plus rituximab has not been previously reported.

Total Parathyroidectomy Under Local Anaesthesia for Renal Hyperparathyroidism

Renal hyperparathyroidism with attendant osteodystrophy is a frequent and severe morbidity affecting the quality of life of end stage renal failure patients surviving on long-term renal replacement therapy. A small subgroup of these patients with severe cardiorespiratory dysfunction was deemed at very high risk for general anaesthesia (GA). We report on a series of total parathyroidectomy under local anaesthesia (LA) for these patients. A total of 32 consecutive patients with severe cardiorespiratory dysfunction who underwent total parathyroidectomy under LA over a period of 7 years were prospectively accrued in this study. The patient characteristics, the operative outcome and the feasibility to surgery under LA were analysed. Sixteen of the patients (50%) had severe restrictive lung disease as a result of renal osteodystrophy and the other 16 patients had poor cardiac status. Histopathological examination confirmed 23 (71.9%) patients had four glands removed and seven (21.9%) patients had three glands removed. Two patients had only two glands removed and had recurrent hypercalcaemia. However, all patients reported symptomatic improvement. The post-operative complications were minimal; one patient had acute coronary syndrome and wound haematoma and another patient had wound haematoma which necessitated exploration under LA. A further patient developed congestive heart failure requiring treatment in the coronary care unit. Total parathyroidectomy can be performed safely and successfully under LA. We believe surgery under LA would be the most appropriate option for selected, high-risk patients to minimise the risk of GA.

Peroral Cholecystoscopy-Directed Electrohydraulic Lithotripsy of Symptomatic Cholecystolithiasis in Poor Surgical Candidates

Purpose: Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones, but not for those who are poor surgical candidates. Choledoscopy-directed electrohydraulic lithotripsy (EHL) using a “baby scope” passed through a side-viewing duodenoscope is effective for treating choledocholithiasis. However, this technique has not been reported for the treatment of symptomatic cholecystolithiasis in patients unable to undergo surgery. This report describes two cases that demonstrate, for the first time, the feasibility of peroral cholecystoscopy-directed EHL (PC-EHL) for treating symptomatic cholecystolithiasis in non-surgical candidates. Case 1: 78 yo female with severe COPD and cholecystostomy tube for recurrent cholecystitis presented with symptomatic cholelithiasis. A laparoscopic cholecystectomy was attempted and aborted due to severe gallbladder inflammation. The patient was a poor surgical candidate based on poor pulmonary status and prior failed surgery. She underwent a PC-EHL of a 3 cm gallstone and multiple smaller gallstones. Subsequently, a 10-Fr, 10 cm cystic duct stent and a 7-Fr CBD stent were placed. After 12 weeks, a repeat ERC showed only fragments of the stones which were washed and removed. A 7-Fr double pigtail gallbladder stent was placed. With follow-up, she has experienced an uneventful recovery and a marked improvement in her symptoms. Case 2: 65 yo male with ischemic cardiomyopathy (NYHA class IV) and recurrent cholangitis s/p cholecystostomy and gallbladder stenting presented with symptomatic cholelithiasis. The patient was a poor surgical candidate based on poor cardiac status. He underwent PC-EHL of a 5 cm gallbladder stone. Subsequently, a 10-Fr double pigtail stent was placed into the gallbladder. After 2 weeks, a repeat ERC demonstrated a 2 cm fragment of the prior stone. A 10-Fr, 10 cm and a 7-Fr, 10 cm double pigtail stents were placed into the gallbladder. The patient is scheduled for cholangioscopy with repeat EHL. With follow-up, he has experienced an uneventful recovery and a marked improvement in his symptoms. Conclusion: These cases represent the first successful demonstration of PC-EHL in the management of symptomatic cholecystolithiasis. This novel technique offers an endoscopic approach to managing patients with symptomatic cholecystolithiasis who are not surgical candidates.

Percutaneous gallbladder drainage in emphysematous cholecystitis

Emphysematous cholecystitis is a serious disorder with a high mortality and morbidity. We report successful drainage of the gallbadder in a male diabetic patient with emphysematous cholecystitis in whom surgery was considered contraindicated because of his poor cardiac status.

Hip Fracture Mortality

Four hundred consecutive hip fractures were studied prospectively. Two hundred forty-seven patients were classified as unhealthy (poor cardiac status, pneumonia, cancer history, bowel obstruction history, malnutrition, dehydration, stroke history, renal failure history, cirrhosis). Twenty-two percent of this unhealthy group died, while only 6% of the remaining healthy group died. Death rates varied with admission activity level and mental status but not when patient health status was factored out. After factoring out health status, age was associated with higher death rates only in patients older than age 85. Confusion, a change of mental status in the hospital, occurred in 25% of patients. Confusion was associated with a medical complication in 94% of cases, was the presenting symptom of a medical complication in 79% of cases, and was associated with a 39% death rate. Major medical complications occurred in 9% of the healthy group (29% of them died) and 21% of the unhealthy group (64% of them died). Major medical complications in unhealthy, shut-in patients were associated with an 80% death rate. Vigorous urinary tract monitoring and early treatment of bacteriuria decreased death rate. Postfracture malnutrition was associated with higher complication rates. Hip surgery performed within 72 hours on patients with acute medical illnesses in addition to their fracture was associated with a higher death rate. Whether a patient walked postfracture seemed not to be correlated with the death rate. Patients who were not walking prefracture but treated by internal fixation had a 34% failure rate.