Procedures In Older Patients Research Articles

PC-FACS

PC-FACS

Implantable Cardiac Device Procedures in Older Patients

Although the effectiveness of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) alone or in combination is well established, limited data are available on device use and short-term outcomes in older patients. We sought to characterize age-specific practices and outcomes among patients with heart failure undergoing device implantation using a large nationally representative administrative database. The cohort comprised patients older than 18 years with a diagnosis of heart failure who underwent implantation of an ICD or CRT between January 1, 2004, and December 31, 2005. Data included patient demographics, comorbidities, type of device, procedural complications, length of stay, total cost of hospitalization, and hospital characteristics. Multivariate stepwise logistic regression analysis was used to identify risk factors for in-hospital mortality. We identified 26 887 patients who received an implantable device. The median age was 70.0 years (17.5% were > or =80 years), 72.6% were male, and 31.3% were of nonwhite race/ethnicity. Compared with younger patients, those 80 years or older were more likely to receive CRT alone. In-hospital mortality increased from 0.7% among patients younger than 80 years to 1.2% among those aged 80 to 85 years and 2.2% among those older than 85 years (P < .001). Independent predictors of in-hospital mortality included age 80 years or older, elevated comorbidity score, inotrope use, and procedure-related complications. Despite the fact that most device trials have excluded patients 80 years or older, more than one-fifth of ICD and CRT devices are implanted in this age group. Advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in older patients.

Catheter‐based closure of atrial septal defects in the oval fossa with the Amplatzer® device in patients in their first or second year of life

To assess feasibility, safety, and efficacy of the use of Amplatzer occluders in closure of atrial septal defects (ASD) in children in the first 2 years of life. Although scattered reports on such closure have been published, no agreement consists on the policy. In 654 patients of all ages, closure was achieved in 632 (96.6%). Data were analyzed retrospectively in all 71 children where an attempt had been made to close the ASD before their second birthday. Median age and body weight were 17.2 months (range 3.9-23.8) and 10.0 kg (range 3.8-14.5), respectively. Median fluoroscopy time was 13.6 min and median device size 15 mm. Successful closure was achieved in 68 children (95.8%). Three times the procedure was aborted: in one, the device repeatedly straddled the septum; in the other two, a small left atrium restricted the movement of the left-sided disc. One device embolized and was reimplanted after retrieval. One infant with multiple disorders died 6 days after closure from acute sepsis probably unrelated to the procedure. No other complications occurred. Only trivial shunts closing with time were registered during follow-up. Symptomatic patients profited markedly from closure. The results and complications of ASD closure with the Amplatzer device in patients in their first 2 years of life compare favorably with procedures in older patients, provided that the size of the septum and the dimensions in the left atrium are taken into consideration when selecting the size of the device.

Laparoscopic cholecystectomy in patients over 70 years of age: review of 176 cases

We assessed the results of laparoscopic cholecystectomy in 176 patients over the age of 70 years. The study included all patients older than 70 years of age who underwent laparoscopic surgery cholelithiasis during the previous ten years. Variables studied included age, sex, type of operation (programmed/emergency), comorbidity, anesthetic risk, intraoperative cholangiography, conversion to open surgery, number of trocars, reoperation, residual choledocholithiasis, postoperative hospital stay, morbidity and mortality. The study included 176 patients (23.29% men and 76.71% women). The mean age was 74.86 years. The mean hospital stay was 1.27 days, with 16.98% morbidity and 0.56% mortality. Laparoscopic cholecystectomy is a safe procedure in older patients. It results in faster recovery, a shorter postoperative stay and lower rates of morbidity and mortality than open bile duct surgery.

Curved varus femoral osteotomy for minimal dysplastic hip in patients older than 45 years of age: comparison with rotational acetabular osteotomy

Periacetabular osteotomies, such as rotational acetabular osteotomy (RAO) for osteoarthritis (OA) secondary to hip dysplasia, have produced satisfactory medium- and long-term results in early OA. However, as the degree of surgical invasion of these procedures is comparatively major and long-term postoperative rehabilitation is required, this procedure is generally not indicated for those in the fifth and sixth decades of life. Curved varus femoral osteotomy (CVO), which is a less invasive procedure, is considered a worthwhile option, although to the best of our knowledge no comparative study has been reported on these two procedures in older patients. We performed a comparative study on the outcomes of CVO for minimal dysplasia of the hip with a center-edge (CE) angle greater than 5° in 15 patients (15 joints) older than 45years of age at a mean period of 8years after surgery and on the outcomes of RAO in 16 patients (18 joints) performed during the same period. No significant difference was observed between the two groups regarding the Merle d’Aubigne score during follow-up. Progression of osteoarthritis was radiologically observed during follow-up in three hips in the CVO group and in one hip in the RAO group. Kaplan-Meier survivorship analysis, with radiological progression of osteoarthritis as the endpoint, predicted a survival rate of 75% at 10years in the CVO group. In the RAO group the predicted 10-year survival rate was 94%, demonstrating no significant difference between the two groups. CVO is a less invasive surgical technique than RAO, requires a comparatively shorter period of postoperative rehabilitation, and is useful as a joint-preserving procedure in older patients with minimal dysplasia of the hip with unilateral involvement. CVO should be selected for elderly patients with a CE angle greater than 5°.

Assessment of cardiovascular changes during laparoscopic hernia repair using oesophageal Doppler

We have used an oesophageal Doppler to measure aortic blood flow velocity before, during and after induction of carbon dioxide pneumoperitoneum in 10 consecutive patients, mean age 58 yr, undergoing laparoscopic hernia repair. Derived values for stroke distance, minute distance and systemic vascular resistance showed considerable interpatient variation indicating unpredictable haemodynamic responses. Five minutes after insufflation of the abdomen there was a significant increase in mean arterial pressure from 82.5 to 103.6 mm Hg (P < 0.05) but both stroke distance and minute distance decreased significantly (mean 12.0 (SEM 1.4) cm to 9.0 (0.7) cm, P < 0.05; and 747.5 (82) cm min-1 to 596 (49) cm min-1, P < 0.05; respectively) indicating a significant decrease in cardiac output. There was a corresponding increase in the index of systemic vascular resistance from 1092 (747) to 2079 (400) (P < 0.05) which persisted after deflation of the abdomen. Oesophageal Doppler can provide continuous online haemodynamic data with a rapid response to acute changes and may have a role in non-invasive haemodynamic monitoring during laparoscopic procedures in older patients with cardiovascular disease.

Peripheral blood stem cell transplantation for relapsed or refractory aggressive lymphoma in patients over 60 years of age

Intensive chemotherapy with autologous bone marrow transplantation is now considered the treatment of choice for young patients with sensitive relapse of non-Hodgkin's lymphoma (NHL) but results of this procedure in older patients remain unknown. We evaluated the feasibility of two cycles of salvage therapy followed by an autologous peripheral blood stem cell (PBSC) transplantation in 13 patients aged more than 60 years (median age: 62; range 61-72) suffering from relapsed (n = 10) or refractory (n = 3) aggressive NHL. All patients had previously received first-line treatment containing doxorubicin. An association of ifosfamide, VP16, cytosine-arabinoside with or without high-dose methotrexate was used as salvage and priming therapy prior to collection of PBSC. All patients received G-CSF following salvage therapy. PBSC collection could be performed in 10 patients and yielded a median number of CFU-GM: 98.4 x 10(4)/kg (range 68-369). Nine patients underwent a transplantation using BEAM conditioning regimen. The median time to granulocyte and platelet recovery was 13 days (range respectively: 9-25 and 9-16). One patient died from sepsis after transplantation. The main adverse experience occurring after transplantation was a prolonged decline of performance status. Seven patients achieved a complete remission and one failed to respond. Three patients are still alive in CR. We conclude that PBSC collection was possible in selected patients over 60 years of age with refractory or relapsed aggressive NHL and myeloablative therapy could be used with tolerable toxicity. Hematologic recovery and organ toxicity appears to be similar to those observed in younger patients. Deterioration of performance status after transplantation is the most important factor that could limit this procedure. Further investigations are necessary to determine which patients will be able to benefit by this procedure in terms of survival and quality of life.

Intra-operative risk and haemodynamic etfects of the CO2-pneumoperitoneum in laparoscopic surgery

The benetits of minimally invasive surgery led to an increasing rate of laparoscopic procedures in older patients. These patients profit most from the p.op. advantages of laparoscopic surgery. On the other hand they often display cardiovascular risks with the intra-operative risk of the CO2-pneumoperitoneum still under discussion. Methods: The haemodynamic etfects of CO2-pneumoperitoneum were investigated. Monitoring included cardiac output (CO), central venous pressure (CVP), pulmonary arterial pressure (PAP) and wedge pressure (PAWP), femoral venous pressure (FVP), intra-oesophageal pressure (IEP), systemic vascular resistance (SVR) and transmural right-atrial pressure (TMP), and was performed in a controlled, experimental model. Results: Establishing the pneumoperitoneum caused initially a 35% decrease in CO. SVR, as an indicator of cardiac afterload, increased clearly. The increased intra-abdominal pressure led to a reduction of venous retlux from the periphery and squeezed the venous reservoir within the abdominal cavity. Cardiac preload was altered, too. The elevated cardiac afterload adapted under pneumoperitoneum. After desufflation cardiac output rose far above normal. Conclusions: These results indicate a strong cardiac stress after insufflation and desufflation. This is caused by the increased intra-abdominal pressure rather than by systemic etfects of resorbed CO2. Laparoscopic procedures in patients with clinical signs of cardiovascular insufficiency should only be performed with substantial intra-operative monitoring. Otherwise low pressure pneumoperitoneum and/or pressure and gasless laparoscopy could be considered.

Theoretical principles of cemented prostheses

Today total hip replacement has become a routine procedure in older patients all over the world. A good result is to be expected only, if the device will meet the following requirements: adequate force transfer to the bone, adequate stiffness and elasticity, sufficient range of motion, biocompatibility of the material, low friction, low rate of wear, sufficient lubrication and a secure anchorage. Up to now, the weak point is the bone cement. Advancements in its composition and improved cement techniques will guarantee good function without pain during a long enough period of time.

Prevention, Diagnosis, and Treatment of Common Infections in Geriatric Patients

Prevention of infection in the elderly is far preferable to treatment of the disease, and can be promoted through precautionary measures when undertaking invasive procedures in older patients as well as through the administration of available vaccines. Difficulties in diagnosing bacterial pneumonia, influenza, tuberculosis, diphtheria, tetanus, and urinary tract infections in the elderly, and schedules for treating these diseases, are discussed.

Spontaneous rupture of endometrial cysts of the ovary presenting as an acute abdominal emergency

Review of 37 cases of spontaneous rupture of endometrial cysts indicates that the diagnosis is rarely made preoperatively because of the similarities between this condition and other more frequently encountered acute abdominal emergencies. These similarities as well as differences are discussed. Surgical therapy must be individualized but, in general, the procedure should be conservative in younger patients even though a second operation may be necessary within a few years. The place of a more extensive surgical procedure in older patients is discussed. The morbidity and hospital stay following surgical therapy can be expected to be minimal.