Technique In High-risk Patients Research Articles

Transapical minimally invasive aortic valve implantation

Objective: To evaluate the feasibility of minimally invasive transapical placement (TAP) of an aortic valve xenograft using an oversizing technique for high risk patients with aortic stenosis.

Transcranial Doppler Monitoring of Transcervical Carotid Stenting With Flow Reversal Protection

Transfemoral carotid stenting, despite becoming very frequent, has some limitations such as difficult groin access in few patients, lack of distal protection during filter placement, or embolization despite protection. Transcervical stenting (TCS) is a novel technique during which a common carotid to jugular vein shunt is placed creating a protective reversal flow in the internal carotid artery after proximal common carotid artery (CCA) clamping. We aim to study, with transcranial Doppler (TCD), cerebral flow changes and microemboli detection during transcervical stenting. From September 2005 to March 2006, of 65 consecutive patients eligible for carotid revascularization, 23 were considered high risk (sapphire criteria) and underwent TCS. Neurologic examination was performed before and after the procedure by a neurologist and a preprocedure vascular reactivity TCD examination was done in all patients. After CCA clamping, flow inversion was observed in the anterior cerebral artery, supplying blood to the middle cerebral artery (MCA) and internal carotid artery (reversal). TCD did not detect any air/solid emboli during stent deployment and angioplasty confirming the reversal flow protection hypothesis. Mean reversal flow time was 15.4 minutes; in all cases, substantial MCA flow was present during CCA clamping (initial mean velocity 30 cm/s), and a slow gradual increase was observed traducing collateral flow recruitment (mean velocity after 5 minutes 36 cm/s, P<0.001). Flow increase was observed in all patients except in those with preprocedural exhausted ipsilateral vascular reactivity (16% versus 2%, P=0.036). The only in-procedure complication was one transient ischemic attack. After CCA unclamping, normal antegrade flow was restored in anterior cerebral artery and mean final MCA velocity increased 16% according to preprocedure flow. TCS with protective internal carotid artery flow reversal can eliminate showers of micoremboli during stent deployment making it a promising carotid revascularization technique in high-risk patients with carotid stenosis.

Sternal closure with titanium plate fixation - a paradigm shift in preventing mediastinitis

Sternal instability predisposes to post-operative mediastinitis. Biomechanical studies have shown the superiority of rigid plate fixation over wire circlage in sternal healing. We studied rigid plate fixation for sternotomies in high-risk patients. High-risk patients were identified as those having three or more historically established risk factors for post-operative mediastinitis, such as COPD, re-operative surgery, renal failure, diabetes, steroid use, obesity, existing infection, and immunosuppression. Three hundred and twenty high-risk patients had prophylactic rigid plate fixation (Group S) between July 2000 and Jan 2005. The control group (Group C) comprised 215 patients with similar risk profiles that were not plated during 2000 and 2001. Average age, male-female ratio, risk factors and type of procedures were similar in both groups. Follow up ranged from 4 to 200 weeks. There were 12 peri-operative deaths (3.75%) in group S and 8.6% (18 patients) in group C. There were no instances of deep mediastinitis in group S. Group C had mediastinitis in 28 (13%, P<0.05), requiring high dose antibiotics and plastic surgical intervention. Sternal fixation with titanium plates is an effective way of ensuring sternal immobility thereby reducing the substrate for bony infections. Application of this technique in high-risk patients prevents mediastinitis.

Percutaneous cholecystostomy: a valuable technique in high-risk patients with presumed acute cholecystitis.

Percutaneous cholecystostomy offers a potentially important therapeutic modality for critically ill patients with acute cholecystitis who represent a high risk for general anaesthesia. The aim of the study was to assess experience with percutaneous cholecystostomy in resolving the acute episode of cholecystitis without operative intervention. Twenty-two consecutive patients with a clinical diagnosis of acute cholecystitis underwent the procedure. All were at high risk for general anaesthesia, and all but one developed cholecystitis while hospitalized for another co-morbid condition; 14 were in an intensive care unit. Twenty-one of the 22 patients proved to have acute cholecystitis (11 acalculous, ten cholelithiasis). There were no acute technical complications. Toxaemia resolved in 17 of the 21 patients with acute cholecystitis. Acute cholecystitis failed to resolve in three patients; all died within 48 h from overwhelming generalized sepsis. One patient required emergency cholecystectomy for bile peritonitis when the cholecystostomy catheter became dislodged 24 h after placement. The 60-day mortality rate for the acalculous and calculous patient groups was 55 and 20 per cent, respectively. Only three interval cholecystectomies have been performed at a mean follow-up of 19 months. In conclusion, percutaneous cholecystostomy may be the procedure of choice for the management of acute cholecystitis in the very high-risk critically ill patient. If symptoms fail to resolve quickly, ongoing sepsis, cholangitis or gallbladder necrosis should be suspected.

Estenosis carotídea en enfermos de alto riesgo. Estudio SAPPHIRE frente a un análisis de decisión. ¿Cuál es la mejor opción terapéutica?

In the results from the SAPPHIRE study on high surgical risk patients with carotid stenosis there are no differences between carotid stent-angioplasty (CSA) and carotid endarterectomy (CEA).The aim of this study was to analyse the cost-effectiveness of these two interventions based on the data from the above-mentioned study and on our own experience in carotid surgery.We evaluated 108 CSA carried out between 1999 and 2003. The morbidity and mortality rates in the subgroup of high risk patients, according to the criteria used in the SAPPHIRE study, were analysed according to whether they were symptomatic or asymptomatic. Data concerning endovascular treatment were taken from the literature. A cost-effectiveness study was conducted considering four possible perioperative events: absence of sequelae, AMI, established CVA and death. The computer software package DATAPro was used after fitting the decision to the theoretical quality of life for each of these groups. Cost-effectiveness was estimated based on the cost of each procedure.Of the 108 patients, 41 (37.96%) belonged to the high risk subgroup; 46.3% of them were asymptomatic and 53.7% were symptomatic. In the 30 days following the intervention, one CVA (5.2%) and one AMI (4.5%) were observed. No deaths occurred. The decision analysis for symptomatic patients showed CEA to be the most effective therapeutic option. Similar results were obtained for asymptomatic patients. The average cost for CEA was 3,963 euros and rose to 5,158 euros in the case of CSA.In our study, CEA is the preferred technique in high risk patients owing to its having a better cost-benefit ratio.

Neurologic outcome after ascending aorta–aortic arch operations: Effect of brain protection technique in high-risk patients

Objective: We sought to assess the optimal strategy for avoiding neurologic injury after aortic operations requiring hypothermic circulatory arrest. Methods: All 717 patients who survived ascending aorta–aortic arch operations through a median sternotomy since 1986 were examined for factors influencing stroke. Temporary neurologic dysfunction was assessed in all patients who survived the operation without stroke since 1993. Multivariate analyses were carried out to determine independent risk factors for neurologic injury. Results: Independent risk factors for stroke were as follows: age greater than 60 years (P <.001; odds ratio, 4.5); emergency operation (P =.02; odds ratio, 2.2); new preoperative neurologic symptoms (P =.05; odds ratio, 2.9); presence of clot or atheroma (P <.001; odds ratio, 4.4); mitral valve replacement or other concomitant procedures (P =.055; odds ratio, = 3.7); and total cerebral protection time, defined as the sum of hypothermic circulatory arrest and any retrograde or antegrade cerebral perfusion (P =.001; odds ratio, 1.02/min). In 453 patients surviving operations without stroke after 1993, independent risk factors for temporary neurologic dysfunction included age (P <.001; odds ratio, 1.06/y), dissection (P =.001; odds ratio, 2.2), need for coronary artery bypass grafting (P =.006; odds ratio, 2.1) or other procedures (P =.023; odds ratio, 3.4), and total cerebral protection time (P <.001; odds ratio, 1.02/min). When all patients with total cerebral protection times between 40 and 80 minutes were examined, the method of cerebral protection did not influence the occurrence of stroke, but antegrade cerebral perfusion resulted in a significant reduction in incidence on temporary neurologic dysfunction (P =.05; odds ratio, 0.3). Conclusions: The occurrence of stroke is principally determined by patient- and disease-related factors, but use of antegrade cerebral perfusion can significantly reduce the occurrence of temporary neurologic dysfunction. (J Thorac Cardiovasc Surg 2001;121:1107-21)

Pulmonary tractotomy as an abbreviated thoracotomy technique.

Operative abbreviated thoracotomy techniques in thoracic trauma include emergency center thoracotomy, ligation of major arterial branches, packing the thoracic cavity for diffuse bleeding, towel clip or Bogota bag closure of the chest, and pulmonary tractotomy. Pulmonary tractotomy with selective vascular ligation was originally described for deep through-and-through lung injuries that did not involve hilar vessels or airways. Pulmonary tractotomy has evolved into use as an abbreviated thoracotomy technique in patients with severe thoracic or multivisceral trauma. As with any operative technique in high-risk patients, specific procedure-related complications may occur and are analyzed herein. The objective of this manuscript is to review the indications, techniques, and results for pulmonary tractotomy in trauma patients requiring abbreviated thoracotomy. Medical records were retrospectively reviewed for 30 of 32 consecutive tractotomy patients treated at Ben Taub General Hospital, during a 3-year period. By using a model for logistic regression analysis, the characteristics of each patient and their clinical course were tested for impact on mortality. Seventy percent of patients had at least one intraoperative parameter indicative of acidosis (pH < 7.2), coagulopathy (prothrombin time > 13.8 or partial thromboplastin time > 38.0 seconds), or hypothermia (core temperature < 34 degrees C), and 50% of patients manifested two of these three parameters. The mortality rate among the 30 patients was 17%. Three of the five patients who died were noted to be acidotic, coagulopathic, and hypothermic. Twelve of 25 patients who survived more than 1 day had at least one thoracic complication. There were no late deaths. There was one failed tractotomy and one missed injury. A second thoracotomy was not required for control of a lung injury in any patient. Logistic regression analysis showed that intraoperative blood loss was the only predictive factor for mortality. Pulmonary tractotomy is a simple and effective technique in injured patients who require an abbreviated thoracotomy and has an acceptable mortality and complication rate. This follow-up report notes that as definitive therapy, tractotomy continues to allow for direct control of bleeding and air leak and obviates the need for formal resection.

Bidirectional Cavo-Pulmonary Anastomosis with an Additional Flow Source to the Lungs: Clinical Experience in 21 Cases

The Fontan operation is considered a palliative procedure for the treatment of complex congenital heart diseases with a morbidity and mortality that are not negligible, expecially in high-risk patients. In these cases, a bidirectional cavopulmonary anastomosis with additional source of blood flow to the lungs can represent a valuable surgical option. Between November 1992 and December 1995, 21 patients with univentricular heart physiology were submitted to bidirectional cavopulmonary anastomosis with additional blood flow the additional flow consisted of an aortopulmonary shunt in 13 cases, pulmonary artery banding in seven cases, and pulmonary artery stenosis in one case. Mean age at operation was 35.5 months (range 4 months to 12 years) and mean body weight 10.9 (range 4–24.4) kg. Hospital mortality was zero. Morbidity (pleuropericardial effusions) was significant in one case. There were three late deaths (14%) caused by worsening atrioventricular valve regurgitation: two of these occurred in patients with right isomerism. Late haemodynamic evaluation documented a significant increase in cardiac output ( P &lt; 0.01) and oxygen saturation ( P &lt; 0.05) during pharmacological stress testing. Angiographic characterization of blood flow distribution to the lungs showed better results when the additional blood flow was represented by an anterograde source (pulmonary artery banding or native pulmonary artery stenosis). In conclusion, bidrectional cavopulmonary anastomosis with additional blood flow is a good alternative to classic or fenestrated Fontan technique in high-risk patients. Secondly, the diagnosis of isomerism could be a contraindication to this type of surgery, because the persistent volume overload could worsen atrioventricular valve regurgitation. Thirdly, the pharmacological stress testing shows a favourable behaviour of cardiac output and arterial oxygen saturation. Fourth, the type of additional blood flow seems to condition both pulsatility and distribution of pulmonary blood flow.

Bidirectional cavo-pulmonary anastomosis with an additional flow source to the lungs: clinical experience in 21 cases

The Fontan operation is considered a palliative procedure for the treatment of complex congenital heart diseases with a morbidity and mortality that are not negligible, expecially in high-risk patients. In these cases, a bidirectional cavopulmonary anastomosis with additional source of blood flow to the lungs can represent a valuable surgical option. Between November 1992 and December 1995, 21 patients with univentricular heart physiology were submitted to bidirectional cavopulmonary anastomosis with additional blood flow the additional flow consisted of an aortopulmonary shunt in 13 cases, pulmonary artery banding in seven cases, and pulmonary artery stenosis in one case. Mean age at operation was 35.5 months (range 4 months to 12 years) and mean body weight 10.9 (range 4-24.4) kg. Hospital mortality was zero. Morbidity (pleuropericardial effusions) was significant in one case. There were three late deaths (14%) caused by worsening atrioventricular valve regurgitation: two of these occurred in patients with right isomerism. Late haemodynamic evaluation documented a significant increase in cardiac output ( P<0.01) and oxygen saturation ( P<0.05) during pharmacological stress testing. Angiographic characterization of blood flow distribution to the lungs showed better results when the additional blood flow was represented by an anterograde source (pulmonary artery banding or native pulmonary artery stenosis). In conclusion, bidrectional cavopulmonary anastomosis with additional blood flow is a good alternative to classic or fenestrated Fontan technique in high-risk patients. Secondly, the diagnosis of isomerism could be a contraindication to this type of surgery, because the persistent volume overload could worsen atrioventricular valve regurgitation. Thirdly, the pharmacological stress testing shows a favourable behaviour of cardiac output and arterial oxygen saturation. Fourth, the type of additional blood flow seems to condition both pulsatility and distribution of pulmonary blood flow.

Awake epidural anesthesia is effective and safe in the high-risk colectomy patient

This study was designed to examine the feasibility and safety of performing open colectomy using awake epidural anesthesia in high-risk patients with comorbid illnesses. We retrospectively compared 15 high-risk patients who underwent colectomy using awake epidural anesthesia with 17 lower risk colectomy patients who received conventional general endotracheal anesthesia. All patients were operated on consecutively during the same time period by the same surgeon. Based on the number of coexisting diseased organ systems and by a weighted multifactorial index of operative risk, the patients receiving awake epidural anesthesia were significantly more ill than the patients receiving general anesthesia. No differences in complications, length of operative procedure, or number of lymph nodes in cancer specimens were found between the two groups. There was a trend favoring the epidural technique when operative blood loss, length of postoperative hospital stay, and return of bowel function were considered. Awake epidural anesthesia is a safe and effective technique in high-risk patients undergoing colectomy and achieves an operative risk that compares favorably with healthier patients receiving general anesthesia.

Relative Indications for Orthotopic Lower Urinary Tract Reconstruction, Continent Urinary Diversion and Conduit Urinary Diversion

Continent urinary diversion has become increasingly popular in the last few years and there are now several situations in which ileal conduit diversion, continent diversion and orthotopic reconstruction of the lower urinary tract are equally valid options. This review was intended to determine specific indications for each. Of 513 patients treated for severe lower urinary tract problems in the last 10 years, 399 underwent orthotopic reconstruction, 68 underwent continent diversion and 46 had an ileal conduit. Problems occurred 2 to 3 times more commonly in the continent diversion group than in either of the other groups. Given a free choice, most patients would choose an orthotopic reconstruction and this should probably be regarded as the gold standard. Continent diversion is specifically indicated in male patients who require a total cystourethrectomy for bladder cancer, in severe post-radiotherapy problems, and in patients with neuropathic bladder dysfunction in whom, for various reasons, self-catheterisation is impossible. Ileal conduit diversion remains the simplest and safest technique in high-risk patients and does not preclude a subsequent continent diversion or orthotopic reconstruction.

Effect of warm heart surgery on perioperative management of patients undergoing urgent cardiac surgery

The anesthetic management and outcome data were examined in a retrospective case-controlled study that compared a conventional hypothermic cardioplegic technique with the recently described method of warm heart surgery, in patients undergoing urgent cardiac surgery. Hypothermic continuous oxygenated blood crystalloid cardioplegia with systemic hypothermia was used for 37 patients who underwent cardiac surgery by the same surgeon over a 16-month period from July 1986 (group 1), whereas normothermic continuous oxygenated blood crystalloid cardioplegia with systemic normothermia was used on 56 patients over the following 16-month period until March 1990 (group 2). The groups were similar in terms of age, sex, ASA status, NYHA classification, and preoperative left ventricular function. Defibrillation following cardiopulmonary bypass was required in only 3.6% of the warm heart surgery patients (group 2) compared with 83.8% in group 1 ( P < 0.0001), and use of warm heart surgery (group 2) eliminated the need for rewarming. There was a trend towards a reduced incidence of myocardial infarction (19% in group 1 vs 9% in group 2), low cardiac output syndrome (40% vs 29%), and use of the intraaortic balloon pump (16% vs 9%) in warm heart surgery patients, but these differences did not reach statistical significance. There were no differences between the two groups in terms of anesthetic drug usage, total heparin or protamine doses, blood loss, transfusion requirements, or duration of ICU stay. These results suggest that: (1) hypothermia is not an absolute requirement for myocardial protection; (2) warm cardioplegia is a useful and safe technique in high-risk patients undergoing urgent cardiac surgery; (3) warm cardioplegia is associated with a reduced requirement for postbypass defibrillation; and (4) introduction into clinical practice of warm heart surgery resulted in no significant changes in perioperative management of patients undergoing urgent cardiac surgery.

The assessment of cardiopulmonary function in thoracic surgery.

Cardiopulmonary function is a determinant of the utmost importance in thoracic surgery. A large battery of tests is available, however, only a relatively limited part of it is obligatory. The essential procedures include testing of global ventilation (inspiratory vital capacity, FEV1), relation of lung volumes (residual volume) and regional quantitation of perfusion (scan). Other costly and invasive tests can be regarded as complementary. This is true in planned lung resection for cancer, where the indication for surgery is of vital importance. Other types of thoracic surgery need a more precise evaluation of risk factors balanced against the expected general improvement of cardiopulmonary function, as in cardiac surgery, decortication, and resection of bullae. But since thoracic surgery is practised mainly for the purpose of lung resection with ensuing loss of function, major attention is paid to this field in order to avoid inconclusive but costly testing, and to discuss indication and use of involved technique in high-risk patients.

Time-related peripartum determinants of postpartum morbidity.

Five time-related peripartum events were prospectively studied in 101 high-risk, internally monitored parturients. These included the duration of labor, the duration of ruptured membranes, the number of vaginal examinations, the length of time from first vaginal examination to delivery, and the duration of internal monitoring. Seventy patients were delivered vaginally and 31 by cesarean section. Several of the time-related peripartum events were found to be individually related to postpartum morbidity. However, combined evaluation by stepwise discriminant analysis revealed that the duration of labor alone was the primary determinant of postpartum morbidity. These findings imply that the observation of a relationship between postpartum morbidity and any of several peripartum time-related factors in isolation may be mediated by its relationship in time to labor duration. This suggests, in turn, that intensive labor monitoring techniques in high-risk patients would not be expected to increase postpartum morbidity above that expected from increases in labor duration alone. The results further suggest that the duration of labor may be the only time-related peripartum event useful in evaluating the risk for postpartum infection in monitored patients in labor who undergo cesarean section.