Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries.

BACKGROUND: As global initiatives increase patient access to surgical treatments, there remains a need to understand the adverse effects of surgery and define appropriate levels of perioperative care. METHODS: We designed a prospective international 7-day cohort study of outcomes following elective adult inpatient surgery in 27 countries. The primary outcome was in-hospital complications. Secondary outcomes were death following a complication (failure to rescue) and death in hospital. Process measures were admission to critical care immediately after surgery or to treat a complication and duration of hospital stay. A single definition of critical care was used for all countries. RESULTS: A total of 474 hospitals in 19 high-, 7 middle- and 1 low-income country were included in the primary analysis. Data included 44 814 patients with a median hospital stay of 4 (range 2-7) days. A total of 7508 patients (16.8%) developed one or more postoperative complication and 207 died (0.5%). The overall mortality among patients who developed complications was 2.8%. Mortality following complications ranged from 2.4% for pulmonary embolism to 43.9% for cardiac arrest. A total of 4360 (9.7%) patients were admitted to a critical care unit as routine immediately after surgery, of whom 2198 (50.4%) developed a complication, with 105 (2.4%) deaths. A total of 1233 patients (16.4%) were admitted to a critical care unit to treat complications, with 119 (9.7%) deaths. Despite lower baseline risk, outcomes were similar in low- and middle-income compared with high-income countries. CONCLUSIONS: Poor patient outcomes are common after inpatient surgery. Global initiatives to increase access to surgical treatments should also address the need for safe perioperative care. STUDY REGISTRATION: ISRCTN5181700

Haemodynamic Issues with Transcatheter Aortic Valve Implantation

Transcatheter aortic valves are typically implanted inside the native (or failed bioprosthetic’s) leaflets, permanently forcing the old leaflets open into a pseudo-cylindrical condition. Due to the passive nature of heart valves, the dynamics of the surrounding fluid environment is critical to their optimum performance. Following intervention, the haemodynamics of the region would ideally be returned to their healthy, physiological state, but major alterations are currently inevitable, such as increased peak flow velocity, the presence of stagnation regions, and increased haemolytic fluid environments. These leaflets reduce the volume of and restrict the flow into the Valsalva’s sinuses, and minimise the development of vortices and associated flow structures, which would aid washout and valve closure. Despite these differences to the healthy condition, implantation of these devices offers much improved flow from that of a moderately stenotic valve, with reduced transvalvular systolic pressure drop, peak blood velocity, and shear stress, which normally outweighs the disadvantages highlighted above, especially for high-risk patients