Valve replacement in octogenarians: increased early mortality but good long-term result

Between January 1983 and December 1990, 20 patients aged 80 years or older underwent valvular surgery. The patients' ages varied from 80 to 87 years (mean, 82 ± 1.5 years). The indication for operation was aortic stenosis in 19 patients, and mitral insufficiency after previous mitral valve replacement with a bioprosthesis in one. There were 15 elective, two urgent, and three emergency operations. Four of these patients had aortic valve replacement plus coronary artery bypass grafting. Six patients (30%) had an uneventful hospital stay, and the other 14 (70%) experienced several post-operative complications. The operative mortality rate was 15± (three patients). All patients before operation were in NYHA (New York Heart Association) class III and IV and all survivors remained in NYHA class I or II. The survivors have been followed from 6 to 70 months (mean 20 ± 8 months). The actuarial survival rate at 1 and 5 years was 78.5% and 67%, respectively. Valvular replacement in octogenarians can be performed, despite the high rate of post-operative complications, with increased but acceptable mortality. Long-term results are goo

Evolution of antimicrobial prophylaxis in cardiovascular surgery

Objective: To examine the optimal duration of antibiotic prophylaxis in major cardiovascular surgery. Methods: In the past 15 years, four prospective randomized, controlled studies, conducted by the same group of authors, compared seven prophylactic antimicrobial regimens in 2970 patients undergoing major cardiovascular surgery. In 1980/81, a 4-day cefazolin (CFZ) prophylaxis was compared with a 2-day cefuroxime (CFX) administration (n=566). In 1982/83, a 2-day CFX prophylaxis was compared with a two shot ceftriaxone (CRO) prophylaxis (n=512). In 1984/87, a 1-day CFZ prophylaxis was compared with a single shot prophylaxis of CRO (n=883). In 1994/1995, a 4 day combination of amoxicillin (AM) and netilmicin (NET) prophylaxis was compared with a single shot prophylaxis of CFX (n=1009). Results: Total infection rate varied between 4.5 and 5.7%, despite different antimicrobial regimen used and their varying duration. Wound infection rate was 1.1% (range 0.4-2.5%), sepsis rate was 0.8% (range 0.4-1.6%), pneumonia rate 2% (0.7-2.9%), urinary tract infection rate 0.4% (range 0-1.4%), and central venous catheter-related infection rate was 0.4% (0-1%). The 30-day mortality rate was 1.3% (range 0.4-2%). All these differences were not statistically significant. Conclusions: A low infection rate (range 4.5-5.7%) occurred despite changes in duration of various prophylactic antibiotic regimen with cephalosporins of first, second or third generation. As a single shot prophylaxis could nowadays successfully be used in cardiovascular surgery, no postoperative antibiotics should be used, unless an intraoperative or a postoperative infection is documented or in presence of major perioperative complication

Regional myocardial ischemia in hypertrophic cardiomyopathy: Impact of myectomy

AbstractObjectiveChest pain is a common finding in patients with hypertrophic cardiomyopathy and can be observed in 40% to 50% of all patients. However, the pathogenesis of these ischemia-like symptoms is still unclear.MethodsTwenty-two patients with hypertrophic cardiomyopathy and 15 controls underwent positron emission tomography for evaluation of regional myocardial perfusion and coronary flow reserve (hyperemic/baseline myocardial blood flow). Myocardial perfusion (mL/min/g) was measured using [13N]ammonia at rest and during hyperemia with dipyridamole (0.56 mg/kg intravenously). Regional coronary flow reserve was assessed in 3 planes (apical, midventricular, basal) in 4 regions (septal, anterior, lateral, inferior). Patients were divided into 2 groups: group 1 consisted of 11 patients treated with surgical myectomy (age 56 ± 10 years) and group 2 consisted of 11 patients treated medically (age 53 ± 13 years).ResultsMean global coronary flow reserve was 3.87 ± 0.92 in controls but 2.31 ± 0.40 in operated (P < .001 vs controls) and 1.76 ± 0.58 in medically treated patients (P < .001 vs controls, P < .05 vs operated). Similarly, septal coronary flow reserve was 4.19 ± 1.22 in controls but significantly reduced in operated patients (2.26 ± 0.48, P < .001 vs controls) and in medically treated patients (1.76 ± 0.58; P < .001 vs controls). However, septal flow reserve was significantly higher in operated patients than in patients with medically treated hypertrophic cardiomyopathy (+37%, P < .05), mainly due to a reduced resting myocardial perfusion.ConclusionsGlobal and regional myocardial perfusion is reduced in patients with hypertrophic cardiomyopathy. However, myectomy may have a beneficial effect on septal perfusion and flow reserve. Thus, ischemia seems to play an important role in the symptomatology and pathophysiology of hypertrophic cardiomyopathy

Dynamics of drug sustainability Mycobacterium tuberculosis in the Belgorod region for the period of 2008-2017

To assess and compare the structure and dynamics of Mycobacterium tuberculosis drug resistance to anti-tuberculosis drugs, including multiple and broad, in the Belgorod region in newly diagnosed patients and patients with relapses of tuberculosi

Serial lactate and admission SOFA scores in trauma: an analysis of predictive value in 724 patients with and without traumatic brain injury

Objective: Arterial lactate, base excess (BE), lactate clearance, and Sequential Organ Failure Assessment (SOFA) score have been shown to correlate with outcome in severely injured patients. The goal of the present study was to separately assess their predictive value in patients suffering from traumatic brain injury (TBI) as opposed to patients suffering from injuries not related to the brain. Materials and methods: A total of 724 adult trauma patients with an Injury Severity Score (ISS)≥16 were grouped into patients without TBI (non-TBI), patients with isolated TBI (isolated TBI), and patients with a combination of TBI and non-TBI injuries (combined injuries). The predictive value of the above parameters was then analyzed using both uni- and multivariate analyses. Results: The mean age of the patients was 39years (77% males), with a mean ISS of 32 (range 16-75). Mortality ranged from 14% (non-TBI) to 24% (combined injuries). Admission and serial lactate/BE values were higher in non-survivors of all groups (all p<0.01), but not in patients with isolated TBI. Admission SOFA scores were highest in non-survivors of all groups (p=0.023); subsequently septic patients also showed elevated SOFA scores (p<0.01), except those with isolated TBI. In this group, SOFA score was the only parameter which showed significant differences between survivors and non-survivors. Receiver operating characteristic (ROC) analysis revealed lactate to be the best overall predictor for increased mortality and further septic complications, irrespective of the leading injury. Conclusion: Lactate showed the best performance in predicting sepsis or death in all trauma patients except those with isolated TBI, and the differences were greatest in patients with substantial bleeding. Following isolated TBI, SOFA score was the only parameter which could differentiate survivors from non-survivors on admission, although the SOFA score, too, was not an independent predictor of death following multivariate analysi

Does exercise-induced myocardial ischaemia cause enhanced platelet activation and fibrin formation in patients with stable angina and severe coronary artery disease?

In this study, betathromboglobulin (BTG) and fibrinopeptide A (FPA) in peripheral venous blood were measured in 20 patients with stable angina pectoris before and immediately after exercise-induced myocardial ischaemia; in 5 of the 20 patients stable angina was associated with typical peripheral artery disease. A total of 10 patients with angiographically documented peripheral artery disease without angina and 10 normal volunteers were taken as control groups. BTG and FPA in the 15 patients with stable angina before exercise were 41±14 ng ml-1 and 2.3±09 ng ml-1 and were not statistically different from the values in normal controls; after exercise-induced myocardial ischaemia no significant increase occurred in these patients. Conversely, in the 5 patients with stable angina associated with peripheral artery disease BTG and FPA before exercise were 6l±10 ng ml-1 and 3.5±0.8 ng ml-1 and increased to 114±14 ng ml-1 (P<0.001) and 4.l±0.5 ng ml-1 (P<0.01): These results were similar to those found in the 10 patients with isolated peripheral artery disease. We conclude that BTG and FPA in peripheral venous blood in patients with stable angina are not elevated either at rest or after exercise-induced myocardial ischaemia. Elevated values of BTG and FPA in patients with stable angina may reflect a major interaction between blood and atherosclerotic vessel wall, suggesting the presence of associated atherosclerotic lesions in peripheral artery diseas

Pretransplant malignancy in candidates and posttransplant malignancy in recipients of cardiac transplantation

Background: Malignancy is generally considered a contraindication for cardiac transplantation, whereas secondary malignancy has been described under chronic immunosuppression. Patients and methods: We report here the frequency of malignancy encountered among the 495 patients evaluated at our cardiac transplant centre as well as the incidence and the course of post-transplant malignancy among 129 consecutive patients who underwent cardiac transplantation, with a subsequent minimum follow-up of 6 months. Results: A total of 10 out of 495 patients (2%) evaluated for heart transplantation presented with a history of previous malignancy: 3 of them underwent transplantation (2 survive, 1 died) whereas in the remaining 7 patients neoplasia was considered a contraindication for cardiac transplantation, and all 7 died (4 cardiac, 3 tumor-related deaths). Post-transplant malignancy was diagnosed in 10 of 129 patients (9%) 35 ± 15 months after transplantation (6 skin cancers, 1 lymphoproliferative disease, 3 solid tumors). No significant association was found between post-transplant malignancy and primary prophylaxis with antithymocyte globulin (ATG) or murine antihuman T-cell monoclonal antibodies (OKT3). Conclusions: These results confirm that pre-transplant malignancy is not an absolute contraindication for cardiac transplantation and that post-transplant follow-up must include careful monitoring of post-transplant malignanc

Advanced training model for beating heart coronary artery surgery: the Zurich heart-trainer

Objective: Coronary artery surgery with beating heart technique is gaining increasing popularity. However, it is a challenging technique even for well-trained cardiac surgeons. Thus, a training model for beating heart surgery was developed to increase safety and accuracy of this procedure. Methods: The model consists of differentially hardened polyurethane resembling mechanical properties of the human heart. The covering used in this model is a 1:1 replica of the human thoracic wall with optionally embedded skeletal structures. Sternotomy, lateral thoracotomy or trocar placement is possible to access the lungs, the pericardium and the heart with adjacent vessels. Disposable artificial coronaries variable in size, wall quality or wall thickness are embedded in the synthetic myocardium. Two-layer vessels, which can simulate dissection, are available. Bypass conduits utilize the same material. Coronaries/bypasses as well as part of the ascending aorta are water-tight and can be rinsed with saline. Lungs can be inflated. A purpose-built pump induces heart movement with adjustable or randomized stroke volume, heart rate and arrhythmia induction. Results: The model was tested in a recent ‘Wet-Lab' course attended by 30 surgeons. All conventional instruments and stabilizers with standard techniques can be used. Training with beating or non-beating heart was possible. Time needed for an anastomosis was similar to clinical experience. Each artificial tissue showed its individual nature-like qualities. Various degrees of difficulty can be selected, according to stroke volume, heart rate, arrhythmia, vessel size and vessel quality. The model can be quickly and easily set up and is fully reusable. Conclusions: The similarity to human tissue and the easy set-up make this completely artificial model an ideal teaching tool to increase the confidence of cardiac surgeons dealing with beating heart and minimally invasive surger