Christopher J. Barreiro

Aortic Valve Replacement and Concomitant Mitral Valve Regurgitation in the Elderly Impact on Survival and Functional Outcome

Background—The impact of mitral regurgitation (MR) on elderly patients (≥70 years) undergoing isolated aortic valve replacement (AVR) is not clearly defined. This study investigates the long-term effects of preoperative, moderate MR on survival and functional outcome in elderly AVR patients. Methods and Results—A retrospective review identified 408 consecutive elderly patients who underwent isolated AVR from January 1983 to February 2004. The pathologic etiology of MR was determined on preoperative echocardiogram, and patients were stratified into no/mild MR (Group I; n =338) versus moderate MR (Group II; n =70). Follow-up was 95.1% complete. Functional outcome was evaluated using the Short Form-12 questionnaire. On univariate analysis, Groups I and II differed in incidence of previous myocardial infarction (13.9% versus 28.6%; P=0.004), hyperlipidemia (18.7% versus 33.3%; P=0.009), and congestive heart failure (50.0% versus 70.0%; P=0.002). On multivariate analysis, moderate MR was an independent risk factor impacting long-term survival (P=0.04). Actuarial survival at 1, 5, and 10 years for Group I was 93.8%, 73.3%, and 40.1% versus 92.3%, 58.2%, and 14.6% for Group II (P=0.04). Available postoperative echocardiograms for Group II (n =37) demonstrated improvement in MR in 81.8% of functional MR patients. However, MR persisted or worsened in 65.4% of patients with intrinsic mitral valve disease (myxomatous, calcific, or ischemic MR). Functional outcomes showed 77% of Group I versus 78.6% of Group II rated their health as good to excellent post-AVR. Conclusions—Moderate MR is an independent risk factor impacting long-term survival in elderly patients undergoing AVR. Therefore, patients with intrinsic mitral valve disease should be considered for concomitant MV surgery.

Diagnostic laparoscopy for periampullary and pancreatic cancer: What is the true benefit?

The role of diagnostic laparoscopy in patients with periampullary and pancreatic malignancies is controversial. A retrospective review was performed including all patients (n = 188) with a periampullary or pancreatic malignancy who underwent both CT and laparotomy at our institution between January 1997 and December 1999. The overall resectability rate for all periampullary cancers was 67.3% (115 of 171 patients). This compared favorably with the resectability rate for cancers of the pancreatic body and tail (3 of 17 patients, 17.6%; P < 0.01 vs. periampullary cancers). Fifty percent of patients with periampullary cancers were unresectable because of metastatic disease, whereas metastatic disease precluded resection in 64.3% of patients with cancers of the pancreatic body and tail. After patients undergoing operative palliation were eliminated, a nontherapeutic laparotomy would have been precluded by the use of diagnostic laparoscopy in only 2.3% of patients with periampullary cancers (4 of 171 patients). In contrast, 6 (35.3%) of 17 patients with cancers of the pancreatic body and tail underwent a nontherapeutic laparotomy (P < 0.01 vs. periampullary cancers). One hundred fifty-eight (84%) of the 188 CT reports reviewed could be definitively categorized as either “likely to be resectable” or “likely to be unresectable.” The remaining 16% were equivocal. Of the 107 patients categorized as likely to be resectable, 89 were actually resected (83.2%). In contrast, only 10 of the 51 patients categorized as likely to be unresectable could be resected (19.6%).

Impact of 24 h continuous hypothermic perfusion on heart preservation by assessment of oxidative stress.

Abstract:  Introduction:  Despite investigating numerous solutions, additives, and techniques over the last two decades, extending donor heart preservation beyond 4–6 h has not been achieved. Hypothermic heart preservation (HP) induces oxidative stress (OS) with reactive oxygen species (ROS) production, causing DNA cleavage and impairing repair. Quantification of cardiomyocyte concentrations of DNA damage by‐products (8‐oxoG) and mismatch repair enzymes (MYH, OGG‐1, MSH2) reflects the severity of OS. If increased repair enzyme production is insufficient to repair injury, cell death occurs and functional outcomes are impacted. We investigated continuous hypothermic perfusion (CHP), a new form of HP, and the mechanism of injury associated with hypothermic storage, by assessing functional outcome and OS after allotransplantation of canine hearts.

Successful Repair of an Atrioesophageal Fistula After Catheter Ablation for Atrial Fibrillation

Catheter ablation of arrhythmias can result in the rare but devastating complication of an atrioesophageal fistula. This complication can be associated with significant neurologic morbidity and high mortality and requires a high index of suspicion to facilitate life-saving surgical intervention. Herein, we report the successful repair of an atrioesophageal fistula after catheter ablation for atrial fibrillation.

Image of the month--quiz case. Foreign body (ingested chicken bone).

A 52-YEAR-OLD WOMAN PRESENTED TO THE emergency department with a 2-week history of sharp, intermittent periumbilical abdominal pain and low-grade fevers. Her medical and surgical histories were significant for hypertension and obesity and a lower abdominal midline laparotomy for ruptured ectopic pregnancy. An abdominal computed tomographic scan revealed a 5-cm-long radiodensity in the mid small bowel directly abutting the anterior abdominal wall with surrounding inflammation and bowel wall thickening (Figure1).Herwhitebloodcellcountwaselevatedat15000/ μL (to convert to 10/L, multiply by 0.001), and her abdominalexaminationrevealedvoluntaryguardingandperiumbilical tenderness to deep palpation. The findings were concerningforsmall-bowelperforation,andthepatientwas taken to the operating room for exploratory laparotomy.

Postoperative and Critical Care in the Elderly Cardiac Surgery Patient

As the population of our country continues to age, the number of elderly patients requiring cardiac surgery is inevitably going to rise. The limited functional and physiological reserve of the elderly provides additional challenges in the perioperative care of these patients. However, there is still much benefit and quality of life to be gained by providing expert cardiac surgical care to the elderly. To do this effectively, close attention must be paid to their preoperative, intraoperative, and postoperative care. In addition, aggressive postoperative cardiac rehabilitation is necessary to achieve our goal of returning our elderly patients to a normal life expectancy with reasonable quality of life.