Janusz Andres

A comparison of minimally invasive and standard aortic valve replacement

OBJECTIVEnThe study objective was to compare aortic valve replacement through a right anterior minithoracotomy with aortic valve replacement through a median sternotomy.nnnMETHODSnWith propensity score matching, we selected 211 patients after aortic valve replacement through a right anterior minithoracotomy and 211 patients after aortic valve replacement who underwent operation between January 2010 and December 2013. Perioperative outcomes were analyzed, and multivariable logistic regression analysis of risk factors of postoperative morbidity was performed.nnnRESULTSnFor propensity score-matched patients, hospital mortality was 1.0% in the aortic valve replacement through a right anterior minithoracotomy group and 1.4% in the aortic valve replacement group (Pxa0=xa01.000). Stroke occurred in 0.5% versus 1.4% (Pxa0=xa0.615), myocardial infarction occurred in 1.4% versus 1.9% (Pxa0=xa01.000), and new onset of atrial fibrillation occurred in 12.8% versus 24.2% (Pxa0=xa0.003) of patients in the aortic valve replacement through a right anterior minithoracotomy and aortic valve replacement groups, respectively. Postoperative drainage was 353.5xa0±xa0248.6xa0mL versus 544.3xa0±xa0324.5xa0mLxa0(Pxa0<xa0.001) and blood transfusion was required for 48.8% versus 67.3% (Pxa0<xa0.001) of patients in the aortic valve replacement through a right anterior minithoracotomy and aortic valve replacement groups, respectively. Mediastinitis occurred in 2.8% of patients after aortic valve replacement and in 0.0% of patients after aortic valve replacement through a right anterior minithoracotomy surgery (Pxa0=xa0.040). Intensive care unit stay (1.3xa0±xa01.2xa0days vs 2.6xa0±xa02.6xa0days) and hospital stay (5.7xa0±xa01.6xa0days vs 8.7xa0±xa04.4xa0days) were statistically significantly shorter in the aortic valve replacement through a right anterior minithoracotomy group. Aortic valve replacement through a right anterior minithoracotomy surgery resulted in reduced postoperative morbidity (odds ratio, 0.4; Pxa0<xa0.001) and postoperative bleeding and blood transfusion requirements (odds ratio, 0.4; Pxa0<xa0.001).nnnCONCLUSIONSnAortic valve replacement through a right anterior minithoracotomy surgery resulted in a reduced infection rate, diminished postoperative bleedingxa0and blood transfusion requirements, reduced occurrence of new onset of atrialxa0fibrillation, and shorter intensive care unit and hospital stays.

The stepchild of emergency medicine: sudden unexpected cardiac arrest during anaesthesia--do we need anaesthesia-centred Advanced Life Support guidelines?

‘No patient whose death is preventable should die in an operating room or in a hospital – ever’ wrote William R. Berry in his recent editorial. The editorial is accompanied by two articles in the same issue of the Canadian Journal of Anaesthesia – one on cardiac arrest in the operating room requiring prolonged resuscitation and the second on anaesthesia advanced circulatory life support. Both articles are important recent contributions to the problem of sudden unexpected cardiac arrest during anaesthesia (SUCADA).

Medicine Goes Female: Protocol for Improving Career Options of Females and Working Conditions for Researching Physicians in Clinical Medical Research by Organizational Transformation and Participatory Design

Background All European countries need to increase the number of health professionals in the near future. Most efforts have not brought the expected results so far. The current notion is that this is mainly related to the fact that female physicians will clearly outnumber their male colleagues within a few years in nearly all European countries. Still, women are underrepresented in leadership and research positions throughout Europe. Objectives The MedGoFem project addresses multiple perspectives with the participation of multiple stakeholders. The goal is to facilitate the implementation of Gender Equality Plans (GEP) in university hospitals; thereby, transforming the working conditions for women working as researchers and highly qualified physicians simultaneously. Our proposed innovation, a crosscutting topic in all research and clinical activities, must become an essential part of university hospital strategic concepts. Methods We capture the current status with gender-sensitive demographic data concerning medical staff and conduct Web-based surveys to identify cultural, country-specific, and interdisciplinary factors conducive to women’s academic success. Individual expectations of employees regarding job satisfaction and working conditions will be visualized based on “personal construct theory” through repertory grids. An expert board working out scenarios and a gender topic agenda will identify culture-, nation-, and discipline-specific aspects of gender equality. University hospitals in 7 countries will establish consensus groups, which work on related topics. Hospital management supports the consensus groups, valuates group results, and shares discussion results and suggested measures across groups. Central findings of the consensus groups will be prepared as exemplary case studies for academic teaching on research and work organization, leadership, and management. Results A discussion group on gender equality in academic medicine will be established on an internationally renowned open-research platform. Project results will be published in peer-reviewed journals with high-impact factors. In addition, workshops on gender dimension in research using the principles of Gendered Innovation will be held. Support and consulting services for hospitals will be introduced in order to develop a European consulting service. Conclusions The main impact of the project will be the implementation of innovative GEP tailored to the needs of university hospitals, which will lead to measurable institutional change in gender equality. This will impact the research at university hospitals in general, and will improve career prospects of female researchers in particular. Simultaneously, the gender dimension in medical research as an innovation factor and mandatory topic will be strengthened and integrated in each individual university hospital research activity. Research funding organizations can use the built knowledge to include mandatory topics for funding applications to enforce the use and implementation of GEP in university hospitals.

KIDS SAVE LIVES: School children education in resuscitation for Europe and the world

Sudden cardiac death is the third leading cause of death in industrialised nations. It is estimated that in Europe and in the United States, more than 700u200a000 patients die annually following sudden cardiac death, even when the emergency medical service has been activated and started cardiopulmonary

Respiratory System Function in Patients after Aortic Valve Replacement through Right Anterior Minithoracotomy

Background The aim of the study was to analyze respiratory system function after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT‐AVR). Methods An observational study of 187 patients electively scheduled for RAT‐AVR between January 2010 and December 2013. Pulmonary complications were analyzed and spirometry examinations were performed preoperatively, 1 week, 1 month, and 3 months after surgery. Results Hospital mortality was 1.1%. A double‐lumen intratracheal tube was used in 88.2% and single‐lumen intratracheal tube was used in 11.8% of patients. Pulmonary complications occurred in 10.8% of the patients. Prolonged (>24 hours) mechanical ventilation time was present in five patients (2.7%). The reasons were stroke (n = 1), perioperative myocardial infarction (n = 2), and pneumothorax (n = 2). Right pleural effusion, which occurred in 7.7% (n = 14) of patients, was the most frequent respiratory system complication. One week after surgery, the spirometry parameters decreased in comparison to the preoperative period, then after 3 months statistically significant improvement occurred; however, the spirometry parameters still had not returned to preoperative values. Multivariable median regression analysis shows that the presence of chronic obstructive pulmonary disease and pulmonary complications were associated with lower values of forced expiratory volume in 1 second after surgery. There was no statistically significant difference regarding spirometry values or incidence of pulmonary complications after surgery between patients in whom single‐lung or double‐lung ventilation was applied. Conclusion Pulmonary functional status measured with spirometry parameters was diminished after RAT‐AVR surgery. Single‐lung ventilation did not result in a higher rate of respiratory complications after RAT‐AVR surgery.

Computed Tomography Helps to Plan Minimally Invasive Aortic Valve Replacement Operations

BACKGROUNDnThis study evaluated the role of multidetector computed tomography (MDCT) in preparation for minimally invasive aortic valve replacement (MIAVR).nnnMETHODSnAn analysis of 187 patients scheduled for MIAVR between June 2009 and December 2014 was conducted. In the study group (nxa0= 86), MDCT of the thorax, aorta, and femoral arteries was performed before the operation. In the control group (nxa0= 101), patients qualified for MIAVR without receiving preoperative MDCT.nnnRESULTSnThe surgical strategy was changed preoperatively in 12.8% of patients from the study group and in 2.0% of patients from the control group (pxa0= 0.010) and intraoperatively in 9.9% of patients from the control group and in none from the study group (pxa0= 0.002). No conversion to median sternotomy was necessary in the study group; among the controls, there were 4.0% conversions. On the basis of the MDCT measurements, optimal access to the aortic valve was achieved when the angle between the aortic valve planexa0and the line to the second intercostal space was 91.9xa0± 10.0 degrees and to thexa0third intercostal space was 94.0 ± 1.4 degrees, with thexa0distance to the valve being 94.8 ± 13.8 mm and 84.5xa0±xa09.9 mm for the second and thirdxa0intercostal spaces, respectively. The right atrium covering the site of the aortotomy was present in 42.9% of cases when MIAVR had been performed through the third intercostal space and in 1.3% when through the second intercostal space (pxa0= 0.001).nnnCONCLUSIONSnPreoperative MDCT of the thorax, aorta, and femoral arteries makes it possible to plan MIAVR operations.

Function of the Respiratory System in Elderly Patients After Aortic Valve Replacement

OBJECTIVEnTo compare the function of the respiratory system after aortic valve replacement through median sternotomy (AVR) or the minimally invasive right anterior minithoracotomy (RAT-AVR) approach among elderly (aged≥75 years) patients.nnnDESIGNnObservational cohort study.nnnSETTINGSnUniversity hospital.nnnPARTICIPANTSnThe study included 65 elderly patients scheduled for RAT-AVR and 82 for standard AVR.nnnINTERVENTIONSnPulmonary function tests (PFT) were performed preoperatively, 1 week, 1 month, and 3 months after surgery. In addition, respiratory complications were analyzed.nnnMEASUREMENTS AND MAIN RESULTSnRespiratory complications occurred in 12.3% of patients in the RAT-AVR group and 18.3% of patients in the AVR group (p = 0.445). Mechanical ventilation time in the intensive care unit was 7.7±3.6 hours for RAT-AVR patients and 9.7±5.4 hours for AVR patients (p = 0.003). Most PFT were worse in the AVR group than in the RAT-AVR group when performed 1 week after surgery. After 1 month, forced expiratory volume in the first second, vital capacity, and total lung capacity differed significantly in favor of the RAT-AVR group (p = 0.002, p<0.001, and p = 0.001, respectively). After 3 months, the PFT parameters still had not returned to preoperative values, but the differences were no longer significant between the RAT-AVR and AVR groups. The multivariable median regression analysis demonstrated that RAT-AVR surgery was a key factor in a patients higher postoperative PFT parameter values.nnnCONCLUSIONSnRAT-AVR surgery resulted in shorter postoperative mechanical ventilation time and improved the recovery of pulmonary function in elderly patients, but it did not reduce the incidence of pulmonary complications when compared with surgery performed through a median sternotomy.

Clinical and echocardiographical study of the aortic homograft implantations in patients with Marfan syndrome

The aim of the study was to assess the long-term results of surgical treatment with homogenic aortic grafts (HAGs) implantation in patients with Marfan syndrome. There were 31 patients with Marfan syndrome and aortic aneurysm who were operated on between 1980 and 1996. Aortic dissection was diagnosed in 14 patients, DeBakey Type I in six patients and Type II in eight patients. Four patients had to be operated urgently in cardiogenic shock with cardiac tamponade. Sealing up and reinforcement with strip of felt or Gore-Tex has been applied in 22 patients. The surgical modifications mentioned above have been applied since 1987 in all patients with the diameter of the aortic ring exceeding 30 mm or with active infective endocarditis or during reoperation. In 16 patients the space between the aortic homograft and patients own aortic wall was joined to the right atrial auricle. Patients were followed up for 12-179 months (average: 94.6 +/- 499). Three patients died in the early postoperative period and four patients died in the late postoperative period. Rethoracotomy because of bleeding complications was necessary in five patients. HAG damage was responsible for six other reoperations-new HAGs have been implanted in three patients and artificial prostheses were implanted in the other three patients. In the late follow-up period significant improvement in cardiac performance was observed in 24 patients (NYHA I or II). Survival probability of 15 years for the whole group was 80%. The lowest survival probability has been shown in the group of patients with DeBakey Type I aortic dissection (35% survived 15 years after operation). Echocardiographic follow-up has shown that the pressure gradient in HAG was low (7.4 +/- 6.2 mmHg). Only in two patients did the HAG gradient exceeded 20 mmHg. There were no significant differences concerning aortic ring diameters, dimensions of HAG and echocardiographic parameters between the group with surgical modifications, i.e. sealing up and reinforcement with strip of felt or Gore-Tex applied and the group in which these modifications were not applied. Homogenic aortic graft implantation as a method of surgical treatment of aortic aneurysm in patients with Marfan syndrome avoids postoperative anticoagulation, results in substantial improvement of cardiac performance and prolongs life. Surgical treatment should be considered in asymptomatic patients with large aneurysms (exceeding 55-65 mm) in patients with Marfan syndrome because there is a high risk of death in this group of patients in the case of dissection.

Respiratory System Function in Patients After Minimally Invasive Aortic Valve Replacement Surgery: A Case Control Study

Objective The aim of the study was to comparatively analyze respiratory system function after minimally invasive, through right minithoracotomy aortic valve replacement (RT-AVR) to conventional AVR. Methods Analysis of 201 patients scheduled for RT-AVR and 316 for AVR between January 2010 and November 2013. Complications of the respiratory system and pulmonary functional status are presented. Results Complications of the respiratory system occurred in 16.8% of AVR and 11.0% of RT-AVR patients (P = 0.067). The rate of pleural effusions, thoracenteses, pneumonias, or phrenic nerve dysfunctions was not significantly different between groups. Perioperative mortality was 1.9% in AVR and 1.0% in RT-AVR (P = 0.417). Mechanical ventilation time after surgery was 9.7 ± 5.9 hours for AVR and 7.2 ±3.2 hours for RT-AVR patients (P < 0.001). Stroke (odds ratio [OR] = 13.4, P = 0.008), increased postoperative blood loss (OR = 9.6, P <0.001), and chronic obstructive pulmonary disease (OR = 7.7, P < 0.001) were risk factors of prolonged mechanical lung ventilation. A week after surgery, the results of most pulmonary function tests were lower in the AVR than in the RT-AVR group (P < 0.001 was seen for forced expiratory volume in the first second, vital capacity, total lung capacity, maximum inspiratory pressure and maximum expiratory pressure, P = 0.377 was seen for residual volume). Conclusions Right anterior aortic valve replacement minithoracotomy surgery with single-lung ventilation did not result in increased rate of respiratory system complications. Spirometry examinations revealed that pulmonary functional status was more impaired after AVR in comparison with RT-AVR surgery.

Perioperative Outcomes of Minimally Invasive Aortic Valve Replacement through Right Anterior Minithoracotomy

Backgroundu2003The aim of the study was to analyze perioperative outcomes after minimally invasive aortic valve replacement through right anterior minithoracotomy (RAT-AVR). Patient selection criteria, anesthesia protocol, and surgical technique are presented. Methodsu2003A retrospective analysis of 194 patients electively scheduled for RAT-AVR was performed between January 2009 and June 2013. For preoperative planning, computed tomography was performed. Resultsu2003Among studied patients, there were 48.5% females and 51.5% males with a mean age of 69.9u2009±u20099.2 years. The predicted mortality calculated with EuroSCORE II was 3.2u2009±u20090.9%, and observed mortality of RAT-AVR patients was 1.5%. Finally, RAT-AVR surgery was performed on 97.9% of patients (nu2009=u2009190). Reasons for conversions to median sternotomy were bleeding from aortotomy site (nu2009=u20094) and from the right ventricle after epicardial pacing wire placement (nu2009=u20091), pleural adhesions (nu2009=u20092), and ascending aorta hidden under the sternum (nu2009=u20092). The second intercostal space was chosen for surgical access in 97.9% of patients.There were 3.6% reoperations for bleeding: aortotomy place (nu2009=u20091), epicardial pacing wire placement (nu2009=u20093), right lung tear (nu2009=u20092), and intercostal vessels (nu2009=u20091). The intensive care unit and hospital length of stays were 1.3u2009±u20091.2 and 5.7u2009±u20091.4 days, respectively. Strokes were present in 1.5% of patients. The perioperative complications rate diminished with time, occurring in 44.9% of the patients between 2009 and 2010 and in 15.6% of patients in 2013. Conclusionsu2003RAT-AVR can be safely performed without increased morbidity and mortality. Reduced complication rates over time reflect a learning curve.