Pierre Sfeir

Smoking and the Risk of Mortality and Vascular and Respiratory Events in Patients Undergoing Major Surgery

IMPORTANCE The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined. OBJECTIVE To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery. DESIGN Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (>1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles. SETTING AND PARTICIPANTS A total of 607,558 adult patients undergoing major surgery in non-Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009. MAIN OUTCOMES AND MEASURES The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement >48 hours). RESULTS The sample included 125,192 current (20.6%) and 78,763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years. CONCLUSIONS AND RELEVANCE Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking-and the benefits of its cessation-on morbidity and mortality in the surgical setting.

Subpleural block is less effective than thoracic epidural analgesia for post-thoracotomy pain: a randomised controlled study.

Context Thoracic epidural and paravertebral blocks provide adequate analgesia for postoperative thoracotomy pain. Both procedures are usually performed percutaneously with considerable failure rates. A subpleural catheter placed in the space posterior to the parietal pleura and alongside the paravertebral area may provide superior postoperative pain relief. Objective To compare subpleural analgesia with thoracic epidural analgesia in patients undergoing thoracotomy. Design Randomised, double-blind study. Setting A tertiary care University Medical Centre between 26 June 2008 and 21 March 2011. Patients Forty-two patients scheduled for elective posterolateral thoracotomy. Patients with American Society of Anesthesiologists physical status ≥4, with a previous history of thoracotomy, on chronic pain medications or with a contraindication to receiving local anaesthetics or thoracic epidural block were excluded from the study. Interventions Patients were randomised to receive either subpleural analgesia or thoracic epidural analgesia for 24-h post-thoracotomy pain control. Main outcome measures A visual analogue scale was used to assess pain at rest and on coughing during the first 24 h postoperatively and the incidence of hypotension was recorded. Results Patients who received subpleural analgesia had higher visual analogue scores at rest and on coughing than those who received thoracic epidural analgesia. Seven patients who started with subpleural analgesia were treated with thoracic epidural analgesia at a mean (SD) of 3.9 (4.8) h. The remaining 14 patients had a median (IQR [range]) visual analogue score of 5 cm (4–5 [3–6]) at rest and were maintained on subpleural analgesia until the end of the study. The visual analogue score at rest was <7 cm in all 21 patients who received thoracic epidural analgesia and none was switched to subpleural analgesia during the study. None of the patients in the subpleural analgesia group experienced hypotension compared with five of the 21 patients in the thoracic epidural analgesia group (P = 0.047). Conclusion Thoracic epidural analgesia is superior to subpleural analgesia in relieving post-thoracotomy pain.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy.

Objective:To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS). Summary Background Data:LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other. Methods:A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes. Results:A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18–0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27–0.76), wound occurrences (OR: 0.37, 95% CI: 0.11–0.79), and sepsis (OR: 0.52, 95% CI: 0.26–0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS. Conclusions:LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patients clinical status.

Prophylactic amiodarone versus lidocaine for prevention of reperfusion ventricular fibrillation after release of aortic cross-clamp

Background and objective Ventricular fibrillation is common after aortic cross-clamp release in patients undergoing open-heart surgeries. The aim of the study was to evaluate the efficacy of the prophylactic administration of 150 mg amiodarone by way of the pump 2 min before release of aortic cross-clamp in preventing ventricular fibrillation. Methods The present study is a prospective, randomized, controlled and blinded study performed at a teaching university hospital where 120 patients undergoing coronary bypass graft surgery were randomly assigned to three groups. Each group received either 150 mg of amiodarone or 100 mg lidocaine or isotonic saline by way of pump 2 min before release of the aortic cross-clamp. The frequency of occurrence of ventricular fibrillation and the subsequent required defibrillation counter shocks were determined in all groups. Results The frequency of occurrence of ventricular fibrillation was significantly higher in both the amiodarone (48%) and the control group (45%) as compared with the lidocaine group (20%) with no statistically significant difference between the amiodarone and the control groups. Furthermore, when ventricular fibrillation occurred, the percentage of patients requiring defibrillation counter shocks was significantly higher in both the amiodarone (58%) and control (61%) groups as compared with the lidocaine group (13%) with no difference between the amiodarone and the control groups, despite a significant decrease in the defibrillation counter shocks energy requirements in the amiodarone group. Conclusion The present study showed no difference between amiodarone (150 mg) and placebo in preventing ventricular fibrillation after release of aortic cross-clamp. In addition, the use of lidocaine was able to reduce the incidence of ventricular fibrillation as compared with both amiodarone and placebo.

Raised haematocrit concentration and the risk of death and vascular complications after major surgery.

Preoperative anaemia is associated with adverse postoperative outcomes. Data on raised preoperative haematocrit concentration are limited. This study aimed to evaluate the effect of raised haematocrit on 30‐day postoperative mortality and vascular events in patients undergoing major surgery.

Primary Dedifferentiated Chondrosarcoma of the Lung

Extraskeletal dedifferentiated chondrosarcomas (DC) are uncommon tumors that predominantly occur in the head and neck. Herein, we describe a case of pulmonary DC detected in a patient with systemic sclerosis and presenting with a symptomatic large pleural effusion and a pulmonary lobar consolidation on chest imaging. To the best of our knowledge, this is the first report of pulmonary chondrosarcoma involving the pleura and occurring in association with systemic sclerosis. Moreover, this is the second report of a dedifferentiated variant among all reported cases of primary lung chondrosarcoma.

Mitral valve repair or replacement in elderly people

Purpose of review Much has been published so far to describe and praise the benefits of mitral valve repair, and to compare it with valve replacement. Now, with mitral valve surgery in elderly people gaining greater acceptance worldwide, repair or replacement remains a controversial issue. This is especially true in the ageing population, in whom many of the complications associated with a mechanical valve can be avoided by using a bioprosthesis. This review will try to assess the latest views in the field and come up with possible answers to this ongoing question. Recent findings The causes of mitral regurgitation in this age group are separately reviewed and discussed in the light of our better understanding of the pathophysiology of the disease. Mitral surgery is recommended when the effective regurgitant orifice reaches 40 mm2. Repair in degenerative disease seems to be feasible, with good long-term results. In chronic ischaemic regurgitation, the concept of a tethered ‘normal valve’ is changing. The ‘poor’ ventricle may be able to withstand surgery as long as the subvalvular apparatus is preserved; on the other hand, repair and replacement seem to have the same survival advantage in high-risk patients. Summary Mitral valve surgery is well tolerated in elderly people. Early intervention leads inevitably to better outcome. The majority of valvular disorders in this age group are amenable to repair, with good reproducible results. Replacement with a bioprosthesis remains a viable option for complex regurgitant jets.

Endovascular Transcatheter Aortic Valve Implantation: An Evolving Standard

e u d ABNORMALITIES OF THE aortic valve morphology and function represent the most common cardiac valve lesion, ith relevant implications for medical and surgical treatent. Aortic valve sclerosis affects about one fourth of dults over 65 years of age, whereas severe aortic stenosis AS) is present in 2% to 9% of the same population.1 AS is suspected to be the result of chronic inflammation secondary to risk factors similar to the ones associated with atherosclerosis.2,3 The number of aortic valve procedures performed over the last 10 years increased if aortic valve replacement is considered alone or combined with myocardial revascularization; mitral valve surgery seemed to be constant in the same period.4 In 1968, Ross and Braunwald,5 in their classic review of the natural history of AS, re-emphasized that sudden death occurred predominantly in symptomatic patients. In asymptomatic patients with acquired severe AS, the risk of sudden death was reported to be between 3% and 5%. It was proposed that patients with acquired severe AS have surgery deferred until the onset of symptoms because the mortality increases steeply afterward (Fig 1).6,7 Surgical replacement of the aortic valve (SAVR) reduces symptoms and improves survival in patients with severe AS.8-10 Its current indications are outlined in Table 1. In the absence of serious comorbidities, the procedure is associated with low operative mortality.11,12 However, in clinical practice, at least 0% of patients with severe symptomatic AS do not undergo urgery for replacement of the aortic valve because of advanced ge, left ventricular (LV) dysfunction, or the presence of muliple coexisting medical conditions.13-16 For these patients who re at high surgical risk, a less invasive treatment may be a orthwhile alternative.17,18 Cribier et al19 reported the first successful implantation of a percutaneous aortic valve in animals in 2000. The first human implantation using the antegrade trans-septal approach followed 2 years later. The first retrograde transfemoral approach was performed in 200320 (Fig 2). At present, most of the available data for transcatheter aortic valve implantation (TAVI) are derived from studies on 2 specific devices: the Sapien valve (Edwards Life Sciences, Inc, Irvine, CA; Fig 3) and the CoreValve (Medtronic, Inc, Minneapolis, MN; Fig 4). The Sapien valve is a trileaflet bovine pericardial valve mounted with a tubular slotted balloonexpandable stent composed of a cobalt chromium alloy. It is available in 23and 26-mm sizes in the United States and 23-, 26-, and 29-mm sizes in Europe. The 23-mm valve is preferred for annular diameters of 18 to 21 mm and the

Airway obstruction secondary to thoracic aortic aneurysm leak A case report

Retropharyngeal hematoma is a rare entity that has various etiologies. Anticoagulation is believed to be the most common cause. Aortic aneurysm leak was reported as a cause of this disease only once. We believe that our case is the second case of retropharyngeal hematoma caused by a leaking aortic aneurysm. A case discussion and management is presented in this article.

Amiodarone and Reperfusion Ventricular Fibrillation

1. Augoustides JGT, Atluri P: Progress in mitral valve disease: nderstanding the revolution. J Cardiothorac Vasc Anesth 23:916-923, 009 2. Lau K-W, Ding Z-P, Hung J-S: Percutaneous transvenous mitral ommissurotomy versus surgical commissurotomy in the treatment of itral stenosis. Clin Cardiol 20:99-106, 1997 3. Hasan-Ali H, Shams-Eddin H, Abd-Elsayed AA, et al: Echocariographic assessment of mitral valve morphology after percutaneous ransvenous mitral commissurotomy (PTMC). Cardiovasc Ultrasound :48, 2007 4. Wilkins GT, Weyman AE, Abascal VM, et al: Percutaneous alloon dilatation of the mitral valve: An analysis of echocardiographic ariables related to outcome and the mechanism of dilatation. Br eart J 60:299-308, 1988 5. Messika-Zeitoun D, Iung B, Brochet E, et al: Evaluation of mitral tenosis in 2008. Arch Cardiovasc Dis 101:653-663, 2008