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Verney C, John M. Transoesophageal echocardiography in cardiac surgery: nearing the limit? Br J Hosp Med (Lond) 2018; 79:58. [PMID: 29315052 DOI: 10.12968/hmed.2018.79.1.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Charlotte Verney
- Specialist Registrar, Department of Anaesthesia, Guys & St Thomas' NHS Foundation Trust, London
| | - Martin John
- Consultant Cardiac Anaesthetist, Department of Anaesthesia, Guys & St Thomas' NHS Foundation Trust, London SE1 7EH
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Manolis AS, Manolis AA. Transcatheter aortic valve implantation in nonagenarians: selectively feasible or extravagantly futile? Ann Cardiothorac Surg 2017; 6:524-531. [PMID: 29062749 DOI: 10.21037/acs.2017.07.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A growing number of nonagenarians is recorded as life expectancy increases. Unfortunately, this extreme-aged group is plagued by increased prevalence of aortic stenosis amidst a higher occurrence of comorbidities that pose dilemmas to cardiologists and cardiac surgeons when having to choose a conservative or interventional treatment modality, and a surgical or transcatheter aortic valve implantation (TAVI) approach. TAVI is an expensive procedure, which also confers a higher mortality and morbidity risk in nonagenarians, compared to younger patients. Considering the physiologic rather the chronologic age alone, and adopting a shared-decision making approach (participatory medicine), it may be more realistic to determine a patient's candidacy for this non-surgical therapeutic modality. Thus, it comes down to the patient selection process by having the heart team review each nonagenarian case individually and getting the patient and the family involved, always aiming to prolong and improve patient's quality of life (QoL), but also taking into consideration patient preferences and values, sharing and respecting goals, realistic expectations, and end-of-life views and ideas. One should keep in mind that there is always the possibility that TAVI may be clinically futile for patients who have a multitude of comorbidities and extreme frailty, for whom a transition to palliative care might be prudent. Selecting nonagenarian patients with low comorbidity index and with no extreme frailty, adopting a minimalistic approach and paying attention to vascular access hemostasis may provide the elements that may lead to a successful, desirable and hopefully cost-effective outcome.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
| | - Antonis A Manolis
- Third Department of Cardiology, Athens University School of Medicine, Athens, Greece
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Kane AE, Howlett SE. Novel cardioprotection strategies for the aged heart: evidence from pre-clinical studies. Clin Exp Pharmacol Physiol 2017; 43:1251-1260. [PMID: 27626269 DOI: 10.1111/1440-1681.12668] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/01/2016] [Accepted: 09/09/2016] [Indexed: 11/30/2022]
Abstract
The incidence of cardiovascular disease is rising as the population ages. This has led to an increase in the need to perform cardiac surgery in older patients. However, aged hearts are particularly susceptible to reperfusion injury following periods of myocardial ischaemia that occur during cardiac surgery. Indeed, older adults experience myocardial dysfunction and reduced survival post-surgery compared to younger people and certain groups, including older women and frail older adults, are at particular risk. This highlights the need to design cardioprotective strategies specifically for the ageing heart. Cardioprotection during surgery is often accomplished by perfusing the heart with chemical arresting agents, known as cardioplegic solutions. New protective strategies have been developed and tested in animal models, where cardioplegic solutions have been modified by changing their temperature, chemical components and/or the frequency of delivery. In addition, drugs designed to activate cardioprotective mechanisms or to inhibit mechanisms involved in injury have been added to improve the efficacy of these solutions. However, most experimental studies have developed and optimized cardioplegic solutions in hearts from younger male animals. This review discusses pre-clinical models used to optimize cardioplegic solutions, with an emphasis on the few studies that have used hearts from older animals. Pharmacologic agents that have been shown to enhance the benefits of cardioplegia in younger hearts and could, in theory, protect vulnerable older hearts are also considered. We emphasize the need to conduct studies in frail older animals of both sexes to facilitate translation of laboratory-based observations to the clinic.
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Affiliation(s)
- Alice E Kane
- Department of Pharmacology, Dalhousie University, NS, B3H 4R2, Canada
| | - Susan E Howlett
- Department of Pharmacology, Dalhousie University, NS, B3H 4R2, Canada.,Department of Medicine (Geriatric Medicine), Dalhousie University, Halifax, NS, B3H 4R2, Canada.,Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK
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Shang X, Lu R, Liu M, Xiao S, Dong N. Mitral valve repair versus replacement in elderly patients: a systematic review and meta-analysis. J Thorac Dis 2017; 9:3045-3051. [PMID: 29221278 DOI: 10.21037/jtd.2017.08.43] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Although mitral valve repair (MVP) is generally accepted as the standard treatment for mitral valve disease, in older patients, there is increasing debate about whether MVP is superior to mitral valve replacement (MVR). We, therefore, performed a meta-analysis to compare MVP vs. MVR in the elderly population. Methods We systematically searched PubMed, the Cochrane Library, and Scopus up to February 2017 and scrutinized the references of relevant literatures. Only studies of MVP vs. MVR in the elderly patients (aged 70 years or older) that were published after 2000 were included. Results The retrieval process yielded seven observational clinical studies with 1,809 patients. Compared with MVR, MVP was associated with a significantly reduced 30-day mortality [risk ratio (RR): 0.40, 95% confidence interval (CI): 0.25-0.64], with shorter duration of postoperative hospital stay (days) (weighted mean difference: -1.47, 95% CI: -2.47--0.48) and less postoperative complications (RR: 0.69, 95% CI: 0.56-0.86). In addition, our study also demonstrated improved 1-year (RR: 1.16, 95% CI: 1.08-1.24) and 5-year (RR: 1.26, 95% CI: 1.13-1.41) survival rates following MVP. There was no difference in reoperations between these two surgery approaches. Conclusions The present meta-analysis indicates that elderly patients who receive MVP have better early and late outcomes than those undergoing MVR. MVP may be the preferred strategy for mitral valve surgery in the elderly population.
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Affiliation(s)
- Xiaoke Shang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Rong Lu
- Department of Intensive Care Unit, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Mei Liu
- Department of Intensive Care Unit, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Shuna Xiao
- Pediatric Intensive Care Unit, Hubei Maternal and Child Health Hospital, Wuhan 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Porizka M, Kunstyr J, Vanek T, Nejedly M, Buckova J, Mokrejs J, Mosna F. Postoperative Outcome of High-Risk Octogenarians Undergoing Cardiac Surgery: A Multicenter Observational Retrospective Study. Ann Thorac Cardiovasc Surg 2017; 23:188-195. [PMID: 28539544 DOI: 10.5761/atcs.oa.16-00280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Cardiac surgery in octogenarians with severely deteriorated functional status is increasingly common, but outcome data are still limited. The aim of this study was to compare postoperative outcome, survival, and quality of life of low-, medium-, and high-risk octogenarians undergoing cardiac surgery. METHODS In all, 285 Czech octogenarians who underwent any cardiac surgical procedure between January 2011 and December 2012 were included in the study. Five out of all twelve national adult cardiac surgical centers participated in the study, representing almost half of all octogenarians operated in our country in that period. Patients' perioperative data were analyzed retrospectively. Follow-up was performed by interviewing patients by telephone. RESULTS There was higher 30-day mortality (20% vs. 6.4% vs. 5.2%, respectively, p <0.001), lower 2-year survival (60% vs. 84.0% vs. 85.4%, respectively, p <0.05), and lower Karnofsky score (44.4 vs. 70.1 vs. 70.6, respectively, p <0.001) in high-risk group compared with medium- and low-risk groups, respectively. Greater improvement in New York Heart Association (NYHA) status was noted in high- and medium-risk groups compared with low-risk group (51% vs. 45% vs. 24%, respectively, p <0.05). CONCLUSION High perioperative mortality, poor 2-year survival, and low postoperative quality of life have been observed in high-risk octogenarians undergoing cardiac surgery.
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Affiliation(s)
- Michal Porizka
- General University Hospital, Department of Anaesthesiology, Resuscitation and Intensive Medicine, The First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jan Kunstyr
- General University Hospital, Department of Anaesthesiology, Resuscitation and Intensive Medicine, The First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Tomas Vanek
- University Hospital Kralovske Vinohrady, Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Michal Nejedly
- University Hospital Kralovske Vinohrady, Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Jana Buckova
- Na Homolce Hospital, Department of Cardiology, Prague, Czech Republic
| | - Jiri Mokrejs
- Faculty Hospital Pilsen, Department of Cardiac Surgery, Charles University in Prague, Pilsen-Bory, Czech Republic
| | - Frantisek Mosna
- Motol University Hospital, Department of Anaesthesiology and Intensive Care Medicine, The Second Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Beverly A, Brovman EY, Malapero RJ, Lekowski RW, Urman RD. Unplanned Reintubation Following Cardiac Surgery: Incidence, Timing, Risk Factors, and Outcomes. J Cardiothorac Vasc Anesth 2016; 30:1523-1529. [DOI: 10.1053/j.jvca.2016.05.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Indexed: 12/15/2022]
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Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2016; 13:593-601. [PMID: 27605940 PMCID: PMC4996834 DOI: 10.11909/j.issn.1671-5411.2016.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes. Methods Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored. Results Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis. Conclusions Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.
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Orkaby AR, Forman DE. Assessing Risks and Benefits of Invasive Cardiac Procedures in Patients with Advanced Multimorbidity. Clin Geriatr Med 2016; 32:359-71. [PMID: 27113152 DOI: 10.1016/j.cger.2016.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Age-related cardiovascular disease in older adults is more likely to occur in combination with other age-related diseases, with mounting interactive complexity as multiple morbidities accumulate. Although invasive cardiac procedures are frequently recommended for cardiovascular disease, their value is less certain in the context of age-related intricacies of care. Tools for risk assessment before invasive procedures are insensitive to risks corresponding to the unique challenges of older adults. Recognizing multimorbidity and other age-related risks provides opportunities to intervene and moderate dangers. By refocusing risk assessment in terms of patient-centered goals, the fundamental utility of invasive cardiac procedures may be reconsidered and alternative therapies prioritized.
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Affiliation(s)
- Ariela R Orkaby
- Division of Cardiology, VA Boston Healthcare System, 400 Veterans of Foreign Wars Pkwy, West Roxbury, MA 02132, USA; Division of Aging, Brigham & Women's Hospital, 1620 Tremont Street, Boston, MA 02120, USA
| | - Daniel E Forman
- Section of Geriatric Cardiology, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213, USA; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, University Dr C, Pittsburgh, PA 15240, USA.
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Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Ebra G. Bilateral Versus Single Internal Mammary Artery Grafting in the Elderly: Long-Term Survival Benefit. Ann Thorac Surg 2015; 100:1374-81; discussion 1381-2. [DOI: 10.1016/j.athoracsur.2015.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/27/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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Cardioprotection: a review of current practice in global ischemia and future translational perspective. BIOMED RESEARCH INTERNATIONAL 2014; 2014:325725. [PMID: 25276778 PMCID: PMC4172998 DOI: 10.1155/2014/325725] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 07/31/2014] [Accepted: 08/11/2014] [Indexed: 12/02/2022]
Abstract
The idea of protecting the heart from ischemic insult during heart surgery to allow elective cardiac arrest is as old as the idea of cardiac surgery itself. The current gold standard in clinical routine is a high potassium regimen added either to crystalloid or blood cardioplegic solutions inducing depolarized arrest. Ongoing patient demographic changes with increasingly older, comorbidly ill patients and increasing case complexity with increasingly structurally abnormal hearts as morphological correlate paired with evolutions in pediatric cardiac surgery allowing more complex procedures than ever before redefine requirements for cardioprotection.
Many, in part adversarial, regimens to protect the myocardium from ischemic insults have entered clinical routine; however, functional recovery of the heart is still often impaired due to perfusion injury. Myocardial reperfusion damage is a key determinant of postoperative organ functional recovery, morbidity, and mortality in adult and pediatric patients.
There is a discrepancy between what current protective strategies are capable of and what they are expected to do in a rapidly changing cardiac surgery community. An increased understanding of the molecular players of ischemia reperfusion injury offers potential seeds for new cardioprotective regimens and may further displace boundaries of what is technically feasible.
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