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Recommendations for Preoperative Assessment and Shared Decision-Making in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2020; 10:185-195. [PMID: 32431570 DOI: 10.1007/s40140-020-00377-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of review Recommendations about shared decision-making and guidelines on preoperative evaluation of patients undergoing non-cardiac surgery are abundant, but respective recommendations for cardiac surgery are sparse. We provide an overview of available evidence. Recent findings While there currently is no consensus statement on the preoperative anesthetic evaluation and shared decision-making for the adult patient undergoing cardiac surgery, evidence pertaining to specific organ systems is available. Summary We provide a comprehensive review of available evidence pertaining to preoperative assessment and shared decision-making for patients undergoing cardiac surgery and recommend a thorough preoperative workup in this vulnerable population.
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Miles LF, Tosif S, Tan CO, Fink M, Weinberg L. Preoperative Optimization and Choreographed Physiological Evaluation for Resection of Giant Abdominal Neoplasm: A Case Report. A A Pract 2019; 13:140-144. [PMID: 31021824 DOI: 10.1213/xaa.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Giant ovarian cystadenoma is a rare and often late presentation. The mass effect of such tumors can lead to profound respiratory and cardiovascular compromise, predominately through inferior vena cava compression, but also restriction of normal lung function through transdiaphragmatic mass effect and, as is seen in this case, cardiac tamponade. In this article, the authors outline an expedited program of preoperative optimization and a choreographed physiological assessment strategy to functionally assess the hemodynamic consequences of a giant ovarian mucinous neoplasm, thereby informing the safe conduct of anesthesia and surgery.
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Affiliation(s)
- Lachlan F Miles
- From the Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Shervin Tosif
- From the Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong O Tan
- From the Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Fink
- Department of Surgery, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Laurence Weinberg
- From the Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
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Yau DKW, Wong MKH, Wong WT, Gin T, Underwood MJ, Joynt GM, Lee A. PREhabilitation for improving QUality of recovery after ELective cardiac surgery (PREQUEL) study: protocol of a randomised controlled trial. BMJ Open 2019; 9:e027974. [PMID: 31092666 PMCID: PMC6530430 DOI: 10.1136/bmjopen-2018-027974] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/31/2019] [Accepted: 03/21/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Frailty is a multidimensional syndrome in which multiple small physiological deficits accumulate gradually, resulting in a loss of physiological reserve and adaptability, putting a patient that is exposed to a stressor at a higher risk of adverse outcomes. Both pre-frailty and frailty are associated with poor patient outcomes and higher healthcare costs. The effect of a prehabilitation programme and standard care on the quality of recovery in pre-frail and frail patients undergoing elective cardiac surgery will be compared. METHOD AND ANALYSIS A single-centre, superiority, stratified randomised controlled trial with a blinded outcome assessment and intention-to-treat analysis. Pre-frail and frail patients awaiting elective coronary artery bypass graft, with or without valvular repair/replacement, will be recruited. 164 participants will be randomly assigned to either prehabilitation (intervention) or standard care (no intervention) groups. The prehabilitation group will attend two sessions/week of structured exercise (aerobic and resistance) training, supervised by a physiotherapist, for 6-10 weeks before surgery with early health promotion advice in addition to standard care. The standard care group will receive the usual routine care (no prehabilitation). Frailty will be assessed at baseline, hospital admission and at 1 and 3 months after surgery. The primary outcomes will be participants' perceived quality of recovery (15-item Quality of Recovery questionnaire) after surgery (day 3), days at home within 30 days of surgery and the changes in WHO Disability Assessment Schedule 2.0 score between baseline and at 1 and 3 months after surgery. Secondary outcomes will include major adverse cardiac and cerebrovascular events, psychological distress levels, health-related quality of life and healthcare costs. ETHICS AND DISSEMINATION The Joint CUHK-NTEC Clinical Research Ethics Committee approved the study protocol (CREC Ref. No. 2017.696 T). The findings will be presented at scientific meetings, in peer-reviewed journals and to study participants. TRIAL REGISTRATION NUMBER ChiCTR1800016098; Pre-results.
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Affiliation(s)
- Derek King Wai Yau
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Man Kin Henry Wong
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Wai-Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Tony Gin
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Malcolm John Underwood
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Gavin Mathew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Michalek J, Vrablikova A, Darinskas A, Lukac L, Prucha J, Skopalik J, Travnik J, Cibulka M, Dudasova Z. Stromal vascular fraction cell therapy for osteoarthritis in elderly: Multicenter case-control study. J Clin Orthop Trauma 2019; 10:76-80. [PMID: 30705536 PMCID: PMC6349628 DOI: 10.1016/j.jcot.2018.11.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/21/2018] [Accepted: 11/22/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Jaroslav Michalek
- Internal Consortium for Cell Therapy and Immunotherapy, Brno, Czech Republic
- Cellthera Clinic, Brno, Czech Republic
- Department of Pediatrics, University Hospital Brno, Brno, Czech Republic
| | | | - Adas Darinskas
- Internal Consortium for Cell Therapy and Immunotherapy, Brno, Czech Republic
- Department of Pharmacology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Jaroslav Prucha
- Department of Health Care Disciplines and Population Protection, Faculty of Biomedical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | - Josef Skopalik
- Cellthera Clinic, Brno, Czech Republic
- Department of Human Pharmacology and Toxicology, Faculty of Pharmacy, University of Veterinary and Pharmaceutical Sciences, Brno, Czech Republic
| | - Jan Travnik
- Cellthera Clinic, Brno, Czech Republic
- Department of Orthopedics, Traumatology Hospital, Brno, Czech Republic
| | | | - Zuzana Dudasova
- Internal Consortium for Cell Therapy and Immunotherapy, Brno, Czech Republic
- Cellthera Clinic, Brno, Czech Republic
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Landoni G, Lomivorotov V, Silvetti S, Nigro Neto C, Pisano A, Alvaro G, Hajjar LA, Paternoster G, Riha H, Monaco F, Szekely A, Lembo R, Aslan NA, Affronti G, Likhvantsev V, Amarelli C, Fominskiy E, Baiardo Redaelli M, Putzu A, Baiocchi M, Ma J, Bono G, Camarda V, Covello RD, Di Tomasso N, Labonia M, Leggieri C, Lobreglio R, Monti G, Mura P, Scandroglio AM, Pasero D, Turi S, Roasio A, Votta CD, Saporito E, Riefolo C, Sartini C, Brazzi L, Bellomo R, Zangrillo A. Nonsurgical Strategies to Reduce Mortality in Patients Undergoing Cardiac Surgery: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2018; 32:225-235. [DOI: 10.1053/j.jvca.2017.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Indexed: 11/11/2022]
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Esses G, Andreopoulos E, Lin HM, Arya S, Deiner S. A Comparison of Three Frailty Indices in Predicting Morbidity and Mortality After On-Pump Aortic Valve Replacement. Anesth Analg 2018; 126:39-45. [PMID: 28857797 DOI: 10.1213/ane.0000000000002411] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Aortic valve replacement is a high-risk surgery (3%-5%, 30-day mortality) performed on approximately 30,000 elderly patients a year in the United States. Currently, preoperative risk assessment is based on a composite of medical examination and a subjective evaluation for frailty ("eyeball test"). Objective frailty assessment using validated indices has the potential to improve risk stratification. The purpose of this study was to (1) establish whether frailty can predict 30-day mortality and composite morbidity in patients undergoing aortic valve replacement and (2) compare the predictive ability of 3 frailty indices in this population. METHODS This study was a retrospective cohort study of 3088 patients 65 years old and older undergoing aortic valve replacement surgery (based on current procedure terminology codes) between the years 2006 and 2012 extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index, risk analysis index, and Ganapathi indices. Outcomes measured were 30-day mortality and composite morbidity (myocardial infarction, cardiac arrest, pulmonary embolism, pneumonia, reintubation, renal insufficiency, coma >24 hours, urinary tract infections, sepsis, deep vein thrombosis, deep wound surgical site infection, superficial site infection, and reoperation). RESULTS Frailty was a better predictor of mortality than morbidity, and it was not markedly different among any of the 3 indices. Frailty was associated with an increased risk of 30-day mortality and longer lengths of stay. CONCLUSIONS Frailty can predict mortality in patients undergoing aortic valve replacement. Choice of frailty index does not make a difference in this patient population.
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Affiliation(s)
| | - Evie Andreopoulos
- Population Health Science and Policy and Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hung-Mo Lin
- Population Health Science and Policy and Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shipra Arya
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Stacie Deiner
- Departments of Anesthesiology, Neurosurgery, Geriatrics & Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
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Pisano A, Galdieri N. Anaesthesia for the Elderly Patient, 2nd ed. Anesth Analg 2018. [DOI: 10.1213/ane.0000000000002569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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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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