Intraoperative Corticosteroids and Pacemaker Implantation After Transcatheter Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis. However, conduction disturbances leading to pacemaker implantation remain a common complication, increasing morbidity and mortality in these patients. Hence, measures to lower its incidence should be taken, and corticosteroid therapy could be effective by reducing inflammation caused by direct mechanical trauma to the conduction system.

METHODS

A retrospective cohort study was conducted at the Centro Hospitalar de Vila Nova de Gaia/Espinho, analyzing the medical records of patients with native severe aortic stenosis who underwent transfemoral TAVR in 2022. The Chi-square test was used to compare the rate of pacemaker implantation in patients who received corticosteroids with patients who didn't. The statistical significance was considered for a p-value <0.05.

RESULTS

A total of 341 patients were included in this study. Monitored anesthesia care was the preferred anesthetic technique (99.1%). Sixty-three point three percent (63.3%) of patients received corticosteroids at the beginning of the procedure. Corticosteroid administration did not significantly affect the incidence of permanent pacemaker implantation (p=0.277), vascular complications on the access site (p=0.765), or in-hospital mortality (p=0.909). Male gender, 1st-degree atrioventricular block, and right branch block were the only identified predictors of permanent pacemaker implantation after transfemoral TAVR (p=0.041 <0.001 and <0.001, respectively).

CONCLUSION

Corticosteroid administration at the beginning of TAVR doesn't seem to influence the incidence of permanent pacemaker implantation, which can suggest that other factors play a more important role in the development of conduction disturbances leading to pacemaker implantation.

Opioid-Free Anaesthesia Reduces Complications in Head and Neck Microvascular Free-Flap Reconstruction

Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients.

The efficacy of cryotherapy following arthroscopic knee surgery

Cryotherapy has historically been used as a treatment following knee surgery. In the literature, there is little evidence of beneficial effects which support this practice. This study examined the effects of cryotherapy treatments on 45 subjects following minor arthroscopic knee surgery. Subjects were randomized to one of two treatment groups and the assessor remained blind to treatment group allocation. Subjects performed a 1-week home program of either cryotherapy and exercises or exercises alone. One week following surgery, a statistically significant difference was found between the groups for the affective dimension of the McGill pain questionnaire, medication consumption, compliance, and weight-bearing status. No significant differences were found between the groups for other outcome variables. These results indicate that the addition of cryotherapy to a regime of exercises following arthroscopic knee surgery produced benefits of increased compliance, improved weight-bearing status, and lower prescription medication consumption.

Isometric hip abductor strength following total hip replacement and its relationship to functional assessments

Despite the rehabilitative emphasis on hip abductor strength following total hip replacement (THR), it is unclear how muscular strength is related to function. The purposes of this study were to examine changes in hip abductor strength during the first 6 months following THR and to determine the relationship between hip abductor strength and functional performances. Forty-three patients (mean age 64 +/- 7 years) completed strength assessments before surgery and at 1, 6, 12, and 24 weeks after surgery, and functional assessments before surgery and at 12 and 24 weeks after surgery. Both hip abductor strength and functional performance were significantly improved at each assessment (p < 0.01). The correlation between isometric hip abductor torques and the distance walked in 6 minutes was modestly high (r = 0.48-0.51; p < 0.01). This study provides baseline data for isometric hip abductor strength that can be used comparatively to assess patient progress and to help set clinical goals. Although strength is related to function, isometric measurements of strength should not be relied upon as the sole predictors of function in patients who have undergone THR.

Reliability of isometric hip abductor torques during examiner- and belt-resisted tests

The purposes of this study were to determine the test-retest reliability of isometric hip abductor torques in elderly females, to compare two assessment protocols, and to compare the performances of elderly and young females. Twenty elderly and 20 young women were tested on two occasions. During the examiner-resisted test the examiner provided the resistance, and during the belt-resisted test the subject's contralateral leg provided the resistance while the examiner positioned the dynamometer. A four-way ANOVA indicated no occasion effects (p greater than .05). Within each group, similar torques were produced by both legs (p greater than .05). Test-retest intraclass reliability coefficients were good-to-high, ranging from 0.84 to 0.98 for the eight combinations of group-method-leg. The elderly females produced 61% of the torques produced by young females (p less than .01), and the examiner-resisted method produced 65% of the torques produced using the belt-resisted method (p less than .01). The belt-resisted method required less physical effort on the part of the tester, provided greater stabilization of the pelvis, and was preferred by 95% of the subjects.

Effect of activation force on knee extensor torques

The purpose of this study was to determine whether the magnitude of the activation force, defined as the force that must be applied to the load cell in order to activate the resistance arm of an isokinetic dynamometer, affected knee extensor torques. Twenty-four healthy female subjects performed resisted knee extension through the range of 95 degrees to 5 degrees knee flexion, with a 5-s rest between concentric and eccentric muscle actions. Six exercise sets, composed of the combinations of activation force (20,50, and 100 N) and angular velocity (45 and 135 degrees.s-1), were randomly assigned on each of two occasions, completed within a 10-d period. Although peak torques were not affected by the activation force, average torques, eccentric torques at mid-range (50 degrees knee flexion), and torques during the initial portion of each muscle action (80 degrees knee flexion during concentric muscle actions and 20 degrees flexion during eccentric actions) increased as the activation force increased. The effect of the activation force tended to be more pronounced during eccentric than during concentric muscle actions, and at the faster angular velocity. Comparisons of torques should be based on similar test protocols, including activation force.