Nutritional status and postoperative outcome after pneumonectomy for lung cancer

BACKGROUND

The influence of nutritional status on outcome after major lung resection remains controversial. Nutritional assessment is not included as a major recommendation in lung cancer guidelines. The purpose of this study was to assess the nutritional status of patients referred for pneumonectomy and to assess the predictive value of malnutrition in determining the surgical outcome.

METHODS

This study was a multicenter observational trial. The eligibility criterion for participants was pneumonectomy for lung cancer. Criteria for group classification according to nutritional status were albumin and transthyretin levels. Predicted outcomes were major infectious and noninfectious complications and 90-day mortality. Univariate analysis identified independent variables for the predictive model of age, sex, induction chemotherapy, extended resections, treatment side, smoking, and malnutrition. Predictive variables were then included in a logistic regression model.

RESULTS

Between January 2010 and December 2011, 86 (mean age, 61.5 years) consecutive patients referred for pneumonectomy (left side, n = 58; right side, n = 28) at 4 thoracic surgery centers were included. The malnutrition group included 33 patients (39%) and the normal nutritional status group included 53 patients. Univariate analysis elected malnutrition, recent active smoking, and extended resection to be included in a multivariate analysis. Multivariate analysis identified malnutrition, recent smoking, and extended resection as predictive variables for major complications and mortality.

CONCLUSIONS

The frequency of malnutrition detected by biological markers was dramatically high. Malnutrition, as well as recent active smoking and extended resection, is a predictive factor for infectious complications and mortality after pneumonectomy. Nutritional assessment with appropriate markers should be considered before pneumonectomy.

Aortic valve replacement in the elderly: the real life

BACKGROUND

Aortic stenosis is of concern in the elderly. Although aortic valve replacement provides good long-term survival with functional improvement, many elderly patients are still not referred for surgery because of their age. Percutaneous aortic valve implantation offers an alternative to open-heart surgery. Concerns about the management of aortic valve stenosis in the elderly will be reviewed.

METHODS

We retrospectively analyzed 1,193 consecutive aortic valve replacements, performed in octogenarians since January 2000. A total of 657 patients (55%) had at least one associated comorbidity (eg, respiratory failure) and 381 (32%) associated coronary lesions. Valve replacement was the only procedure in 883 patients (74%), and was associated with coronary revascularization in 262 cases, or with another cardiac procedure in 48 patients.

RESULTS

Overall operative mortality was 6.9% (83 of 1,193 patients); 5.5% for single replacement and 11.5% if associated with coronary artery bypass surgery. Univariate and multivariate analyses identified 11 operative risk factors related to general status, cardiologic condition, and the procedure itself: older age (p<0.015); respiratory failure (p<0.03); aortic regurgitation (p<0.001); emergency surgery (p<0.0029); New York Heart Association class IV (p<0.0007); right heart failure (p<0.03); atrial fibrillation (p<0.04); impaired ejection fraction (p<0.001); coronary disease (p<0.01); redo surgery (p<0.02); associated coronary revascularization (p<0.008).

CONCLUSIONS

Today, valve replacement has acceptable low hospital mortality, even in the elderly. Thus, older patients should not be denied surgery due to their advanced age alone. Conventional surgery remains the gold standard treatment for aortic stenosis; the decision should be made on an individual basis. If several risk factors suggest very high-risk surgery, then percutaneous valve implantation should be considered instead.

Current hospital mortality of aortic valve replacement in octogenarians

BACKGROUND AND AIM OF THE STUDY

The increasing incidence of cardiovascular disease with age, coupled to a constant extension of life expectancy in industrialized countries, is leading to an ever-increasing number of elderly patients being referred for aortic valve replacement (AVR). In light of advances in surgical technology and cardiac protection, the operative mortality and risk factors have been updated in order to specify surgical indications.

METHODS

Between January 2000 and December 2004, a total of 442 patients (203 males, 239 females) aged > or =80 years (mean age 82.7 +/- 2.3 years) underwent AVR at the authors' institution. Surgery was either isolated (n = 344) or associated with coronary revascularization (n = 86), mitral valvuloplasty (n = 5) or aortic surgery (n = 7). Seventeen patients had undergone previous cardiac surgery. The EuroScore was calculated for each patient.

RESULTS

Overall operative mortality was 7.5% (n = 33). Independent predictive factors of mortality were: aortic insufficiency (30%, p <0.004), NYHA class IV (20.5%, p < 0.001), left and right heart failure (11.5% and 19.4%, p <0.02), chronic renal insufficiency (18.5%, p <0.04), emergency (37.5%, p <0.001, OR = 4.7), left ventricular ejection fraction (21.1%, p <0.004, OR = 0.9), and redo surgery (35.3%, p <0.001, OR = 6). Mortality was also increased in case of associated coronary revascularization (11.6%), mitral or tricuspid surgery (20%) and ascending aorta procedure (25%).

CONCLUSION

Patient functional improvement achieved after valve replacement at the cost of a rather low operative mortality justifies considering octogenarians for surgery. However, decisions should be taken on an individual basis. An earlier referral to surgery before the onset of altered cardiac function could lead to further reductions in hospital mortality.