Aortic Valve Replacement in the Era of Transcatheter Aortic Valve Implantation: Current Status in Korea.

BACKGROUND: In the era of transcatheter aortic valve implantation, this study was conducted to investigate the current trend of aortic valve procedures in Korea and to evaluate the early and mid-term outcomes of isolated surgical aortic valve replacement (SAVR) using bioprosthetic valves in contemporary Korea. METHODS: Contemporary outcomes of isolated bioprosthetic SAVR in Korea were analyzed using the datasets on a multicenter basis. Patients who underwent isolated SAVR using bioprostheses from June 2015 to May 2019 were included, and those with concomitant cardiac procedures, SAVR with mechanical valve, or SAVR for infective endocarditis were excluded. A total of 456 patients from 4 large-volume centers were enrolled in this study. Median follow-up duration was 43.4 months. Early postoperative outcomes, mid-term clinical outcomes, and echocardiographic outcomes were evaluated. RESULTS: Mean age of the patients was 73.1 ± 7.3 years, and EuroSCORE II was 2.23 ± 2.09. The cardiopulmonary bypass time and aortic cross-clamp times were median 106 and 76 minutes, respectively. SAVR was performed with full median sternotomy (81.8%), right thoracotomy (14.7%), or partial sternotomy (3.5%). Operative mortality was 1.8%. The incidences of stroke and permanent pacemaker implantation were 1.1% and 1.1%, respectively. Paravalvular regurgitation ≥ mild was detected in 2.6% of the patients. Cumulative incidence of all-cause mortality at 5 years was 13.0%. Cumulative incidences of cardiovascular mortality and bioprosthetic valve dysfunction at 5 years were 7.6% and 6.8%, respectively. CONCLUSION: The most recent data for isolated SAVR using bioprostheses in Korea resulted in excellent early and mid-term outcomes in a multicenter study.

Aortic arch isolation to reduce cerebral embolic risk during replacement of the atherosclerotic aortic arch.

OBJECTIVE: To analyze the efficacy of isolating the upper body circulation from the lower body (isolation technique) in reducing the risk of embolic stroke during cardiopulmonary bypass in patients with severe atherosclerosis undergoing aortic arch surgery. METHODS: Between 2006 and 2019, 156 patients with severe atherosclerosis undergoing total arch replacement were enrolled. Since 2017, the right axillary or innominate artery and ascending aorta were both cannulated before cardiopulmonary bypass in the isolation group (n = 30). The left common carotid artery was clamped and inserted with a 13-Fr balloon perfusion catheter. The innominate artery was clamped in succession and cardiopulmonary bypass was instituted, establishing a parallel noncommunicating circulation for the upper and lower body. Patients without atherosclerosis that were not considered at high risk of embolic complications were excluded. The no-isolation group was drawn from historically matched control patients undergoing total arch replacement. RESULTS: The permanent stroke rate in the isolation and no-isolation groups were 3.3% (n = 1) and 15.9% (n = 15.9), respectively. After inverse-probability-of-treatment-weighting adjustment, the early mortality (P = .043), stroke (P = .044), and composite of early mortality or stroke (P = .005) rates were significantly lower in the isolation group. The logistic regression analysis after inverse-probability-of-treatment-weighting risk adjustment showed a significantly reduced composite risk of early death and stroke in the isolation group (odds ratio, 0.09; 95% confidence interval, 0.01-0.70; P = .023). CONCLUSIONS: The isolation technique was associated with a significant reduction in early postoperative embolic stroke and mortality risks in patients with severe aortic atherosclerosis undergoing total arch replacement.

Non-Surgical Resolution of Inflow Cannula Obstruction of a Left Ventricular Assist Device: A Case Report.

A 55-year-old woman who had received an implantable left ventricular assist device 3 months earlier presented with dyspnea and a low-flow alarm of the device. Computed tomography and log-file analysis of the device system suggested inflow cannula obstruction. Since the patient had cardiogenic shock due to pump failure, venoarterial extracorporeal membrane oxygenation (ECMO) was initiated. With ECMO, surgical exchange of the pump was considered. However, the obstruction spontaneously resolved without surgical intervention. It turned out that an obstructive thrombus was washed out by rebooting the pump. Moreover, the thrombus was embolized in the patient's left subclavian artery. The patient underwent heart transplantation 4 months after the pump obstruction accident and continued to do well.

Comparison of Clinical Outcomes in Patients Undergoing a Salvage Procedure for Thrombosed Hemodialysis Arteriovenous Grafts.

BACKGROUND: The major limitation of arteriovenous graft access is the high incidence of thrombotic occlusion. This study investigated the outcomes of our salvage strategy for thrombosed hemodialysis arteriovenous grafts (including surgical thrombectomy with balloon angioplasty) and evaluated the efficacy of intragraft curettage. METHODS: Salvage operations were performed for 290 thrombotic occluded arteriovenous grafts with clinical stenotic lesions from 2010 to 2018. Of these, 117 grafts received surgical thrombectomy and balloon angioplasty from 2010 to 2012 (group A), and 173 grafts received surgical thrombectomy and balloon angioplasty, with an additional salvage procedure using a curette and a graft thrombectomy catheter, from 2013 to 2018 (group B). Outcomes were described in terms of post-intervention primary patency and secondary patency rates. RESULTS: The post-intervention primary patency rates in groups A and B were 44.2% and 66.1% at 6 months and 23.0% and 38.3% at 12 months, respectively (p=0.003). The post-intervention secondary patency rates were 87.6% and 92.6% at 6 months and 79.7% and 85.0% at 12 months, respectively (p=0.623). Multivariate Cox regression analysis demonstrated that intragraft curettage was a positive predictor of post-intervention primary patency (hazard ratio, 0.700; 95% confidence interval, 0.519-0.943; p=0.019). CONCLUSION: Surgical thrombectomy and balloon angioplasty showed acceptable outcomes concerning post-intervention primary and secondary patency rates. Additionally, intragraft curettage may offer better patency to salvage thrombotic occluded arteriovenous grafts with intragraft stenosis.

Use of Extracorporeal Life Support for Heart Transplantation: Key Factors to Improve Outcome.

Although patients receiving extracorporeal life support (ECLS) as a bridge to transplantation have demonstrated worse outcomes than those without ECLS, we investigated the key factors in the improvement of their posttransplant outcome. From December 2003 to December 2018, 257 adult patients who underwent heart transplantation (HTx) at our institution were included. We identified 100 patients (38.9%) who underwent HTx during ECLS (ECLS group). The primary outcome was 30-day mortality after HTx. The median duration of ECLS was 10.0 days. The 30-day mortality rate was 3.9% (9.2% in peripheral ECLS, 2.9% in central ECLS, and 1.9% in non-ECLS). The use of ECLS was not an independent predictor of 30-day and 1-year mortality (p = 0.248 and p = 0.882, respectively). Independent predictors of 30-day mortality were found to be higher ejection fraction (p < 0.001), Sequential Organ Failure Assessment score (p < 0.001), and total bilirubin level (p = 0.005). In a subgroup analysis, cannulation type was not a predictor of 30-day mortality (p = 0.275). Early ECLS application to prevent organ failure and sophisticated management of acute heart failure may be important steps in achieving favorable survival after HTx.

Outcomes of emergency endovascular versus open repair for abdominal aortic aneurysm rupture.

PURPOSE: Ruptured abdominal aortic aneurysm (rAAA) is one of the most common aortic emergencies in vascular surgery and is associated with high operative mortality and morbidity rates despite recent treatment advances. We evaluated operative mortality risks for the outcomes of emergency endovascular aneurysm repair (eEVAR) vs. open repair in rAAA. METHODS: Twenty patients underwent eEVAR (n = 12) or open repair (n = 8) for rAAA between 2016 and 2020. We adopted the EVAR first strategy since 2018. Primary endpoints included in-hospital mortality and 1-year survival. The outcome variables were analyzed with Fisher exact, Mann-Whitney test, and linear by linear association. The Kaplan-Meier method was used to estimate survival. RESULTS: There were 13 males (65.0%) and the median age of the study cohort was 78.0 years (range, 49-88 years). In-hospital mortality occurred in 7 patients (35.0%); 5 (50.0%) in the early period and 2 (20.0%) in the later period of this series. According to the procedure type, 4 (50.0%) and 3 (25.0%) in-hospital mortalities occurred in the open repair and eEVAR patients, respectively. In 6 patients (50.0%), eEVAR was performed on unfavorable anatomy. The 1-year survival of eEVAR vs. open repair group was 75% ± 12.5% and 50% ± 17.7%, respectively. On univariate analysis, preoperative high-risk indices, postoperative acute renal failure requiring dialysis, pulmonary complications, and prolonged mechanical ventilation were associated with higher operative mortality. CONCLUSION: The current data showed relatively superior outcomes with eEVAR vs. open repair for rAAA, even in some patients with unfavorable anatomy supporting the feasibility, efficacy, and safety of EVAR first strategy.

Changes in Prevalence and Treatment Pattern of Benign Prostatic Hyperplasia in Korea.

PURPOSE: Benign prostatic hyperplasia (BPH) is associated with lower urinary tract symptoms and negatively affects the quality of life. We aimed to investigate the treatment pattern of BPH in South Korea. METHODS: Information on treatment modalities and diagnoses of BPH was obtained from the Health Insurance Review and Assessment Service-Aged Patient Sample. Data on BPH patients aged ≥60 years from 2012 to 2016 were obtained. We surveyed the treatment pattern of BPH, including the types of drugs used and surgeries performed, according to the type of institution. RESULTS: In this study, 18,260-24,657 BPH patients treated between 2012 and 2016 were included. The number of patients showed an increasing pattern, and drug therapy was the major treatment method used for BPH (98.77%). Moreover, the pattern of increased pharmacotherapy use for BPH was reinforced by the increasing number of patients. Prescription of α-blockers only was dominant in this cohort (45.7%). Transurethral resection of the prostate (TURP) was the most commonly used surgical treatment for BPH (53.6%), but it showed a decreasing pattern over time. In contrast, holmium laser enucleation of the prostate (HoLEP) showed an increase from 19.4% to 39.7%. CONCLUSION: The most common treatment for BPH was drug therapy, predominantly only α-blocker therapy. The surgical treatment trend has changed from TURP to HoLEP.

A 10-year study of surgical results of descending aorta aneurysm repair following chronic aortic dissection.

BACKGROUND: Patients presenting with descending aortic aneurysms developing after aortic dissection often undergo continued aortic expansion which may require operative interventions to address the risk of aortic rupture. In light of the current advances in various treatment options, including endovascular approaches, we analyzed our experience with open surgical repair (OSR) of aneurysms of the descending aorta following aortic dissection. METHODS: Patients who underwent open repair for aneurysmal changes of the descending aorta after chronic dissection were retrospectively studied. The 30-day operative mortality rate, midterm survival, and major complications were analyzed. Patients were divided into two categories; primary chronic type B aortic dissection and remnant repaired type A aortic dissection (RTAAD). RESULTS: There were 149 patients with enlargement of the descending thoracic aorta developing after aortic dissection. Of these, 49 patients had medical management, while the remaining 100 patients received OSR. These patients were included in the present analysis. The 30-day mortality and permanent paraplegia rates were 9% and 4%, respectively. The 1-, 3-, and 5-year survival rates were 83%, 80.9%, and 76.1%, respectively. The 1- and 5-year survival rates between the primary chronic type B aortic dissection and remnant RTAAD groups showed no significant between-group differences at 86.7% and 84.3%, and 80% and 71.3%, respectively (P = .289). The overall outcomes of other complications such as renal injury, bleeding reoperation, and extracorporeal membrane oxygenation support showed no significant between-group differences, including an insignificantly higher neurologic complication rate in the remnant RTAAD group. The survival rate in patients with Marfan syndrome was significantly higher than in the patients without Marfan syndrome (P = .033). CONCLUSIONS: OSR for descending aortic aneurysms developing after chronic aortic dissection showed good early and mid- to long-term outcomes, with acceptably low complication rates. OSR for descending aortic aneurysm after chronic aortic dissection associated with Marfan syndrome also showed good early and mid- to long-term outcomes.

Three-Dimensional Computed Tomographic Analysis of Normal and Aneurysmal Aortic Roots: Is There a Specific Geometric Pattern in the Aortic Root?

Current knowledge of the aortic root geometric anatomy and its surgical implications remain limited. We analyzed multiple predefined parameters of the aortic root to increase our understanding of the geometric changes that occur in normal and aneurysmal transformations. Between November 2003 and September 2015, the aortic roots of 107 healthy subjects (control group) and 105 annuloaortic ectasia (AAE) patients (AAE group) were analyzed using multiplanar reformatted computed tomographic images. The intercommissural distance (ICD), sinus width (SW), and sinus volume (SV) of the left (LCS), right (RCS), and noncoronary sinuses (NCS) of Valsalva were adopted as study parameters. In the control group, all study parameters of the LCS were smaller than those of the RCS and the NCS. In the AAE group, all parameters of the LCS were significantly smaller than those of the RCS or NCS, but the RCS and NCS parameters were similar. Proportionately less LCS enlargement relative to either the RCS or NCS was observed in root aneurysm(AAE group) than in the control group. We observed a distinct aortic root geometric pattern which was characterized by the LCS being smaller than either the RCS or NCS, while the latter were similar. This geometric configuration was significantly accentuated in AAE patients due to the greater disproportionate disparity in the LCS relative to either the RCS or NCS than in the roots of normal control subjects. Clin. Anat. 32:117-123, 2019. © 2019 Wiley Periodicals, Inc.

Guidelines for Transcatheter Aortic Valve Replacement in Korea: Past Obstacles and Future Perspectives.

BACKGROUND: Analyses of the efficacy and safety of transcatheter aortic valve replacement (TAVR) in most countries have been based on outcomes obtained in accordance with national practice guidelines and monitoring protocols. The purpose of this study is to share our experience regarding the process for establishing guidelines and monitoring protocols for the use of TAVR in Korea, in the hopes that it may be helpful to others undergoing a similar process in their own country. METHODS: The Korean guidelines for TAVR were established on June 1, 2015 in through a tri-party agreement involving the Department of Health and Welfare, the Korean Society of Thoracic and Cardiovascular Surgery and the Korean Society of Cardiology. We agreed to monitor the guidelines transparently and to exchange opinions regarding amendments or continuation of its contents after 3 years of monitoring. RESULTS: The monitoring meetings were not held as regularly as agreed, and monitoring was also made difficult by insufficient and incomplete data. Nevertheless, during the meetings, measures to improve the monitoring process were discussed, and accordingly, an agreement was made to continue the monitoring process, with the aim of completing data collection by 2018. CONCLUSION: Compliance with guidelines is critical for assessing the efficacy and safety of TAVR. Moreover, the TAVR monitoring process must be properly conducted for an accurate evaluation to be made. Any country planning to introduce TAVR may encounter difficulties with regards to the optimal initiation strategy and subsequent monitoring. Nevertheless, continued efforts should be made to persuade the government and the corresponding medical societies to facilitate the optimal application of TAVR.

A Systemic Review and Meta-Analysis of Sutureless Aortic Valve Replacement Versus Transcatheter Aortic Valve Implantation.

BACKGROUND: Sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are increasingly adopted methods to treat high-risk patients with severe aortic valve stenosis. We conducted a systematic review and meta-analysis to compare the clinical outcomes between these two recent methods to treat aortic valve disease. METHODS: We systematically searched multiple databases (January 2000 to October 2016) to identify original studies comparing clinical outcome between SU-AVR and TAVI. End points studied were early mortality, development of paravalvular leak, early stroke, bleeding events, and the need for pacemaker insertion. A random-effect inverse-variance weighted analysis was performed. Event rates were compared as odds ratio (OR) and 95% confidence interval (CI). RESULTS: The meta-analysis included seven observational studies comprising 617 SU-AVR and 621 TAVI patients. Early mortality was 2.5% and 5% in the SU-AVR and TAVI cohorts, respectively (OR, 0.52; 95% CI, 0.30 to 0.90; p = 0.02; I2 = 2%). Postprocedural significant paravalvular leak was much lower after SU-AVR (OR, 0.18l; 95% CI, 0.11 to 0.30; p < 0.0001). Postprocedural stroke (OR, 0.71; 95% CI, 0.24 to 2.08; p = 0.53) and the need for pacemaker insertion (OR, 0.884; 95% CI, 0.364 to 2.18; p = 0.7) were comparable between the two cohorts. CONCLUSIONS: Our meta-analysis of observational studies demonstrates that early mortality is lower after SU-AVR than after TAVI in selected patients. The rates of stroke and pacemaker implant are comparable between procedures; however, the incidence of paravalvular leak is higher after TAVI.

Outcomes of ring versus suture annuloplasty for tricuspid valve repair in patients undergoing mitral valve surgery.

OBJECTIVE: There is controversy regarding the comparative effectiveness of methods of tricuspid valve (TV) repair-prosthetic ring versus suture annuloplasty-in patients undergoing operation for primary mitral valve (MV) disease. In this study, we analyzed factors associated with patient survival and recurrent tricuspid regurgitation (TR) following TV repair and focused on results stratified by method of tricuspid valve repair. METHODS: We reviewed patients who underwent TV repair with suture (De Vega) or flexible ring annuloplasties at the time of MV surgery from 1995 to 2010. Patients with prior cardiac or concomitant aortic valve operations were excluded. Propensity matching was performed to account for potential differences in baseline characteristics between the groups. Primary outcomes were long-term mortality and postoperative TR grade. RESULTS: In the overall study, there were 415 patients with median age 72 years (range, 63-78 years), from which 148 matched pairs were identified by propensity score analysis. In the overall cohort, patients in the ring annuloplasty group more often had preoperative transvenous pacemakers (P = .05), lower ejection fractions (P = .028), and more recent years of operation (P < .001). For patients who had De Vega suture annuloplasty, long-term mortality was not different from that of patients who had ring annuloplasty (hazard ratio, 0.93; 95% confidence interval, 0.67-1.30). Older age, preoperative diabetes, and preoperative right ventricular dysfunction were predictors for long-term mortality. Durability of the annuloplasty methods was similar with no significant difference in trend of recurrent TR grades over follow-up (P = .807). Etiology of mitral regurgitation was not associated with recurrent TR during follow-up (P = .857). CONCLUSIONS: Late survival and TV durability following concomitant TV repair during MV surgery did not differ with respect to TV repair technique. In this series of patients with repaired tricuspid valves, etiology of MV disease did not influence postoperative changes in TR.

Evidence-based surgical management of acquired tricuspid valve disease.

Tricuspid valve (TV) disease most often occurs secondary to left-sided heart disease, particularly mitral valve (MV) regurgitation or stenosis. Appropriate treatment, even when TV regurgitation is secondary to left-sided heart disease, can improve long-term outcome. Valvuloplasty is the most common procedure for TV disease, and has received an increasing amount of attention, as right-sided heart failure combined with TV regurgitation is associated with poor long-term outcome. Although some controversies exist regarding the indication and timing of the TV operation, concomitant surgical repair of TV regurgitation at the time of MV surgery should be considered, as this procedure improves perioperative outcomes, functional class, and survival. Importantly, TV repair does not increase operative mortality. In our experience, both suture annuloplasty and partial ring annuloplasty give satisfactory results, and bioprosthetic valves can be used when leaflets are damaged and the TV annulus is extremely dilated.

A simple method of substernal bar removal after the Nuss procedure.

The Nuss procedure for pectus excavatum is a well-known technique. Although there are numerous reports on the Nuss procedure, the reports on its removal are few. Removal has been done with many variations in the supine position, which involves bending the bar or bringing the bar beneath the operating table, which can prove to be troublesome and dangerous. Our simple technique allows easy removal of the substernal bar without bar bending. This technique was used in 21 patients without complication.

Primary peripheral pulmonary adenoid cystic carcinoma: report of a case diagnosed by fine needle aspiration cytology.

Adenoid cystic carcinoma (ACC) arising from anatomic sites other than the salivary gland is rare and those occurring in the lung are extremely rare. When arising from the lung, the tumor generally arises from extrapulmonary bronchi, originating from bronchial glands. Primary ACC of the lung located peripherally within lung parenchyma is an even rarer event. To the best of our knowledge, this is the first case of primary peripheral pulmonary ACC preoperatively diagnosed by fine needle aspiration cytology (FNAC). We report a case of primary peripheral ACC of the anterior segment of the right upper lobe in a 46-year-old woman diagnosed by FNAC and a brief review of the literature.

Double primary tumor, thymic mass and posterior mediastinal neurogenic tumor, in a patient with acute pancreatitis performed with single-staged robotic-assisted thoracoscopic surgery.

Finding 2 primary benign lesions at 2 extremes of the mediastinum is a rare event. A minimal invasive operation performed in a single-staged procedure can prove to be difficult, especially when the procedure is performed with a robot. We discuss the positioning and details of the procedure carried out in a 52-year-old woman with acute pancreatitis.

Short- and long-term results of triple valve surgery: a single center experience.

Triple valve surgery is usually complex and carries a reported operative mortality of 13% and 10-yr survival of 61%. We examined surgical results based on our hospital's experience. A total of 160 consecutive patients underwent triple valve surgery from 1990 to 2006. The most common aortic and mitral valve disease was rheumatic disease (82%). The most common tricuspid valve disease was functional regurgitation (80%). Seventy-four percent of the patients were in New York Heart Association (NYHA) class III and IV. Univariate and multivariable analyses were performed to identify predictors of early and late survival. Operative mortality was 6.9% (n=11). Univariate factors associated with mortality included old age, preoperative renal failure, postoperative renal failure, pulmonary complications, and stroke. Of them, postoperative renal failure and stroke were associated with mortality on multivariable analysis. Otherwise, neither tricuspid valve replacement nor reoperation were statistically associated with late mortality. Survival at 5 and 10 yr was 87% and 84%, respectively. Ninety-two percent of the patients were in NYHA class I and II at their most recent follow-up. Ten-year freedom from prosthetic valve endocarditis was 97%; from anticoagulation-related hemorrhage, 82%; from thromboembolism, 89%; and from reoperation, 84%. Postoperative renal failure and stroke were significantly related with operative mortality. Triple valve surgery, regardless of reoperation and tricuspid valve replacement, results in acceptable long-term survival.

Results of annular reconstruction with a pericardial patch in active infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Annular reconstruction in active infective endocarditis (IE) is technically difficult, and results in a high mortality and morbidity. The study aim was to determine the midterm results of annular reconstruction with a pericardial patch in active IE. METHODS: A total of 57 operations was performed in 56 patients (38 men, 18 women; mean age 48.3 +/- 16.9 years) with active IE. Twenty-five cases (44%) were included in whom the preoperative NYHA class was III or IV. RESULTS: Bovine pericardium was used in 52 cases, autologous pericardium in three, and bovine + autologous pericardium in two. The aortic annulus was reconstructed in 18 cases, combined with aortomitral continuity in 13 cases, and both aortic and mitral annulus were combined with aortomitral continuity in three cases. The mitral annulus was reconstructed in 21 cases, and the complete cardiac skeleton was reconstructed in one case. There were three operative deaths. Postoperative complications included reexploration due to bleeding in two cases, mediastinitis in one case, complete atrioventricular block in five cases, and cerebral hemorrhage in six cases. The follow up was 93% complete (52/56); the mean duration of follow up was 45.1 +/- 32.6 months (range: 2-138 months). There were two late deaths, at three and eight months postoperatively. Endocarditis recurred five times in four patients. Re-do surgery was performed in four cases due to endocarditis recurrence in three patients at two, three, and 29 months after surgery, respectively, and to a pseudoaneurysm in one patient at one month postoperatively. The mean survival at two years was 91 +/- 3.9%; the two-year event-free survival was 82 +/- 5.4%. CONCLUSION: Annular reconstruction with a pericardial patch in active IE can be performed safely, and showed good durability at the mid-term follow up examination.

Efficacy of emergent percutaneous cardiopulmonary support in cardiac or respiratory failure: fight or flight?

We retrospectively evaluated early outcome and conducted this study to determine the predictive factors for percutaneous cardiopulmonary support (PCPS) weaning and hospital discharge. From January 2004 to December 2006, 92 patients diagnosed as cardiac or respiratory failure underwent PCPS using the Capiox emergent bypass system (Terumo, Tokyo, Japan). The mean+/-S.D. age was 56+/-18 (range, 14-85) years and 59 (64%) were male. The mean duration of PCPS was 90.9+/-126.0 h and that of cardiopulmonary resuscitation (CPR) was 51.1+/-27.8 min. The rate of weaning was 59/92 (64%) and the rate of survival to discharge was 39/92 (42%). The results indicated that the etiologic disease (myocarditis) and the cause of PCPS (cardiopulmonary arrest) are significantly correlated with weaning, whereas cardiopulmonary arrest and a shorter CPR duration (<60 min) are considerably correlated with survival. On the contrary, elderly patients (>75 years) have similar rates of weaning and survival compared with younger patients. PCPS provides an acceptable survival rate and outcome in patients with cardiac or respiratory failure. Prompt application and selection of patients with a specific disease (myocarditis) provides good results. It is also effective in elderly patients, providing hospital survival similar to that for younger patients.