Outpatient Total Shoulder Arthroplasty Does Not Increase the 90-Day Risk of Complications Compared With Inpatient Surgery in Prescreened Patients.

Outpatient total joint arthroplasty is becoming a more attractive option for hospitals, surgeons, and patients. In this study, the authors evaluated the safety of outpatient shoulder arthroplasty by comparing an outpatient cohort with an inpatient cohort. Ninety-day outcomes of consecutively performed elective shoulder arthroplasty cases from 2012 to 2016 were retrospectively reviewed. Patients were preoperatively assigned to outpatient or inpatient care. Primary outcomes were emergency department visits, readmissions, mortality, and surgical morbidity within 90 days of surgery. Two-tailed t tests were used to evaluate differences. Bivariate and multivariate logistic regressions were used to determine if the odds of emergency department visit, readmission, or complications were significantly different between the cohorts. There were 118 outpatient and 64 inpatient shoulder arthroplasty procedures. Mean age and American Society of Anesthesiologists score were lower in the outpatient group compared with the inpatient group-68.1 vs 72.4 years (P=.01) and 2.3 vs 2.6 (P<.01), respectively. In the multivariate logistic regression model including all arthroplasty cases, the odds of outpatient to inpatient readmission was significantly different (odds ratio, 0.181; P=.027). However, when only total shoulder arthroplasty cases were included, no difference was detected. No statistically significant difference was noted for number of emergency department visits, mortality, or surgical morbidity within 90 days of surgery in any of the models. There was 1 death in the ambulatory group at 28 days after surgery. On the basis of these findings, the authors believe that, for carefully selected patients, an outpatient shoulder arthroplasty protocol is safe when compared with inpatient protocols. [Orthopedics. 2018; 41(4):e563-e568.].

Role of inadequate adaptive left ventricular hypertrophy in the genesis of mitral regurgitation in patients with severe aortic stenosis: implications for its prevention.

BACKGROUND AND AIM OF THE STUDY: Mitral regurgitation (MR) is frequent in patients with severe calcific aortic stenosis (AS). This complicates not only the clinical course of AS, but also its surgical management. The aim of the present study was to investigate the mechanism of genesis of MR in patients with severe AS. METHODS: The echocardiographic database was searched for subjects with severe AS defined as a calculated (continuity equation) aortic valve area < 0.7 cm2. Patients with previous valve surgery were excluded; thus, the study group comprised 123 patients. RESULTS: Among 123 patients (mean age 75 +/- 10 years) with severe AS, 54 (44%) had no MR, 37 (30%) had mild MR, 20 (16%) had moderate MR, and 12 (10%) had severe MR. Hence, moderate or severe MR was present in approximately 25% of patients. Patients with moderate or severe MR had a larger left ventricular (LV) end-diastolic diameter (5.1 +/- 1.0 versus 4.8 +/- 0.8 cm; p = 0.08), larger LV end-systolic diameter (3.8 +/- 1.2 versus 3.1 +/- 0.8 cm; p = 0.001), lower LV ejection fraction (40 +/- 16 versus 58 +/- 18%; p = 0.0001), higher degree of aortic regurgitation (p = 0.002), larger left atrial diameter (4.7 +/- 0.9 versus 4.1 +/- 0.6 cm; p = 0.001), lower LV free wall thickness (1.1 +/- 0.2 versus 1.3 +/- 0.4 cm; p = 0.05), and lower combined wall thickness (2.4 +/- 0.3 versus 2.7 +/- 0.5 cm; p = 0.02) and relative wall thickness (0.5 +/- 0.1 versus 0.6 +/- 0.1 cm; p = 0.02). Both groups had similar degrees of AS and mitral annular calcification. CONCLUSION: MR in severe AS is associated with a larger LV size and lesser wall thickness, and this may result from failure of adequate adaptive LV hypertrophy necessitated by the pressure overload imposed by AS. This might have important clinical implications in terms of timing of aortic valve replacement before the left ventricle begins to dilate, and also in the choice of pharmacologic therapy that may modulate the adaptive response of the left ventricle.