An Individualized, Less-Invasive Surgical Approach Algorithm Improves Outcome in Elderly Patients Undergoing Mitral Valve Surgery.

BACKGROUND: For mitral valve surgery (MVS) in elderly, frail patients with increasing life expectancy, finding the least harmful means of access is a challenge. In the complexity of MVS approach evolution, using three different approaches (mini-thoracotomy (MT), partial upper-sternotomy (PS), full-sternotomy (FS), we developed a personalized, minimized-invasiveness algorithm for MVS. METHODS: In this retrospective analysis, 517 elderly patients (≥70 years) were identified who had undergone MVS ± TV repair. MVS was performed via MT (n = 274), FS (n = 128) and PS (n = 115). The appropriate access type was defined according to several clinical patient conditions. Using uni- and multivariate regression models, we analyzed combined operative success (residual MV regurgitation, conversion to MV replacement or larger thoracic incisions); perioperative success (30-days mortality, thoracotomy, ECMO, pacemaker implantation, dialysis, longer ventilation); and reoperation-free long-term survival. An additional EuroSCORE2 adjustment was performed to reduce the bias of clinical conditions between all access types. RESULTS: The EuroSCORE2-adjusted Cox regression analysis showed significantly increased reoperation-free survival in the MT cohort compared to FS (HR 0.640; 95% CI 0.442-0.926; p = 0.018). Mortality was additionally reduced after the implementation of PS (p = 0.023). Combined operative success was comparable between the three access types. The perioperative success was higher in the MT cohort compared to FS (OR 2.19, 95% CI 1.32-3.63; p = 0.002). CONCLUSION: Less-invasive approaches in elderly patients improve perioperative success and reoperation-free survival in those undergoing MVS procedures.

Extracorporeal Life Support in Myocardial Infarction-Induced Cardiogenic Shock: Weaning Success.

BACKGROUND: Outcome data of patients with acute myocardial infarction (AMI)-induced cardiogenic shock (CS) receiving extracorporeal life support (ECLS) are sparse. METHODS: A consecutive series of 106 patients with AMI-induced CS receiving ECLS was evaluated regarding ECLS weaning success, hospital mortality, and long-term outcome. The Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) risk score was applied, and multivariable Cox regression analysis was performed. RESULTS: Mean patient age was 58.2 ± 11.2 years, and 78.3% were men. In 34 patients (32.1%), ECLS was implemented during ongoing cardiopulmonary resuscitation. De novo AMI was present in 58 patients (54.7%), and percutaneous coronary intervention complications were causative among 48 patients (45.3%). Multivessel coronary artery disease was diagnosed among 73.6% with mean Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) scores of 30.8 ± 4.8. Actuarial survival was 54.4% at 30 days, 42.2% at 1 year, and 38.0% at 5 years and was significantly higher among patients with low and intermediate IABP-SHOCK II risk scores at ECLS onset (log-rank P = .017). ECLS weaning with curative intention after a mean perfusion time of 6.6 ± 5.1 days was feasible in 51 patients (48.1%) and more likely among patients with complete revascularization (P = .026). Multivariable Cox regression analysis identified complete revascularization (hazard ratio, 2.38; 95% confidence interval, 1.1 to 5.1; P = .028) and absence of relevant mitral regurgitation at ECLS discontinuation (hazard ratio, 2.71; 95% confidence interval, 1.2 to 6.0; P = .014) to be associated with beneficial long-term survival after ECLS discontinuation. CONCLUSIONS: Emergency ECLS is a valuable option among patients with AMI-induced CS with low and intermediate IABP-SHOCK II risk scores. ECLS weaning is manageable, but additional revascularization of all nonculprit lesions is mandatory after ECLS implementation.

Clamshell thoracotomy and open heart massage--A potential life-saving procedure can be taught to emergency physicians: An educational cadaveric pilot study.

AIMS: Selected patients in traumatic cardiac arrest may benefit from pre-hospital thoracotomy. Pre-hospital care physicians rarely have surgical training and the procedure is rarely performed in most European systems. Limited data exists to inform teaching and training for this procedure. We set out to run a pilot study to determine the time required to perform a thoracotomy and the a priori defined complication rate. METHODS: We adapted an existing system operating procedure requiring four instruments (Plaster-of-Paris shears, dressing scissors, non-toothed forceps, scalpel) for this study. We identified a convenience sample of surgically trained and non-surgically trained participants. All received a training package including a lecture, practical demonstration and cadaver experience. Time to perform the procedure, anatomical accuracy and a priori complication rates were assessed. RESULTS: The mean total time for the clamshell thoracotomy from thoracic incision to delivery of the heart was 167 s (02:47 min:sec). There was no statistical difference in the time to complete the procedure or complication rate among surgeons, non-surgeons and students. The complication rate dropped from 36% in the first attempt to 7% in the second attempt but this was not statistically significant. This is a pilot study and small numbers of participants arguably saw it underpowered to define differences between study groups. CONCLUSION: Clamshell thoracotomy can be taught using cadaver models. In this simulated environment, the procedure may be performed rapidly with minimum equipment.