ObjectiveDespite improvements in its management, infective endocarditis (IE) is associated with poor survival. The aim of this study was to evaluate the impact of a multidisciplinary endocarditis team (ET), including a cardiologist, microbiologist and a cardiac surgeon, on the outcome of patients with acute IE according to medical or surgical treatment strategies.MethodsWe conducted an observational before-and-after study of 196 consecutive patients with definite IE, who were treated at a tertiary reference centre between 2009 and 2015. The study was divided into two periods: period 1, before the formation of the ET (n=101), and period 2, after the formation of the ET (n=95). The role of the ET included regular multidisciplinary team meetings to confirm diagnosis, inform the type and duration of antibiotic therapy and recommend early surgery, when indicated, according to European guidelines.ResultsThe patient demographics and predisposing conditions for IE were comparable between the two study periods. In the time period following the introduction of the ET, there was a reduction in both the time to commencement of IE-specific antibiotic therapy (4.0±4.0 days vs 2.5±3.2 days; P=0.004) and the time from suspected IE to surgery (7.8±7.3 days vs 5.3±4.2 days; P=0.004). A 12-month Kaplan-Meier survival for patients managed medically was 42.9% in the pre-ET period and 66.7% in the post-ET period (P=0.03). The involvement of the ET was a significant independent predictor of 1-year survival in patients managed medically (HR 0.24, 95% CI 0.07 to 0.87; P=0.03).ConclusionsA standardised multidisciplinary team approach may lead to earlier diagnosis of IE, more appropriate individualised management strategies, expedited surgery, where indicated, and improved survival in those patients chosen for medical management, supporting the recent change in guidelines to recommend the use of a multidisciplinary team in the care of patients with IE.
LD filtration during CABG reduced the number of cerebral microemboli recorded by TCD and showed a strong trend towards improving NP performance post-operatively. These findings suggest that the use of such filters in CABG surgery may offer increased neuroprotection.
A case of severe intractable angina pectoris with normal angiography is presented. Following video assisted thoracic sympathectomy the patient died of heart failure. Microvascular cardiac amyloidosis was diagnosed at the postmortem examination. This report alerts clinicians to this possible diagnosis when treating patients with severe angina when no cause is found and discusses the poor prognosis in such cases. E arly amyloidosis without myocardial involvement can produce severe anginal symptoms by obstructing the intramural (rather than the epicardial) coronary arteries. The prognosis for this condition is poor.1 In a case series, five of 153 (3%) patients with angina and a normal coronary angiogram had small vessel disease secondary to amyloidosis.2 Another unrelated series found up to 30% of patients with anginal symptoms to have a normal coronary angiogram. 3 The overall frequency of such amyloid related angina is unknown. However, we suggest that amyloid be considered in cases of severe angina that is not otherwise explicable. CASE REPORTA 65 year old non-smoking male retired squash coach presented with exertional dyspnoea. An exercise ECG showed myocardial ischaemia. He also developed a widespread inflammatory arthritis treated with sulfasalazine and methotrexate. Coronary angiography showed good left ventricular function and mild atheroma at the origin of the left anterior descending coronary artery, which would not be expected to cause angina even at extreme exertion. The exertional angina persisted and one year later an exercise test was also positive with major ST changes after only four minutes of the Bruce protocol. Repeat angiography showed the same minor stenosis. In addition, the coronary arteries were described as being mildly atheromatous and tortuous in keeping with hypertension. The patient's angina continued to worsen despite maximum medical treatment with a b blocker, angiotensin converting enzyme inhibitor, calcium channel blocker, and oral nitrates. His first cardiologist sought a second opinion from a colleague, who thought that a combination of mild atheroma, spasm of the coronary arteries, and microvascular coronary disease could be causing the severe symptoms. The first cardiologist performed an angioplasty and stented the left anterior descending coronary artery stenosis. This did not relieve symptoms at all and the patient found his angina increasingly intolerable. He reached the stage where he was able to walk only a few yards without angina, which was also brought on by eating. The patient was referred to a thoracic surgeon to be considered for a sympathectomy. During consultation with the surgeon the patient again experienced angina at rest with ST depression. Very soon afterwards a chemical sympathectomy (stellate ganglion block) was performed with a good but temporary result and on this basis the patient proceeded to have a video assisted thoracoscopic (VATS) left sympathectomy. The left sympathetic chain was divided with diathermy over the necks of the second, third, and fourth...
A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Using the reported search criteria, 137 papers were found. Of these, 11 papers (N = 1712) represent the best evidence to answer the clinical question, and include one meta-analysis, two randomized, controlled trials (RCTs), five retrospective cohort studies and two case-control series. In-hospital mortality was lower for the surgical group in the meta-analysis [n = 582, odds ratio (OR) 0.31 (0.20-0.48), risk difference (RD) 0.19 (0.13-0.26), number needed to treat (NNT) 5] as well as significant decreases in ventilator days [mean 8 days, 95% confidence interval (CI) 5-10 days] and intensive care unit stay (mean 5 days, 95% CI 2-8 days). A reduction was found for septicaemia [n = 345, OR 0.36 (0.19-0.71), RD 0.14 (0.56-0.23), NNT 7], pneumonia [n = 616, OR 0.18 (0.11-0.32), RD 0.31 (0.21-0.41), NNT 3, P = 0.001], tracheostomy (OR 0.06, 95% CI 0.02-0.20) and chest wall deformity [n = 228, OR 0.11 (0.02-0.60), RD 0.30 (0.00-0.60), NNT 3]. Eight studies (n = 1015) had a shorter duration of mechanical ventilation following surgery. A reduction in intensive care unit stay was demonstrated in four papers (n = 389, 3.1-9.0 days), whereas a further three papers described a reduction in the duration of hospitalization (n = 489, 4-10.6 days). Three studies (n = 166) showed a lower risk for tracheostomy. One retrospective cohort study estimated lower total treatment costs in surgically treated patients ($32 300 vs $37 100) although not statistically significant. One retrospective case-control study described a lower risk for reintubation (n = 50, P = 0.034) and home oxygen requirements (n = 50, P = 0.034). One cohort study showed a better APACHE II score 14 days after trauma in the surgical group (P = 0.02). Surgical stabilization of flail chest in thoracic trauma patients has beneficial effects with respect to reduced ventilatory support, shorter intensive care and hospital stay, reduced incidence of pneumonia and septicaemia, decreased risk of chest deformity and an overall reduced mortality when compared with patients who received non-operative management.
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