The thoracic approach for cardiac surgery in a patient with a tracheostoma can result in difficult problems, such as mediastinitis, stoma necrosis or inadequate operative exposure. We present a distinct approach consisting of an incision at the second intercostal space, transverse sternum transection and longitudinal median sternotomy to the xiphoid process, performed for coronary artery bypass grafting and aortic valve replacement, in a patient with previous tracheotomy. This approach permitted adequate surgical exposure for cardiopulmonary bypass, aortic valve replacement and coronary revascularization procedures.
OBJECTIVES
Frailty syndrome predicts adverse outcomes after surgical aortic valve replacement. However, disability or comorbidity is frequently associated with preoperative frailty evaluation. The effects of these domains on early and late outcomes were analysed.
METHODS
A prospective study including patients aged ≥75 years with symptomatic severe aortic stenosis who received aortic valve replacement with or without coronary artery bypass grafting was conducted. We used the Cardiovascular Health Study Frailty Phenotype to assess frailty, the Lawton–Brody index to define disability and the Charlson comorbidity index (CCI) to evaluate comorbidity.
RESULTS
Frailty was identified in 57 (31%), dependence in 18 (9.9%) and advanced comorbidity (CCI ≥ 4) in 67 (36.6%) of the 183 enrolled patients. Operative mortality (1.6%), transfusion rate and duration of stay increased in patients with CCI ≥4 (P < 0.005). There was a non-significant trend for these adverse outcomes among the frail patients. Follow-up was achieved in all patients (median/interquartile range 869/699–1099 days). Kaplan–Meier univariable analysis showed a reduced survival rate for frail and dependent patients and for those with multiple comorbidities (P < 0.05). According to multivariable analysis, frailty and comorbidity were independent risk factors for 1-year mortality, while disability and comorbidity, but not frailty, were risk factors for 3-year mortality (P < 0.05).
CONCLUSIONS
Surgical aortic valve replacement in patients aged ≥75 years is a safe procedure with low mortality rates. Operative outcomes are mainly affected by comorbidities. The main influence of survival occurs throughout the first year, and an improved functional status prevents any progression towards disabilities, which could potentially benefit long-term outcomes.
Clinical trial registration number
NCT02745314
Significant tricuspid regurgitation requiring surgical correction is associated with poor survival in patients undergoing tricuspid valve reoperations. Right chamber dilatation increases the risk of injury during resternotomy. The novel technique of peripheral cannulation using an expandable venous cannula for cardiopulmonary bypass can help to reduce the risk of complications and associated morbidity, thus enhancing the short-term outcomes.
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