Background-Mitral valve (MV) repair is preferred over replacement in clinical guidelines and is an important determinant of the indication for surgery in degenerative mitral regurgitation (MR). Yet, the level of evidence supporting current recommendations is low, and recent data cast doubts on its validity in the current era. Accordingly, the aim of the present study was to analyze very long-term outcome after MV repair and replacement for degenerative MR with a flail leaflet. Methods-MIDA is a multicenter registry enrolling patients with degenerative MR with a flail leaflet in 6 tertiary European and US centers. We analyzed the outcome after MV repair (n=1,709) and replacement (n= 213), overall, by propensity score matching and by inverse probability-of-treatment weighting. Results-At baseline, patients undergoing MV repair were younger, had more comorbidities and were more likely to present with a posterior leaflet prolapse than those undergoing MV replacement. After propensity score matching as well as after inverse probability-of-treatment weighting, the 2 treatments groups were balanced and absolute standardized differences were usually below 10%, indicating adequate match. Operative mortality (defined as a death occurring within 30 days from surgery or during the same hospitalization) was lower after MV repair than after replacement, both in the entire (1.3 vs 4.7%; p<0.001) and in propensity-matched population (0.2% vs 4.4%; p<0.001). During a mean follow-up of 9.2 years, 552 deaths were observed, of which 207 were of cardiovascular origin. Twenty-year survival was better after MV repair than after MV replacement, both in the entire (46% vs 23%, p<0.001) and in matched population (41% vs 24%, p<0.001). Similar superiority of MV repair were obtained in patients' subsets based on age, sex or any stratification criteria (all p<0.001). MV repair was also associated with reduced incidence of reoperations and valve-related complications.Conclusions-Among patients with degenerative MR with a flail leaflet, referred to mitral surgery, MV repair was associated with lower operative mortality, better long-term survival and fewer valve-related complications compared to MV replacement.
Background: Persistent hypercapnia after COPD exacerbation is associated with excess mortality and early rehospitalization. High Flow Nasal cannula (HFNC), may be theoretically an alternative to long-term noninvasive ventilation (NIV), since physiological studies have shown a reduction in PaCO2 level after few hours of treatment. In this clinical study we assessed the acceptability of HFNC and its effectiveness in reducing the level of PaCO 2 in patients recovering from an Acute Hypercapnic Respiratory Failure (AHRF) episode. We also hypothesized that the response in CO 2 clearance is dependent on baseline level of hypercapnia. Methods: Fifty COPD patients recovering from an acute exacerbation and with persistent hypercapnia, despite having attained a stable pH (i.e. pH > 7,35 and PaCO 2 > 45 mmHg on 3 consecutive measurements), were enrolled and treated with HFNC for at least 8 h/day and during the nighttime Results: HFNC was well tolerated with a global tolerance score of 4.0 ± 0.9. When patients were separated into groups with or without COPD/OSA overlap syndrome, the "pure" COPD patients showed a statistically significant response in terms of PaCO 2 decrease (p = 0.044). In addition, the subset of patients with a lower pH at enrolment were those who responded best in terms of CO 2 clearance (score test for trend of odds, p = 0.0038). Conclusions: HFNC is able to significantly decrease the level of PaCO 2 after 72 h only in "pure" COPD patients, recovering from AHRF. No effects in terms of CO2 reduction were found in those with overlap syndrome. The present findings will help guide selection of the best target population and allow a sample size calculation for future long-term randomized control trials of HFNC vs NIV. Trial registration: This study is registered with www. clinicaltrials.gov with identifier number NCT03759457.
Introduction: Recent evidence suggests that, with a well-trained staff, severe exacerbations of chronic obstructive pulmonary disease (COPD) with moderate respiratory acidosis (pH > 7.3) can be successfully treated with noninvasive mechanical ventilation (NIMV) on a general respiratory care ward. We conducted an open prospective study to evaluate the efficacy of this approach on a general medicine ward. Material and methods: This study population consisted in 27 patients admitted to a general medicine ward (median nurse:patient ratio 1:12) December 1, 2004 May 31, 2006 for acute COPD exacerbation with hypercapnic respiratory failure and acidosis (arterial pH < 7.34, PaC02 > 45 mmHg). All received assist-mode NIMV (average 12 h / day) via oronasal masks (inspiratory pressure 10-25 cm H2O, expiratory pressure 4-6 cm H2O) to maintain O2 saturation at 90-95%. Treatment was supervised by an experienced pulmonologist, who had also provided specific training in NIMV for medical and nursing staffs (90-day course followed by periodic refresher sessions). Arterial blood pressure, O2 saturation, and respiratory rate were continuously monitored during NIMV. Based on baseline arterial pH, the COPD was classified as moderate (7.25-7.34) or severe (< 7.25). Results: In patients with moderate and severe COPD, significant improvements were seen in arterial pH after 2 (p < 0.05) and 24 h (p< 0.05) of NIMV and in the PaC02 after 24 hours (p < 0.05). Four (15%) of the 27 patients died during the study hospitalization (in-hospital mortality 15%), in 2 cases due to NIMV failure. For the other 23, mean long-term survival was 14.5 months (95% CI 10.2 to 18.8), and no significant differences were found between the moderate and severe groups. Over half (61%) the patients were alive 1 year after admission. Conclusions: NIMV can be a cost-effective option for management of moderate or severe COPD on a general medicine ward. Its proper use requires: close monitoring of ventilated subjects, optimum staff:patient ratio, well-trained staff dedicated to NIMV, and supervision by a pulmonologist with experience in NIMV. The treatment was effective at improving arterial blood gases in both groups of COPD patients. The severity of the COPD did not significantly affect length of hospital stay, in-hospital mortality, or long-term survival.
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