Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA.

Background— Severe primary (degenerative) mitral regurgitation (MR) is repaired with durable results when simple single-scallop disease is addressed. The midterm quality outcomes of minimally invasive repair for complex disease are unknown, however. Methods and Results— From January 2008 to January 2015, 487 patients (56±11 years, 360 men, ejection fraction 65±6%, 98.8% complete follow-up) underwent robotic mitral valve repair for severe nonischemic degenerative MR. Simple pathology was addressed in 289 of 487 (59%) patients, and complex repair (all others) was performed in 198 of 487 (41%). Four patients died during follow-up with a 5-year survival rate 99.5% (99.4% simple; 99.5% complex; hazard ratio, 0.48; 95% confidence interval, 0.05–4.59); and New York Heart Association functional class I/II was documented in 97.9% (477/487). Eight patients had recurrence of moderate-to-severe MR (4 simple, 4 complex), with a 5-year freedom from MR of 94.6% (96.2% simple; 92.7%, complex; P =0.67; hazard ratio, 1.36; 95% confidence interval, 0.34–5.43). Seven patients (2 simple, 5 complex), underwent mitral reoperation, with a 5-year freedom from reoperation of 97.7% (99.1% simple; 95.7% complex; P =0.13; hazard ratio, 3.35; 95% confidence interval, 0.65–17.32). Conclusions— At a large tertiary care referral center, midterm quality outcomes after robotic correction of degenerative MR are excellent, with very high survival, infrequent complications, and a low likelihood of MR recurrence, regardless of mitral valve repair complexity. Awareness of these improvements in outcome is important to inform contemporary decisions regarding high-quality alternatives to conventional and percutaneous mitral repair.

All patients with CA/cold hemagglutinin disease at the Mayo Clinic College of Medicine safely underwent cardiac surgery without major adverse morbidity or mortality. Patients with CA but without evidence of cold hemagglutinin disease can safely undergo normothermic cardiopulmonary bypass at 37°C and warm cardioplegia without further testing. Patients with cold hemagglutinin disease should undergo laboratory testing including CA titers and thermal amplitude and hematology consultation before cardiac surgery.

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This article has been selected for the Anesthesiology CME Program. After reading the article, go to http:// www.asahq.org/journal-cme to take the test and apply for Category 1 credit. Complete instructions may be found in the CME section at the back of this issue.SURGICAL site infections (SSIs) continue to be a substantial source of morbidity and mortality in the surgical patient population. They are the second most common cause of nosocomial infection after urinary tract infections and account for approximately 17% of all hospital-acquired infections. 1 These infections lead to longer hospital and intensive care unit stays, lead to substantially increased mortality, and contribute significantly to healthcare costs. 2 In a 1999 series of cardiac surgery patients, each deep sternal wound infection added an average of $26,400 in hospital charges and increased the average duration of stay by 16 days. 3 The incidence of SSI varies for each operative procedure, each surgeon, and each hospital. In addition, each patient presents with his or her own unique risk profile for the development of a SSI. Although sterile surgical technique is extremely important to the prevention of SSIs, there is increasing evidence that anesthesiologists play a prominent yet under appreciated role in the prevention of SSIs. While infections typically present several days postoperatively, the first few hours after bacterial contamination are the critical window for the establishment of infection. 4,5 Therefore, decreasing SSIs hinges on the optimization of perioperative conditions, many of which are controlled by anesthesiologists.In this review, we will discuss the literature surrounding six perioperative factors over which anesthesiologists have at least partial control and how these factors may influence the risk of postoperative surgical site infection. Although we acknowledge that many anesthesiologists care for patients in the intensive care unit, we limit our discussion here to the immediate perioperative period. HypothermiaMild perioperative hypothermia (core body temperature 34°-36°C) is commonly observed in surgical patients. The complications of mild perioperative hypothermia have been studied extensively and include increased duration of hospitalization, 5 increased intraoperative blood loss and transfusion requirements, increased adverse cardiac events, and an increase in patient thermal discomfort in the recovery room. 6 The effects of mild hypothermia on SSI have also been studied.A series of 200 patients undergoing colorectal surgery were randomized to a hypothermic group (34.4°Ϯ 0.4°C) or a normothermic group (37°Ϯ 0.3°C) and followed for 2 weeks postoperatively. 5 The authors had planned to enroll 400 patients; however, the trial was stopped early because of a statistically significant difference in infection between the two groups. The incidence of SSI was 5.8% in the normothermic group and 18.8% in the hypothermic group. The patients who developed SSIs required hospital stays nearly 1 week longer than those who did not d...

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Gamma Knife surgery may control the residual pituitary adenoma and decrease ACTH levels in patients with Nelson's syndrome. Delayed hypopituitarism or cranial nerve palsies can occur after GKS. Patients with Nelson's syndrome require continued multidisciplinary follow-up care. Given the difficulties associated with management of Nelson's syndrome, even the modest results of GKS may be helpful for a number of patients.