Concurrent chemo-radiotherapy in elderly patients: tolerance and compliance in a series of 137 patients.

INTRODUCTION: Aggressive cancer treatment is a challenge in elderly patients. The present study aims to assess tolerance in terms of acute toxicity and compliance of concurrent chemo-radiotherapy (cCRT) in a series of patients aged ≥70 years. MATERIALS AND METHODS: Clinical records of patients aged ≥70 years who underwent cCRT between January 2005 and December 2013 were reviewed. Concurrent CRT had curative intent in 134 patients (97.8 %) and palliative intent in 3 patients (2.2 %). Chemotherapy (CT) drugs and schedule were selected according to tumor histology. Radiotherapy median dose was 45.0 Gy (range 11-70 Gy) for curative purposes and 54 Gy (range 40-56 Gy) for palliative purposes. Incidence of acute toxicity and compliance to cCRT were analyzed and correlated with age, Karnofsky Performance Status (KPS), and Charlson Comorbidity Index (CCI). RESULTS: Overall, 137 patients, 82 males (60 %) and 55 females (40 %), median age 74 years (range 70-90 years) were analyzed. Concurrent CRT schedule was completed by 132 patients (96.4 %). Thirty-one of these patients (23.5 %) temporarily interrupted treatment. Hematological toxicity with grade ≥1 was observed in 25 patients (18.2 %), gastrointestinal toxicity in 55 (40.1 %), and genitourinary in 13 (9.5 %). Mucositis with grade ≥1 was recorded in 19 patients (13.9 %). No statistical significant correlation between KPS, CCI, and toxicity was found. A correlation trend between mucositis and patient age (p = 0.05) was observed. CONCLUSION: Concurrent CRT for elderly was feasible and quite well tolerated. Great attention in prescribing CT dose should be paid to limit acute toxicity.

Intraoperative treatment of chronic atrial fibrillation with ultrasound.

AIM: The purpose of this retrospective study is to evaluate the efficacy of intraoperative atrial compartmentalization utilizing ultrasound (US) energy in selected patients with chronic atrial fibrillation (CAF). METHODS: From March 1999 to June 2000, 27 patients with ages ranging from 15 to 69 (mean 44.62+/-15.61 years), 15 of whom were female, underwent intraoperative atrial compartmentalization with US. Mitral valve replacement was performed in 22 patients, mitral valve repair in 4 and 1 patient with paroxysmal atrial fibrillation (AF) underwent isolated atrial compartmentalization. The compartmentalization procedure was started using an ultrasonic device (UltraCision) at the level of the right atrium on cardiopulmonary bypass (CPB) and with beating heart, and then, after the mitral valve procedure, the ablation-lines were traced in an inverted U-shape, involving the 4 pulmonary veins. All patients were given verapamil or amiodarone for electrical atrial remodeling for 6 months. RESULTS: Time of surgery was 166 min on average, that is approximately 79 min of CPB, 59 min of aortic crossclamping, 12.5 min for right atrial lesion lines and 14 min for the left ones. After weaning CPB, all the patients maintained adequate cardiac output. Immediate reversion to sinus rhythm was achieved in 24 patients (88.8%). A small intraoperative left atrial wall rupture due to the ablation technique was easily repaired by a direct continuous suture. Another complication observed in 1 patient was a sternal instability, which was fixed successfully. Two patients died because of postoperative respiratory failure due to bilateral pneumonia in 1 case and low cardiac output, complicated by septicemia. The pharmacological anti-arrhythmic treatment was stopped 6 months after surgery. During 29 months of follow-up, 20 patients (74%) were still in sinus rhythm. CONCLUSIONS: The use of US during mitral valve operation in patients with CAF allowed for easy and rapid reestablishment of the sinus rhythm. This technique modifies and makes the Maze procedure easier, decreases surgical time and the incidence of postoperative complications.

Prognosis after stroke followed by surgical closure of patent foramen ovale: a prospective follow-up study with brain MRI and simultaneous transesophageal and transcranial Doppler ultrasound.

BACKGROUND: The risk of stroke and the long-term prognosis of recurrent strokes in young patients with patent foramen ovale (PFO) are not well known. For this reason, the treatment of these patients remains empirical. An alternative treatment to prolonged antithrombotic therapy may be surgical closure of the PFO. METHODS: Thirty patients (20 men and 10 women) with stroke and PFO were prospectively selected among 138 patients with stroke and PFO for a study of surgical closure of PFO at our center. Eligible patients were < 60 years old, had negative results of a systematic search for another cause of stroke (first criterion), and met two of the four following criteria: (1) recurrent clinical cerebrovascular events or multiple ischemic lesions on brain MR, (2) PFO associated with an atrial septal aneurysm, (3) > 50 microbubbles counted in the left atrium on contrast transesophageal echocardiography (TEE), and (4) Valsalva maneuver or cough preceding the stroke. Patients selected in this manner for surgery were considered to be a subgroup with a higher risk of stroke recurrence. RESULTS: All patients had a direct suture of PFO while under cardiopulmonary bypass without recorded early or delayed significant complication. All patients underwent a new brain MRI and TEE simultaneous with transcranial Doppler ultrasonography after contrast injection at 8 +/- 3 months after surgery. After a mean follow-up of 2 years without antithrombotic treatment, no recurrent cerebrovascular event (stroke or transient ischemic attack [TIA]) and no new lesion on MRI had developed. Postoperative contrast TEE and transcranial Doppler ultrasonography showed that two patients had residual interatrial right-to-left shunting, although much smaller than before surgery, associated with single versus double continuous suture. CONCLUSIONS: Our study of 30 selected stroke patients with surgical suture of PFO showed a stroke recurrence rate of 0% and no significant complication. Residual right-to-left shunting may be avoided by double continuous suture of the PFO. In the absence of controlled studies to guide individual therapeutic decisions, our findings show that PFO closure can be done safely and may be considered to avoid recurrence in selected patients with long life expectancy and presumed paradoxic embolism.

Surgical prophylaxis of recurrent stroke in patients with patent foramen ovale: a pilot study.

Prevention of recurrent stroke in adults with patent foramen ovale represents a therapeutic challenge. Antiplatelet or anticoagulant treatment is widely introduced, but its exact indication is not known. In this pilot study, eight men and three women with previous ischemic cerebral events underwent direct surgical closure of the patent foramen ovale. Mean age was 39.4 (from 30 to 58) years. No coexisting cause of stroke was found after extensive investigations, including blood and coagulation tests, echocardiography, 24-hour three-lead electrocardiographic monitoring, extracranial and transcranial Doppler ultrasonography, and cerebral angiography. Criteria for operation also included at least two of the following: atrial septal aneurysm, multiple cerebral infarcts, a history of multiple cerebral events, and Valsalva strain before stroke. Before operation, one patient had two shunts (1 patent foramen ovale, 1 intrapulmonary shunt). No intraoperative or postoperative complications occurred, but a few hours after operation transient arrhythmias developed in two patients without atrial fibrillation, hemodynamic instability, or embolism. During a median follow-up of 12.2 months, no patient had recurrent stroke. All patients prospectively underwent brain magnetic resonance imaging and contrast echocardiography with simultaneous transcranial Doppler ultrasonography. A residual right-to-left interatrial shunt, smaller than the preoperative one, was observed in only one patient, whereas no lesion was seen on magnetic resonance imaging. Our study suggests that surgical closure of patent foramen ovale in patients with presumed paradoxic embolism is safe, with no recurrent stroke in the first year of follow-up. Further studies are needed to evaluate the long-term prognosis of patients with versus without operation and to define the role of operation as an alternative to prolonged antithrombotic treatment.

Surgical closure of the patent ductus arteriosus with an intravascular prosthesis: clinical experience.

The authors developed a new prosthesis for patent ductus arteriosus (PDA) closure, using a delivery device inserted through the main pulmonary artery (MPA) avoiding ductal dissection and use of cardiopulmonary bypass. The prosthesis was inserted in 19 consecutive patients between 1985 and 1992. They have been followed for a mean of 4.8 years (minimum 30 days, maximum 7.5 years). There were 14 women (72%) and the average age was 11 years (16 months to 38 years). All patients presented with pulmonary hypertension (4 severe, 5 moderate, and 10 mild). Simultaneous surgical procedures for congenital heart disease were performed in two cases. One patient had a diffuse calcified PDA. The average diameter of the inserted prosthesis was 7.5 mm (3.5 to 12.5 mm). Neither hemorrhage nor prosthesis dislocation/embolization occurred during the implantation or in the postoperative period. In a newborn (30 days) with severe cardiomegaly and thin MPA, we decided to ligate the ductus. Chronic cor pulmonale contributed to death in one patient 3.7 years after operation. The remaining patients recovered well, without clinical evidence of residual shunt. Therefore, we recommend the use of this new prosthesis for PDA closure in cases of large ductus or ductus complicated with calcification, pulmonary hypertension, and when associated open heart surgery is required.

[Prevention of pulmonary embolism with the Günther filter]. / La prophylaxie de l'embolie pulmonaire par le filtre de Günther.

From 1987 to 1989 a Günther vena caval filter was implanted in the inferior caval vein in 37 patients to prevent pulmonary embolism. 20 patients had already suffered from lung emboli and full anticoagulation did not prevent reembolization (11) or was contra-indicated because of hemorrhagic complications (5) or recent operation (4). 17 patients had developed severe deep venous thrombosis with a free ending thrombus (15) as shown by phlebography and in 2 other patients of old age prophylaxis seemed indicated to prevent migration of the thrombi. This device can be inserted percutaneously via a 10-French introduction system. No local complications were observed. 3 patients showed an oedema of a leg 2 to 7 days after insertion with spontaneous regression. One patient had the filter 12 days after implantation completely obstructed by a new embolus that needed to be removed surgically. One patient had an acute caval obstruction 1 1/2 years after implantation. it could not be determined if this was due to new embolisation or to thrombosis of the filter. No pulmonary reembolization was observed. Even if long-term results with the Günther vena caval filter can not be reported yet, it seems to be a satisfactory device for preventing pulmonary embolism.