RESUMEN
Introduction: Transcatheter aortic valve implantation (TAVI) is the standard of care for the majority of patients with severe symptomatic aortic stenosis (AS) at excessive-, high- and intermediate-surgical risk. A proportion of patients referred for TAVI do not undergo the procedure and proceed with an alternate treatment strategy. There is scarce data describing the final treatment allocation of such patients. Hence, we sought to evaluate the final treatment allocation of patients referred for TAVI in contemporary practice. Methods: We performed a single center prospective observational study, including all patients referred to our institution for treatment of severe aortic stenosis between February 2014 and August 2017. Baseline demographic and clinical data were recorded. Patients were categorized according to treatment allocation: TAVI, surgical aortic valve replacement (SAVR) or optimal medical therapy (OMT). Clinical outcomes were adjudicated according to VARC-2 definitions. All patients were discussed at a dedicated Heart Team meeting. Results: Total of 245 patients were referred for assessment to a dedicated TAVI clinic during the study period. Patients with moderate (N = 32; 13.1%) and asymptomatic (N = 31; 13.1%) AS were excluded. Subsequently, 53.9% (N = 132) received TAVI, 12.7% (N =31) were managed with OMT, and 7.3% (N =18) had SAVR. Reasons for OMT included primarily: patient's preference (N = 12; 38.7%); excessive surgical risk (N = 4; 12.9%) and severe frailty (N = 5; 16.1%). Reasons for surgical referral included low surgical risk (N = 11; 61.1%), excessive annulus size (N = 5; 27.8%), and aortic root dilatation (N = 2; 11.1%). Patients proceeding to SAVR had lower surgical risk than those in either the OMT or TAVI cohorts (P < 0.001). Mean STS score in SAVR group was 2.2 ± 1.3 vs. 4.5 ± 2.4 in OMT cohort and 6.1 ± 4.9 in TAVI cohort. Six-month all-cause mortality was 16.7, 19.4, and 9.3% among those receiving SAVR, OMT, and TAVI, respectively. Conclusions: Almost half of all patients with severe AS referred to a dedicated TAVI clinic did not receive a TAVI. A considerable proportion of patients were reclassified as moderate AS (13%), were asymptomatic (13%), or intervention was determined to be futile (13%) due to advanced frailty. Early detection and increased awareness of valvular heart disease are required to increase the number of patients that can benefit from TAVI.
RESUMEN
Postoperative nausea and vomiting is common after cardiac surgery and may contribute to significant morbidity. Gastric decompression during anesthesia has been used for postoperative nausea and vomiting prophylaxis in shorter duration noncardiac surgery with conflicting results. We tested the hypothesis that gastric decompression during elective coronary revascularization surgery with cardiopulmonary bypass and continued afterwards until tracheal extubation would reduce the incidence of vomiting or retching and nausea. In a prospective, randomized, cohort study, 104 patients with at least 2 Apfel's risk factors for postoperative nausea and vomiting were allocated to receive a gastric tube on free gravity drainage after induction of anesthesia (n = 52) or to a control group (n = 52). The gastric tube was removed simultaneously with tracheal extubation postoperatively. The primary outcome measure was the incidence of vomiting or retching. Secondary outcomes included the incidence and severity of nausea measured on a visual analog scale. The incidence of vomiting or retching was 13.4% in patients with gastric decompression, compared with 11.5% in the control group (P = 0.7). Similarly, there was no statistically significant difference between the two groups in the incidence of nausea (32.7% versus 25.0%, P = 0.6), median severity of nausea on a visual analog scale at 12 h (25; range, 0-55 mm versus 30; range, 0-60 mm, P = 0.4), or antiemetics administration (38.5% versus 28.8%, P = 0.3). Continuous gastric decompression during coronary revascularization surgery and afterwards until tracheal extubation did not reduce the incidence of vomiting or retching or the incidence and severity of nausea in these patients.