Outcomes of reoperative aortic valve replacement via right mini-thoracotomy versus median sternotomy.

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine the safety and efficacy of a minimally invasive right mini-thoracotomy for aortic valve replacement (AVR) in patients who had undergone previous median sternotomy. METHODS: Between January 2005 and December 2011, a total of 3,603 consecutive cases was retrospectively reviewed to identify patients with previous median sternotomy who subsequently underwent AVR. The outcomes of patients having minimally invasive surgery were compared with those in whom a median sternotomy approach had been employed. RESULTS: Among 77 patients identified, 36 (47%) underwent a minimally invasive approach, and 41 (53%) had a median sternotomy. The mean age of the minimally invasive group (33 males, three females) was 75.3 +/- 9.0 years, and that of the median sternotomy group (33 males, eight females) was 68.2 +/- 13.6 years (p = 0.009). The minimally invasive group had more prior sternotomy for coronary artery bypass graft surgery (86% versus 59%, p = 0.007), and fewer for prior valve surgery (33% versus 59%, p = 0.02). In-hospital mortality was zero for the minimally invasive cohort versus four (10%) in the median sternotomy group (p = 0.08); composite postoperative complications occurred in six (17%) versus 19 (46%) (p = 0.005) of these two groups, respectively. The median intensive care unit and total hospital length of stay were 48 h [interquartile range (IQR) 41-97] versus 69 h [IQR 45-174] (p = 0.03), and seven days [IQR 5-10] versus 9 days [IQR 7-15] (p = 0.03) for the minimally invasive and median sternotomy group, respectively. CONCLUSION: Minimally invasive AVR via a right mini-thoracotomy in patients with previous cardiac surgery can be performed safely, and is associated with shorter intensive care unit and total hospital stays, a lower morbidity, and a trend towards lower mortality.

[Comparison of mortality by femur fracture versus hip fracture in elderly patients in a period of five years]. / Comparación de mortalidad por fractura de fémur frente a fractura de cadera en ancianos en un periodo de cinco años.

BACKGROUND: Fractures in the elderly population are an economic, social and medical challenge. Not much is known about fractures in this population, which makes difficult the selection of an appropriate treatment. Hip fractures (HF) increase the risk of death and morbidity. Patients with midshaft femur fracture (MFF) have less morbidity and risk of death. The objective was to compare HF and MFF's survival. METHODS: Observational analytic study. The Hospital General de México database was used to gather patients aged 65 to 94 years with HF and MFF from 2010 to 2014. Patients had an heterogeneous follow-up and their cognitive status was not considered; we had a total of 146 patients. Follow-up was made through phone call. RESULTS: Kaplan-Meier estimate was used to assess survival. We compared survival depending on type of fracture and found no statistically significant difference (p = 0.97). On sub-analysis, we compared type of fracture on male gender (p = 0.21) and female gender (p = 0.316) and found no statistically significant difference on survival. This differs from what has been reported. It was used t test to evaluate survival in months, according to male (39.61 ± 19.1) and female (36.58 ± 23.19) gender; this showed a significant difference in both groups (p = 0.037). CONCLUSIONS: In the presence of fractures, we must consider gender when estimating survival on patients with hip or midshaft femur fracture.

INTRODUCCIÓN: las fracturas en los ancianos son un desafío económico, social y médico, de las cuales se desconoce mucho, lo cual dificulta la selección de un tratamiento adecuado. Las fracturas de cadera (FC) incrementan el riesgo de muerte y morbilidad. Los pacientes con fractura de diáfisis femoral (FDF) tienen menos morbilidad y riesgo de muerte. El objetivo fue comparar las FC y la supervivencia de la FDF. Métodos: estudio observacional analítico. Se usó la base de datos del Hospital General de México para recolectar pacientes de 65 a 94 años de edad con FC y FDF del 2010 al 2014. Los pacientes tenían un seguimiento heterogéneo y no se consideraba el estado cognitivo; fueron un total de 146. El seguimiento se hizo por medio de llamada telefónica. RESULTADOS: se usó la estimación de Kaplan-Meier para calcular la supervivencia. Se comparó la supervivencia dependiendo del tipo de fractura y no se encontró diferencia estadísticamente significativa (p = 0.97). En el subanálisis, se comparó el tipo de fractura en el sexo masculino (p = 0.21) y el sexo femenino (p = 0.316) y no hubo diferencias estadísticamente significativas en la supervivencia. Esto difiere de los hallazgos de la literatura. Se utilizó la prueba t para evaluar la supervivencia en meses según el sexo masculino (39.61 ± 19.1) y femenino (36.58 ± 23.19), lo que demuestra una diferencia significativa en ambos grupos (p = 0.037). Conclusión: ante la presencia de fracturas, debemos considerar el género para estimar la supervivencia en pacientes con FC o FDF.7.

Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater.

BACKGROUND: Advanced age is a major predictor of poor outcome in patients undergoing valve surgery. We hypothesized that elderly patients who underwent minimally invasive valve surgery for aortic or mitral valve disease would do better when compared with those undergoing the standard median sternotomy. METHODS: We retrospectively reviewed 2,107 consecutive heart operations at our institution and identified 203 patients, age 75 years or greater, who underwent isolated mitral or aortic valve surgery. Outcomes of those who had minimally invasive valve surgery through a right minithoracotomy were compared with those who had a median sternotomy. RESULTS: Of the 203 patients, 119 (59%) underwent a minimally invasive approach, while 84 (41%) had a median sternotomy. The median postoperative length of stay was 7 days (interquartile range [IQR] 6 to 10) versus 12 days (IQR 9 to 20), p less than 0.001, and intensive care unit length of stay was 52 hours (IQR 44 to 93) versus 119 hours (IQR 57 to 193), p less than 0.001 for minimally invasive and median sternotomy, respectively. In-hospital mortality was 2 (1.7%) versus 8 (9.5%, p=0.01 and composite postoperative morbidity and mortality occurred in 25 (21%) versus 38 (45.2%), p less than 0.001, in minimally invasive versus median sternotomy, respectively. The difference was driven by the following: a lower incidence of acute renal failure, 1 (0.8%) versus 14 (16.7%), p<0.001; prolonged intubation 23 (19.3%) versus 32 (38.1%), p=0.003; wound infections 1 (0.8%) versus 5 (6%), p=0.034; and death. CONCLUSIONS: Minimally invasive surgery for isolated valve lesions in elderly patients yields a lower morbidity and mortality when compared with median sternotomy and should be considered when such individuals require valve surgery.