Cardiac surgery in nonagenarians: single-centre series and review.

BACKGROUND: Cardiac surgery is widely believed to be an excessively high-risk intervention for very elderly patients with coronary artery or valvular disease. However, as life expectancy and the prospect of sustained quality of life into older age increase, this assumption should be challenged so that surgery is not denied to patients who may derive significant symptomatic benefit with acceptable levels of operative risk. OBJECTIVE: To evaluate outcomes from cardiac surgery in nonagenarian patients. DESIGN: Analysis of prospectively collected single-centre data and review of outcomes reported in the literature. RESULTS: Twenty-three patients (13 males) aged 90 years or more underwent open cardiac surgery between 1998 and 2007. Four patients died within 30 days of surgery (surgical mortality 17.4%) and all-cause in-hospital morbidity was 74%. Actuarial survival at 1 and 5 years was estimated at 72 and 54%, respectively. Comparison of patients' survival against age-matched life tables for the English population found a standardised mortality ratio of 0.57 (95% CI: 0.24-0.99; one-sample log-rank test chi(2) = 3.93; p < 0.05) representing a significant survival benefit associated with surgery. The majority of patients reported symptomatic improvement reflected by significant decreases in angina and dyspnoea scores. Six single-centre series of nonagenarians and 3 reviews from national databases in the US and UK were identified in the literature. Pooled surgical mortality was 12.7% (95% CI: 8.7-17.3%) with no significant heterogeneity (chi(2) = 4.12; p = 0.77; I(2) = 0). CONCLUSION: Cardiac surgery in the elderly carries higher operative risk than in younger patients. However, in selected nonagenarians, surgery can be performed with acceptable morbidity and early mortality, and patients gain significant symptomatic relief and survival benefit.

Death in low-risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FIASCO) study.

Death in low-risk patients is not studied as frequently as it is in other cardiac patients. We, therefore, sought to determine why some low-risk patients die after cardiac surgery. All low-risk patients (EuroSCORE

Blood, sweat, toil, and tears of surgical training. Part I: Blood.

There may be conflict between the requirements of surgical training and those of the clinical service if training has an impact on clinical outcomes. One area of potential impact is perioperative blood loss. We compared total and 12-hour blood loss after 2,079 consecutive cardiac operations performed over 2 years by trainees and consultants. One- and two-way analyses of variance with EuroSCORE and surgeon status as factors were carried out to evaluate the impact of surgeon status on blood loss. There was no difference in blood loss between consultants and trainees. We also compared the rates between consultants and trainees of patients returning to the operating room due to bleeding. This showed a significant difference, with trainees having a higher rate of investigation for bleeding. Cardiac surgical training can be achieved without an adverse effect on blood loss, but it may be associated with a higher rate of re-intervention for bleeding.

Definitive management of advanced empyema by two-window video-assisted surgery.

We describe how 2-window video-assisted thoracoscopic decortication and lung mobilization can provide definitive management of stage III empyema. This technique was used in 52 patients with stage III empyema. None required additional ports or a thoracotomy. Three patients (6%) needed computed tomography-guided drainage of persistent large loculi, but none required further surgery. Chest radiographs at 6 weeks after surgery confirmed full lung expansion and resolution of pleural collection in the other 49 patients (94%).

Double lung transplantation in a patient with tracheobronchomegaly (Mounier-Kuhn syndrome).

Mounier-Kuhn syndrome is a rare condition characterized by marked dilation of the trachea and main bronchi resulting in bronchiectasis and emphysema. We report a case in which a patient underwent successful double lung transplantation for COPD that was found on pathologic examination of the explanted lungs to be Mounier Kuhn syndrome. To our knowledge this is the first case reporting lung transplantation in this syndrome.

Does body mass index (BMI) affect cost in cardiac surgery? 'A pound (pound) for pound (lb) analysis'.

The effect of BMI on cost of intensive care unit (ICU) stay and ward stay in cardiac surgery is currently unknown. To assess these data on BMI, ICU stay and EuroSCORE were prospectively collected for 6100 patients undergoing cardiac surgery between 2000 and 2004. Patients were categorised according to BMI and comparisons were conducted, using non-parametric tests (Kruskal-Wallis and Mann-Whitney U-tests). One day in ICU was costed at pound1,300 and one ward-day pound300/day by this hospital's finance department. Despite similar median (due to a distribution skewed to a short ICU stay), a significant difference is observed between all 6 groups (Kruskal-Wallis; P<0.001) for ICU stay and ward stay. Underweight and morbidly obese patients had longer ICU stays compared with the ideal weight patients (P=0.010 and P=0.004, respectively); while overweight and obese patients had shorter ICU stays (P<0.001 and P=0.007, respectively). Underweight patients had a longer ward stay than ideal weight patients (P=0.005) but there was no difference between ideal and morbidly obese patients (P=0.789). These results demonstrate that BMI has a significant impact on ICU and ward stay with 'ideal weight' not always being ideal for patients undergoing cardiac surgery. This cost appears to be independent of EuroSCORE.

Mesothelioma with non-pleural malignancy: a red herring or just an uncommon pairing?

Malignant pleural mesothelioma (MPM) is a highly aggressive cancer of the pleura with a well-established male predominance and causative link with asbestos exposure. We report four cases of female patients with MPM referred for palliation of symptoms thought to be due to previous non-pleural malignancy.With emerging novel treatments for MPM, this article discusses four unusual cases of MPM occurring in the setting of other malignancy, highlights the importance of considering a primary diagnosis of MPM even in patients with other malignancy, and reinforces the benefits of video-assisted surgical biopsy which allows simultaneous diagnosis and treatment.