Invasive management of significant tricuspid regurgitation in clinical practice.

BACKGROUND: Tricuspid regurgitation (TR) is a prevalent condition inside valvular heart disease (VHD) with relevant prognosis implications. However, concordance between real management in clinical practice and invasive treatment recommendations of European Society of Cardiology (ESC) guidelines is unknown. METHODS: A substudy of ESC VHD II survey was performed to evaluate the real treatment of TR compared to the clinical ESC guidelines recommendations published in 2012, 2017 and 2021 was performed. TR cases with surgical indication were divided in 3 groups: 1: severe isolated TR without previous left VHD; 2: moderate/severe TR and concomitant severe left VHD; 3: severe TR plus previous left VHD surgery. RESULTS: Of 902 patients assessed, 123 had significant TR. Fifty (41%) cases demonstrated ESC guidelines 2012-2017 Class I or IIa recommendations for invasive treatment: 9(18%) of group 1, 37(74%) of group 2 and 4(8%) of group 3. Surgery was performed in 24 patients (48%); 1 in group 1(4%), 22 in group 2(92%) and 1 in group 3(4%). Overall concordance was 48% (group 1: 11%; group 2: 59%; group 3: 25%). Regarding the 2021 ESC guidelines only one patient changed groups with an overall concordance of 47% (group 1: 10%; group 2: 59%; group 3: 25%). CONCLUSION: Concordance between 2012, 2017 and 2021 ESC guidelines recommendations and clinical practice for TR surgical intervention is low, especially in those without concomitant severe left VHD. These results suggest the need to improve further guideline implementation and alternative treatments, such as percutaneous, which could resolve potential discrepancies in those clinical scenarios.

Clinical Prognosis of Right-Sided Infective Endocarditis not Associated with Cardiac Devices or Intravenous Drug use: a Cohort Study and Meta-Analysis.

Right-sided infective endocarditis (RSIE), classically associated with intravenous drug use or intracardiac devices, is considered a good-prognosis infective endocarditis (IE) form. However, predisposing factors and prognosis for "NODID" RSIE (NOt associated with cardiac Devices or Intravenous Drug use) remain unclear. The aim of this study was to evaluate predisposing factors and prognosis of NODID RSIE compared to other RSIE forms. A retrospective cohort study (January 2008-January 2019) was conducted in a reference center on 300 patients diagnosed with IE. Endocarditis-related events were defined as related to IE in mortality or open-heart surgery during follow-up. A review and meta-analysis of associated literature (January 2008-January 2019) were also performed. Fifty-seven patients presented RSIE (19%), 22 of which were NODID RSIE (39%). Use of intravascular catheters (23% vs 3%; p = 0.027) and congenital heart diseases (18% vs 0%; p = 0.019) were associated with NODID RSIE. This group had a higher in-hospital mortality (23% vs 3%; p = 0.027) and endocarditis-related event rates (41% vs 6%; p = 0.001) than non-NODID RSIE. Furthermore, NODID RSIE was independently associated with in-hospital endocarditis-related events (OR = 19.29; 95%CI:2.23-167.16; p = 0.007). Our meta-analysis evaluated four studies and identified 96 cases (30%) of NODID RSIE from 320 total RSIE cases. NODID RSIE patients demonstrated higher in-hospital mortality (RR = 2.81; 95%CI:1.61-4.90; p < 0.001; I2 = 0.0%) and necessity of open-heart surgery (RR = 13.89; 95%CI:4.14-46.60; p < 0.001; I2 = 0.0%) than non-NODID RSIE cases. Our study suggests that NODID RSIE has the highest endocarditis-related event rate and in-hospital mortality among RSIE cases and therefore should not be considered a good-prognosis IE.

Tumor Grade Correlation Between Preoperative Biopsy and Final Surgical Specimen in Endometrial Cancer: The Use of Different Diagnostic Methods and Analysis of Associated Factors.

OBJECTIVE: This study aimed to identify the correlation between histology tumor grade of the preoperative biopsy using dilatation and curettage (D&C), Pipelle, or hysteroscopy and final surgical specimen in women with endometrioid endometrial cancer. MATERIALS AND METHODS: Patients on whom a preoperative biopsy was performed between 2009 and 2016 were reviewed and cases with apparent early-stage endometrioid endometrial cancer were included in the study. The accuracy of preoperative biopsy performed before hysterectomy using D&C, Pipelle, or hysteroscopy was compared. RESULTS: A total of 332 patients were included. The diagnostic method was D&C in 43 cases (13%), Pipelle in 102 (31%), and hysteroscopy in 187 (56%). The preoperative diagnosis included G1 tumors in 177 cases (53.3%), G2 in 103 (31%), and G3 in 52 (15.6%). The surgical specimen confirmed endometrioid endometrial tumor in 309 patients (93%).The accuracy rates of preoperative biopsy and surgical specimen were 74.69%, 73.19%, and 89.75% for G1, G2, and G3, respectively. Hysteroscopy showed better κ index (κ = 0.551) than did D&C (κ = 0.392) and Pipelle (κ = 0.430). Tumor diameter greater than 30 mm was the only factor independently associated with absence of correlation between preoperative and postoperative tumor grade (odds ratio [95% confidence interval], 1.959 [1.096-3.504], P = 0.023). CONCLUSIONS: Preoperative biopsy, regardless of the method, has its limitations in predicting the tumor grade compared with final surgical specimen in women with endometrioid endometrial cancer at an apparent early stage. Concordance between the biopsy and hysterectomy specimen is less likely to happen in the case of preoperative G1 or G2 tumors, as well as in big tumors. Although hysteroscopy was associated with the highest tumor grade agreement, no differences in correlation between the 3 methods (D&C, Pipelle, and hysteroscopy) were found.

Chest physiotherapy revisited: evaluation of its influence on the pulmonary morbidity after pulmonary resection.

OBJECTIVE: The study aimed to evaluate if perioperative chest physiotherapy modifies the risk of pulmonary morbidity after lobectomy for lung cancer. METHODS: We have reviewed a prospectively recorded database of 784 lung cancer patients treated by scheduled lobectomy (361 operated after implementing a new physiotherapy program). No other changes were introduced in the patients' perioperative management during the study period. A propensity matching score was generated for all eligible patients and two logistic models were constructed and adjusted. The first one (model A) included age of the patient, forced expiratory volume in 1s (percent) (FEV1%) and predicted postoperative forced expiratory volume in 1s (percent) (ppoFEV1%); for the second model (model B); chest physiotherapy was added to the previous ones. Using each model, patients' individual probability of postoperative complication was calculated and maintained in the database as a new variable (risk A and risk B). Individual risks calculated by both models were plotted on a time series and presented in two different graphs. RESULTS: Rates of pulmonary morbidity were 15.5% before the intensive physiotherapy program and 4.7% for patients included in the implemented program (p = 0.000). The propensity score identified 359 pairs of patients. Model A included age (p = 0.012), FEV1% (p = 0.000), and ppoFEV1% (p = 0.031) as prognostic variables. Model B included age (p = 0.012), FEV1% (p = 0.000), and physiotherapy (p = 0.000). On graphic representation, a great decrease of the estimated risk could be seen after the onset of the physiotherapy program. CONCLUSIONS: Implementing a program of perioperative intensive chest physiotherapy reduced the overall pulmonary morbidity after lobectomy for lung cancer.

Chest physiotherapy in lung resection patients: state of the art.

The role of chest physiotherapy in limiting postoperative pulmonary complications and in the recovery of pulmonary function and exercise capacity after lung surgery is still unclear because of the lack of conclusive, well-designed clinical trials. In this article the available literature on these topics is reviewed, and the effects of respiratory physiotherapy, instituted preoperatively or administered after surgery to patients undergoing lung resection, are commented on. The authors conclude that chest physiotherapy improves preoperative exercise capacity; this is a parameter highly predictive of postoperative pulmonary complications. Also physiotherapy administered during the immediate period after lung resection probably decreases frequency of pulmonary complications. Finally, further investigation is required for a better understanding of the effects of long-term chest physiotherapy after hospital discharge in lung resection patients.

Results of a simple exercise test performed routinely to predict postoperative morbidity after anatomical lung resection.

BACKGROUND AND OBJECTIVE: Exercise tests are considered the most reliable ones for the preoperative workup of lung resection candidates but frequently are indicated only in cases with low predicted postoperative forced expiratory volume in 1s (FEV1) and carbon monoxide diffusing capacity (DLCO). The aim of this investigation is to evaluate if a simple, standardised incremental bicycle exercise test routinely performed in patients considered operable is predictive of postoperative cardio-respiratory complication and if its performance is comparable to a logistic regression model including frequently cited clinical predictive variables. METHODS: A series of 103 lung resection candidates were included in a prospective observational study. All patients underwent a standardised, incremental exercise test on a bicycle up to exhaustion. The analysed outcome was the occurrence of postoperative cardio-respiratory complications prospectively recorded and codified. The correlation of distance reached at the end of the test and the outcome was estimated by non-parametric tests. A logistic regression model including age, BMI, predicted postoperative (ppoFEV1%) and predicted postoperative DLCO (ppoDLCO) was adjusted and the individual probability of complication calculated and set as a new variable. Finally, two receiver operating characteristic (ROC) curves were constructed and compared: one with distance at the exercise test and the other with logistic regression probability of complication. RESULTS: Mortality of the series was nil. Outcome prevalence was 14%. Distance reached at the end of the exercise test was lower in cases with a positive outcome (3498.6m vs 4543.5m, p=0.001). On logistic regression analysis, age of the patient (p=0.016) and ppoDLCO (p=0.000) were predictive for the outcome. On ROC analysis, C-indices were 0.77 (distance) and 0.78 (logistic model, p=0.95). CONCLUSION: Reached distance in a simple standardised exercise test is related to postoperative morbidity after lung resection; and the accuracy of prediction using this variable alone is comparable to a logistic regression model including age and ppoDLCO.

Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy.

OBJECTIVE: To evaluate the cost-effectiveness balance of implementing an intensive program of chest physiotherapy in pulmonary lobectomy. DESIGN: cross-sectional study with historical controls. Cases are 119 patients operated on during a 15-month period of time, after implementation of an intensive chest-physiotherapy program. Controls are 520 patients operated on by the same team before the program started. In these patients, only incentive spirometry was indicated besides routine nursing care. In both series, operative selection criteria and anaesthetic management were similar. Population homogeneity was assessed by comparing age, body mass index (BMI) and estimated postoperative FEV1 (ppoFEV1) of the patients in both series. Selected outcomes were as follows: 30-day mortality, prevalence of respiratory morbidity (atelectasis and pneumonia) and hospital stay. Hospital stay was estimated by Cox regression using age, ppoFEV1, BMI, diagnosis and postoperative morbidity as covariates. Costs were calculated adding chest therapists' salaries and acquisition value of specific training and monitoring devices and its consumable items. Savings from avoided hospitalisation days was discounted. RESULTS: Prevalence of atelectasis and median hospital stay decreased in physiotherapy group. Cost of the program was 48,447.81 (407.12 per treated patient). An estimated total of 151.75 hospital days was saved in the physiotherapy group. Since daily hospitalisation cost is 590.00 in our centre, 89,532.50 savings was estimated from avoided hospitalisation days. CONCLUSIONS: We have found a significant decrease in the rate of postoperative atelectasis without additional costs. In fact, the program has produced considerable monetary savings.