Aortic valve replacement in patients over 60: Real-world surgical outcomes.

OBJECTIVE: With the advent of transcatheter aortic valve implantation (TAVI) has come an expectation that there will be a decline in surgical aortic valve replacement (SAVR). This has been fueled by trials comparing outcomes between TAVI and SAVR in lower-risk patients. The aim of this study was to examine outcomes following SAVR in patients over the age of 60. MATERIALS AND METHODS: This retrospective cohort study observed 1005 patients ≥60 who underwent isolated primary SAVR from January 2015 to December 2018. The cohort was stratified by surgical risk, defined as European System for Cardiac Operative Risk Evaluation (EuroSCORE) II < 4 versus ≥4. The cohort was also divided by age (60-69, 70-79, ≥80) for additional comparisons. Outcomes included in-hospital complications and patient survival. RESULTS: The median age and EuroSCORE II were 75 years and 1.6, respectively. The overall 30-day mortality was 1.7% and increased significantly with surgical risk (p = .007). The 30-day mortality of elective patients was 1.1%. Overall, 1- and 2-year survival rates were 94.3% and 91.7%, respectively, which significantly decreased with surgical risk (p < .001) and age (p = .002, p = .003). The rates of postoperative stroke and pacemaker implantations were 1.2% and 3.6%, respectively. CONCLUSIONS: SAVR can be performed in patients ≥60 years old with excellent outcomes, which compare favorably with outcomes from TAVI trials, with their highly selected patient cohorts. SAVR remains a reliable, tried and tested, treatment option in these patients.

Twelve tips to maximise medical student learning during emergency medicine placements.

Placements in the emergency department provide medical students with countless clinical and practical learning opportunities. However, medical education may not always be optimised for students in this busy, potentially overwhelming environment. Prior knowledge of how to make the most of emergency medicine placements helps to facilitate student learning and enjoyment. In this article, the authors compiled twelve tips based on the relevant literature and their experiences on emergency attachments. These tips will better prepare medical students for their emergency medicine placements and ensure that they experience the full benefits of working in the emergency department.

The role of the angle of the fibularis longus tendon in foot arch support.

INTRODUCTION: Understanding the contribution of the fibularis longus tendon to the support of the midfoot arches has potential therapeutic applications. This cadaveric study sought to quantify this support across both the transverse arch and medial longitudinal arch and to establish whether a correlation exists between this support and the angle at which the tendon enters the sole. MATERIALS AND METHODS: Markers placed in 11 dissected cadaveric foot specimens defined the arch boundaries. Incremental weights up to 150 N were applied to the fibularis longus tendon to simulate progressive muscle contraction, and associated changes in the transverse and medial longitudinal arch boundaries were recorded. RESULTS: A force of 150 N reduced the transverse arch distance by 4.6 (1.7) mm (mean [SD]) and medial longitudinal arch distance by 6.8 (1.4) mm. The angle of the fibularis longus tendon on the sole correlated well with changes in the transverse arch distance (slope ± s.e. = 0.56 ± 0.13 mm/degree, Pearson r = .83, p = .002) but only weakly with the medial longitudinal arch (0.18 ± 0.18 mm/degree, r = .32, p = .33). CONCLUSIONS: The results of this preliminary study raise the possibility that physical therapies targeting the fibularis longus tendon may be valuable in the management of midfoot arch collapse. The correlation observed with the transverse arch suggests the possibility that surgical modification of the angle of the fibularis longus tendon on the sole may benefit patients with transverse arch collapse.

Tricuspid atresia: Where are we now?

Tricuspid atresia (TA) is a complex congenital heart disease that presents with cyanosis in the neonatal period. It is invariably fatal if left untreated and requires multiple stages of palliation. Early recognition and timely surgical intervention are therefore pivotal in the management of these infants. This literature review considers the pathophysiology, presentation, investigations, and classification of TA. Moreover, it discusses the evidence upon which the latest medical and surgical treatments are based, as well as numerous recent case reports. Further work is needed to elucidate the etiology of TA, clarify the role of pharmacotherapy, and optimize the surgical management that these patients receive.

Abdominal aortic aneurysms part two: Surgical management, postoperative complications and surveillance.

Large, symptomatic and ruptured abdominal aortic aneurysms are usually treated surgically if patients are deemed fit enough. This may be achieved through endovascular or open surgical repair. The type of treatment that a patient receives is dependant on many factors, such as the rupture status of the aneurysm. Each approach is also associated with different risks and postoperative complications. Multiple guidelines exist to inform the surgical management of abdominal aortic aneurysms. This literature review combines these recommendations and explores the evidence upon which they are based. In addition, it highlights the key perioperative considerations that need to be considered in cases of unruptured and ruptured abdominal aortic aneurysms.

Abdominal aortic aneurysms part one: Epidemiology, presentation and preoperative considerations.

An abdominal aortic aneurysm is an irreversible dilatation of the abdominal aorta. The majority of abdominal aortic aneurysms are asymptomatic and identified incidentally while investigating a separate pathology. Others are detected by national screening programmes and some present due to a growth or rupture. Symptomatic or ruptured aneurysms require urgent or emergency repair in patients fit for surgery. Perioperative practitioners should therefore be aware of how patients with abdominal aortic aneurysms present and are investigated, so that they can implement timely management. Guidelines have been recently updated to reflect this. This literature review discusses these recommendations and explores the evidence upon which they are based. The aim of this article is to highlight the important preoperative principles that need to be considered in cases of abdominal aortic aneurysm.