Pleural empyema caused by Klebsiella oxytoca: a case series.

We report on 19 patients from Western Australia of pleural empyema with Klebsiella oxytoca, an organism never before reported in association with this condition. Median age was 65 years, 14/17 (83%) had been in hospital within 30 days prior to diagnosis, 12/18 (67%) had active cancer, 9/17 (53%) had been in intensive care and 7/17 (41%) had prior surgery. Nine patients died at the time of censure, five within 90 days of infection.

Frail patients having vascular surgery during the early COVID-19 pandemic experienced high rates of adverse perioperative events and amputation.

BACKGROUND: Frailty predicts adverse perioperative outcomes and increased mortality in patients having vascular surgery. Frailty assessment is a potential tool to inform resource allocation, and shared decision-making about vascular surgery in the resource constrained COVID-19 pandemic environment. This cohort study describes the prevalence of frailty in patients having vascular surgery and the association between frailty, mortality and perioperative outcomes. METHODS: The COVID-19 Vascular Service in Australia (COVER-AU) prospective cohort study evaluates 30-day and six-month outcomes for consecutive patients having vascular surgery in 11 Australian vascular units, March-July 2020. The primary outcome was mortality, with secondary outcomes procedure-related outcomes and hospital utilization. Frailty was assessed using the nine-point visual Clinical Frailty Score, scores of 5 or more considered frail. RESULTS: Of the 917 patients enrolled, 203 were frail (22.1%). The 30 day and 6 month mortality was 2.0% (n = 20) and 5.9% (n = 35) respectively with no significant difference between frail and non-frail patients (OR 1.68, 95%CI 0.79-3.54). However, frail patients stayed longer in hospital, had more perioperative complications, and were more likely to be readmitted or have a reoperation when compared to non-frail patients. At 6 months, frail patients had twice the odds of major amputation compared to non-frail patients, after adjustment (OR 2.01; 95% CI 1.17-3.78), driven by a high rate of amputation during the period of reduced surgical activity. CONCLUSION: Our findings highlight that older, frail patients, experience potentially preventable adverse outcomes and there is a need for targeted interventions to optimize care, especially in times of healthcare stress.

Covered stents in iliac artery occlusive disease: what is the evidence?

The last two decades have seen a revolution in the treatment of aortoiliac occlusive disease (AIOD). Acceptable safety and durability outcomes have now been realized with endovascular treatments, which is increasingly finding a place in the treatment of AIOD. Evolution of stent technologies and endovascular techniques is seeing an expansion of AIOD lesions indicated for primary endovascular treatment. The literature evidence basis is continuously evolving, and questions remain as to the optimal form of vessel treatment. Covered stents have been increasingly promoted for their long-term durability, particularly in extensive, challenging AIOD lesions. Here, we explore the seminal evidence basis for covered stents in the treatment of AIOD, and aim to provide a sound evidence based argument for their use.

Medium-term outcomes after pulmonary valve replacement with the Freestyle valve for congenital heart disease: a case series.

OBJECTIVES: The Freestyle valve may be used for pulmonary valve replacement (PVR). Whether its stentless design and anticalcification treatment improve durability relative to alternative bioprostheses, however, is unknown and long-term data are lacking. METHODS: We performed a retrospective review of all Freestyle PVRs performed by a single surgeon in two institutions. All patients were contacted for follow-up to establish survival, New York Heart Association class and reintervention. Up to date, echocardiography was obtained to assess valve function. Perioperative factors associated with structural valve dysfunction (SVD) were assessed using Cox regression. RESULTS: Between 2000 and 2014, PVR with a Freestyle valve was performed in 114 patients with congenital heart disease. There were 70 males and 44 females. The median age was 21 years (interquartile range 11-35 years). The median clinical and echocardiographic follow-up was 62 months (interquartile range 35-115 months, n = 110) and 58 months (interquartile range 30-93 months, n = 107), respectively. Follow-up was complete for 107 of 114 patients (94%). The survival rate was 95% at 5 years and 91% at 10 years. The rate of freedom from SVD at 5 years was 82%, and at 10 years was 61%. The reintervention-free survival rate was 85% at 5 years, and 71% at 10 years. CONCLUSION: The Freestyle valve in the pulmonary position in a congenital population is associated with low medium-term incidences of SVD and reintervention. It performs equally well to the homograft when a conduit is required and can be considered a valid alternative to stented bioprostheses when PVR alone is required.

The freestyle valve as a right ventricle to pulmonary artery conduit. A systematic review and meta-analysis.

INTRODUCTION: Reconstruction of the right ventricular outflow tract is the most commonly performed valve repair/replacement procedure in congenital cardiac surgery. There is an ongoing shortage of homografts, and existing bioprosthetic options suffer from substantial rates of structural valve deterioration over time. The Medtronic Freestyle valve is used extensively in the aortic position, but little data is available on its performance in the pulmonary position. METHODS: A systematic review and meta-analysis of primary studies reporting echocardiographic and clinical outcomes, including reintervention and functional status, associated with the Freestyle valve in the pulmonary position for both Ross and congenital surgery. RESULTS: 13 observational studies including 334 patients with a mean follow-up of 34 months (range 10-98 months) fulfilled the eligibility criteria and were included in the review. Structural valve deterioration occurred in 4.8% (95% confidence interval 0.8-10.6%) of patients. Reintervention was required in 1.1% (95% confidence interval 0.0-3.3%). Freedom from symptoms of heart failure occurred in 97.7% (94.6-99.7%). The results did not change substantially when analysed according to Ross or congenital surgery. CONCLUSIONS: The Freestyle valve performs well at short-term follow-up and provides a viable alternative when homografts are unavailable. Further long-term studies are required to better assess its role in right ventricular outflow tract reconstruction.