Representation of racial minorities in cardiac surgery randomized clinical trials.

BACKGROUND: Racial minorities account for 39.9% of the population in the United States, but are often underrepresented in clinical research. Results from studies predominantly enrolling White patients may not apply to racial minorities. The aim of this analysis is to assess the representation of racial minorities in cardiac surgery randomized clinical trials (RCTs). METHODS: A systematic search of the literature was performed. All RCTs published from 2000 to 2020 including at least 100 patients and comparing two or more adult cardiac surgery procedures were included. Meta-analytic estimates were calculated. RESULTS: Among 51 cardiac surgery RCTs published between 2000 and 2020, only 9 (17.6%) reported the race of patients and were included in the final analysis. All of them were multicentric, with a mean of 33 centers included. Six RCTs enrolled patients undergoing coronary artery bypass grafting (66.7%), while the remaining three were on valve surgery (33.3%). Overall, 9193 patients were included; of them, 8034 (87.4%) were White and 1026 (11.2%) nonWhite (386 [4.2%] Black, 191 [2.1%] Hispanic, 274 [3.0%] from other races, and 175 [1.9%] nonWhite patients of unspecified race). The proportion of nonWhite patients did not change over time. CONCLUSIONS: Only 9 (17.6%) of the 51 cardiac surgery RCTs published between 2000 and 2020 reported the race of the patients enrolled and only 11.2% of them were nonWhite patients. Given the association between race and clinical outcomes, future RCTs should either guarantee a balanced inclusion of racial minorities or be designed to specifically enroll them.

Predictors of outcome in a multicenter port-access valve registry.

BACKGROUND: The aim of this study was to examine the predictors of outcome in patients undergoing isolated valve operation using port-access techniques. METHODS: Logistic regression analysis was performed in a prospective, multi-institutional registry of patients undergoing isolated aortic valve replacement (AVR, n = 252), mitral repair (MVP, n = 491), or mitral replacement (MVR, n = 568) using port-access techniques from 1997 to 1999. RESULTS: Endoaortic balloon occlusion was used in 2% (AVR), 93% (MVP), and 90% (MVR) of cases. Conversion to full sternotomy occurred in 3.8% of all cases. For all patients, early mortality was 50 of 1,311 (3.8%) and onset of new atrial fibrillation occurred in 140 of 1,311 (11%) patients. The determinants of 30-day mortality were redo, age, and MVR or AVR. The determinants of reoperation for bleeding were age, reoperation, and MVR. Age was a predictor for stroke, and age and low or medium volume center were predictors of new atrial fibrillation. CONCLUSIONS: Excellent short-term results can be obtained using port-access techniques in isolated mitral or aortic valve operations. Patient outcome is not related to institutional case volume, and the primary determinants of outcome after port-access valve procedures are generally patient-related factors.

Outcome of isolated coronary artery bypass surgery in octogenarians.

BACKGROUND: Between 1989 and 1992 100 consecutive patients aged 80 or older underwent isolated coronary artery bypass grafting (CABG) in our institution. Eighty-six percent had angina grade III or IV symptoms. METHODS: Emergency surgery was required in 31, urgent surgery in 30, and elective surgery in 39 patients. The average left ventricular ejection fractions (LVEF) in these groups were 36%, 43%, and 45% respectively. The operative mortality was 8% for these octogenarians compared to 2% in the younger cohort (p = 0.002). It was zero in elective cases and 13% (8/61) in urgent and emergency cases. It was increased by preoperative admission to coronary care unit (CCU) (p = 0.02), urgency of operation (p = 0.02), the use of intra-aortic balloon pump (IABP) (p = 0.0002), preoperative renal dysfunction (p < 0.03), and < or = 3 grafts (p < 0.04). The late mortality was increased by LVEF < or = 20% (p = 0.03) and operation from CCU (p < 0.05). On multivariate stepwise logistic regression analysis, the use of IABP (p < 0.0003) and preoperative renal dysfunction (p < 0.02) were independent predictors of operative mortality. LVEF < or = 20% was the only independent predictor (p < 0.02) of late mortality. RESULTS: Actuarial survival was noted to be 87%, 80%, 77%, and 73%, respectively, at 1, 2, 3, and 4 years, with two cardiac-related late deaths. Long-term follow-up revealed that 97% of patients had no or minimal anginal symptoms. CONCLUSIONS: Due to increasing use of nonsurgical options, the profile of elderly referred for CABG currently involves gravely ill patients with comorbidities. CABG under elective conditions, before deterioration of left ventricular function, can achieve normal life expectancy and good symptomatic relief in octogenarians.

Feeding the frail elderly.

1. Frail older adults need to be fed carefully and observed closely while eating to prevent choking and aspiration of food and fluids. They choke more easily on clear liquids than on soft foods with some texture. 2. The licensed nurse is responsible for evaluating the physical status of frail older adults before feeding them and for assuring that less qualified personnel are aware of the dangers and specific precautions in feeding these types of patients. 3. The use of nutritious finger foods allows frail older people some degree of independence by encouraging them to feed themselves whenever possible. Careful menu planning can result in a variety of nutritious foods for older people. 4. Soft-cooked vegetables and fruits are more appetizing and acceptable to frail edentulous older adults than pureed or ground foods. Making mealtime special may be one of their few pleasures. 5. Frail older adults should remain in a sitting or semi-Fowler's position for at least one to two hours after eating to prevent possible regurgitation and aspiration of food or fluids.

Treatment of neonatal necrotizing tracheobronchitis with extracorporeal membrane oxygenation and bronchoscopy.

Necrotizing tracheobronchitis has recently been described as a complication of mechanical ventilation of newborns with respiratory failure. Despite the use of bronchoscopy, 45% of the reported patients to date have died. In this study, we report the use of extracorporeal membrane oxygenation (ECMO) to stabilize two patients with necrotizing tracheobronchitis. While supported by bypass, both patients underwent prolonged bronchoscopies with removal of extensive amounts of tracheal debris. ECMO provided efficient oxygenation in the face of near total airway occlusion, and permitted far more extensive bronchoscopic debridement and lavage than would have been possible if the lungs were required for oxygenation. In addition, ECMO provided a period of lung "rest" during which ventilator settings were reduced, thus minimizing further barotrauma and allowing for lung and airway healing. Both patients recovered without significant respiratory sequelae. ECMO and bronchoscopy are effective forms of therapy for patients with life-threatening necrotizing tracheobronchitis when conventional modalities of treatment have failed.

Anaesthesia in the morbidly obese. A comparison of anaesthetic and analgesic regimens for upper abdominal surgery.

Seventy morbidly obese patients presented for upper abdominal surgery; 17% had pre-existing cardiovascular disease and 23% pre-existing respiratory disease. Twenty-eight patients received general anaesthesia, plus narcotic analgesia postoperatively, and 42 general anaesthesia plus thoracic epidural analgesia intra- and postoperatively. Aspects of anaesthetic management are discussed and compared with previous similar reports. Doses of local anaesthetic for induction of epidural analgesia were less than those for the non-obese but doses of local anaesthetic for maintenance of epidural analgesia were similar to those in non-obese patients. Patients who had thoracic epidural analgesia required less volatile anaesthesia than the group who had general anaesthesia and narcotic analgesics. Postoperative respiratory complications were more common in patients with pre-existing cardiovascular and respiratory disease, and occurred less frequently in patients who had thoracic epidural analgesia.

Ventilation-perfusion relationships after hemorrhage and resuscitation: an inert gas analysis.

Previous investigations suggest that ventilation-perfusion (VA/Q) relationships after hemorrhagic shock are primarily dependent on regional distribution of pulmonary blood flow and implicated early VA/Q heterogeneity secondary to disproportionate redistribution of pulmonary blood flow to dependent lung regions. Multiple inert gas elimination analysis, as described by Wagner et al. (J. Appl. Physiol.: Respirat. Environ. Exercise Physiol. 36: 588-599, 1974), was applied to a standard hemorrhagic shock preparation to test this hypothesis. Soon after hemorrhage, VA/Q distributions shifted homogeneously into high VA/Q compartments, preserving base-line VA/Q relationships around a new mean VA/Q ratio. Although the mean VA/Q and VA/Q distribution returned to base line after resuscitation with autologous blood, absolute dead space ventilation persisted. Gas exchange defects included increased Bohr dead space ventilation, which could be attributed to 1) a homogeneous shift of VA/Q distributions into high VA/Q compartments, and 2) new absolute dead space ventilation associated with observed intravascular leukostasis and vascular occlusion. In contrast to previous investigations, these data suggest that VA/Q heterogeneity does not occur after hemorrhage, but rather pulmonary blood flow decreases proportionately throughout all lung regions, preserving base-line VA/Q patterns around a new mean VA/Q ratio.

Steroid therapy following isolated smoke inhalation injury.

Steroids have no positive influence upon pulmonary related morbidity and mortality following combined smoke inhalation and thermal cutaneous injury (3, 4). Steroid administration following isolated smoke inhalation without concomitant thermal cutaneous injury has, however, been shown to have beneficial effects in previous animal studies (1). This potential therapeutic approach to treatment has not been examined in the clinical setting. Recent hotel fires in Las Vegas, Nevada, resulted in a large cohort of individuals with similar smoke exposures without associated injuries. Two of four hospitals in the triage system administered steroids following injury. Patients were divided into two groups, a steroid-treated, and a non-treated group. These groups were compared using multivariate and frequency analyses. There were no detectable differences in sex, signs, symptoms, and previous medical history. There were likewise no differences between groups with respect to oxyhemoglobin saturation, arterial oxygen tension, arterial pH, and pulmonary-related morbidity and mortality. These data suggest that steroid coverage has little beneficial effect upon pulmonary-related morbidity and mortality following isolated smoke inhalation injury.

Ventilation and perfusion alterations following homologous blood transfusion.

A previous study in this laboratory examined the effect of micropore ultrafiltration of blood products on pulmonary gas exchange and subsequent pulmonary dysfunction--related morbidity and death. Morbidity and death from pulmonary failure was not affected; however, gas exchange was improved following ultrafiltration with 40 micrometers filters, as reflected by lower Bohr dead-space fractions. This difference might be explained by reduction of the microaggregate load seen in the pulmonary microvasculature. The purpose of this study was to examine in more detail these gas exchange alterations, paying particular attention to the correlation of changing Bohr dead-space ventilation detected with multiple inert gas analysis with direct determinations of microaggregate size and number. Fourteen patients with isolated cutaneous thermal injury scheduled for major early burn would excision were selected for study. Following transfusion with homologous blood products, the ventilation/perfusion ratio (Va/Q) distributions determined by inert gas analysis remained essentially unchanged except for subtle changes in both high VA/Q and dead-space compartments, resulting in significantly increased Bohr dead-space fractions (P less than 0.05). This combination of gas exchange alteration is consistent with vasoactive and occlusive changes in the pulmonary microvasculature following microaggregate infusion. The correlation of changing dead-space ventilation with the total microaggregate load was poor (r = 0.15) but was significant when compared with counts of microaggregates greater than 90 micrometers in diameter (r - 0.85). These findings suggest that gas exchange alterations following blood transfusion are primarily reflected by increased dead-space ventilation secondary to vasoconstriction and occlusion of the pulmonary microvasculature with microaggregates greater than 90 micrometers in diameter.

Ventilation and perfusion alterations after smoke inhalation injury.

Previous studies of human victims of smoke inhalation injury have demonstrated retention of intravenously infused 133xenon2, 6 suggesting either: (1) true intrapulmonary shunting (Qs) secondary to alveolar collapse, flooding, or obliteration, or (2) perfusion of low ventilation/perfusion compartments (low VA/Q) secondary to bronchospasm, bronchial constriction, or partial bronchial occlusion by cellular debris. To differentiate between and quantitate the relative contribution of intrapulmonary shunt versus low VA/Q compartments, multiple inert gas analysis, as described by Wagner et al.,12 was applied to human victims of smoke inhalation. Studies of an animal model of injury were subsequently performed to confirm these observations. These experiments suggest that early alterations of ventilation and perfusion resulted from increased high VA/Q and dead-space ventilation. Late alterations included significantly increased perfusion of low VA/Q compartments and return of high VA/Q ventilation to baseline levels. True intrapulmonary shunting was notably absent. This physiologic sequence may represent early regional pulmonary vasospasm followed by regional bronchial obstruction and gradual alveolar secondary to bronchospasm, bronchial edema, or partial occlusion by cellular debris.

Pulmonary dirofilariasis in man. A case report and review of the literature.

Pulmonary dirofilariasis in man is becoming a well-recongnized entity. Its pathogenesis and histopathologenical picture have been well characterized but the preoperative diagnosis still remains a challenge. The roentgenographic picture, usually described as a "coin lesion," is nonspecific and easily mistaken for other inflammatory and neoplastic nodules. Forty-seven clinical instances of pulmonary dirofilariais have been reported in the literature, with most of them in the last two decades. Considering the entire clinical picture, a strong suspicion can be based on serological studies, thus improving the possibilities of a correct preoperative diagnosis.