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PubMed2000

Preoperative predictors of late postoperative outcome among patients with nonischemic mitral regurgitation with 'high risk' descriptors and comparison with unoperated patients.

Among patients with chronic nonischemic mitral regurgitation (MR), high short-term mortality risk can be identified by left (LV) and/or right ventricular (RV) ejection fraction (EF) criteria (LVEF </=45% and/or RVEF </=30%). Mitral valve replacement or repair (MVR) significantly improves outcome in this subgroup, but predictors of late postoperative survival are not known, and the benefit of MVR has not been defined in patients matched for severity of LV and RV dysfunction. Therefore, prospective assessment of 14 consecutive high risk MR patients was performed before MVR and during 9 years (average) postoperatively to define echocardiographic and radionuclide angiographic predictors of survival; survival also was evaluated in a contemporaneous series of 9 high risk unoperated MR patients, and in subgroups of operated and unoperated patients matched for EF. Of 14 MVR patients, 4 died (3 cardiac: 1 sudden, 2 congestive heart failure). Only preoperative RVEF </=20% significantly predicted postoperative deaths (rest p = 0.032; exercise p = 0.05). Of 9 unoperated patients, 8 died. Mortality risk of unoperated patients remained higher than that of MVR patients when groups were matched for preoperative LVEF (p = 0.0001). Among patients with RVEF >20%, MVR significantly improved survival versus medical treatment (rest: p < 0.0001, exercise: p = 0.0003). In high risk MR patients, MVR improves survival; preoperative RV performance can define subgroups with different long-term postoperative survival.

Chronic Disease↗

PubMed1994

Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery.

One hundred twenty patients undergoing coronary artery surgery completed a randomized controlled study designed to investigate whether prophylactic chest physiotherapy affected the incidence of postoperative pulmonary complications. Group 1 patients received no preoperative or postoperative chest physiotherapy. Group 2 patients received preoperative education and instruction in breathing and coughing exercises and postoperative supervision and assistance in performing the same. These exercises were supervised by a physiotherapist twice per day on the first 2 postoperative days and once per day on the 3rd and 4th postoperative days. Physiotherapy for group 3 patients was the same as for group 2 patients except that patients were seen by a physiotherapist 4 times per day on the first 2 postoperative days and twice per day on the 3rd and 4th postoperative days. Group 2 and 3 patients were instructed to practice breathing and coughing exercises every hour. Overall, an incidence of clinically significant postoperative pulmonary complications of 7.5 percent was demonstrated. In general, these patients demonstrated lower levels of preoperative pulmonary function and very low early postoperative oxygenation compared with those who did not develop pulmonary complications. There was no indication that the incidence or severity of fever, hypoxemia, chest roentgenologic abnormalities or clinically significant postoperative pulmonary complications was different between groups. These results suggest that the necessity for prophylactic chest physiotherapy after routine coronary artery surgery should be reviewed.

Breathing Exercises↗

PubMed1996

Use of dobutamine stress echocardiography for risk assessment before noncardiac surgery.

Preoperative cardiac risk stratification has been traditionally performed using clinical variables indicative of increased cardiac risk, more recently dipyridamole-thalium imaging has been used with variable success. Several well-designed clinical studies have now shown that DSE is a feasible, safe, and useful modality for cardiac risk stratification before surgical procedures; its accuracy is comparable to nuclear perfusion testing. DSE has the additional advantages of having a relatively lower cost and providing additional information regarding ventricular and valvular function.

Cardiotonic Agents↗

PubMed2006

Impact of preoperative biofeedback on incontinence in cancer patients undergoing radical prostatectomy.

OBJECTIVE: Post-radical prostatectomy incontinence is mainly attributable to iatrogenic verify the importance of preoperative biofeedback (BFB) in an attempt to identify a strategy to improve postoperative urinary incontinence. MATERIALS AND METHODS: Ninety candidates (median age 68 years: range 49-75) for radical retropubic prostatectomy were evaluated. Forty-five patients underwent preoperative pelvic floor training (PFT) and BFB, whereas the remaining 45 (control group) had preoperative PFT only. Patients started PFT exercises two weeks before surgery and continued during the immediate postoperative period, after catheter removal (6-7 days after surgery), and thereafter at home. No adjuvant therapy was administered and all 90 patients were assessed at follow up visits timed 1, 3 and 6 months post surgery. RESULTS: Patients who were completely dry and without use of pads were defined as continent. At the 1-month follow-up, 6.6% (3/45) of both the PFT+BFB group and the PFT only arm were continent. After 3 months, the continence rate had increased to 33.3% (15/45) and 26.6% (12/45), respectively, and at 6-month follow-up, this percentage had further risen to 71.1% (32/45) in the former group and 66.6% (30/45) in the latter group. No significant differences were observed between the two arms during follow-up, but there was a statistically significant correlation between follow-up time and continence improvement in each group. CONCLUSIONS: Preoperative BFB associated with PFT does not significantly influence urinary continence recovery after radical prostatectomy.

Aged↗

PubMed1986

Exercise in children before and after coarctectomy: hemodynamic, echocardiographic, and biochemical assessment.

After repair of coarctation of the aorta, some patients with normal blood pressure at rest have an exaggerated hypertensive response to activity. Blood pressure response to exercise was studied in 15 children, aged 5 to 15 years, prior to and at periods up to 6 months following coarctectomy. Preoperatively, 11 of 15 children had systolic hypertension at rest and 12 of 15 after exercise. After surgery, only one child had mild systolic hypertension at rest, whereas exercise-induced hypertension persisted in 33% of patients (all older than 10 years). Exercise plasma renin activity was elevated preoperatively but normalized following surgery. No significant difference was seen in resting and exercise plasma catecholamine levels measured before and after surgery. Over the follow-up period of 6 months, echocardiographic evidence of left ventricular hypertrophy regressed in the younger patients but not in the older patients with exercise-induced hypertension. Exercise testing defines a subgroup of patients with exercise-induced hypertension evident soon after surgery. Structural upper segment arterial vessel wall changes in the older patient may explain these observations.

Adolescent↗

PubMed2003

[Preoperative cardiovascular assessment in non-cardiac surgery: the role of non-invasive procedures].

The aim of cardiovascular preoperative evaluation in non-cardiac surgery is to assess the patient's current cardiovascular status, to detect unknown diseases, to make recommendations concerning the medical management of the patient in the peri- and postoperative period, to plan the surgical strategy or, in some cases, to postpone non-cardiac surgery until the cardiac condition is corrected or stabilized; rarely, cardiovascular evaluation may result in an absolute contraindication for non-cardiac surgery. The basic clinical evaluation obtained by history, physical examination and review of the ECG usually provides enough data to estimate the cardiac risk. Patient's risk factors (unstable coronary syndromes, congestive heart failure, life-threatening arrhythmias, severe valvular heart diseases) and the type and setting of surgery are to be considered together with the clinical evaluation. Additional non-invasive tests may be recommended to evaluate left ventricular function and the presence of myocardial ischemia only if expected data will eventually result in changing the surgical procedure or perioperative management. Echocardiography is particularly useful in patients with major risk factors whereas exercise stress test is able to assess the patient's functional capacity or to identify silent myocardial ischemia or significant arrhythmias. The overall goal of cardiac assessment should be a consideration of both the impending surgery and the long-term cardiac risk independent of the decision to go to surgery. It is almost never appropriate to recommend coronary bypass surgery or other invasive interventions such as coronary angioplasty in an attempt to reduce the risk of non-cardiac surgery when they would not otherwise be indicated.

Cardiovascular Diseases↗

PubMedDate not supplied

[Nuclear cardiology in the preoperative evaluation of the patient at risk of coronary disease; meta-analysis of the contribution of thallium dipyridamole scintigraphy].

Coronary disease may be assessed by several techniques of nuclear cardiology: classical thallium myocardial scintigraphy, position scintigraphy, left ventricular angioscintigraphy. These techniques measure the response of coronary flow, myocardial metabolism, or left ventricular contractility during a physical or pharmacologic stress test. Many studies have reported the interest of dipyridamole thallium scintigraphy in the assessment of the surgical risk for a coronary event. Regarding the meta-analysis of up-to-day published studies, the surgical risk is 26% for an abnormal test against 3% for a normal study. Considering only the risk of infarction or cardiac death, corresponding probabilities are 18% and 2%, respectively. Dipyridamole stress test is a fairly safe and accurate method for discriminating between high and low risk patients in a population selected on clinical grounds.

Coronary Disease↗

PubMed1981

Serial exercise testing after coronary artery bypass surgery.

To determine the duration of functional benefit from coronary bypass surgery, 111 patients with angina pectoris were serially evaluated by standard exercise testing prior to and for up to 4 years after surgery. Exercise testing 6 to 18 months after surgery showed greater heart rate-blood pressure product at peak work load, improved work capacity, and less symptomatic and electrocardiographic evidence of ischemia than was demonstrated preoperatively. Twenty patients were tested 37 to 48 months postoperatively and showed improved exercise performance in comparison with preoperative results, but the frequency of positive tests during this period no longer differed. Thus, improved exercise performance appears to persist for at least 4 years after coronary bypass surgery.

Angina Pectoris↗

PubMed1995

Preoperative cardiac risk assessment for noncardiac surgery.

UNLABELLED: Coronary artery disease (CAD) represents an important risk in patients undergoing elective noncardiac surgical procedures, in whom the stress of surgery and postoperative recovery can represent a significant ischemic burden. Population considerations: Preoperative cardiac assessment should be based on the prevalence of CAD (if known) in the population undergoing the procedure and the institutional event rate for the procedure. Procedures considered high-risk are vascular, intra-abdominal or thoracic, major orthopedic, and any emergency procedures. Individual considerations: CLINICAL HISTORY: A history of angina, congestive heart failure, diabetes mellitus, prior myocardial infarction, ventricular ectopy, and/or elderly (age > 70) are clinical parameters of increased risk. Functional capacity: Good functional capacity is the ability of a 50-70-year-old patient to achieve 6-8 METS of activity without significant symptoms of dyspnea on exertion. Further noninvasive testing: Preoperative testing may include routine treadmill exercise testing, ambulatory ECG monitoring, echocardiographic stress testing with dobutamine or exercise, and/or thallium perfusion imaging. Strategy for high risk patients: Assessing the severity of an abnormality (e.g., with thallium) results in a small percentage of positive test results yielding a high positive predictive value for events. Therefore, more aggressive interventions should be reserved for the most abnormal noninvasive test results, and the severity of the risk assessment should impact the timing of any coronary revascularization procedure, not the decision to proceed to more invasive testing and therapies. In summary, it is important to realize that most of the patients being screened, even vascular surgery patients (with high prevalence of CAD and procedural risk), will be found suitable to go to surgery without additional invasive intervention and cardiac revascularization. Thus good functional capacity and absence of cardiac risk factors should direct 30-40% of this population to elective surgery without further evaluation. The finding of high-risk perfusion scan abnormalities appears to be limited to 15-20% of those patients being recommended for further noninvasive testing.

Coronary Disease↗

PubMed1997

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction.

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Abdominal Muscles↗

PubMed2003

Cardiopulmonary effects of closed repair of pectus excavatum.

BACKGROUND/PURPOSE: Increasing numbers of patients with pectus excavatum defects are presenting for operative repair. Studies that follow-up with patients after open repair have found a decrease in pulmonary function with some improvement in cardiac output and exercise tolerance; however, these effects have not been examined systematically after closed or Nuss repair of pectus excavatum. This study examined the early postoperative effects of closed repair of pectus on pulmonary function, exercise tolerance, and cardiac function. METHODS: Patients were followed up prospectively after initial evaluation for operation. All patients underwent preoperative computed tomography (CT) scan, and pre- and postoperative (3 months) pulmonary function studies, exercise tolerance, and echocardiographic evaluation of cardiac function. RESULTS: Eleven patients underwent evaluation. Preoperative CT index was 4.1 +/- 0.9. Patients reported an improvement in subjective postoperative exercise tolerance (4.1 +/- 0.7; maximal, + 5). Pulmonary function studies (FVC and vital capacity) were significantly reduced at 3 months postsurgery: change in FVC, -0.67 +/- 0.92 L and VC, -0.5 +/- 0.72 L. Similarly, VO2 max was reduced: preoperative, 35.6 +/- 1.5 versus postoperative, 29.1 +/- 11.9 L/kg/min. Cardiac function was significantly improved postoperation (stroke volume preoperative, 61.6 +/- 25 versus 77.5 +/- 23 mL postoperative). All comparisons had a P value less than.05 by Student's paired t test. CONCLUSIONS: These results show that closed repair of pectus excavatum is associated with a subjective improvement in exercise tolerance, which is paralleled by an increase in cardiac function and a decline in pulmonary function. These findings support the use of closed repair of pectus excavatum in patients who complain of subjective shortness of breath; further study is required to delineate the long-term cardiopulmonary implications after closed repair.

Adolescent↗

PubMed1990

Atrial pacing for sick sinus syndrome.

Atrial pacing is the most physiological way to pace patients with sinus node disease, as it provides both AV synchrony and a normal ventricular activation pattern. Long-term studies comparing atrial and ventricular pacing imply that atrial pacing results in fewer cardiac complications and, possibly, reduced mortality. Ventricular pacing should thus, if possible, be avoided in patients with sinus node disease. The potential risk of impending high-grade AV block during atrial pacing is low, with an annual incidence around 1% if patients are selected appropriately. Approximately 40-50% of patients with sinus node disease show signs of chronotropic incompetence during physical exercise, and are thus candidates for atrial rate responsive pacing. A preoperative evaluation of candidates for atrial pacing should include long-term Holter/telemetry, exercise test, carotid sinus stimulation, and an electrophysiological study excluding significant AV conduction disturbances.

Atrioventricular Node↗

PubMed1978

[Regional ventricular function at rest during exercise before and after bypass surgery (author's transl)].

In 9 patients with coronary heart disease isovolumetric contractility indices and ejection phase parameters were measured simultaneously, using an angiographic catheter with a manometer at the tip (Millar). Regional wall motion at rest, after leg raising and during physical exercise (bicycle ergometer) was analyzed applying the hemiaxis method. Five weeks after aortocoronary bypass surgery the same examinations were repeated. Preoperatively left ventricular enddiastolic pressure (LVEDP) increased from 21 to 37 mm Hg following leg raising. The velocity mean of fiber shortening (Vcf) and of regional fiber shortening in the anterior wall decreased significantly.--All patients discontinued physical exercise due to angina pectoris. LVEDP increased from 21 to 39 mm Hg. Large hypokinetic and akinetic areas developed especially in the anterior wall. Velocity of fiber shortening of the anterior wall decreased from 1.43 to 0.76/s. Enddiastolic volume remained unchanged while endsystolic volume increased significantly. In six patients with patent grafts surgery had a beneficial effect. Comparing angiograms at rest no significant changes were found. After leg raising and physical exercise, however, marked improvement in ventricular function occurred, compared to the preoperative performance. All 6 patients were exercised without complaints at a load of 100 watts for 8 minutes. Velocity of fiber shortening in the anterior wall increased significantly from 0.76 to 2.56/s, mean Vcf from 1.11 to 2.12 circ/s, max dP/dt from 2302 to 4280 mm Hg/s and Vpm from 27.8 to 55.7/s. Functional improvement in individual wall segments amounted to 500% in the mean. Ejection fraction increased from 54 to 76%. Enddiastolic volume remained unchanged while endsystolic volume decreased from 67 to 33 ml/1.37 m2 (p less than 0.002). In three patients the bypass occluded or myocardial infarction occurred intraoperatively. Postoperative findings at rest and during exercise were unchanged as compared to preoperative values. Following successful bypass surgery ventricular function at rest did not change. During exercise, however, a marked improvement in overall and in regional ventricular function was found.

Angiocardiography↗

PubMed2003

Muscle strength and walking ability after laparoscopic hernioplasty versus conventional repair.

PURPOSE: We examined muscle strength and walking ability after hernia repair to compare the effects of laparoscopic hernioplasty and conventional repair. METHODS: Twenty-seven patients with primary inguinal hernias were randomly divided into two groups according to the surgical procedure: 15 patients were treated with laparoscopic hernioplasty and 12 with conventional repair. Two types of muscle testing around the inguinal region, one by manual examination and one using a musculator, were done preoperatively and 1 week postoperatively. Walking exercise tests were performed at the same time as muscle testing. RESULTS: Manual examination showed that the postoperative muscle strength of the iliopsoas muscle was decreased in six patients from the conventional repair group, but not in any of those from the laparoscopic hernioplasty group. The musculator showed decreased strength of the iliopsoas muscle after conventional repair, but not after laparoscopic hernioplasty. The walking exercise test showed that conventional hernia repair influenced walking. CONCLUSION: A decline in muscle strength of the iliopsoas muscle and walking ability was evident after conventional repair, but not after laparoscopic hernioplasty. Thus, laparoscopic hernioplasty is superior to conventional repair from the perspective of muscle testing and walking ability.

Adult↗

PubMed2006

What I have learned about the ACL: utilizing a progressive rehabilitation scheme to achieve total knee symmetry after anterior cruciate ligament reconstruction.

Anterior cruciate ligament surgery and rehabilitation have changed drastically during the past 30 years. The patellar tendon autograft fixed with buttons provides tight bone-to-bone placement of the graft and quick bony healing, which allows accelerated rehabilitation to obtain full range of motion and strength. Although surgical stability is easily reproducible, long-term patient satisfaction is difficult to guarantee. Full knee range of motion should be compared to that of the contralateral normal knee, including full hyperextension. We followed the progress of all patients to gauge the utility of our rehabilitation program. In order of importance, the lack of normal knee range of motion (within 2 degrees extension and 5 degrees of flexion compared with that of the normal knee), partial or total medial meniscectomy, partial or total lateral meniscectomy, and articular cartilage damage were related to lower subjective scores. Rehabilitation after ACL reconstruction must first strive to achieve full symmetrical knee range of motion before aggressive strengthening can begin. Our current perioperative rehabilitation starts at the time of injury and preoperatively includes aggressive swelling reduction, hyperextension exercises, gait training, and mental preparation. Goals after surgery are to control swelling while regaining full knee range of motion. After quadriceps strengthening goals are reached, patients can shift to sport-specific exercises. When using a graft from the contralateral knee, the conflicting goals of strengthening the donor site and achieving full knee range of motion are divided between the knees. Thus, normal range of motion and strength can be achieved more easily and more quickly than when using an ipsilateral graft. Regardless of the graft source, a systematic rehabilitation program that emphasizes the return to symmetrical knee motion, including hyperextension, is necessary to achieve the optimum result.

Anterior Cruciate Ligament↗

PubMed2005

Lung cancer: Preoperative pulmonary evaluation of the lung resection candidate.

Lung resection provides the best chance of cure for individuals with early stage non-small cell lung cancer. Naturally, lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses in lung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second and the diffusing capacity for carbon monoxide are useful predictors of postoperative outcome. In situations in which lung function is not normal, the prediction of postoperative lung function from preoperative results and the assessment of exercise capacity can be performed to further clarify risks. Published guidelines help to direct the order of testing, permitting us to offer resection to as many patients as possible.

Exercise Test↗

PubMedDate not supplied

Perioperative cardiac evaluation for noncardiac surgery noninvasive cardiac testing.

Prognostic risk stratification to identify perioperative and long-term cardiac risk in selected patients undergoing noncardiac surgery is part of good clinical practice. Exercise variables associated with significant increased risk include poor functional capacity (eg, <4 metabolic equivalents), marked exercise-induced ST segment shift or angina at low workloads, and inability to increase or actually decrease systolic blood pressure with progressive exercise. Approximately 40% of patients tested before peripheral vascular surgery will have an abnormal exercise electrocardiogram (ECG). The predictive value for a perioperative event, ie, death or myocardial infarction, ranges from 5% to 25% for a positive test and 90% to 95% for a negative test. Whereas exercise cardiac imaging is the modality of choice in patients with a noninterpretable exercise ECG, pharmacological stress imaging should be used in the 30% to 50% of patients who require perioperative noninvasive risk stratification and are unable to perform an adequate level of exercise to test cardiac reserve. Myocardial perfusion variables predictive of increased cardiac events include severity of the perfusion defect, number of reversible defects, extent of fixed and reversible defects, increased lung uptake of thallium-201, and marked ST segment changes associated with angina during the test. The reported sensitivity and specificity of dobutamine-induced echocardiographic wall motion abnormalities in patients with peripheral vascular disease is similar to myocardial perfusion scintigraphy, but the confidence limits are wider due to the smaller sample size in these more recent studies. In conclusion, noninvasive cardiac testing should be used selectively in patients undergoing noncardiac surgery; the results provide useful estimates of short- and long-term risk of cardiac events, and the magnitude of abnormal response on noninvasive testing should be used to formulate decisions regarding the need for coronary angiography and subsequent revascularization.

Activities of Daily Living↗

PubMed2001

Electromyographic analysis of quadriceps fatigue after anterior cruciate ligament reconstruction.

STUDY DESIGN: Prospective, observational study. OBJECTIVES: To document changes in surface electromyographic activity during sustained maximum quadriceps contractions in patients before and 5 weeks after anterior cruciate ligament (ACL) reconstruction. BACKGROUND: Quadriceps weakness after injury and reconstruction of the ACL is well documented. The effect of weakness on muscle fatigue, however, is not well understood. METHODS AND MEASURES: Electromyographic signals were recorded from the vastus lateralis, vastus medialis, and rectus femoris muscles during 30-second maximum isometric contractions at 30 degrees, in 42 patients preoperatively and 5 weeks postoperatively. Signal amplitude was quantified by integrating the rectified signal (iEMG) for the initial and final 5 seconds and comparing the involved and uninvolved sides. Median frequency (MF) was computed from 4,096 point fast Fourier Transforms performed at the beginning and end of the 30-second contractions. RESULTS: Patients had moderate preoperative quadriceps weakness (16% deficit) and gross postoperative weakness (41% deficit). Weakness was associated with deficits in both MF and iEMG (r = 0.69-0.67). During the preoperative fatigue test, torque declined similarly on the involved and uninvolved sides (significant fatigue effect). During the postoperative fatigue tests, however, torque increased on the involved side and declined on the uninvolved side (significant side by fatigue interaction). For the initial 5 seconds, MF was lower on the involved than the uninvolved side but subsequently showed a smaller decline over 30 seconds preoperatively and postoperatively (significant side by fatigue interactions). IEMG was lower on the involved side preoperatively and postoperatively. During the fatigue tests, iEMG increased similarly in the involved and uninvolved sides both preoperatively and postoperatively. CONCLUSION: Quadriceps endurance exercises are not indicated after ACL reconstruction. Quadriceps weakness after ACL reconstruction was associated with fatigue resistance. Lower initial MF and smaller decline in MF during sustained contraction is consistent with fast-twitch fiber atrophy and explains fatigue resistance.

Adult↗