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PubMed1990

[Quantitative assessment of dyspnea by introducing new indices based on the Borg scale during exercise test and the correlation with parameters of pulmonary functions at rest].

Incremental exercise test with a bicycle ergometer was performed on thirty eight patients (11 patients with chronic obstructive pulmonary disease, 6 patients with interstitial lung disease, 21 patients with preoperative check up for respiratory disease). In 34 patients except four patients with interstitial lung disease, there was a close correlation between dyspnea expressed on the Borg scale (BS) and oxygen consumption (VO2) (r = 0.778-0.998). To evaluate dyspnea in more quantitative manner, we introduced three parameters by the BS-VO2 regression line. The Borg scale slope (BSS) represents the slope of the regression line, threshold load of dyspnea (TLD) represents the onset of dyspnea on the regression line, and the breakpoint load of dyspnea (BLD) represents the maximum oxygen consumption before the subject interrupted exercise. BSS had significant negative correlations with VC, %VC, FEV1.0, TLC, DLco, and %DLco. TLD and BLD had significant positive correlations with VC, FEV1.0, DLco, and %DLco. No correlation was found between dyspnea evaluated by the Hugh-Jones classification and the parameters of pulmonary functions (VC, FEV1.0, DLco) at rest. From these findings, we conclude that the degree of dyspnea sensation on exercise correlated with parameters of pulmonary function at rest, and that these newly introduced parameters using the Borg scale were useful for a quantitative assessment of dyspnea in health and disease.

Dyspnea↗
PubMed2005

Ventilation and exercise performance after phrenic nerve and multiple intercostal nerve transfers for avulsed brachial plexus injury.

BACKGROUND: Diaphragmatic excursion, lung function, exercise performance, and clinical symptoms have not been previously described in patients after phrenic nerve transfer (PNT) and/or multiple intercostal nerve transfer (MIT) for the repair of avulsed brachial plexus injury (ABPI) to prevent functional musculoskeletal impairment in the shoulder. SETTING: A university-based hospital. METHODS: Dyspnea scores, chest ultrasonography to assess diaphragmatic excursion, and pulmonary function testing were performed to assess ventilation in patients sustaining trauma to their brachial plexus. In addition, cardiopulmonary exercise testing was also performed. These studies were obtained prior to surgical intervention, and were repeated postoperatively at 6, 12, 18, 24, and 36 months. The results obtained preoperatively were compared to those obtained throughout the postoperative monitoring period. RESULTS: This study demonstrates that the PNT-MIT procedure results in permanent ipsilateral diaphragmatic paralysis accompanied by an approximately 8% decrease in inspiratory capacity, FVC, and total lung capacity. There was also an 11% increase in diffusing capacity noted during the period between 6 months and 3 years after PNT-MIT procedure. Despite these measurable changes in lung function, the patients reported amelioration of their dyspnea complaint within 6 months of undergoing this procedure, which was due mainly to an improvement in their cardiovascular exercise performance related to increased daily activity. CONCLUSIONS: This study demonstrates that the PNT-MIT procedure is a safe method for the restoration of drop shoulder incurred by ABPI. This surgery has an impact on measurable diaphragmatic and lung function but with minimal impact in terms of postoperative clinical symptoms and exercise performance.

Adult↗
PubMed1984

The ischemic exercise test in patients with peripheral vascular disease. Implications for management.

We observed myocardial ischemia in 135 of 808 patients undergoing routine ECG-monitored treadmill tests before vascular reconstructive operations. Postoperative infarction incidence was 27% among 56 patients who had operations regardless of test results. When patients had a lesser procedure, such as extra-anatomic bypass, infarction incidence decreased to 17% (not statistically significant). Ten patients having staged aortocoronary and peripheral reconstruction had no myocardial infarctions postoperatively or during follow-up of up to five years. Of 37 patients asymptomatic for coronary artery disease who had normal ECGs at rest, 24% of those undergoing a standard intra-abdominal operation suffered myocardial infarctions. At present, such asymptomatic but high-risk patients can be identified only by routine ECG stress testing or coronary angiography. Patients with an ischemic response to exercise have the best chance for long-term survival through staged coronary and vascular reconstruction.

Coronary Angiography↗
PubMed1983

Factors related to the early phase of rehabilitation following aortocoronary bypass surgery.

Physical and psychosocial functioning of 30 male patients prior to and 3 months following aortocoronary bypass surgery were compared. Relationships between rehabilitation outcome and selected physical, psychosocial, and health care system variables were examined. Although patients' perceptions of their health improved after surgery, there was little improvement in physical and psychosocial functioning, and vocational functioning declined. When the outcome variables were regressed on their possible explanatory variables, the variance in exercise tolerance and energy expenditure on household activities remained unexplained. Energy expenditure on postoperative leisure activities was related to fear of injury. Preoperative psychosocial functioning, depression, and postoperative perception of health explained postoperative psychosocial functioning. Postoperative perception of health dependent on the number of bypass grafts and spouse's/family's fear of patients' injury.

Activities of Daily Living↗
PubMedDate not supplied

Postoperative fatigue.

Uncomplicated major surgery is followed by a pronounced increased feeling of fatigue extending throughout the first month in about one-third of patients. Postoperative fatigue correlates with the degree of surgical trauma but is not related to duration of general anesthesia and surgery or to preoperative nutritional status, age, or sex. Fatigue also correlates with postoperative deterioration in nutritional parameters and impaired adaptability of heart rate during exercise. Furthermore, a postoperative decrease in muscle force and endurance is related to postoperative fatigue, whereas psychological factors are of minor importance. These findings suggest postoperative fatigue to be mediated by the endocrine-metabolic response to surgery, impaired nutritional intake, or immobilization, but the relative role of these factors remains to be established. Until then, therapeutic measures against the development of postoperative fatigue should aim at reducing the surgical stress response, effective treatment of pain to facilitate mobilization, and exercise to increase postoperative nutritional intake.

Convalescence↗
PubMed2001

The safety of dipyridamole in patients undergoing myocardial perfusion scintigraphy prior to lung volume reduction surgery.

Patients with end-stage chronic obstructive pulmonary disease (COPD) undergoing lung volume reduction surgery (LVRS) are at high risk of peri-operative cardiac complications, and myocardial perfusion scintigraphy (MPS) is commonly used for risk stratification. This study prospectively assessed the safety of dipyridamole in these patients and compared the incidence of side-effects (particularly dyspnoea) with that in patients undergoing dipyridamole MPS prior to elective non-cardiothoracic surgery. Fifty patients were enrolled: 25 in the LVRS cohort (13 males, 12 females), with a mean age of 65 years and a mean FEV1 of 0.791, and 25 (with no history of asthma or COPD) in the control cohort (14 males, 11 females), with a mean age of 66 years. Fourteen patients (56%) in each group developed side-effects. Dyspnoea was reported by five patients (20%) in the LVRS and two patients (8%) in the control cohort (P=NS). One patient in each cohort developed severe hypotension and bradycardia. Eight (32%) other patients developed minor side-effects in the LVRS cohort compared with 11 (44%) in the control group. All side-effects responded promptly to intravenous aminophylline. In summary, there was a statistically non-significant increase in the incidence of dyspnoea in patients with end-stage COPD and all side-effects responded to aminophylline. Thus, dipyridamole can be used safely in these patients.

Aged↗
PubMed2006

"No more couch-potato!" Patients' experiences of a pre-operative programme of cardiac rehabilitation for those awaiting coronary artery bypass surgery.

BACKGROUND: The waiting period for coronary artery bypass surgery is a difficult time for patients and families. Pre-operative cardiac rehabilitation may be safe and effective, but there is limited evidence regarding patients' experience and perceptions of such intervention. AIM: To describe patients' experiences of a pre-operative programme of cardiac rehabilitation developed specifically for those awaiting coronary artery bypass surgery. METHOD: A convenience sample of eight patients awaiting non-urgent surgery who had completed a 12 week pilot programme of cardiac rehabilitation were invited to be interviewed using a descriptive phenomenological approach. Domicillary interviews using an open technique were taped, transcribed and analysed using Colaizzi's framework. RESULTS: Participants described this programme as a useful means of improving exercise capacity and decreasing anxiety. Through the combination of exercise, advice and support participants stated that their initial fear that exercise would cause a heart attack was replaced with confidence, enabling them to become fitter and modify other risk factors. CONCLUSIONS: Findings of this study suggest that the programme was acceptable and perceived as beneficial by participants. Further research is required to evaluate the efficacy of pre-operative rehabilitation on risk factor modification.

Aged↗
PubMed2006

Cardiac resynchronization therapy delays heart transplantation in patients with end-stage heart failure and mechanical dyssynchrony.

BACKGROUND: Cardiac dyssynchrony is frequent in advanced heart failure, and cardiac resynchronization therapy (CRT) may offer an alternative to heart transplantation. We aimed to investigate the impact of CRT on freedom from Tx and death in transplant candidates with end-stage heart failure. METHODS: Over a period of 2 years, 46 consecutive patients with refractory congestive heart failure due to dilated cardiomyopathy were referred for heart transplant evaluation. Patients with cardiac dyssynchrony > 107 milliseconds according to tissue Doppler imaging (TDI) or QRS duration > 150 milliseconds were treated with CRT (CRT group, n = 24), whereas patients without dyssynchrony were not treated (non-CRT group, n = 22). RESULTS: At baseline, both groups showed similar hemodynamic and functional parameters, including ejection fraction (19 +/- 10% vs 21 +/- 12%, not statistically significant [NS]) and Vo2max (11.9 +/- 2.0 vs 12.0 +/- 1.8 ml/kg/min, NS). After a follow-up of 488 +/- 346 days, cumulative survival with freedom from transplantation and death was higher in CRT vs non-CRT patients (92% vs 39%; p < 0.001). CRT patients showed a decrease in New York Heart Association (NYHA) class from 3.2 +/- 1.1 to 2.2 +/- 0.9 (p = 0.003) and an increase in Vo2max from 11.9 +/- 2.0 to 13.1 +/- 1.8 ml/kg/min (p = 0.02), and 71% (17 of 24) of these patients were successfully removed from the waiting list. CONCLUSIONS: In heart transplant candidates with significant dyssynchrony, CRT delays heart transplantation and improves NYHA class and exercise capacity. For these patients, CRT should be considered before heart transplantation.

Aged↗
PubMed1983

Quantitation of aortic and mitral regurgitation in the pediatric population: evaluation by radionuclide angiocardiography.

The ability to quantitate aortic (AR) or mitral regurgitation (MR), or both, by radionuclide angiocardiography was evaluated in children and young adults at rest and during isometric exercise. Regurgitation was estimated by determining the ratio of left ventricular stroke volume to right ventricular stroke volume obtained during equilibrium ventriculography. The radionuclide measurement was compared with results of cineangiography, with good correlation between both studies in 47 of 48 patients. Radionuclide stroke volume ratio was used to classify severity: the group with equivocal regurgitation differed from the group with mild regurgitation (p less than 0.02); patients with mild regurgitation differed from those with moderate regurgitation (p less than 0.001); and those with moderate regurgitation differed from those with severe regurgitation (p less than 0.01). The stroke volume ratio was responsive to isometric exercise, remaining constant or increasing in 16 of 18 patients. After surgery to correct regurgitation, the stroke volume ratio significantly decreased from preoperative measurements in all 7 patients evaluated. Results from the present study demonstrate that a stroke volume ratio greater than 2.0 is compatible with moderately severe regurgitation and that a ratio greater than 3.0 suggests the presence of severe regurgitation. Thus, radionuclide angiocardiography should be useful for noninvasive quantitation of AR or MR, or both, helping define the course of young patients with left-side valvular regurgitation.

Adolescent↗
PubMed1988

Inflow failure of grafts originating in the axillary artery.

During the last three years we identified three distinct entities which compromised inflow and led to thrombosis of axillofemoral or axillopopliteal grafts. The first patient had recurrent thrombosis of a right axillopopliteal graft. Five thromboses were treated with thrombectomy and distal revisions; the last thrombosis was treated with simple thrombectomy because the patient had right thoracic outlet axillosubclavian artery compression in his usual sleeping posture. Conservative posture modification resulted in continued patency for two years until the patient's death. Stenosis of the subclavian or innominate artery accounted for multiple failures in three other patients. In one no significant preoperative upper extremity pressure difference was seen, whereas differences were noted with an open graft, suggesting a vascular steal at rest. In the second patient, preoperative balloon dilatation of an innominate lesion appeared successful, but the lesion recurred six months later with hemodynamic graft failure and exercise-induced vascular steal. The third patient had a significant kink of the axillary artery with eventual graft thrombosis secondary to "pulling" from the extraanatomic graft. We conclude that pre-and postoperative noninvasive testing, exclusion of thoracic outlet compression, and avoidance of a "pulled down" proximal anastomosis are important in preventing inflow failures of grafts originating from the axillary artery.

Aged↗
PubMed1995

The value of dipyridamole echocardiography in risk stratification before vascular surgery. A multicenter study. The EPIC (Echo Persantine International Study) Group--Subproject: Risk Stratification Before Major Vascular Surgery.

PURPOSE: Patients undergoing major vascular surgery are at relatively high risk of cardiac events, and pharmacological stress echocardiography is increasingly used for peri-operative risk stratification. PATIENTS AND METHODS: One hundred and twenty-one patients undergoing vascular surgery (age 65 +/- 7 years) were studied by dipyridamole echocardiography testing in six different centres. Of the total 136 patients, 15 were subsequently excluded because surgery was either cancelled (n = 8) or postponed pending cardiac revascularization (n = 7) because of the presence of a 'high-risk' stress echo response (identified 'a priori' as a positive dipyridamole echocardiography testing with a dipyridamole-time < 5 min and/or a peak wall motion score index > 2, upon scoring each segment from 1 = normal to 4 = dyskinetic in an 11-segment model). RESULTS: No major complications occurred during dipyridamole echocardiography testing. Technically adequate images were obtained in all patients; however, in one patient only the low dipyridamole dose (56 mg.kg-1 over 4 min) was given to limit side effects. Of the 121 patients undergoing surgery 28 (23%) had a positive test. Peri-operative events occurred in nine patients (8%): two deaths, two myocardial infarctions, five cases of unstable angina. Sensitivity and specificity of dipyridamole echocardiography testing for predicting cardiac events were 78% and 81%, respectively, with a positive predictive value of 25% and a negative predictive value of 98%. Dipyridamole echocardiography testing effectively singled out patients with, from those without, events, but neither clinical parameters, such as Detsky score, nor baseline echo parameters, such as resting wall motion score index or ejection fraction were able to distinguish between such patients. CONCLUSION: In conclusion, dipyridamole echocardiography testing is safe and well tolerated in patients undergoing major vascular surgery, and provides an effective pre-operative screening test for risk stratification of these patients mainly due to the extremely high negative predictive value. Stress echocardiography is a better discriminator than clinical and rest echocardiographic variables.

Aged↗
PubMed2004

Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study.

OBJECTIVE: The objective of this study was to investigate the effects of 2 levels of intraoperative fluid administration on perioperative physiology and outcome after laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA: Intraoperative fluid administration is variable as a result of limited knowledge of physiological and clinical effects of different fluid substitution regimens. METHODS: In a double-blind study, 48 ASA I-II patients undergoing laparoscopic cholecystectomy were randomized to 15 mL/kg (group 1) or 40 mL/kg (group 2) intraoperative administration of lactated Ringer's solution (LR). All other aspects of perioperative management as well as preoperative fluid status were standardized. Primary outcome parameters were assessed repeatedly for the first 24 postoperative hours and included pulmonary function (spirometry), exercise capacity (submaximal treadmill test), cardiovascular hormonal responses, balance function, pain, nausea and vomiting, recovery, and hospital stay. RESULTS: Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR led to significant improvements in postoperative pulmonary function and exercise capacity and a reduced stress response (aldosterone, antidiuretic hormone, and angiotensin II). Nausea, general well-being, thirst, dizziness, drowsiness, fatigue, and balance function were also significantly improved, as well as significantly more patients fulfilled discharge criteria and were discharged on the day of surgery with the high-volume fluid substitution. CONCLUSIONS: Intraoperative administration of 40 mL/kg compared with 15 mL/kg LR improves postoperative organ functions and recovery and shortens hospital stay after laparoscopic cholecystectomy.

Adult↗
PubMedDate not supplied

Both leaflet preservation during mitral valve replacement: modified anterior leaflet preservation technique.

BACKGROUND: Satisfactory results of bileaflet preserving mitral valve replacement (MVR) had forced several institutes to preserve both leaflets during MVR. Modifications were required to prevent the preserved tissue from interfering with prosthetic valve function, to implant an adequate size of valve and to prevent left ventricle outflow tract (LVOT) obstruction. MATERIALS AND METHODS: Conventional MVR was performed to 51 patients (group 1) and bileaflet preserving MVR was performed to 43 patients (group 2). Mitral anterior leaflet incised from the middle of the leaflet to mitral annulus without chordal injury in group 2 patients. Sutures were placed through the mitral annulus first and then passed from the bottom to the tip of anterior leaflet. Posterior leaflet was also preserved. Prosthetic valve was put down into the mitral annulus and sutures were ligated. Excessive anterior leaflet tissue was attached to left atrial wall. RESULTS: Cross-clamping time was 45 +/- 5.33 minutes versus 61.32 +/- 4.43 minutes (p = 0.0001) and total cardiopulmonary bypass time was 60.80 +/- 4.44 minutes versus 80.55 +/- 3.65 minutes (p = 0.0001) in groups 1 and 2, respectively. Inotropy requirement was higher in group 1 (p = 0.0058). When compared with preoperative values postoperative left ventricle ejection fraction (LVEF) increased both at rest (from 52.74% +/- 3.88% to 62.86% +/- 3.18%, p = 0.0001) and during exercise (from 53.16% +/- 3.16% to 64.11% +/- 2.46%, p = 0.0001) in bileaflet preserving MVR group. But in conventional MVR group LVEF decreased postoperatively both at rest (from 51.45% +/- 4.27% to 48.27% +/- 3.35%, p = 0.0001) and during exercise (from 54.47% +/- 7.36% to 42.96% +/- 3.58%, p = 0.0001). CONCLUSION: Leaflet preserving MVR operation not only improves the left ventricular performance but also reduces the mortality and morbidity after MVR. LVEF increases both at rest and during exercise. Risk of LVOT obstruction can be completely eliminated with our simple technique.

Adult↗
PubMed2004

Clinical review: how to identify high-risk surgical patients.

Postoperative outcome is mainly influenced by ventricular function. Tests designed to identify myocardial ischemia alone will fail to detect cardiac failure and are thus inadequate as a screening test for identification of cardiac risk in noncardiac surgical patients. We find that the degree of cardiac failure is the most important predictor of morbidity and mortality. We use cardiopulmonary exercise testing to establish the anaerobic threshold as the sole measure of cardiopulmonary function as well as to detect myocardial ischemia. Patients with an anaerobic threshold < 11 ml/min/kg are at risk for major surgery, and perioperative management must be planned accordingly. Myocardial ischemia combined with moderate to severe cardiac failure (anaerobic threshold < 11 ml/min/kg) is predictive of the highest morbidity and mortality.

Anaerobic Threshold↗
PubMed1990

Value of continuous passive motion in total knee arthroplasty.

Two methods of rehabilitation after 91 total knee arthroplasties in 74 patients were reviewed. Patients in each group were well matched for age, sex, and diagnosis. Forty-four knees in 39 patients were treated with conventional physiotherapy, consisting of 3 days of immobilization followed by a program of active assisted range-of-motion exercises. Forty-seven knees in 41 patients were placed in a continuous passive motion machine immediately after operation. Other aspects of preoperative, intraoperative, and postoperative care were identical in both groups. Patients in the continuous passive motion group were found to have a lower incidence of complications, especially of wound healing problems and thromboembolic disease. Analgesic use in patients in the continuous passive motion group was reduced. Straight leg raising was achieved slightly earlier in patients in the continuous passive motion group (4.9 days) compared with patients not treated with continuous passive motion (5.2 days). Although the range of motion of the knee at discharge from the hospital in patients in the continuous passive motion group was greater (91 degrees) compared with patients not treated with continuous passive motion (81 degrees), the range of motion in both groups at ultimate follow up was equivalent. However, when knee-rating scores were considered, patients treated with continuous passive motion averaged 9 points higher on a 100-point scale than patients not treated with continuous passive motion. In addition, the length of hospital stay for patients in the continuous passive motion group was 2.1 days shorter. We concluded that continuous passive motion was an effective adjunct to physiotherapy in the postoperative care of patients undergoing total knee arthroplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗