Acute respiratory care in the open heart surgery patient.
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Breathing Exercises↗
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Results for “Preoperative Exercise”
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Total hip arthroplasty and postoperative rehabilitation.
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Activities of Daily Living↗
[Clinical results of transmyocardial laser revascularization for 77 patients with coronary artery disease].
OBJECTIVE: To analyses the clinical results of transmyocardial laser revascularization (TMLR) for 77 patients with coronary artery diseases (CAD). METHODS: The mean age of the patients was (65 +/- 7) years. Previous medical record included CABG (6 patients), PTCA (9), AMI (66.2%), hypertension (70.1%), and diabetes mellitus (45.5%). TMLR was performed on the beating heart via a left anterolateral thoracotomy at the fifth intercostal space. Transesophageal echocardiography showed transmyocardial penetration of 23 +/- 6 channels. RESULTS: The hospital mortality was 3.8%, and postoperative complications were AMI (3.8%), left ventricular failure (2.6%), PVC (5.2%). After operation, the mean CCS angina class was improved from the baseline 3.5 +/- 0.7 to 2.1 +/- 0.3 at 3 months, 1.7 +/- 0.3 at 6 months, 1.7 +/- 0.3 at 12 months and 1.8 +/- 0.4 at 24 months. One patient died of AMI and two died not due to cardiac events during a follow-up of 3 to approximately 24 months. Echocardiography showed that the average of left ventricular ejection fractions was improved significantly at 6 months after operation compared with the preoperative value (P = 0.0457). (201)TI-SPECT showed a remarkable improvement in reversible ischemia in 70% patients followed up. Metabolic stress test for 20 patients followed up patients demonstrated an average increase in exercise tolerance from 7.1 +/- 3.2 min at the baseline to 9.6 +/- 1.3 min at 12 months (P = 0.021). Similarly the METs increased from 4.3 +/- 2.1 at the baseline to 5.4 +/- 2.0 at 12 months. CONCLUSIONS: TMLR is a safe and effective procedure for the treatment of end stage coronary artery diseases not amenable to PTCA or CABG. The effect of TMLR is associated with indication, correct evaluation of myocardial ischemia, and management for postoperative complications.
Aged↗
Surgical implications of anomalous aortic origin of the left coronary artery.
We report a patient with exertional chest pain and anomalous aortic origin of the left coronary artery from the right coronary sinus. This patient also had circumflex coronary and right coronary artery stenoses. Following coronary bypass grafting of the circumflex and right coronary arteries in this patient, angina persisted and there was abnormal septal perfusion shown on the exercise thallium imaging despite patent grafts. The angina and perfusion defect were improved by bypass grafting of the unstenosed left anterior descending coronary artery in this patient. Thallium imaging may be useful in the preoperative assessment of patients with this anomaly.
Angina Pectoris↗
[Psychological preparation for surgery in children].
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Adolescent↗
The effect of structured and unstructured pre-operative teaching: a replication.
This study conducted an approximate replication of the Lindeman and Van Aernam study (1971) on a sample of 49 patients from a large metropolitan hospital. Factors controlled in this study that were not present in the original study included sample restrictions to patients of three surgeons with similar techniques and to patients having lower or upper abdominal surgery. Structured pre-operative teaching was conducted primarily by the principle investigator and associate and a check list was used to indicate that the patients could perform the deep breathing, coughing, and exercises. For this sample, using p = .05, structured pre-operative instruction improved significantly the ability of the patients to deep breathe and cough post-operatively as measured by pulmonary function tests. Hypothesis I was supported. Structured pre-operative instruction did not reduce significantly the mean length of hospital stay and hypothesis II was not supported.
Adult↗
Early and long-term improvement in left ventricular performance following coronary bypass surgery.
Changes in left ventricular performance after coronary artery bypass grafting (CABG) have been variable. Earlier studies based on contrast left ventriculography have shown occasional improvement in left ventricular function in patients with unstable angina or abnormal preoperative ventricular performance, but for the most part repeat cardiac catheterization several months after operation has shown no significant changes in global left ventricular contraction. In the past few years, advances in radiopharmaceutical technology have made the characterization of left ventricular wall motion accurate and highly reproducible. Since prognosis in patients with coronary artery disease and survival after CABG have been related to global ejection fraction (EF), we employed prospectively on analysis of short-term and long-term changes in EF after CABG utilizing multidose hypothermic potassium crystalloid cardioplegia as the method of myocardial protection. Concomitantly, newer techniques in anesthesia and perioperative patient management were employed to minimize myocardial damage in these patients. Postoperative scintigraphic evaluation showed a transient (2-hour) depression in left ventricular function, followed by recovery to preoperative levels at 24 hours and significant improvement in EF at 7 days. From 7 days to 8 months postoperatively, there was no further change in resting EF, but there was another significant exercise-induced increase in EF at the long-term examination. Thus, present advances in the multidisciplinary management of patients with coronary artery disease are associated with improvement in resting and exercise-related EF postoperatively.
Aged↗
What patients need most before and after thoracotomy.
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Breathing Exercises↗
[Predictive value of ergospirometry in preoperative assessment of risk factors before lung resections].
Surgical resection for lung cancer provides the only real chance for cure. However, there is a high risk of postoperative complications including death for patients with pulmonary dysfunction. Therefore preoperative identification of patients at risk is necessary. Apart from history and physical examination three tests are currently used: 1. resting lung function (RFL), 2. invasive measurement of pulmonary vascular resistance (PVR) and 3. exercise testing with measurement of oxygen consumption (VO2). Main studies in the literature report the probability of abnormal tests for prediction of pulmonary complications (positive predictive value) and the probability of normal tests for prediction of uneventful outcome (negative predictive value) as follows: [table: see text] In conclusion, the "ideal" test predictive for morbidity and mortality after lung resection has not been found. The positive predictive values of RLF and PVR are disappointing, while the negative predictive values are acceptable. Measurement of VO2 is simple, noninvasive and might predict survivable morbidity, as suggested in the literature. Obviously, additional studies are necessary.
Exercise Test↗
[Clinical usefulness of cardiopulmonary exercise testing in patients with cardiac failure waiting heart transplantation].
Heart transplantation has recently become an accepted method of treating heart failure patients, also in Poland. Criteria of patient selection to heart transplantation and follow-up was based (and in some centers still is) on the assessment of the patients' clinical status according to NYHA classification and on the data on the extend of myocardial damage obtained from echocardiography or ventriculography at rest. However, examinations performed in the resting state do not provide complete information on the patient's clinical status, especially during increased oxygen demand. Recently cardiopulmonary exercise testing (CPX-to measure maximal oxygen consumption) has been increasing used to establish the prognosis in patients with severe heart failure and to define indications to heart transplantation. CPX combines exercise testing with monitoring the air flow and gas exchange. The measurement of oxygen uptake and anaerobic threshold during exercise is an objective, reproducible, safe and non-invasive method to assess cardiac reserve. There is evidence implying that in heart failure patients VO2max is a good short-term indicator of mortality and that its deterioration frequently precedes clinical decompensation. Thus, the parameter may be useful not only in defining the indications, but also in the monitoring the patient's clinical state and timing of heart transplantation.
Exercise Test↗
Prognostic value of myocardial perfusion imaging in predicting outcome after renal transplantation.
Cardiovascular disease is a significant cause of morbidity and mortality after renal transplantation. Pretransplant screening in a subset of these patients for occult coronary artery disease (CAD) may improve outcome. The objective of this study was to examine the outcome of 600 patients after renal transplantation for end-stage renal disease. Prospective outcome data were collected on 600 consecutive patients who had renal transplantation between 1996 and 1998 at our institution at 42 +/- 12 months after surgery. Stress single-photon emission computed tomographic (SPECT) myocardial perfusion imaging was performed in 174 patients before surgery, 136 (78%) of whom had diabetes mellitus. There were a total of 59 events: 17 cardiac deaths, 14 nonfatal myocardial infarctions, and 28 noncardiac deaths. There were 12 cardiac events and 11 noncardiac deaths among those who had SPECT myocardial perfusion imaging. In a multivariate analysis that included important risk factors, age (p = 0.03 and 0.003, respectively) and diabetes (p = 0.02 and 0.005, respectively) were the predictors of total events and cardiac events in patients who did not undergo stress SPECT perfusion imaging. In the subgroup who had stress perfusion imaging, an abnormal perfusion SPECT study was the only predictor of cardiac events (p = 0.006). The 42-month cardiac event-free survival rate was 97% in patients with normal SPECT images and 85% in patients with abnormal SPECT images (RR 5.04, 95% confidence interval 1.4 to 17.6, p = 0.006). Thus, there is a 2.8% event rate per year after renal transplantation, and approximately 50% of these events are noncardiac. In high-risk patients (most of whom had diabetes) with preoperative stress perfusion imaging, those with normal images had significantly lower cardiac events than those with abnormal images. These results have important implications in patient screening and postoperative management.
Adult↗
Mid term effects of pulmonary thromboendarterectomy on clinical and cardiopulmonary function status.
BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) can be successfully treated surgically by pulmonary thromboendarterectomy (PTE) but there are few data on mid-term cardiopulmonary function, particularly on exertion, and clinical benefits following pulmonary PTE. METHODS: A 2 year follow up study was undertaken of clinical status, haemodynamic and lung function indices, gas exchange, and exercise tolerance in 38 patients of mean (SD) age 50 (15) years who had undergone PTE. RESULTS: In-hospital mortality was about 10%. Before PTE all the patients were severely impaired (NYHA classes III-IV). There was no time difference in the improvement in the parameters: nearly all the improvement in cardiac output, gas exchange, and clinical status was achieved in the first 3 months as a result of the relief of pulmonary obstruction. At 3 months the percentage of patients with normal cardiac output and PaO(2) and of those with reduced clinical impairment increased to 97%, 59%, and 87%, respectively, without any further change. Only mean pulmonary artery pressure (mPAP), carbon monoxide transfer factor (TLCO), and exercise tolerance improved gradually during the second year, probably due to the recovery of the damaged small vessels. TLCO was overestimated before PTE but afterwards the trend was similar to that of mPAP. CONCLUSIONS: At mid term only a few patients did not have a satisfactory recovery because of lack of operative success, hypertension relapse, or the effect of preoperative hypertension on vessels in non-obstructed segments. Most of the patients, even the more compromised ones, had excellent long lasting results.
Blood Pressure↗
Prospective study of the extent of internal anal sphincter division during lateral sphincterotomy.
PURPOSE: The aim of lateral internal anal sphincterotomy when treating anal fissure is to divide the distal one-third to one-half of the internal anal sphincter. This study aimed to evaluate prospectively the extent of disruption to the internal anal sphincter following lateral anal internal sphincterotomy and also to establish the prevalence of symptoms of anal incontinence in these patients. METHODS: Fifteen patients with anal fissure (ten females and five males) had bowel symptoms assessed and anal endosonography performed preoperatively and two months after lateral internal anal sphincterotomy. RESULTS: Anal endosonography was normal preoperatively in all but two females who had anterior external sphincter defects (presumedly from previous obstetric trauma). Postoperatively, apart from one male in whom no defect could be identified, all had an internal anal sphincter defect corresponding to the site of lateral internal anal sphincterotomy. In nine of the ten females, the defect involved the full length of the internal anal sphincter, but in the other four males, the defect involved the distal internal anal sphincter only. All were continent preoperatively, but after lateral internal anal sphincterotomy, three females became incontinent to flatus (two of whom had a preoperative external sphincter defect). CONCLUSION: In contrast to lateral internal anal sphincterotomy in males, division of the internal anal sphincter in most females tends to be more extensive than intended. This is probably related to their shorter anal canal. In some females, lateral internal anal sphincterotomy may compromise sphincter function and precipitate anal incontinence, particularly in the presence of other sphincter defects. Care should be exercised especially in the presence of previous obstetric trauma, as internal anal sphincter division may further compromise sphincter function.
Adult↗
Preoperative cardiac management of patients undergoing non cardiac surgery.
The estimation of an individual patient's "resistance" to major surgery has become an complex matter. Clinical parameters allow risk stratification in a large number of patients who are about to undergo noncardiac surgery. Low risk patients can be "cleared" for surgery. Moderate risk patients should undergo further testing. Exercise testing and pharmacological stress testing with myocardial perfusion imaging can refine risk estimation in these patients. This risk stratification is well backed by scientific data, although most of it is derived from studies in the same very high risk population, i.e. patients scheduled for vascular surgery. Less hard evidence exists when it comes to the management of the high-risk patient. Coronary bypass surgery should probably be reserved for those in whom additional indications for this procedure exist. The perioperative use of beta-blockers can possibly reduce operative risk. Data on perioperative monitoring and anesthetic technique are not yet convincing. The relative merits of various perioperative management strategies will remain uncertain until randomised trials are performed to evaluate the alternatives systematically.
Age Factors↗
[Quantification of reversible perfusion abnormality using exercise-stress thallium SPECT before and after coronary revascularization].
Reversible myocardial perfusion abnormality was quantified by bull's eye and unfolded surface mapping methods in exercise thallium SPECT before and after coronary revascularization in 47 patients with angina pectoris, including 34 patients with previous myocardial infarction (PMI) and 13 with effort angina (AP). There was no difference in the incidence or extent of myocardial ischemia between the 2 groups before revascularization. However, the ischemic scores were significantly smaller in PMI group preoperatively than the reductions of the ischemic scores after revascularization. The ischemic scores, preoperatively estimated reversible perfusion abnormality was 32%, 69% and 48% of the improvement of the ischemic score (extent score, severity score, and ischemic area, respectively). Using the 3 ischemic scores, the improvement of perfusion abnormality was well predicted in 70-89% of AP patients but 35-57% of PMI patients. Thus, quantitative analysis in stress thallium SPECT is useful for detecting myocardial ischemia and evaluating the effect of coronary revascularization. However, about a half of myocardial viability was underestimated in one third of PMI patients by the conventional exercise-stress thallium SPECT study.
Adult↗
Electromyographic changes in postmeniscectomy patients. Role of the pneumatic tourniquet.
Delayed rehabilitation in postmeniscectomy patients may be due to a slowly resolving axonal compression syndrome secondary to the use of the pneumatic tourniquet. Twenty-five patients who underwent meniscectomy were examined to determine whether the pneumatic tourniquet used during the procedure caused a neurological dificit detectable by electromyography (EMG). Of these, 18 had postsurgical EMG changes that eventually resolved. Analysis of the data suggests a relationship between the occurrence of EMG abnormalities, the duration of the tourniquet inflation during surgery, and patient's recovery time. Quadricep muscle weakness after knee surgery has generally been attributed to disuse atrophy. In an attempt to prevent this problem, patients participate in a quadriceps exercise program, if possible, before surgery, with continuation after surgery. The persistence of weakness has been believed to be secondary to inadequate exercise.
Adolescent↗
[Preoperative cardiac risk assessment and diagnosis. The view of the cardiologist].
Perioperative morbidity and mortality in noncardiac surgery are mainly due to cardiovascular complications. Therefore, perioperative risk assessment is crucial to avoid these adverse events. In patients above the age of 40 years, the ECG is a basic investigation, often providing hints for cardiovascular diseases. Stress testing and, in special cases, stress echocardiography or scintigraphy (the latter only in those patients, in which exercise is impossible) can detect significant coronary artery disease. The vascularization reduced the perioperative risk in particular in those patients with unstable angina or severe coronary artery disease. However, prophylactic revascularization the stable patient does not improve overall outcome, because the risk of the revascularizing procedure must be added to the risk of noncardiac surgery. Other diagnostic procedures like echocardiography, chest roentgenogram, routine scintigraphy, halter ECG or halter blood pressure measurement do not add information to the perioperative risk assessment, although these techniques might be very relevant in evaluating other coexisting diseases (heart failure; valve lesions, in particular aortic stenoses etc.) and can be useful to improve medical treatment preoperatively (e.g. normalization of blood pressure).
Heart Diseases↗
Laparoscopic Heller myotomy with Toupet fundoplication for achalasia straightens the esophagus and relieves dysphagia.
BACKGROUND: A standard procedure for the treatment of achalasia remains to be established. We assessed the usefulness of a laparoscopic Heller myotomy with a Toupet fundoplication (LHT). METHODS: LHT was performed in 30 patients (12 men, 18 women; mean age, 41.8 y) who had esophageal achalasia with severe dysphagia. Caution was exercised when the esophagus was pulled downward and straightened. Symptoms and esophageal function were evaluated before and after surgery. RESULTS: The esophagus was straightened surgically in 22 (88%) of 25 patients with esophageal curvature on preoperative esophagography. The dysphagia score decreased to 1.7 +/- 1.2 (mean +/- SD) points from a preoperative value of 10. The lower esophageal sphincter pressure decreased significantly. Two patients (7%) had esophageal diverticula as postoperative sequelae. Pathologic acid reflex was noted in 3 patients (12%). CONCLUSIONS: LHT is a useful procedure for straightening the esophagus, reducing lower esophageal sphincter pressure, and relieving dysphagia in patients with achalasia.
Adult↗