Invited Commentary [Comment]
Analgesic Use in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis
Background/UNASSIGNED:Pain is common in patients with chronic kidney disease (CKD). Analgesics may be appropriate for some CKD patients. Objectives/UNASSIGNED:To determine the prevalence of overall analgesic use and the use of different types of analgesics including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), adjuvants, and opioids in patients with CKD. Design/UNASSIGNED:Systematic review and meta-analysis. Setting/UNASSIGNED:Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity. Patients/UNASSIGNED:Adults with stage 3-5 CKD including dialysis patients and those managed conservatively without dialysis. Measurements/UNASSIGNED:Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of analgesic use, and the types of analgesics prescribed. Methods/UNASSIGNED:statistic was computed to measure heterogeneity. Random-effects models were used to account for variations in study design and sample populations, and a double arcsine transformation of the prevalence variables was used to accommodate potential overweighting of studies with very large or very small prevalence measurements. Sensitivity analyses were performed to determine the magnitude of publication bias and assess possible sources of heterogeneity. Results/UNASSIGNED:Forty studies were included in the analysis. The prevalence of overall analgesic use in the random-effects model was 50.8%. The prevalence of acetaminophen, NSAIDs, and adjuvant use was 27.5%, 17.2%, and 23.4%, respectively, while the prevalence of opioid use was 23.8%. Due to the possibility of publication bias, the actual prevalence of acetaminophen use in patients with advanced CKD may be substantially lower than this meta-analysis indicates. A trim-and-fill analysis decreased the pooled prevalence estimate of acetaminophen use to 5.4%. The prevalence rate for opioid use was highly influenced by 2 large US studies. When these were removed, the estimated prevalence decreased to 17.3%. Limitations/UNASSIGNED:There was a lack of detailed information regarding the analgesic regimen (such as specific analgesics used within each class and inconsistent accounting for patients on multiple drugs and the use of over-the-counter analgesics such as acetaminophen and NSAIDs), patient characteristics, type of pain being treated, and the outcomes of treatment. Data on adjuvant use were very limited. These results, therefore, must be interpreted with caution. Conclusions/UNASSIGNED:There was tremendous variability in the prescribing patterns of both nonopioid and opioid analgesics within and between countries suggesting widespread uncertainty about the optimal pharmacological approach to treating pain. Further research that incorporates robust reporting of analgesic regimens and links prescribing patterns to clinical outcomes is needed to guide optimal clinical practice.
Current AATS guidelines on surgical treatment of infective endocarditis
The 2016 American Association for Thoracic Surgery (AATS) guidelines for surgical treatment of infective endocarditis (IE) are question based and address questions of specific relevance to cardiac surgeons. Clinical scenarios in IE are often complex, requiring prompt diagnosis, early institution of antibiotics, and decision-making related to complications, including risk of embolism and timing of surgery when indicated. The importance of an early, multispecialty team approach to patients with IE is emphasized. Management issues are divided into groups of questions related to indications for and timing of surgery, pre-surgical work-up, preoperative antibiotic treatment, surgical risk assessment, intraoperative management, surgical management, surveillance, and follow up. Standard indications for surgery are severe heart failure, severe valve dysfunction, prosthetic valve infection, invasion beyond the valve leaflets, recurrent systemic embolization, large mobile vegetations, or persistent sepsis despite adequate antibiotic therapy for more than 5-7 days. The guidelines emphasize that once an indication for surgery is established, the operation should be performed as soon as possible. Timing of surgery in patients with strokes and neurologic deficits require close collaboration with neurological services. In surgery infected and necrotic tissue and foreign material is radically debrided and removed. Valve repair is performed whenever possible, particularly for the mitral and tricuspid valves. When simple valve replacement is required, choice of valve-mechanical or tissue prosthesis-should be based on normal criteria for valve replacement. For patients with invasive disease and destruction, reconstruction should depend on the involved valve, severity of destruction, and available options for cardiac reconstruction. For the aortic valve, use of allograft is still favored.
Surgical treatment of right-sided infective endocarditis
OBJECTIVE:Right-sided infective endocarditis is increasing because of increasing prevalence of predisposing conditions, and the role and outcomes of surgery areÂ unclear. We therefore investigated the surgical outcomes for right-sided infective endocarditis. METHODS:From January 2002 to January 2015, 134 adults underwent surgery for right-sided infective endocarditis. Patients were grouped according to predisposing condition. Hospital outcomes, time-related death, and reoperation for infective endocarditis were analyzed. RESULTS:A total of 127 patients (95%) had tricuspid valve and 7 patients (5%) pulmonary valve infective endocarditis; 66 patients (49%) had isolated right-sided infective endocarditis, and 68 patients (51%) had right- and left-sided infective endocarditis. Predisposing conditions included injection drug use (30%), cardiac implantable devices (26%), chronic vascular access (19%), and other/none (25%). One native tricuspid valve was excised, 76% were repaired or reconstructed, and 23% were replaced. Intensive care unit and postoperative hospital stays were similar among groups. Injection drug users had the best early survival (no hospital mortality), and patients with chronic vascular access had the worst late survival (18% at 5Â years). Survival was worst for concomitant mitral valve versus isolated right-sided infective endocarditis or concomitant aortic valve infective endocarditis. Survival after tricuspid valve replacement was worse than after repair/reconstruction. Estimated glomerular filtration rate was the strongest risk factor for death, not predisposing condition. Eleven patients underwent 12 reoperations for infective endocarditis; more reoperations occurred in injection drug users (PÂ =Â .03). CONCLUSIONS:Overall outcomes after surgery are variable and affected by patient condition, not predisposing condition. Injection drug use carries a higher risk of reoperation for infective endocarditis. Earlier surgery may permit more valve repairs and improve outcomes. Whenever possible, tricuspid valve replacement should be avoided.
The incorporated aortomitral homograft for double-valve endocarditis: the 'hemi-Commando' procedure. Early and mid-term outcomes
OBJECTIVES:Surgical management of invasive double-valve infective endocarditis (IE) involving the intervalvular fibrosa (IVF) is a technical challenge that requires extensive debridement followed by complex reconstruction. In this study, we present the early and mid-term outcomes of the hemi-Commando procedure and aortic root replacement with reconstruction of IVF using an aortomitral allograft. METHODS:From 2010 to 2017, 37 patients with IE involving the IVF underwent the hemi-Commando procedure. Postoperative clinical data and echocardiograms were reviewed for the assessment of cardiac structural integrity and clinical outcomes. RESULTS:Twenty-nine (78%) cases were redo surgery and 15 (41%) were emergency surgery. Preoperatively, 70% (nâ€‰=â€‰26) of patients were admitted to the intensive care unit and 11% (nâ€‰=â€‰4) of patients were in septic shock. Ten (27%) patients had native aortic valve IE, while 27 (73%) patients had prosthetic valve IE. Hospital death occurred in 8% (nâ€‰=â€‰3) of patients due to multisystem organ failure. Postoperative echocardiogram showed no aortic regurgitation in 86% (nâ€‰=â€‰32) and mild regurgitation in 14% (nâ€‰=â€‰5) of patients, while mitral regurgitation prevalence was none/trivial in 62% (nâ€‰=â€‰23), mild in 32% (nâ€‰=â€‰12) and moderate in 5%. Intact IVF reconstruction was confirmed in all patients with no abnormal communication between the left heart chambers. One-year survival was 91%, while 3-year survival was 82%. Mid-term follow up revealed 1 death secondary to recurrent IE. CONCLUSIONS:Compared to double-valve replacement with IVF reconstruction ('Commando operation'), the early and mid-term outcomes of the hemi-Commando procedure proved to be a feasible treatment option for IVF reconstruction, enabling preservation of the mitral valve and the subvalvular apparatus in high-risk patients with invasive double-valve IE.
Early and mid-term results of autograft rescue by Ross reversal: A one-valve disease need not become a two-valve disease
OBJECTIVES:Risk of reoperation and loss of a second native valve are major drawbacks of the Ross operation. Rather than discarding the failed autograft, it can be placed back into the native pulmonary position by "Ross reversal." We review our early and mid-term results with this operation. METHODS:From 2006 to 2017, 39 patients underwent reoperation for autograft dysfunction. The autograft was successfully rescued in 35 patients: by Ross reversal in 30, David procedure in 4, and autograft repair in 1. Medical records were reviewed for patient characteristics (mean age was 46Â Â±Â 13Â years, range 18-67Â years, and 23 were male), previous operations, indications for reoperation, hospital outcomes, and echocardiographic findings for the 30 patients undergoing successful Ross reversal. Follow-up was 4.1Â Â±Â 3.5Â years (range 7 months-11 years). RESULTS:Median interval between the original Ross procedure and Ross reversal was 12Â years (range 5-19Â years). Eight patients also had absolute indications for replacement of the pulmonary allograft. There was no operative mortality. One patient required reoperation for bleeding. Another had an abdominal aorta injury from use of an endoballoon clamp. There was no other major postoperative morbidity, and median postoperative hospital stay was 7.2Â days (range 4-41Â days). No patient required reoperation during follow-up. Twenty-four patients had acceptable pulmonary valve function, and 6 had clinically well-tolerated moderate or severe pulmonary regurgitation. CONCLUSIONS:Ross reversal can be performed with low morbidity and acceptable pulmonary valve function, reducing patient risk of losing 2 native valves when the autograft fails in the aortic position.
Rarity of invasiveness in right-sided infective endocarditis
OBJECTIVE:The rarity of invasiveness of right-sided infective endocarditis (IE) compared with left-sided has not been well recognized and evaluated. Thus, we compared invasiveness of right- versus left-sided IE in surgically treated patients. PATIENTS AND METHODS:From January 2002 to January 2015, 1292 patients underwent surgery for active IE, 138 right-sided and 1224 left-sided. Among patients with right-sided IE, 131 had tricuspid and 7 pulmonary valve IE; 12% had prosthetic valve endocarditis. Endocarditis-related invasiveness was based on echocardiographic and operative findings. RESULTS:Invasive disease was rare on the right side, occurring in 1 patient (0.72%; 95% confidence interval 0.02%-4.0%); rather, it was limited to valve cusps/leaflets or was superficial. In contrast, IE was invasive in 408 of 633 patients with aortic valve (AV) IE (65%), 113 of 369 with mitral valve (MV) IE (31%), and 148 of 222 with AV and MV IE (67%). Staphylococcus aureus was a more predominant organism in right-sided than left-sided IE (right 40%, AV 19%, MV 29%), yet invasion was observed almost exclusively on the left side of the heart, which was more common and more severe with AV than MV IE and more common with prosthetic valve endocarditis than native valve IE. CONCLUSIONS:Rarity of right-sided invasion even when caused by S aureus suggests that invasion and development of cavities/"abscesses" in patients with IE may be driven more by chamber pressure than organism, along with other reported host-microbial interactions. The lesser invasiveness of MV compared with AV IE suggests a similar mechanism: decompression of MV annulus invasion site(s) toward the left atrium.
Randomized clinical trials of surgery for infective endocarditis: Reality versus expectations! [Comment]
Tell it like it is: Experience in mitral valve surgery does matter for improved outcomes in mitral valve infective endocarditis [Comment]
Allografts remain a cornerstone of surgical treatment of invasive and destructive aortic valve infective endocarditis: Surgeon and technique do matter! [Comment]