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Objective: Heart valve surgery in elderly very-high risk patients (pts) is associated with a considerable morbidity-mortality. Epidural anesthesia has been proposed as a technique to improve the results. Thus, we (1) determined post-operative survival impact of epidural anesthesia with and without mechanical ventilation versus standard general anesthesia and (2) explored post-operative complications’ freedoms within groups.
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Claudio Muneretto, Alberto Negri, Tomaso Bottio, Gianluigi Bisleri, Paolo Piccoli, Aldo Manzato.
Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
Methods: From 1/1/2002 to 31/7/2006, 144 very-high risk pts (Additive EuroScore >7) underwent elective heart valve surgery. Fifty-five pts underwent surgery with the aid of high-thoracic-epidural-anesthesia and were matched to 89 pts on general anesthesia. The pts were comparable on mean age, pre-operative clinical status, and comorbidities (left-ventricle ejection fraction <30%, chronic-renal-failure, pulmonary-hypertension, cerebral-event, myocardial-infarction). Perioperative and post-operative outcomes were compared between matched groups.
Results: Any morbidity epidural-catheter-related has been detected. After matching, epidural-pts had a lower rate, although not significant, of renal failure (43% vs 56%), prolonged ventilation (16.3% vs 27%), and indeed they showed a better myocardial preservation with a lower low-output-syndrome rate [mean Tn-I value (21 vs 29 μg/liter)]. Pts undergoing heart valve surgery on general anesthesia had comparable in-ICU length of stay (3.4 vs 3.2 days), atrial fibrillation rate (51% vs 47%), sternal complications rate (1% vs 0.5%), and A-V block requiring pace-maker placement (1% vs 1%). Post-operative mortality was comparable between groups (16.3% vs 15.6%) and it was quite lower than the predicted by the EuroScore (26% and 28.8% in general and epidural group, respectively). Among the epidural group, 16 pts underwent aortic valve surgery without using mechanical ventilation. After matching by propensity scores, awake pts, despite an higher Additive EuroScore (awake 11.4 vs general 10.8), showed in comparison with general group a lower rate of: mortality (6.2% vs 15.7%: p=0.02), new cerebrovascular events rate (p=0.005), acute renal failure rate (p=0.018); indeed, they showed an abbreviated ICU length of stay (p=0.0008). Moreover, they had a better post-operative myocardial preservation with a significantly lower mean Tn-I detection (p=0.005).
Conclusions: Heart valve surgery by using epidural anesthesia is feasible and safe. The avoidance of general anesthesia and mechanical ventilation significantly reduces the in-hospital morbidity and mortality in this high-risk subset population.
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