Percutaneous Mitral Valve Repair in Patients with Severe Mitral Regurgitation and Acute Decompensated Heart Failure

The role of percutaneous mitral valve repair (PMVr) in management of high-risk patients with severe mitral regurgitation (MR) and acute decompensated heart failure (ADHF) is undetermined. We screened all patients who underwent PMVr between October 2015 and March 2020. We evaluated immediate, 30-day, and 1-year outcomes in patients who underwent PMVr during hospitalization due to ADHF as compared to elective patients. From a cohort of 237 patients, we identified 46 patients (19.4%) with severe MR of either functional or degenerative etiology who underwent PMVr during index hospitalization due to ADHF, including 17 (37%) critically ill patients. Patients’ mean age was 75.2 ± 9.8 years, 56% were males. There were no differences in background history between ADHF and elective patients. Patients with ADHF were at higher risk for surgery, reflected in higher mean EuroSCORE II, compared with elective patients. After PMVr, we observed higher 30-day mortality rate in ADHF patients as compared to the elective group (10.9% vs. 3.1%, respectively, p = 0.042). One-year mortality rate was similar between the groups (21.7% vs. 17.9%, p = 0.493). Clinical and echocardiographic follow-up showed improvement of NYHA functional class and sPAP reduction in both groups ((54 ± 15 mmHg to 50 ±15 in the elective group (p = 0.02), 58 ± 13 mmHg to 52 ± 12 in the ADHF group (p = 0.02)). PMVr could be an alternative option for treatment of patients with severe MR and ADHF.

P-BN14 Differences in rate of complications between emergency and elective laparoscopic cholecystectomy at district general hospital

Background Current NICE guidelines recommend healthy low risk patients who present with acute biliary disease should be offered laparoscopic cholecystectomy on the same index admission. The increased complexity of the acute operations may impact on the operative complication rates; hence the aim of this study is to evaluate and compare the operative complication rates between elective and emergency laparoscopic cholecystectomies and additionally to assess the difference in surgical techniques comparing complete cholecystectomy versus subtotal versus open procedures. Methods Retrospectively, data was collected from emergency and elective Laparoscopic Cholecystectomies completed in the period 01/01/2021-01/06/2021 at the Queen Elizabeth Hospital Gateshead. The data set was gathered from an electronic theatre database and the individual cases were sub-analyzed further by delving into the electronic patient records database. Statistical analysis done by using Excel 2010. Results The average age of both groups was 50 years. There wasn’t a statistical significance on the rate of complication between the elective Vs emergency cholecystectomies (Elective 2%, Emergency 9% P = 0.17). Out of 42 Elective procedures, 4 had Sub-total cholecystectomy Vs 3 out of 42 patients on the emergency group who had Subtotal cholecystectomy (9% Vs 7%), implying there was no significant difference noted between the two groups. Average hospital stays was 5.6 days for the acute presentation with biliary disease Vs 0.14 days on the planned elective group. 2% of the elective group were noted to have a surgical drain inserted during the operation; whilst the emergency cohort had a slightly higher rate at 5%. Conclusions Overall there was no significant difference noted between the surgical complications arising in emergency cholecystectomy compared to planned surgeries. In addition to this the data also suggests that there is negligible difference in the rates of sub-total cholecystectomies in both cohorts.

TP6.1.9 Prolonged post-operative stay following emergency and elective laparoscopic cholecystectomies and its contributing factors

Aims Patients who undergo laparoscopic cholecystectomy (LC) for gallstone disease are a heterogenous population with many variables involved in their management. The aim was to identify the proportion of patients who have a prolonged post-operative stay (PPS; >3days) following elective and emergency LC and the variables that most contribute to PPS. Methods We retrospectively collected data for all patients who underwent an elective and emergency LC across three surgical units from 2015 to 2020. Rates of PPS were compared between elective and emergency groups and variables associated with PPS were identified using multivariate logistic regression models. Results 2769 patients were included in the study (median age, 53years(range, 13-92); M:F,1:2.7; emergency:elective,1:3.6) The rate of PPS was higher in the emergency versus elective group (25.1% versus 6.6%; p<0.0001). Pain was one of the major causes in both groups. In the elective group, factors associated with PPS included cholecystitis (OR,1.96; p=0.008), previous gallstone related admissions (OR,1.48; p=0.008), pre-operative ERCP (OR,3.58;p<0.0001), ASA (OR,1.82; p=0.001) and age (years) (OR,1.03;p=0.001). In the emergency group, factors associated with PPS include cholecystitis (OR,5.3;p<0.0001), ASA (OR,1.96; p = 0.01) and pre-operative ERCP (OR,4.44;p=0.001). Conclusions The rate of PPS following laparoscopic cholecystectomy is significant, particularly in the emergency group. Although the possibility of PPS cannot be avoided, patient information regarding the possibility of PPS is important, particularly for those at risk. The risk factors for PPS should be used to guide surgical decision making and should be followed by targeted management of these patients including optimised pain relief.

Impact of a Body Mass Index Threshold on Abdominal Wall Hernia Repair at a Safety-Net Hospital

Background Body mass index (BMI) thresholds are utilized as a preoperative optimization strategy for obese patients prior to elective abdominal wall hernia repair. The objectives of this study were to determine the proportion of patients at our institution who ultimately underwent hernia repair after initial deferral due to BMI and to evaluate outcomes of those who required emergent repair during the deferral period. Methods A retrospective review was performed from 2016 to 2018 to identify all patients with abdominal wall hernias who were deferred surgery due to BMI. Patient characteristics, hernia type, change in BMI, progression to surgery, acuity of surgery (elective or emergent), and postoperative outcomes were examined. Results 200 patients were deferred hernia repair due to BMI. Of these, 150 (75%) did not undergo repair over a mean period of 27 months. The remaining 50 patients ultimately underwent repair, 36 of which (72%) were elective and 14 (28%) emergent. The mean initial BMI of the elective group was 35.3 ± 1.8, compared to 39.1 ± 5.3 in the no surgery group and 40.6 ± 8.2 in the emergent group ( P < .01). While the elective group lost weight before surgery, the other groups did not. Patients who required emergent surgery had worse outcomes than those repaired electively. Conclusions Preoperative weight loss is unsuccessful in most obese patients presenting for abdominal wall hernia repair at our institution. Patients who required emergent hernia repair had worse outcomes than those who underwent elective repair. Our institution’s BMI threshold is a failed optimization strategy that needs to be reconsidered.

398 Outcome of Laparoscopic Cholecystectomy in Patients Over 80 Years Old

Background Gallstone disease is a common cause of morbidity in old patients. Conservative treatment is usually the first line of treatment due to concerns about the risk of surgery. In our study we are trying to assess the outcome of laparoscopic cholecystectomy in patients over 80 years old. Method Retrospective cohort study done in a large district general hospital where good number of laparoscopic cholecystectomy is done every year. Main outcome is Mortality, return to theatre and post op ITU admission. Data collected from patients records. Results 74 patients in total were operated on. 14 operations were done as emergency (during the same inpatient admission). Indication for surgery varied between cholecystitis, pancreatitis and biliary colic. But the main indication in the emergency group was acute cholecystitis. 55 % of the patients had significant medical background with ASA 3. 30 days mortality was 0 in both emergency and elective groups. 2 patients required ITU admission post op, mainly for premorbid status, and both were in the emergency group. There was only one return to theatre in the emergency group for washout. 90% of the elective group patients were done as day case with no post op complications. Conclusions Laparoscopic cholecystectomy is safe operation to be done in the elderly population. ITU admission is mainly because of the patient’s co-morbidities so patients should be selected carefully and have proper pre op assessment.

OUTCOMES OF COMPARISON BETWEEN EMERGENCY VS ELECTIVE LOWER SEGMENT CESAREAN SECTION

Objective; To compare emergency vs elective LSCS for their various outcomes. Study setting; Sheikh Zayed Hospital, Rahim Yar Khan Duration; 01-09-2018 to 28-02-2019 Methodology: This was a randomized controlled-trial, in which pregnant females irrespective of their duration of gestation, gravida and parity having age equal more than 20 years were included. The cases were subdivided into 2 equal groups. The cases in group A were operative for emergency C section surgery and those, who were in group B underwent elective surgery. These cases were then followed to look for various surgical outcomes. Results: In this study total 150 cases of C section were included with 75 in each group. The mean age of the group A and B was 28.87±4.43 vs 29.54±5.13 years and mean duration of gestation at presentation was 37.13±2.56 vs38.67±1.39 weeks. SSI was seen in 3 (5.33%) cases in emergency group vs 2 (2.66%) in elective group with p= 0.07. PPH was observed in 2 (2.66%) of the cases each with p= 1.0 and both hysterectomy and maternal mortality was observed in 1 (1.33%) cases each in emergency group with p= 0.81 each. Conclusion; Complications are rate are relatively higher in emergency as compared to elective C section and SSI is nearly significantly high in this group.

Primary endoscopic bile duct stone removal for severe acute cholangitis: a retrospective study

Introduction: While the Tokyo Guidelines 2018 suggest primary stone removal for mild to moderate cholangitis, a guideline for severe acute cholangitis is not mentioned. We, therefore, investigated the clinical outcomes of patients with severe acute cholangitis to confirm the usefulness and safety of primary stone removal. Method: This study included 104 severe acute cholangitis patients without gallstone pancreatitis diagnosed at our institution between January 2014 and December 2020. Patients with percutaneous transhepatic biliary drainage as the primary drainage, bile duct stenosis, and endoscopically unidentified bile duct stones were excluded from this study. The clinical results of 14 patients with primary stone removal (primary group) and 23 patients with elective stone removal (elective group) were then retrospectively examined (excluding abnormal values due to underlying diseases). Results: Upon comparing the patient characteristics between groups, the elective group had significantly higher cardiovascular dysfunction (57% vs 7%; p = 0.004), septic shock (39% vs 0%; p = 0.006), disseminated intravascular coagulation treatment (57% vs 14%; p = 0.016), and positive blood cultures (91% vs 43%; p = 0.006) than those in the primary group. Endoscopic sphincterotomy for naïve papilla (90% vs 21%; p = 0.01) and endoscopic nasobiliary drainage (50% vs 9%; p = 0.014) were higher in the primary group, while endoscopic biliary stenting (7% vs 87%; p < 0.001) was lower than that in the elective group. Discussion: There were no significant differences in adverse events or complete stone removal rates between the two groups. In the primary group, the period from the first endoscopic retrograde cholangiopancreatography to stone removal (0 days vs 12 days; p < 0.001) and hospitalization period (12 days vs 26 days; p = 0.012) were significantly shorter and the hospitalization cost ($7731 vs $18758; p < 0.001) was significantly lower than those in the elective group. Conclusion: If patients are appropriately selected, bile duct stones may be safely removed for the treatment of severe acute cholangitis.

Performance of the Parasympathetic Tone activity (PTA) index to predict changes in mean arterial pressure in anaesthetized horses with different health conditions

Background: The parasympathetic tone activity (PTA) index is based on heart rate variability recently and has been developed in animals to assess their relative parasympathetic tone and their analgesia nociception balance. The present study aimed to evaluate the variation of PTA in anaesthetized horses according to haemodynamic status and health conditions and to determine the performance of dynamic variations of PTA (∆PTA) to predict mean arterial pressure (MAP) variations.Results: Thirty-nine client-horses admitted to the Veterinary Campus of Lyon were anaesthetized for elective or emergency surgery and divided into “Colic” and “Elective” groups. During anaesthesia, dobutamine was administered as treatment of hypotension (MAP < 60 mmHg). No significant variation of PTA and MAP were detected immediately before and after the time of cutaneous incision. PTA increased 5 min before each hypotension (+15% in Elective and +11.4% in Colic group), conversely, PTA decreased 1 min after the administration of dobutamine (-12.7% in Elective and -9% in Colic group). Horses of the Colic group had lower PTA values than those in Elective group, whereas MAP didn’t differ between groups. Globally, to predict a 10% increase in MAP, ΔPTA performance was associated with: AUC ROC [95% CI] = 0.77 [0.70 to 0.83] (p<0.0001), with a sensitivity of 88.2% and a specificity of 57.7% for a threshold value of −1%. Besides, to predict a 10% decrease in MAP, ΔPTA performance was associated with: AUC ROC [95% CI] =0.80 [0.73 to 0.85] (p<0.0001), with a sensitivity of 62.5% and a specificity of 94.6% for a threshold value of 25%.Conclusions: The PTA index in anaesthetized horses appears to be influenced by the haemodynamic status and the health condition. The shift toward lower PTA values in colic horses may potentially reflects a sympathetic tone predominance. Of clinical significance, a PTA increase of >25% in 1 min showed an acceptable performance to predict a MAP decrease of >10% within 5 min. Even though these results require further evaluation, this index may thus help to predict potential autonomic dysfunctions in sick animals.

Use of Organs for Heart Transplantation after Rescue Allocation: Comparison of Outcome with Regular Allocated High Urgent Recipients

Background The number of patients waiting for heart transplantation (HTx) is exceeding the number of actual transplants. Subsequently, waiting times are increasing. One possible solution may be an increased acceptance of organs after rescue allocation. These organs had been rejected by at least three consecutive transplant centers due to medical reasons. Methods Between October 2010 and July 2019, a total of 139 patients underwent HTx in our department. Seventy (50.4%) of the 139 patients were transplanted with high urgency (HU) status and regular allocation (HU group); the remaining received organs without HU listing after rescue allocation (elective group, n = 69). Results Donor parameters were comparable between the groups. Thirty-day mortality was comparable between HU patients (11.4%) and rescue allocation (12.1%). Primary graft dysfunction with extracorporeal life support occurred in 26.9% of the elective group with rescue allocated organs, which was not inferior to the regular allocated organs (HU group: 35.7%). No significant differences were observed regarding the incidence of common perioperative complications as well as morbidity and mortality during 1-year follow-up. Conclusions Our data support the use of hearts after rescue allocation for elective transplantation of patients without HU status. We could show that patients with rescue allocated organs showed no significant disadvantages in the early perioperative morbidity and mortality as well at 1-year follow-up.

Performance of the Parasympathetic Tone activity (PTA) index to predict mean arterial pressure variations in anaesthetized horses with different health conditions

Background The parasympathetic tone activity (PTA) is an index based on heart rate variability recently developed in animals to assess their relative parasympathetic tone and their analgesia nociception balance. The present study aimed to evaluate the variation of PTA in anaesthetized horses according to haemodynamic status and health conditions and to determine the performance of dynamic variations of PTA (∆PTA) to predict mean arterial pressure (MAP) variations. Results Thirty-nine client-horses admitted to the Veterinary Campus of Lyon were anaesthetized for elective or emergency surgery and divided into “Colic” and “Elective” groups. During anaesthesia, dobutamine was administered as treatment of hypotension (MAP < 60 mmHg). No significant variation of PTA and MAP were detected at steady-state and following cutaneous incision. PTA increased before each hypotension (+ 15% in Elective and + 11.4% in Colic group), conversely, the administration of dobutamine was accompanied by a significant decrease in PTA (-12.7% in Elective and − 9% in Colic group). Horses of the Colic group had lower PTA values than those in Elective group, whereas MAP didn’t differ between groups. Globally, to predict a 10% increase in MAP, ΔPTA performance was associated with: AUC ROC [95% CI] = 0.77 [0.70 to 0.83] (p < 0.0001), with a sensitivity of 88.2% and a specificity of 57.7% for a threshold value of − 1%. Besides, to predict a 10% decrease in MAP, ΔPTA performance was associated with: AUC ROC [95% CI] = 0.80 [0.73 to 0.85] (p < 0.0001), with a sensitivity of 62.5% and a specificity of 94.6% for a threshold value of 25%. Conclusions The PTA index in anaesthetized horses appears to be influenced by the haemodynamic status and the health condition. The shift toward lower PTA values in colic horses may potentially reflect a sympathetic tone predominance. Of clinical significance, a PTA increase of > 25% in 1 min showed fair performance to predict a MAP decrease of > 10% within 5 min but a decrease in PTA was poorly specific to predict an increase in MAP. Even though these results require further evaluation, this index may thus help to predict potential autonomic dysfunctions in sick animals.