RESUMEN
A 25-year-old man with no medical history presented with a seizure one month after taking a self-administered dose of albendazole. Magnetic resonance imaging (MRI) of the brain revealed multiple ring-enhancing lesions, and the workup confirmed neurocysticercosis (NCC). Treatment with antiparasitics was delayed due to concern for worsening symptoms from the presence of cysts in the midbrain and hippocampus. The balance between treating NCC and limiting cerebral inflammation is delicate and relies on judgment from a multispecialty clinical team. In this case, corticosteroids and antiepileptics alone prevented additional seizures but failed to reduce the overall inflammation of cysts and the progression of the disease. Evidence of new cysts on MRI at week 13 from the onset of symptoms was evidence of an acute, evolving infectious process. Treatment with albendazole and praziquantel was initiated at 13 weeks from the onset of symptoms, and by 31 weeks, nearly all cysts had resolved with minimal residual inflammation.
RESUMEN
BACKGROUND: Despite modern advances in surgical care, triple-valve surgery (TVS) remains a challenge and carries a mortality of 10% to 20%. No validated risk score is available for TVS, and the effect of advanced age is unknown. This study examined our results in the modern era with the aim of identifying perioperative predictors of adverse outcomes. METHODS: Between 1997 and 2013, 131 patients (mean age, 67.2±13.4 years) underwent TVS at our institution. Sixty-eight patients (51.9%) were aged 70 years and older. The most common etiology for aortic and mitral disease was degenerative (77.1%), rheumatic (10%), and endocarditis or prosthetic-related, or both, in the rest. Tricuspid valve disease was functional in 96%. New York Heart Association functional class III/IV was present in 69.4%, and 24% had had previous cardiac operations. One or more concomitant cardiac procedures were performed in 77 patients (58.8%), including coronary revascularization in 54. All aortic procedures were replacements, 14 patients required a prosthetic root conduit and 7 thoracic aorta replacement. Mitral replacements were used in 55%, repairs in 45%, and 96.2% of tricuspid procedures were repairs. Univariate and multivariate analyses were used to determine predictors of adverse outcomes. RESULTS: The 30-day and hospital mortality was 10.6% (n=14). Major complications occurred in 70 (53.4%). Univariate analysis identified New York Heart Association functional class III/IV (p=0.04), preoperative renal failure requiring dialysis (p=0.04), urgent operation (p=0.04), intraaortic balloon pump placement (p=0.02), and postoperative low cardiac output (p<0.0001) as predictors for early death. Proximal aortic operations, urgent operation, and New York Heart Association class IV correlated with increased early mortality (p<0.04) in patients aged 70 and older in addition to their decreased overall survival and decreased likelihood of discharge to home. Overall actuarial survival at 1, 5, and 10 years was 84.5%, 75%, and 45%, respectively. CONCLUSIONS: TVS remains a surgical challenge in the modern era. Despite a trend of increasing age and surgical risk, the early mortality rate and long-term survival remain respectable. Advanced age is associated with increased perioperative risk, but age per se should not be a contraindication for TVS.