Cost-utility analysis of sutureless and rapid deployment versus conventional aortic valve replacement in patients with moderate to severe aortic stenosis in Thailand.

BACKGROUND: Sutureless and rapid deployment aortic valve replacement (SUAVR) has become an alternative to conventional aortic valve replacement (CAVR) for aortic stenosis (AS) treatment due to its advantages in reducing surgery time and improving outcomes. This study aimed to assess the cost-utility of SUAVR vs. CAVR treatment for patients with moderate to severe AS in Thailand. METHODS: A two-part constructed model was used to estimate the lifetime costs and quality-adjusted life years (QALYs) from both societal and healthcare perspectives. Data on short-term mortality, complications, cost, and utility data were obtained from the Thai population. Long-term clinical data were derived from clinical studies. Costs and QALYs were discounted annually at 3% and presented as 2022 values. The incremental cost-effectiveness ratio (ICER) was calculated to determine additional cost per QALY gained. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: SUAVR treatment incurred higher costs compared with CAVR treatment from both societal (THB 1,733,355 [USD 147,897] vs THB 1,220,643 [USD 104,150]) and healthcare provider perspectives (THB 1,594,174 [USD 136,022] vs THB 1,065,460 [USD 90,910]). In addition, SUAVR treatment resulted in lower health outcomes, with 6.20 life-years (LYs) and 4.95 QALYs, while CAVR treatment achieved 6.29 LYs and 5.08 QALYs. SUAVR treatment was considered as a dominated treatment strategy using both perspectives. Sensitivity analyses indicated the significant impact of changes in utilities and long-term mortality on the model. CONCLUSION: SUAVR treatment is not a cost-effective treatment strategy compared with CAVR treatment for patients with moderate-severe AS in Thailand, as it leads to higher costs and inferior health outcomes. Other important issues related to specific patients such as those with minimally invasive surgery, those undergoing AVR with concomitant procedures, and those with calcified and small aortic root should be taken into account.

Comparison of the outcomes between total arch replacement and nontotal arch replacement in patients with acute type A aortic dissection.

Objective: To compare the outcomes between total arch replacement (TAR) and nontotal arch replacement (non-TAR) in patients with acute type A aortic dissection (ATAAD). Methods: Between 2006 and 2018, 275 ATAAD patients were divided into 2 groups, the TAR group (n = 63) and the non-TAR group (n = 212), and multiple variables were analyzed. Results: The TAR patients were older than the non-TAR patients (61.5 ± 11.8 vs. 57.4 ± 14.5 years, p = 0.024). The TAR group had longer operative, cardiopulmonary bypass, aortic clamping, and circulatory arrest times than the non-TAR group (all p < 0.001). The overall hospital mortality rate was 8.7% with no statistically significant difference between the TAR and non-TAR groups (9.5% vs. 8.5%, p = 0.799). There was no significant difference in the incidence of acute kidney injury (AKI), intubation time, incidence of postoperative atrial fibrillation (AF), or reoperation for bleeding or reintervention rates between the TAR and non-TAR groups (68.3% vs. 65.7% (p = 0.912), 44.8% vs. 33.8% (p = 0.127), 30.2% vs. 22.6% (p = 0.222), 9.5% vs. 9.5% (p = 0.189), and 7.9% vs. 7.1% (p = 0.077), respectively). The TAR group had a higher rate of new permanent neurological deficit (PND) than the non-TAR group and longer median length of hospital stay (17.5% vs. 6.1% (p < 0.001) and 9 vs. 12 days (p = 0.049), respectively). TAR (relative risk (RR) 3.66, p = 0.005) and preoperative cardiopulmonary resuscitation (CPR) (RR 6.60, p = 0.019) were risk factors of PND. Survival rate was similar between the two groups. Conclusion: The mortality rates in ATAAD patients with TAR and non-TAR were similar. However, the incidence of new permanent postoperative neurological deficit was significantly higher, and the length of hospital stay was longer in patients with TAR. TAR in ATAAD should be avoided especially in patients who have experienced preoperative CPR to abate risk of PND.

Trends in Economic Burden and Mortality of Hospitalized Patients With Aortic Stenosis in Thailand.

This study aimed to assess the temporal trends in aortic stenosis (AS)-related hospitalizations, in-hospital mortality, and economic burden in Thailand. The study cohort was derived from the electronic claim system of the National Health Security Office, which serves as a reimbursement database for all Thai beneficiaries under the Universal Health Coverage Scheme, covering ∼70% of the entire population. Hospitalization, mortality, and costs were estimated by year, with the primary diagnosis for AS-related hospitalizations identified using code I350. The Cochrane Armitage test was used to examine trends in AS-related hospitalization and in-hospital mortality, whereas a nonparametric trend test was used to analyze the trend of hospitalization costs. Of the 8-year period, 10,406 adults were admitted with a primary diagnosis of AS. AS-related hospitalizations increased from 1,274 in 2015 to 1,945 in 2022 (p = 0.251), with the most significant observed in the age group 60 to 79 years (p <0.001). In-hospital mortality increased from 4.8% to 6.1%. Hospitalization cost significantly increased from $2,879 to $3,443 (p <0.001), with an average length of stay of 6.6 ± 9.2 days. The trend of patients admitted with primary diagnosis of AS in Thailand has significantly increased in the age group 60 to 79 years. In-hospital admission is found at older age and is likely to have high mortality rate. The increased hospitalization cost may impose a substantial economic burden on the Thai health care system.

Uncomplicated Type B Aortic Dissection: Challenges in Diagnosis and Categorization.

BACKGROUND: Acute type B aortic dissection (TBAD) is a rare disease that is likely under-diagnosed in the UK. As a progressive, dynamic clinical entity, many patients initially diagnosed with uncomplicated TBAD deteriorate, developing end-organ malperfusion and aortic rupture (complicated TBAD). An evaluation of the binary approach to the diagnosis and categorisation of TBAD is needed. METHODS: A narrative review of the risk factors predisposing patients to progression from unTBAD to coTBAD was undertaken. RESULTS: Key high-risk features predispose the development of complicated TBAD, such as maximal aortic diameter > 40 mm and partial false lumen thrombosis. CONCLUSION: An appreciation of the factors that predispose to complicated TBAD would aid clinical decision-making surrounding TBAD.

Tips and tricks in redo aortic surgery.

Redo aortic surgery is challenging, and the operative risk is higher than that in primary aortic surgery. Preoperative imaging is a crucial guide for a safe re-entry. Scrutinized preparing in cannulation and organ protection strategies have affected surgical outcomes. With comprehensive planning and meticulously executed surgery, mortality and morbidity can be acceptable. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-021-01322-x.

Preprocedural and procedural variables that predict new-onset conduction disturbances after transcatheter aortic valve replacement.

BACKGROUND: Conduction disturbances are a common complication after transcatheter aortic valve replacement (TAVR). The aim of this study was to investigate the preprocedural and procedural variables that predict new-onset conduction disturbances post-TAVR (hereafter CD/CDs). METHODS: Consecutive patients who underwent TAVR during December 2009-March 2021 at the Faculty of Medicine Siriraj Hospital, Mahidol University-Thailand's largest national tertiary referral center-were enrolled. Patients with prior implantation of a cardiac device, periprocedural death, or unsuccessful procedure were excluded. Clinical and electrocardiographic data, preprocedural imaging, including membranous septum (MS) length, and procedural variables, including implantation depth (ID), were analyzed. CD was defined as new left or right bundle branch block, significant intraventricular conduction disturbance with QRS interval ≥ 120 ms, new high-grade atrioventricular block, or complete heart block. Multivariate binary logistic analysis and receiver operating characteristic (ROC) curve analysis were used to identify independent predictors and the optimal ∆MSID (difference between the MS length and ID) cutoff value, respectively. RESULTS: A total of 124 TAVR patients (mean age: 84.3 ± 6.3 years, 62.1% female) were included. The mean Society of Thoracic Surgeons score was 7.3%, and 85% of patients received a balloon expandable transcatheter heart valve. Thirty-five patients (28.2%) experienced a CD, and one-third of those required pacemaker implantation. The significant preprocedural and procedural factors identified from univariate analysis included intraventricular conduction delay, mitral annular calcification, MS length ≤ 6.43 mm, self-expanding device, small left ventricular cavity, and ID ≥ 6 mm. Multivariate analysis revealed MS length ≤ 6.43 mm (adjusted odds ratio [aOR] 9.54; 95% CI 2.56-35.47; p = 0.001) and ∆MSID < 0 mm (adjusted odds ratio [aOR] 10.77; 95% CI 2.86-40.62; p = < 0.001) to be independent predictors of CD. The optimal ∆MSID cutoff value for predicting conduction disturbances was less than 0 mm (area under the receiver operating characteristic curve [AuROC]: 0.896). CONCLUSION: This study identified MS length ≤ 6.43 mm and ∆MSID < 0 mm as independent predictors of CDs. ∆MSID < 0 was the strongest and only modifiable predictor. Importantly, we expanded the CD criteria to cover all spectrum of TAVR-related conduction injury to lower the threshold of this sole modifiable risk. The optimal ∆MSID cutoff value was < 0 mm. TRIAL REGISTRATION: TCTR, TCTR20210818002. Registered 17 August 2021-Retrospectively registered, http://www.thaiclinicaltrials.org/show/TCTR 20210818002.

Mortality and complications following total aortic arch replacement: 14 years' experience.

BACKGROUND: Open total arch replacement is one of the most challenging procedures in cardiothoracic surgery and is the gold standard treatment for aortic arch pathology. Total arch replacement is associated with high rates of mortality and neurological morbidity. Using 14 years of data, we studied postoperative, in-hospital mortality, major complications, and examined associated risk factors. MATERIALS AND METHOD: Medical records of patients who underwent open, total arch replacement surgery at Siriraj Hospital from 2006 to December 2019 were reviewed. Demographic data, clinical factors, preoperative status, intraoperative data, and postoperative data were analyzed. RESULT: A total of 330 patients were included and 36 (10.9%) died in the hospital. More than one concomitant operation (odds ratio (OR) 5.16, p < 0.001) and emergency operation (OR 3.45, p = 0.003) were risk factors for in-hospital mortality. Major postoperative morbidity occurred in 124 (37.7%) patients (124 of 329). Emergency operation (OR 2.88, p <0.001), preoperative creatinine clearance < 60 ml/ min/ 1.73 m2 (OR 2.04, p = 0.004), and aortic cross-clamp time > 180 min (OR 1.75, p = 0.022) were risk factors for major postsurgical complications. CONCLUSION: In-hospital mortality after total arch replacement was 10.9% compared to international reports. Emergency operation was a major risk factor for both mortality and major complications. More than one concomitant operation, especially coronary artery bypass graft, more than doubled the risk of major complications.

Clinical outcomes of hypogastric artery occlusion for endovascular aortic aneurysm repair.

PURPOSE: To determine the midterm outcomes of internal iliac artery (IIA) coverage by a stent-graft in endovascular aortic aneurysm repair (EVAR) under specific anatomic and technical circumstances. MATERIAL AND METHODS: From January 2003 until January 2014, 57 patients with aortoiliac aneurysms, including 20 with 24 IIA aneurysms (IIAAs), underwent EVAR with IIA coverage. IIAA diameter change or IIA thrombosis, buttock claudication, type II endoleak, and secondary interventions related to the IIA were studied. RESULTS: Twenty-five of the 37 patients without IIAA were embolized prior to stent-graft placement, all unilateral, and in 12, the IAA orifice was only overstented. Buttock claudication occurred in only nine (20%) of the embolization patients (9/49 IIA's) (p = .14), while one IIA-related type II endoleak, occurred in the nonembolization group (p = .16). In patients with IIAA(s), the aneurysm diameter decreased in 16 cases (67%). Buttock claudication occurred in 75% of bilateral, and in 14.6% of unilateral embolizations (p = .046). CONCLUSIONS: Carefully selected patients with aortoiliac aneurysm without IIAA may safely undergo hypogastric artery overstenting without preemptive embolization during EVAR. IIA embolization is associated with buttock claudication and should be avoided if possible. Otherwise, at least one IIA should be preserved.

Surgical correction of vascular ring in Thai patients at a tertiary hospital.

BACKGROUND: Vascular ring is a rare congenital vascular disease. The result of vascular ring surgery in Thailand remains unknown as it lacks serial data. The purpose of the present study was to evaluate the result of vascular ring surgery at Siriraj Hospital and demonstrate the usefulness of the computed tomograph angiographic scanning (CTA) for preoperative anatomical diagnosis of the vascular ring for planning the surgical correction. MATERIAL AND METHOD: We reviewed our experiences for all patients that underwent vascular rings surgery at our institute between 1979 and 2009, about preoperative diagnostic imaging, operative technique, and clinical outcome. RESULTS: Twelve medical records of patients that underwent vascular rings surgery were reviewed. The age at time of operation ranged from one month to two years (median 3 months). The surgical approaches were eight median sternotomies, three left thoracotomies, and one right thoracotomy. There were two cases ofpostoperative complication (residual tracheal and left pulmonary artery stenosis and surgical bleeding). There was one hospital mortality (pneumonia and sepsis). CONCLUSION: Surgical correction of vascular ring is effective and safe. CTA can give the precise anatomic diagnosis of the vascular rings, lead to good surgical planning, proper surgical approach, and good outcome.

Ninety days mortality after thoracic endovascular aortic repair.

BACKGROUND: The thoracic endovascular aortic repair (TEVAR) has become popular due to its favorable immediate outcome. However, the outcome in longer duration is still questionable. The aim of the present study was to analyze the incidence and risk factors associated with 90 days mortality after TEVAR. MATERIAL AND METHOD: After the Siriraj Institutional Review Board, Thailand approved and waived the needfor the informed consent, the database that included 160 consecutive patients having TEVAR procedures between December 2006 and December 2010 was examined Patients' characteristics, including operative procedures and anesthesia techniques were studied. The mortality and complications were extracted and analyzed. Major adverse events and the others factors were analyzed to determine the risk factors. Other complications such as bleeding, endoleak, infection, and reintervention were examined and analyzed. RESULTS: One hundred sixty patients underwent TEVAR. They included 118 male (74%) and 42 female (26%) with mean age of 65. Perioperative mortality (within 24 hours postoperatively) was 1 (0.6%), 30 days mortality was 7 (4.4%) and the overall 90 days mortality was 10 (6.25%). Causes of death included sepsis [4 patients (2.5%)], multi-organ failure [3 patients (1.9%)], ischemic heart disease [1 patient (0.6%)], uncontrolled bleeding [1 patient (0.6%)], and graft ruptured [1 patient (0.6%)]. The risk factor related to mortality was postoperative neurological morbidity (OR 6.77, 95% CI = 1.08-42.36, p = 0.4). General anesthesia with endotracheal tube was used in the majority of the patients (92.5%), with no statistical significance in anesthesia-related mortality. Major adverse events including pneumonia 11.9%, cardiac arrhythmia 11.3%, graft infection 7.5%, neurological complication 7.0% (ischemic stroke 9 andparaplegia 1), renal failure 3.8%, and myocardial ischemia 0.6%. CONCLUSION: The incidence of 90 days mortality after TEVAR was 6.25% (10 from 160). The risk factor associated with mortality was the development of neurologic complication postoperatively.

Validation of EuroSCORE for coronary artery bypass grafting at Siriraj Hospital.

OBJECTIVE: To access the performance of the EuroSCORE when applied to CABG patients at Siriraj hospital. MATERIAL AND METHOD: One thousand five hundred forty nine patients diagnosed with coronary artery disease (CAD) who underwent isolated CABG between January 2007 and December 2009 was prospectively studied. RESULTS: The patients included 1,102 men and 447 women and had a mean age of 67 years old. The mean additive score in expired and survived groups were 9.65 +/- 5.14 and 3.87 +/- 3.06. In logistic, score were 25.43 +/- 26.31 and 4.88 +/- 7.88 respectively (p < 0.001). The best cut-off value of EuroSCORE for prediction of a death rate was 6 for additive score and 10 for logistic score. Area under the curve was 0.831 for the additive score and 0.823 for the logistic score. The observed overall mortality rate was 2.0% while the predict mortality was 5.27%. The difference between observed and predicted deaths was significant with additive score and logistic score (p < 0.001). CONCLUSION: Our results suggest that EuroSCORE is not valid for CABG in Thai patient due to over prediction.

Transcatheter aortic valve implantation (TAVI): first case in Thailand.

Aortic valve replacement (AVR) is the standard treatment for patients with symptomatic severe aortic stenosis (AS). However many patients are not offered surgery due to high surgical risk for open AVR. Transcatheter aortic valve implantation has been an alternative to open heart surgery in patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The first transcatheter aortic valve implantation in Thailand via the transapical route is described. An 87-year-old woman with symptomatic severe AS, calcified aorta and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at six-months follow-up.

Computed tomography of aortic intramural hematoma and thrombosed dissection.

A retrospective study was undertaken to evaluate the appearance of the aortic wall on computed tomography for the purpose of developing criteria for differentiating acute aortic intramural hematoma from thrombosed false lumen seen in aortic dissection. Computed tomography angiography findings of the thoracoabdominal aorta in 23 patients with suspected intramural hematoma and 25 with thrombosed false lumen were reviewed. The more common features of an intramural hematoma were hyperattenuation of the aortic wall, wall thickness less than a quarter of the aortic diameter, intrinsic wall calcification, a lesion extending around the entire aortic circumference, and ulcer-like projections that may be precursors of intramural hematoma. Wall thickness less than a quarter of the aortic diameter, lesion extending around the entire aortic circumference, and ulcer-like projections were the most useful indicators for distinguishing intramural hematoma from the thrombosed false lumen in aortic dissection.

CT angiography evaluation of endoleak after thoracic endovascularaortic repair in thoracic aortic aneurysm.

OBJECTIVE: Analyze the incidence and findings of endoleak after thoracic endovascular aortic repair by using CT angiography MATERIAL AND METHOD: Between August 2006 and December 2008, 68 patients diagnosed with thoracic aortic aneurysm underwent thoracic endovascular aortic repair and were included in the present study. The patients were 47 men and 21 women, with a mean age of 69 +/- 9.4 years old. Thoraco-abdominal CT angiographic images (64-slice MDCT) after operation of 68 patients were retrospectively reviewed to evaluate incidence of endoleak and classify findings of endoleak. RESULTS: Endoleaks were detected in 26 patients (38.2%). There were type I endoleaks in three cases (11.5%), type II endoleaks in 22 cases (84.6%), and type III endoleaks in one case (3.9%). Type II endoleaks were detected as peritubular collection, mostly located at periphery of the aneurysm. Eleven cases (50%) of type II endoleaks were supplied by left subclavian artery. Twenty patients who had completed 1, 3, and 6 months follow-up CT angiography were selected for further evaluation of changing in size of aneurysm. The measurement of the thoracic aneurysm showed no decreasing of the maximum length of diameter and volume of the aneurysmal sac in endoleak group. CONCLUSION: Follow-up CT angiography is useful for detection and characterization of endoleak after endovascular aortic repair of thoracic aneurysm. Most of type II endoleaks show peritubular (collection) shape and locate at the periphery. Patients with endoleak after thoracic endovascular aortic repair tend to continue to have sac expansion.

Repair of an isolated congenital left ventricular diverticulum.

Left ventricular diverticulum is a rare congenital anomaly. We report two cases of isolated left ventricular diverticulum with a different clinical presentation. The first case was a nine-year-old boy with a history of congestive heart failure and ventricular arrhythmia. The second case was a 51-year-old asymptomatic male with abnormal electrocardiogram. Both patients had the diagnosis confirmed by cardiac magnetic resonance imaging and underwent successful surgical correction of the abnormality.

Valve repair versus valve replacement for degenerative mitral valve disease.

OBJECTIVE: The study objective was to identify characteristics differentiating patients undergoing valve replacement versus valve repair for degenerative mitral valve disease and to use this information to compare survival and reoperation after each procedure. METHODS: From 1985 to 2005, 3286 patients underwent isolated primary operation for degenerative mitral valve disease. Valve repair was performed in 3051 patients (93%), and valve replacement was performed in 235 patients (7.2%). A propensity model and score developed for fair comparison of outcomes yielded 195 matched pairs. RESULTS: Patients undergoing replacement were older (70 +/- 12 years vs 57 +/- 13 years) and had more complex valvar pathology, symptoms, and left ventricular dysfunction. Thus, the characteristics of the propensity-matched patients undergoing repair more resembled those of the patients undergoing replacement (older, complex valvar pathology) than patients undergoing typical repair. Eight patients died in the hospital (0.26%) after repair and 5 patients (2.1%) died after replacement (P = .001). Unadjusted survival at 5, 10, and 15 years was 95%, 87%, and 68% after repair and 80%, 60%, and 44% after replacement, respectively (P < .0001); however, among propensity-matched patients, survival was similar (P = .8): 86% versus 83% at 5 years, 63% versus 62% at 10 years, and 43% versus 48% at 15 years. Freedom from reoperation among propensity-matched patients was 94% at 5 and 10 years after repair and 95% and 92% at 5 and 10 years after replacement, respectively (P = .6). CONCLUSION: It is reasonable to perform valve repair in elderly patients with complex degenerative mitral valve pathology because it can eliminate the need for anticoagulation and risk of prosthesis-related complications. However, when valve pathology is so complex that repair is infeasible, this study demonstrates that valve replacement does not diminish long-term outcomes.

Thrombus and calcium in aortic aneurysm necks: validation of a scoring system in a Dutch cohort study.

This study was conducted to validate a proposed classification system on the characteristics of the abdominal aortic aneurysm neck. The cohort comprised 100 consecutive patients who underwent open or endovascular aneurysm repair. Aneurysm neck characteristics of diameter, calcium, thrombus, and angulation were reviewed. The presence of calcium at the aortic aneurysm wall was associated with lower body mass index. Thrombus was found in 52% of the patients. Hypertension was correlated with the presence of aortic wall thrombus. At the renal artery level, angulation was anterior in 56%, right lateral in 39%, and left lateral in 27%. At the origin of the aneurysm, angulation was posterior in 76%, right lateral in 46%, and left lateral in 42%. A wide variety in these characteristics was found. A scoring system allows comparison of patient characteristics in studies describing the clinical outcome of endovascular aneurysm repair and should be included in study reports.

Deep sternal wire infection resulting in severe pulmonary valve endocarditis.

Right-sided infective endocarditis is uncommon, comprising less than 5% of all cases of endocarditis. This is primarily seen in patients with drug abuse, long-term intravenous catheters, and congenital malformations, or a combination of these. Isolated pulmonary valve endocarditis is difficult to recognize due to its rarity, minimal cardiac manifestations, and predominance of pulmonary infections secondary to embolization of the vegetations. We describe an unusual case of chronic sternal wound infection and migration of an infected braided sternal wire causing right ventricular outflow tract and pulmonary valve endocarditis, which necessitated a complicated reoperation including pulmonary valve replacement with a homograft.

Ruptured right aortic arch aneurysm.

A case of a ruptured right aortic arch aneurysm in a 74-year-old woman presenting with shock is reported. The diagnostic and operative findings are presented. We discuss the surgical approach and review the literature.

Spontaneous rupture of the left subclavian artery in neurofibromatosis.

Two patients with neurofibromatosis presented with expanding masses at the left supraclavicular region. Computed tomography (CT) scans revealed vascular masses. The patients underwent surgery and ruptures of the left subclavian artery were found. Both patients were treated by ligation of subclavian artery.