Closing the care gap: combining enhanced recovery with minimally invasive valve surgery.

PURPOSE OF REVIEW: Patients with advanced age and frailty require interventions for structural heart disease at an increasing rate. These patients typically experience higher rates of postoperative morbidity, mortality and prolonged hospital length of stay, loss of independence as well as associated increased costs to the healthcare system. Therefore, it is becoming critically important to raise awareness and develop strategies to improve clinical outcomes in the contemporary, high-risk patient population undergoing cardiacprocedures. RECENT FINDINGS: Percutaneous options for structural heart disease have dramatically improved the therapeutic options for some older, frail, high-risk patients; however, others may still require cardiac surgery. Minimally invasive techniques can reduce some of the physiologic burden experienced by patients undergoing surgery and improve recovery. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) is a comprehensive, interdisciplinary, evidence-based approach to perioperative care. It has been shown to improve recovery and patient satisfaction while reducing complications and length of stay. SUMMARY: Combining minimally invasive cardiac surgery with enhanced recovery protocols may result in improved patient outcomes for a patient population at high risk of morbidity and mortality following cardiac surgery.

Measuring Healthcare Experiences Among People With Intellectual Disability: A Rapid Evidence Synthesis of Tools And Methods.

OBJECTIVES: Patient-reported experience measures (PREMs) collect essential data for service and system-wide quality improvement and performance monitoring toward value-based care. However, the experiences of people with intellectual disability, who have high healthcare utilization couple with poorer outcomes, are often omitted from system-wide PREMs and service-wide PREMs data. The use of PREMs instruments for data collection among people with intellectual disability has not been explored. This review aimed to identify and synthesize measurement tools and approaches that have been used to gather patient-reported experience data from people with intellectual disability. METHODS: Rapid evidence assessment was used, in which comprehensive search strategies were applied to electronic databases and gray literature. Narrative synthesis was used with the included articles to address the review aim. RESULTS: A total of 48 documents were included; 26 peer-reviewed journal articles and 22 articles from gray literature. Patient-reported experiences have been gathered from people with intellectual disabilities in relation to specific services or encounters, predominantly using qualitative methods. To date, there is an absence of targeted service- or system-wide surveys. Existing clinic- and condition-specific instruments provide insight for broader application. CONCLUSIONS: Patient experience assessment among people with intellectual disability requires consideration of (1) how individuals are identified and approached, (2) the content, design and structure of measurement instruments, and (3) the process by which data are collected, and (4) how it may be applied to create change. Despite the collection of patient experience data from people with intellectual disability, there is little research available about how this information is later used to support health service improvement. Applying PREMs for quality improvement is critical to realize the improvements to healthcare provision required for people with intellectual disability toward equitable care quality.

Approaches for enhancing patient-reported experience measurement with ethnically diverse communities: a rapid evidence synthesis.

BACKGROUND: Patient-reported experience measures (PREMs) are used to drive and evaluate unit and organisational-level healthcare improvement, but also at a population level, these measures can be key indicators of healthcare quality. Current evidence indicates that ethnically diverse communities frequently experience poorer care quality and outcomes, with PREMs data required from this population to direct service improvement efforts. This review synthesises evidence of the methods and approaches used to promote participation in PREMs among ethnically diverse populations. METHODS: A rapid evidence appraisal (REA) methodology was utilised to identify the disparate literature on this topic. A search strategy was developed and applied to three major electronic databases in July 2022 (Medline; PsycINFO and CINAHL), in addition to websites of health agencies in Organisation for Economic Co-operation and Development countries via grey literature searches. A narrative evidence synthesis was undertaken to address the review question. RESULTS: The review resulted in 97 included studies, comprised 86 articles from electronic database searches and 11 articles from the grey literature. Data extraction and synthesis identified five strategies used in PREM instruments and processes to enhance participation among ethnically diverse communities. Strategies applied sought to better inform communities about PREMs, to create accessible PREMs instruments, to support PREMs completion and to include culturally relevant topics. Several methods were used, predominantly drawing upon bicultural workers, translation, and community outreach to access and support communities at one or more stages of design or administration of PREMs. Limited evidence was available of the effectiveness of the identified methods and strategies. PREMs topics of trust, cultural responsiveness, care navigation and coordination were identified as pertinent to and frequently explored with this population. CONCLUSIONS: The findings provide a basis for a maturity model that may guide change to increase participation of ethnically diverse communities in PREMs. In the short-medium term, health systems and services must be able to recognise and respond to cultural and linguistic diversity in the population when applying existing PREMs. In the longer-term, by working in collaboration with ethnically diverse communities, systems and services may co-create adapted or novel PREMs that tackle the factors that currently inhibit uptake and completion among ethnically diverse communities.

The silent threat: investigating sleep disturbances in hospitalized patients.

Sleep disruptions in the hospital setting can have adverse effects on patient safety and well-being, leading to complications like delirium and prolonged recovery. This study aimed to comprehensively assess the factors influencing sleep disturbances in hospital wards, with a comparison of the sleep quality of patients staying in single rooms to those in shared rooms. A mixed-methods approach was used to examine patient-reported sleep quality and sleep disruption factors, in conjunction with objective noise measurements, across seven inpatient wards at an acute tertiary public hospital in Sydney, Australia. The most disruptive factor to sleep in the hospital was noise, ranked as 'very disruptive' by 20% of patients, followed by acute health conditions (11%) and nursing interventions (10%). Patients in shared rooms experienced the most disturbed sleep, with 51% reporting 'poor' or 'very poor' sleep quality. In contrast, only 17% of the patients in single rooms reported the same. Notably, sound levels in shared rooms surpassed 100 dB, highlighting the potential for significant sleep disturbances in shared patient accommodation settings. The results of this study provide a comprehensive overview of the sleep-related challenges faced by patients in hospital, particularly those staying in shared rooms. The insights from this study offer guidance for targeted healthcare improvements to minimize disruptions and enhance the quality of sleep for hospitalized patients.

From Detractors to Promoters: A comparative analysis of patient experience drivers across Net Promoter Score subcategories.

BACKGROUND: The utilization of patient experience surveying by health care institutions has become increasingly prevalent, yet its effectiveness in promoting quality improvement remains uncertain. To enhance the utility of patient feedback, the examination of free-text comments may provide valuable insights to guide patient experience strategy. AIMS: This study aims to explore the utility of free-text comments and identify key differences for patient experience drivers between Net Promoter Score (NPS) subcategories of Detractors, Passives, and Promoters. METHODS: Evaluation and classification of comments was conducted using the eight Picker Principles of Person Centred Care, with descriptive analysis of patient comments performed on the NPS data. RESULTS: Analysis of patient NPS comments can be classified into three key drivers: "feeling well-treated" (for Detractors), "feeling comfortable" (for Passives), and "feeling valued" (for Promoters). Specifically, Detractor comments provided the most comprehensive and detailed feedback to guide patient experience improvement activities. CONCLUSION: This study highlights differences between NPS subcategories, particularly regarding aspects of safety, comfort, and feeling valued. Comments from Detractor respondents may be especially useful for guiding quality improvements due to increased specificity and insights. These results also emphasize the essential nature of empathy and compassionate interactions between patients and clinicians to achieve the highest level of patient satisfaction and experience.

The HUSH Project: Using codesign to reduce sleep disruptions for patients in hospital.

BACKGROUND: Poor quality sleep in hospitals may be problematic for patients, negatively impacting their recovery and wellbeing. This project aimed to investigate the effectiveness of codesign in addressing key issues affecting sleep disruption in the healthcare setting. METHODS: Codesign with patients, staff and consumer representatives was conducted in an acute metropolitan tertiary public hospital in Sydney, Australia. Through a four-stage process, a multimodal intervention to address and reduce the impact of sleep disruptions among hospital inpatients was created. Pre- and post-intervention evaluation was used to determine changes in patient-reported sleep disruption. RESULTS: 'The HUSH Project' (Help Us Support Healing) intervention resulted from the codesign process, which included the provision of HUSH Sleep Packs (with earplugs, eye masks and herbal tea), patient information resources, and ward-based Sleep Champions. Survey data from 210 patients revealed a statistically significant decrease in patient-reported noise disturbances for patients in shared rooms following the 4-week intervention period of the HUSH program. CONCLUSION: The HUSH Project demonstrated that a novel multimodal intervention may be valuable in reducing sleep disruption in hospitals. These findings also indicate the benefits of using codesign methodology to support improvement projects that seek to enhance patient experiences of care. PATIENT OR PUBLIC CONTRIBUTION: This project utilised codesign methodology, which involved significant contributions from patients and consumer representatives, from research conceptualisation into intervention design, implementation and project evaluation.

The rare case of double valve surgery in a patient with factor VII deficiency.

Performing cardiac surgery on patients with bleeding diatheses poses significant challenges since these patients are at an increased risk for complications secondary to excessive bleeding. Despite its rarity, patients with factor VII (FVII) deficiency may require invasive procedures such as cardiac surgery. However, we lack guidelines on their pre-, peri-, and post-operative management. As FVII deficiency is rare, it seems unlikely to design and learn from large clinical studies. Instead, we need to base our clinical decision-making on single reported cases and registry data. Herein, we present the rare case of a patient with FVII deficiency who underwent double valve surgery. Pre-operatively, activated recombinant FVII (rFVIIa) was administered to reduce the risk of bleeding. Nevertheless, the patient experienced major bleeding. This case highlights the significance of FVII deficiency in patients undergoing cardiac surgery and emphasizes the importance of adequate and appropriate transfusion of blood products for these patients.

Teaching heart valve surgery techniques using simulators: a systematic review.

The apprentice model has traditionally been the primary method of teaching cardiac surgery trainees. Limitations of this model include insufficient time to learn all necessary skills, minimal exposure to rare cases and to complex repair techniques, small number of patients in small centres, high cost and absence of objective measures of feedback. In recent years, simulation-based training (SBT) has been used in order to address the gaps left by the apprentice model. We performed a systematic review of PubMed and Embase for articles investigating the use of SBT in teaching surgical valve techniques published in 2022 or earlier in order to summarize the current literature regarding the use of SBT for trainees learning surgical valve repair and replacement techniques. We compiled data on the impact of SBT on time to completion of tasks, proportion of trainees who committed technical errors, skills scores and theoretical knowledge. Studies in which outcomes were evaluated showed significant improvement in these measures after participation in SBT. Simulation-based training has been shown to improve the surgical skills of trainees in a rela-tively short period. As hands-on experience in the field of cardiac surgery is invaluable and often difficult to reproduce effectively, it is likely that a combination of hands-on training and SBT will be adopted moving forward to provide optimal exposure for surgical trainees.

Sex-Related Differences in Transcatheter Mitral Valve Repair: A Systematic Review and Meta-Analysis.

OBJECTIVE: Inequalities in postoperative outcomes between males and females are well described with females often experiencing inferior outcomes after heart valve surgery. The recent literature has demonstrated equivalent or improved outcomes for females after transcatheter aortic valve replacement. Transcatheter mitral valve repair (TMVr) and replacement (TMVR) is a relatively newer field with significantly less literature comparing sex differences. This systematic review and meta-analysis looks to provide a comprehensive summary of the published literature comparing outcomes between males and females undergoing transcatheter MV interventions. METHODS: PubMed, MEDLINE, and Scopus were systematically searched for all studies comparing outcomes between males and females undergoing TMVr and TMVR. A total of 2,178 English manuscript titles and abstracts were reviewed. Articles were excluded if data were not provided regarding sex differences, transcatheter MV intervention, full-length text was not accessible, or if insufficient data was provided. A total of 2,170 articles were excluded, and 8 articles were included in this study. RESULTS: Pooled estimates of outcomes demonstrated rates of acute kidney injury (OR 1.28 [95% CI, 1.14-1.44; p < 0.0001]) favored females, while rates of major bleeding favored males (OR 0.85 [95% CI 0.76-0.96; p = 0.01]). Rates of mortality, postoperative MI, and stroke did not differ significantly. CONCLUSION: A trend has emerged in heart valve interventions with males tending to have improved outcomes after surgical intervention and females experiencing equivalent or improved outcomes after transcatheter interventions. This meta-analysis identified increased rates of acute kidney injury for males, increased rates of major bleeding for females, and otherwise comparable morbidity and mortality in males and females undergoing TMVr.

The ultimate question? Evaluating the use of Net Promoter Score in healthcare: A systematic review.

BACKGROUND: Patient experience is a complex phenomenon that presents challenges for appropriate and effective measurement. With the lack of a standardized measurement approach, efforts have been made to simplify the evaluation and reporting of patient experience by using single-item measures, such as the Net Promoter Score (NPS). Although NPS is widely used in many countries, there has been little research to validate its effectiveness and value in the healthcare setting. The aim of this study was to systematically evaluate the evidence that is available about the application of NPS in healthcare settings. METHODS: Studies were identified using words and synonyms that relate to NPS, which was applied to five electronic databases: Medline, CINAHL, Proquest, Business Journal Premium, and Scopus. Titles and abstracts between January 2005 and September 2020 were screened for relevance, with the inclusion of quantitative and qualitative studies in the healthcare setting that evaluated the use of NPS to measure patient experience. RESULTS: Twelve studies met the inclusion criteria. Four studies identified benefits associated with using NPS, such as ease of use, high completion rates and being well-understood by a range of patients. Three studies questioned the usefulness of the NPS recommendation question in healthcare settings, particularly when respondents are unable to select their service provider. The free-text comments section, which provides additional detail and contextual cues, was viewed positively by patients and staff in 4 of 12 studies. According to these studies, NPS can be influenced by a wide range of variables, such as age, condition/disease, intervention and cultural variation; therefore, caution should be taken when using NPS for comparisons. Four studies concluded that NPS adds minimal value to healthcare improvement. CONCLUSION: The literature suggests that many of the proposed benefits of using NPS are not supported by research. NPS may not be sufficient as a stand-alone metric and may be better used in conjunction with a larger survey. NPS may be more suited for use in certain healthcare settings, for example, where patients have a choice of provider. Staff attitudes towards the use of NPS for patient surveying are mixed. More research is needed to validate the use of NPS as a primary metric of patient experience. PATIENT OR PUBLIC CONTRIBUTION: Consumer representatives were provided with the research findings and their feedback was sought about the study. Consumers commented that they found the results to be useful and felt that this study highlighted important considerations when NPS data is used to evaluate patient experience.

Variational Monte Carlo Calculations of A≤4 Nuclei with an Artificial Neural-Network Correlator Ansatz.

The complexity of many-body quantum wave functions is a central aspect of several fields of physics and chemistry where nonperturbative interactions are prominent. Artificial neural networks (ANNs) have proven to be a flexible tool to approximate quantum many-body states in condensed matter and chemistry problems. In this work we introduce a neural-network quantum state ansatz to model the ground-state wave function of light nuclei, and approximately solve the nuclear many-body Schrödinger equation. Using efficient stochastic sampling and optimization schemes, our approach extends pioneering applications of ANNs in the field, which present exponentially scaling algorithmic complexity. We compute the binding energies and point-nucleon densities of A≤4 nuclei as emerging from a leading-order pionless effective field theory Hamiltonian. We successfully benchmark the ANN wave function against more conventional parametrizations based on two- and three-body Jastrow functions, and virtually exact Green's function Monte Carlo results.

Review of transapical off-pump mitral valve intervention with NeoChord implantation.

PURPOSE OF REVIEW: Mitral valve repair surgery has recently shifted from resection-based techniques to leaflet sparing approaches using synthetic neochordae. This has facilitated the growth of a new strategy of transapical off-pump mitral valve intervention with neochord implantation. RECENT FINDINGS: Minimally invasive approaches for mitral valve repair with robotic or video-assisted mini-right anterolateral thoracotomy have been developed to mitigate the morbidity associated with conventional median sternotomy. Recently, an alternative, less invasive surgical strategy has emerged. This transapical off-pump technique employs the NeoChord DS1000 (NeoChord, Inc., Minneapolis, MN, USA) system to achieve repair with neochordae via a left minithoracotomy incision. With appropriate patient selection, advanced cardiac imaging, and training in device deployment are important for procedural success. SUMMARY: Early results suggest that transapical off-pump mitral valve intervention with NeoChord implantation is a safe procedure with favorable outcomes for select patients with degenerative mitral regurgitation. Continued experience and clinical trials will assess the potential of this minimally invasive strategy, but this technique is likely to become part of the surgical repertoire for managing chronic degenerative mitral valve disease.

Transcatheter mitral valve repair and replacement: the next frontier of transcatheter valve intervention.

PURPOSE OF REVIEW: We summarize the recent developments in transcatheter mitral valve repair (TMVr) and replacement (TMVR), discuss determinants of MitraClip outcomes in various mitral regurgitation causes, and highlight newly emerging devices and randomized trials. RECENT FINDINGS: The discordant results published in the two recent randomized trials for MitraClip, the COAPT and the MITRA-FR trial have led to the emergence of a new conceptual framework such as the proportionate versus disproportionate mitral regurgitation and hemodynamics assessment tools like the real-time continuous left atrial pressure monitoring. Learning curve and volume-outcome analyses and studies examining the MitraClip usage in patients with degenerative mitral regurgitation are recent developments that have influenced MitraClip regulation and coverage. Several trials for TMVr devices that take an alternative approach to the edge-to-edge repair are underway and advancements in the TMVR technologies are continuing to progress to fill the unmet needs of treating high surgical risk patients whose complex valve anatomy make TMVr unfeasible. SUMMARY: Evidence supports careful analysis of the valve area and left ventricular function in addition to the left atrial hemodynamics will improve the MitraClip outcome. Operator experience plays a greater effect when achieving excellent results with 1+ or less residual mitral regurgitation whereas surgical MVr volume did not influence TMVr outcome. Interventions on the complex primary mitral regurgitation remain under the surgical domain, but MITRA high risk (HR) and REPAIR mitral regurgitation trials are underway to evaluate the role of MitraClip in high to intermediate surgical risk patients with primary mitral regurgitation. Despite the slow developments in TMVR, the results of the early trials of its devices are promising.

Right anterior mini thoracotomy approach for isolated aortic valve replacement: Early outcomes at a Canadian center.

OBJECTIVE: The goal of this manuscript was to report the clinical outcomes of the initial series of 100 consecutive Right Anterior Mini Thoracotomy (RAMT) aortic valve replacement (AVR) implantations at a Canadian Center. METHODS: This retrospective study reported the clinical outcomes of the first 100 patients who underwent the RAMT approach for isolated surgical AVR in Calgary, Canada, between 2016 and 2020. Primary outcomes were death within 30 days of surgery and disabling stroke. Secondary outcomes included surgical times, the need for permanent pacemaker (PPM), incidence of postoperative blood transfusion in the intensive care unit (ICU), postsurgical atrial fibrillation (AF), length of ICU/hospital stay, postsurgical AF, residual paravalvular leak (PVL), postoperative transvalvular gradient, need for postsurgical intravenous opioids, duration of invasive ventilation in the ICU, and chest tube output in the first 12 h postsurgery. RESULTS: In this study, 54 patients were male, and the average age of the cohort was 72 years. Mortality within 30 days of surgery was 1% with no disabling postoperative strokes. Mean cardiopulmonary bypass and cross clamp was 84 and 55 min, respectively. PPM rate was 3%, incidence of blood transfusion in the ICU was 4%, and the rate of postoperative AF was 23%. Median length of ICU and hospital stay was 1 and 5 days, respectively. Rate of mild or greater residual PVL was 3%, while the average residual transvalvular mean gradient was 8.5 mmHg. CONCLUSION: The sternum-sparing RAMT approach can be safely integrated into surgical practice as a minimally invasive alternative for isolated AVR, and can reduce postoperative bleeding and narcotic requirements.

Regional differences in aortic valve replacements: Atlantic Canadian experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is evolving rapidly and is increasingly being adopted in the treatment of aortic valve disease. The goal of this study was to examine regional differences in surgical aortic valve replacement (SAVR) and TAVI across Atlantic Canada. METHODS: We identified all patients who underwent SAVR or TAVI between Jan. 1, 2010, and Dec. 31, 2014, in New Brunswick, Nova Scotia and Newfoundland and Labrador. Data obtained included patient demographic characteristics and surgical procedure details. We performed univariate descriptive analyses and calculated crude and age- and sex-adjusted incidence rates. RESULTS: A total of 3042 patients underwent SAVR or TAVI during the study period, 1491 in Nova Scotia, 1042 in New Brunswick and 509 in Newfoundland and Labrador. Patient demographic characteristics were similar across regions. A much higher proportion of patients in Newfoundland and Labrador (43.6%) than in Nova Scotia (4.2%) or New Brunswick (13.6%) received a mechanical versus a bioprosthetic valve. Rates of TAVI increased over the study period, with New Brunswick adopting their program before Nova Scotia (144 v. 74 procedures). Adjusted rates of all AVR procedures remained stable in Nova Scotia (40-50 per 100 000 people). Adjusted rates were lower in New Brunswick and Newfoundland and Labrador than in Nova Scotia; they increased slowly in New Brunswick over the study period. CONCLUSION: Despite geographical proximity and similar patient demographic characteristics, there existed regional differences in the management of aortic valve disease within Atlantic Canada. Further study is required to determine whether the observed differences in age- and sex-adjusted rates of AVR may be explained by geographical disease-related differences, varying practice patterns or barriers in access to care.

CONTEXTE: Le remplacement valvulaire aortique par cathéter, une méthode en pleine évolution, est de plus en plus utilisé pour le traitement des valvulopathies aortiques. Cette étude visait à examiner les différences régionales quant au remplacement valvulaire aortique par cathéter ou par chirurgie dans les provinces de l'Atlantique. MÉTHODES: Nous avons recensé tous les patients ayant subi un remplacement valvulaire aortique entre le 1er janvier 2010 et le 31 décembre 2014 au Nouveau-Brunswick, en Nouvelle-Écosse et à Terre-Neuve-et-Labrador. Nous avons recueilli des données sur les caractéristiques démographiques des patients et les interventions chirurgicales, puis nous avons réalisé une analyse descriptive univariée et avons calculé les taux d'incidence bruts et corrigés selon l'âge et le sexe. RÉSULTATS: En tout, 3042 patients ont subi un remplacement valvulaire aortique par cathéter ou par chirurgie pendant la période à l'étude : 1491 en Nouvelle-Écosse, 1042 au Nouveau-Brunswick et 509 à Terre-Neuve-et-Labrador. Les caractéristiques démographiques des patients étaient semblables d'une région à l'autre. La proportion des patients recevant une prothèse mécanique plutôt qu'une bioprothèse était beaucoup plus élevée à Terre-Neuve-et-Labrador (43,6 %) qu'en Nouvelle-Écosse (4,2 %) ou au Nouveau-Brunswick (13,6 %). Les taux de remplacement par cathéter ont augmenté au cours de la période à l'étude; le Nouveau-Brunswick a adopté un programme à ce sujet avant la Nouvelle-Écosse (144 c. 74 interventions). Les taux corrigés pour tous les remplacements étaient stables en Nouvelle-Écosse (40-50 par 100 000 habitants); ils étaient plus faibles au Nouveau-Brunswick et à Terre-Neuve-et-Labrador, mais ont augmenté lentement au Nouveau-Brunswick pendant la période à l'étude. CONCLUSION: Malgré la proximité géographique des provinces de l'Atlantique et les caractéristiques démographiques semblables des patients, il existait des différences dans la prise en charge des valvulopathies aortiques. D'autres études seront nécessaires pour déterminer si les variations dans les taux de remplacement corrigés selon l'âge et le sexe pourraient s'expliquer par des différences géographiques dans le nombre de cas, des différences dans les pratiques ou des obstacles à l'accès aux soins.

Primary Cardiac T Cell Lymphoma Mimicking ST-Elevation Myocardial Infarction.

Primary cardiac T cell lymphoma is an extremely rare condition with only a handful of biopsy-proven cases worldwide. We present a 62-year-old female presenting with nonspecific chest discomfort, shortness of breath, and anterolateral ST-elevation on electrocardiogram mimicking a ST-elevation myocardial infarction. Imaging revealed a cardiac mass and cardiac catheterization showed diffuse noncritical coronary disease with an occluded 2nd diagonal branch. Biopsy via minimally invasive cardiac surgery showed a pathologically proven diagnosis of primary cardiac T cell lymphoma. To our knowledge, this is the first documented case worldwide of primary cardiac T cell lymphoma that has resulted in ST-elevation mimicking a myocardial infarction.

Comparison of outcomes of root replacement procedures and supracoronary techniques for surgical repair of acute aortic dissection.

BACKGROUND: Surgical approach to type A acute aortic dissection (AADA) is usually dictated by the presenting anatomy. We compared long-term outcomes of AADA repaired with a root replacement versus a supracoronary tube graft, regardless of the proximal extent of the intimal tear. METHODS: A single-centre, retrospective cohort of consecutive patients undergoing repair of AADA between December 1999 and March 2012 were stratified based on the proximal surgical procedure performed: supracoronary tube graft or root replacement. Imaging, chart reviews and clinical follow-ups were analyzed to identify the presenting anatomy and clinical outcomes. RESULTS: We included the cases of 75 patients in our analysis: 54 received a supracoronary tube graft and 21 received a root replacement. The proximal tear was identified below the sinotubular junction in all patients in the root group and in 61% of patients in the supracoronary group. We detected no differences between the groups for in-hospital mortality, length of stay, or complications. However, the root group had significantly increased renal failure (0% v. 9.5%, p = 0.018), cardiopulmonary bypass time (198.4 ± 80.0 min v. 316.5 ± 102.5 min, p < 0.001), cross-clamp time (91.6 ± 34.9 min v. 191.3 ± 52.8 min, p < 0.001), duration of surgery (457.5 ± 129.9 min v. 611.6 ± 197.8 min, p < 0.001), and platelet transfusions (8.1 ± 7.6 v. 12.8 ± 8.7 units, p = 0.021) than the supracoronary group. Long-term follow-up demonstrated a greater incidence of 2+ aortic regurgitation among patients in the supracoronary group than the root group (29.7% v. 0.0%, p = 0.006); however, there was no difference between the groups in symptoms or reoperation. CONCLUSION: In AADA, aortic root replacement involves a longer procedure with increased risk of early renal impairment. Long-term follow-up identified significantly more aortic regurgitation and root dilation in the supracoronary group than the root group, with a trend toward worse long-term survival. However, we found no difference between the groups in mortality, reoperation or New York Heart Association class.

CONTEXTE: L'approche chirurgicale à la dissection aigüe de l'aorte de type A (DAAA) dépend habituellement de la présentation anatomique. Nous avons comparé les résultats à long terme d'une DAAA réparée par remplacement de la racine de l'aorte c. greffon supracoronarien artificiel, indépendamment de la portée proximale de la déchirure de l'intima. MÉTHODES: Une cohorte rétrospective monocentrique de patients consécutifs soumis à une réparation de DAAA entre décembre 1999 et mars 2012 a été stratifiée en fonction de l'intervention chirurgicale proximale effectuée : greffon supracoronarien artificiel ou remplacement de la racine de l'aorte. Les épreuves d'imagerie, résumés de dossiers et suivis cliniques ont été analysés pour cerner la présentation anatomique et les résultats cliniques. RÉSULTATS: Nous avons inclus 75 patients dans notre analyse : 54 ont reçu un greffon supracoronarien artificiel et 21 ont subi un remplacement de la racine de l'aorte. Une déchirure proximale a été identifiée sous la jonction sinotubulaire chez tous les patients du groupe racine de l'aorte et chez 61 % des patients du groupe greffon supracoronarien. Nous n'avons décelé aucune différence entre les groupes pour ce qui est de la mortalité en milieu hospitalier, de la durée de l'hospitalisation ou des complications. Mais, le groupe racine de l'aorte a présenté des augmentations significatives du nombre de cas d'insuffisance rénale (0 % c. 9,5 %, p = 0,018), de la durée de la circulation extracorporelle (198,4 ± 80,0 min c. 316,5 ± 102,5 min, p < 0,001), du clampage de l'aorte (91,6 ± 34,9 min c. 191,3 ± 52,8 min, p < 0,001) et de la chirurgie (457,5 ± 129,9 min c. 611,6 ± 197,8 min, p < 0,001), ainsi que du nombre de transfusions plaquettaires (8,1 ± 7,6 unités c. 12,8 ± 8,7 unités, p = 0,021) comparativement au groupe greffon supracoronarien. Le suivi à long terme a fait état d'une incidence plus élevée de régurgitation aortique 2+ chez les patients du groupe greffon supracoronarien comparativement au groupe racine de l'aorte (29,7 % c. 0,0 %, p = 0,006); toutefois, on n'a noté aucune différence entre les groupes pour ce qui est des symptômes ou du taux de réopération. CONCLUSION: Dans la DAAA, le remplacement de la racine de l'aorte suppose une intervention de plus longue durée qui s'accompagne d'un risque accru d'insuffisance rénale précoce. Un suivi à long terme a révélé un nombre significativement plus élevé de cas de régurgitation aortique et de dilatation de la racine de l'aorte dans le groupe greffon supracoronarien que dans le groupe racine de l'aorte, avec une tendance moins favorable au plan de la survie à long terme. Toutefois, nous n'avons trouvé aucune différence entre les groupes pour ce qui est de la mortalité, du taux de réopération ou de la classe de la New York Heart Association.

Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair.

BACKGROUND: Concerns remain that minimally invasive atrial septal defect (ASD) repair may compromise patient outcomes. We compared clinical outcomes of adult patients undergoing ASD repair via a minimally invasive endoscopic approach versus a "gold standard" sternotomy. METHODS: We retrospectively reviewed the clinical outcomes of consecutive patients who underwent ASD patch repair at our institution between 2002 and 2012. We compared in-hospital/30-day mortality, postoperative complications, length of stay in hospital and in the intensive care unit and blood product requirements between patients who underwent right mini-thoracotomy (MT) and those who underwent conventional sternotomy. RESULTS: During the study period, 73 consecutive patients underwent ASD patch repair at our institution: 51 (age 47 ± 16 yr, 66.7% women) in the MT group and 22 (age 46 ± 21 yr, 59.1% women) in the sternotomy group. In-hospital mortality was similar between the 2 groups (MT 0% v. sternotomy 4.5%, p = 0.30). There were no significant differences in any postoperative complications or blood product requirements. No patients in the MT group suffered stroke, retrograde aortic dissection or leg ischemia. Mean intensive care unit (MT 1.2 ± 1.2 d v. sternotomy 1.7 ± 2.2 d, p = 0.26) and hospital length of stays (MT 5.1 ± 2.2 d v. sternotomy 6.3 ± 3.6 d, p = 0.17) were similar between the groups; however, there was a trend toward fewer patients requiring prolonged hospital stays (> 10 d) in the MT group (3.9% v. 18.2%, p = 0.06). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via MT endoscopic approach with similar outcomes as sternotomy. Patient preference for a more cosmetically appealing incision may be considered without concern of compromised outcomes.

CONTEXTE: Des inquiétudes persistent au sujet des résultats potentiellement négatifs chez les patients soumis à une intervention de réparation de communication interauriculaire (CIA) minimalement effractive. Nous avons comparé les résultats cliniques chez des patients adultes soumis à une réparation de CIA par approche endoscopique minimalement effractive ou par sternotomie classique ­ « l'étalon-or ¼. MÉTHODES: Nous avons passé en revue de manière rétrospective les résultats cliniques chez des patients consécutifs qui ont subi un traitement d'occlusion de leur CIA dans notre établissement, entre 2002 et 2012. Nous avons comparé la mortalité en cours d'hospitalisation et à 30 jours, les complications postopératoires, la durée des séjours à l'hôpital et aux soins intensifs et le recours aux produits sanguins chez les patients selon qu'ils avaient subi une mini-thoracotomie (MT) ou une sternotomie classique. RÉSULTATS: Durant la période de l'étude, 73 patients consécutifs ont subi un traitement d'occlusion de leur CIA dans notre établissement : 51 (âge 47 ± 16 ans, 66,7 % femmes) dans le groupe MT et 22 (âge 46 ± 21 ans, 59,1 % femmes) dans le groupe sternotomie. La mortalité perhospitalière a été similaire entre les 2 groupes (MT 0 % c. sternotomie 4,5 %, p = 0,30). On n'a noté aucune différence significative quant aux complications postopératoires et aux besoins en produits sanguins. Aucun patient du groupe MT n'a subi d'AVC, de dissection aortique rétrograde ou d'ischémie à la jambe. La durée moyenne des séjours aux soins intensifs (MT 1,2 ± 1,2 j c. sternotomie 1,7 ± 2,2 j, p = 0,26) et à l'hôpital (MT 5,1 ± 2.2 j c. sternotomie 6,3 ± 3,6 j, p = 0,17) a été similaire entre les groupes; toutefois, on a noté une tendance à un nombre moindre de patients nécessitant une hospitalisation prolongée (> 10 j) dans le groupe MT (3,9 % c. 18,2 %, p = 0,06). CONCLUSION: La réparation de la CIA au niveau de l'ostium secundum et du sinus veineux peut se faire de manière sécuritaire par approche endoscopique MT, avec des résultats similaires à ceux de la sternotomie. On peut tenir compte de la préférence des patients pour une incision plus acceptable au plan esthétique sans crainte de compromettre les résultats.