Unexplained fever following DeBakey type I aortic dissection repair with woven Dacron grafts.

Transient fever is not uncommon postcardiac surgery, usually related to underlying clinical process such as inflammation related to the physiological insult or infection. Here, we present a case series of two patients who underwent repair for type A aortic dissection with Gelweave graft prosthesis who had persistent fevers, leukocytosis, and raised inflammatory markers persisting months after surgery. Both patients were found to have sterile perigraft fluid collections. Comprehensive investigations excluded common causes of postoperative inflammation, as well as rarer causes of fever of unknown origin. The presence of this idiopathic inflammatory state lead to extended hospitalization and resource utilization, prompting need for further characterization of its mechanism and proper management.

Impact of preoperative fractional flow reserve on arterial bypass graft anastomotic function: the IMPAG trial.

AIMS: Visual estimation is the most commonly used method to evaluate the degree of coronary artery stenosis prior to coronary artery bypass grafting. In interventional cardiology, the use of fractional flow reserve (FFR) to guide revascularization decisions has become routine. We investigated whether the preoperative FFR measurement of coronary lesions is associated with anastomosis function 6 months after surgical revascularization using a multiarterial grafting strategy. METHODS AND RESULTS: In this prospective double-blind study, 67 patients were enrolled from two institutions in Europe and Canada. From these patients, 199 coronary lesions were assessed visually and with FFR at the time of the preoperative angiogram. All patients received coronary revascularization using multiple arterial grafts. A post-operative 6-month angiogram was performed to assess anastomosis functionality using a described angiographic method. The primary outcome was the association between preoperative FFR values and anastomosis function 6 months after surgery. Preoperative FFR was significantly associated with 6-months anastomotic function for all conduits and for all targets (P < 0.001). An FFR value of ≤0.78 was associated with an anastomotic occlusion rate of 3%. CONCLUSION: We found a significant association between the preoperative FFR measurement of the target vessel and the anastomotic functionality at 6 months, with a cut-off of 0.78. Integration of FFR measurement into the preoperative diagnostic workup before multiarterial coronary surgical revascularization leads to improved anastomotic graft function. CLINICAL TRIALS. GOV IDENTIFIER: NCT02527044.

Sex differences in outcomes of heart failure in an ambulatory, population-based cohort from 2009 to 2013.

BACKGROUND: Heart failure remains a substantial cause of morbidity and mortality in women. We examined the sex differences in heart failure incidence, mortality and hospital admission in a population-based cohort. METHODS: All Ontario residents who were diagnosed with heart failure in an ambulatory setting between Apr. 1, 2009, and Mar. 31, 2014, were included in this study. Incident cases of heart failure were captured through physician billing using a validated algorithm. Outcomes were mortality and hospital admission for heart failure within 1 year of the diagnosis. Probability of death and hospital admission were calculated using the Kaplan-Meier method. The hazard of death was assessed using a multivariable Cox proportional hazard model. RESULTS: A total of 90 707 diagnoses of heart failure were made in an ambulatory setting during the study period (47% women). Women were more likely to be older and more frail, and had different comorbidities than men. The incidence of heart failure decreased during the study period in both sexes. The mortality rate decreased in both sexes, but remained higher in women than men. The female age-standardized mortality rate was 89 (95% confidence interval [CI] 80-100) per 1000 in 2009 and 85 (95% CI 75-95) in 2013, versus male age-standardized mortality rates of 88 (95% CI 80-97) in 2009 and 83 (95% CI 75-91) in 2013. Conversely, the rates of incident heart failure hospital admissions after heart failure diagnosis decreased in men and increased in women. INTERPRETATION: Despite decreases in overall heart failure incidence and mortality in ambulatory patients, mortality rates remain higher in women than in men, and rates of hospital admission for heart failure increased in women and declined in men. Further studies should focus on sex differences in health-seeking behaviour, medical therapy and response to therapy to provide guidance for personalized care.

Transfusion Requirements in Cardiac Surgery III (TRICS III): Study Design of a Randomized Controlled Trial.

OBJECTIVES: To determine if a restrictive transfusion threshold is noninferior to a higher threshold as measured by a composite outcome of mortality and serious morbidity. DESIGN: Transfusion Requirements in Cardiac Surgery (TRICS) III was a multicenter, international, open-label randomized controlled trial of two commonly used transfusion strategies in patients having cardiac surgery using a noninferiority trial design (ClinicalTrials.gov number, NCT02042898). SETTING: Eligible patients were randomized prior to surgery in a 1:1 ratio. PARTICIPANTS: Potential participants were 18 years or older undergoing planned cardiac surgery using cardiopulmonary bypass (CPB) with a preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE I) of 6 or more. INTERVENTIONS: Five thousand patients; those allocated to a restrictive transfusion group received a red blood cell (RBC) transfusion if the hemoglobin concentration (Hb) was less than 7.5 g/dL intraoperatively and/or postoperatively. Patients allocated to a liberal transfusion strategy received RBC transfusion if the Hb was less than 9.5 g/dL intraoperatively or postoperatively in the intensive care unit or less than 8.5 g/dL on the ward. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of all-cause mortality, myocardial infarction, stroke, or new onset renal dysfunction requiring dialysis at hospital discharge or day 28, whichever comes first. The primary outcome was analyzed as a per-protocol analysis. The trial monitored adherence closely as adherence to the transfusion triggers is important in ensuring that measured outcomes reflect the transfusion strategy. CONCLUSION: By randomizing prior to surgery, the TRICS III trial captured the most acute reduction in hemoglobin during cardiopulmonary bypass.

Practice meta-environment of the cardiovascular perfusionist.

Though historically the development of cardiovascular perfusion grew out of the need for cardiopulmonary bypass, the application of technologies of extracorporeal support has more recently expanded beyond the traditional domain of the cardiac surgical operative and peri-operative environment. As a result, perfusionists are sometimes required to work in novel clinical settings. As part of our recent national survey to evaluate the effects of changes in entry-to-practice criteria introduced in Canada in 2006, we asked perfusionists if their current position as a perfusionist involves work outside the OR. We found that, in addition to regularly working in the Intensive Care Unit and Cardiac Catheterization Lab, 55.3% of respondents reported working "occasionally" in the Emergency Room and 74.7% reported working "occasionally" or "often" in other clinical areas. However, while 96% of respondents believed their training adequately prepared them for their job as a perfusionist, only 68% felt their training adequately prepared them for their duties outside the operating room. We also noted a trend that admission under experience-based entry-to-practice criteria was associated with a higher likelihood of perceived adequacy of training in preparation for duties outside the OR than education-based admission criteria (72% vs 59.4%, p=0.065). These findings raise important questions pertaining to the sufficiency of perfusion education in Canada and the influence of soft skills in preparing perfusionists for their duties, and indicate that a systematic study of the practice environment of cardiovascular perfusionists is timely.

Effects of a change in entry-to-practice criteria for cardiovascular perfusion in Canada: results of a national survey.

INTRODUCTION: Years of experience and level of education are two important determinants of a clinician's expertise. While entry-to-practice criteria for admission to perfusion training in Canada changed from clinical experience-based criteria to education-based criteria in 2006, the effects of these changes have not been studied. OBJECTIVE: To determine the academic and clinical backgrounds of perfusionists in Canada, ascertain perceptions about the adequacy of training and evaluate the effects of the changes on the composition of the perfusion community of Canada. METHODS: An electronic questionnaire was distributed to all practicing perfusionists in Canada, addressing details regarding clinical experience, academic education and perceptions about the adequacy of training. RESULTS: Two hundred and twenty-eight questionnaires were completed, representing a 72% response rate. Perfusionists admitted under academic-based criteria have significantly higher levels of education (100% degree holders vs 69.1%, p<0.001), but less antecedent clinical training and experience (median, IQR: 0, 0 - 4.5 years vs 2, 2 - 8 years, p<0.0001), are younger (median age range 31-35 years vs 51-55 years, p<0.0001), more likely to be female (58.7% vs 41.3%, p=0.006) and are significantly more likely to enter perfusion because of attraction to the type of work (p=0.045). Many perfusionists (70, 32%) in Canada believe themselves inadequately trained for their clinical assignments outside the OR. In addition, 19% of perfusionists plan to retire over the next 10 years. CONCLUSIONS: The introduction of education-based entry criteria has changed the academic and clinical experience levels of perfusionists in Canada. Strategies designed to better prepare perfusionists for their clinical assignments outside the OR are merited.

Development of a high fidelity pressurized porcine beating heart simulator for cardiac surgery training.

BACKGROUND: Development of a high-fidelity cardiac surgery simulator (CSS) requires integration of a heart model with a mock cardiopulmonary bypass (CPB) circuit that can provide feedback to mimic the pathophysiology of cardiac surgery. However, the cost of commercially available simulators precludes regular use. We describe steps in the construction of a high-fidelity CSS that integrates a pulsatile paracorporeal ventricular-assist device (Pulse-VAD) and a commercially available CPB simulator. METHODS/RESULTS: Eight porcine hearts were initially prepared. The configuration consisted of cannulation of the distal descending aorta and the inferior vena cava to enable pressurization of the heart after connection to the Califia® simulator, as well as Pulse-VAD cannulation (fitted with inflatable balloons) of both ventricles. After each simulation run, the team addressed key issues to derive successive model changes through consensus. Key modifications included: a) pressure maintenance of the cardiac chambers (removal of lungs, Pulse-VAD cannulation sites at the left pulmonary artery and vein, double ligation of arch vessels); b) high-fidelity beating of both ventricles (full Pulse-VAD bladder filling and ensuring balloon neck placement at the valvular plane) and c) reproducible management of porcine anatomy (management of porcine aorta, ligation of left azygous vein and shortened ascending thoracic aortic segment). CONCLUSION: A CSS can be prepared at low cost, with integration into a high-fidelity CPB simulator with a novel beating heart component. This setup can be used in teaching the basics of CPB techniques and complex surgical procedures. Future work is needed to validate this model as a simulation instrument.

Efficiency and safety of coronary CT angiography compared to standard care in the evaluation of patients with acute chest pain: a Canadian study.

The optimal assessment of patients with chest pain and possible acute coronary syndrome (ACS) remains a diagnostic dilemma for emergency physicians. Cardiac computed tomographic angiography (CCTA) may identify patients who can be safely discharged home from the emergency department (ED). The objective of the study was to compare the efficiency and safety of CCTA to standard care in patients presenting to the ED with low- to intermediate-risk chest pain. This was a single-center before-after study enrolling ED patients with chest pain and low to intermediate risk of ACS, before and after implementing a cardiac CT-based management protocol. The primary outcome was efficiency (time to diagnosis). Secondary outcomes included safety (30-day incidence of major adverse cardiovascular events (MACE)) and length of stay in the ED. We enrolled 258 patients: 130 in the standard care group and 128 in the cardiac CT-based management group. The cardiac CT group had a shorter time to diagnosis of 7.1 h (IQR 5.8-14.0) compared to 532.9 h (IQR 312.8-960.5) for the standard care group (p < 0.0001) but had a longer length of stay in the ED of 7.9 h (IQR 6.5-10.8) versus 5.5 h (IQR 3.9-7.7) (p < 0.0001). The MACE rate was 1.6 % in the standard care group and 0 % in the cardiac CT group. In conclusion, a cardiac CT-based management strategy to rule out ACS in ED patients with low- to intermediate-risk chest pain was safe and led to a shorter time to diagnosis but increased length of stay in the ED.

Clinical Correlation of Early Atelectasis after Bilateral Internal Thoracic Artery Harvest for Coronary Artery Bypass Grafting.

BACKGROUND: Atelectasis is a significant complication after cardiac surgery. The current study was designed to assess the significance of atelectasis after bilateral internal thoracic artery (BITA) harvest. METHODS: The ICU admission chest x-ray of 565 patients undergoing BITA was reviewed. Linear regression modelling was used to assess the relationship between atelectasis and oxygenation as well as patient variables to length of ventilation and length of stay in the Intensive Care Unit (ICU). RESULTS: Eighty-nine patients (15.8%) had Grade 2/3 atelectasis which was significantly more common on the left as compared to the right (left 0.149 95% CI [0.119-0.178], right 0.027 95% CI [0.013-0.040], p<0.001). Grade 2/3 atelectasis on the right was associated with a significant drop in the pO2 (p=0.001) and the per cent O2-fractional O2 (PF) ratio (p=0.002). Factors associated with increased ventilation time included presence of Grade 2/3 atelectasis (p=0.001) and peripheral vascular disease (PVD) (p<0.001), both of which were predictors of prolonged ICU length of stay (p=0.002 and p<0.001 respectively). CONCLUSIONS: Early atelectasis is related to impaired oxygenation, prolonged ventilation and prolonged ICU stay. Future research should focus on strategies to minimise atelectasis and to determine if these changes translate into better patient outcomes.

Determinants of persistent or recurrent congestive heart failure after contemporary surgical aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Although one of the goals of surgical aortic valve replacement (AVR) is to alleviate congestive heart failure (CHF), the latter often occurs after AVR. Surprisingly, the incidence of CHF after AVR remains unclear, as outcomes are reported according to valve-related complications, each of which may result in CHF. The study aim was to: (i) validate a previously described model predicting persistent or recurrent CHF after AVR in a contemporary cohort; and (ii) apply the model to predict late outcomes following AVR with the Trifecta valve. METHODS: A previously described statistical model was validated in a cohort of 1,014 patients who received the St. Jude Trifecta prosthesis between 2007 and 2009. A sensitivity analysis was performed to determine the influence of risk factors associated with late CHF. Model prediction was verified with a Monte Carlo simulation employing 10,000 iterations. RESULTS: The model accurately predicted late CHF events in a contemporary cohort. Sensitivity analysis identified mean transprosthesis gradient (MTG), body surface area (BSA), and preoperative NYHA class as important CHF risk factors. Based on the model, a 5 mmHg decrease in MTG was associated with 2.5% and 10.4% reductions in late CHF at five and 15 years, respectively. A 10% decrease in mean BSA and preoperative NYHA class IV symptoms were associated with a 1% decrease and a 5% increase in CHF events at 15 years after AVR. CONCLUSION: The authors' previously described model predicting persistent or recurrent CHF after AVR was validated in a contemporary cohort. This model may be applied to predict outcomes in patients who receive modern prostheses, without long-term follow up.

Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women.

BACKGROUND: Multiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women. METHODS: This cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression. RESULTS: A total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes. CONCLUSIONS: In patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.

Edge-to-edge with partial band mitral valve repair compared to replacement and undersized restrictive annuloplasty for ischemic mitral regurgitation.

Objective: Evidence supports replacement over repair for ischemic mitral regurgitation due to improved durability; however, the latter often involves an undersized ring annuloplasty that does not include edge-to-edge approximation. The objective of this study was to evaluate the outcomes of replacement, edge-to-edge leaflet approximation with mild-undersized annuloplasty and undersized ring annuloplasty for ischemic mitral regurgitation. Methods: This is a single-center retrospective study of patients undergoing mitral surgery for moderate-severe or greater ischemic mitral regurgitation, between 2004 and 2020, with mild-undersized annuloplasty, mitral valve replacement, or undersized restrictive annuloplasty (undersized ring annuloplasty). The primary outcome was all-cause mortality. Secondary outcomes included first recurrence of mitral regurgitation, heart failure hospitalization, and composite of valve-related events (bleeding, thromboembolism, endocarditis, and mitral valve reoperation). Results: There were 121, 93, and 78 patients in the mitral valve replacement, mild-undersized annuloplasty, and undersized restrictive annuloplasty groups, respectively, with a median follow-up of 3.1, 5.9, and 3.8 years, respectively. Both mitral valve replacement (hazard ratio, 1.87; 95% CI, 1.029-3.415) and undersized restrictive annuloplasty (hazard ratio, 2.73; 95% CI, 1.480-5.061) were associated with worse survival compared with mild-undersized annuloplasty. At 2 years, the rate of mild-moderate mitral regurgitation was greater in the mild-undersized annuloplasty group compared with the mitral valve replacement group (P = .001) but less than in the undersized restrictive annuloplasty group (P = .001). The rate of recurrent moderate or greater mitral regurgitation at 2 years was similar between mild-undersized annuloplasty and mitral valve replacement groups but significantly higher after undersized restrictive annuloplasty (P < .0001). Mitral valve replacement and undersized restrictive annuloplasty were associated with a significant increase in the incidence of first heart failure hospitalization compared with mild-undersized annuloplasty (P < .001 and P = .001, respectively). Mitral valve replacement was associated with an increased incidence of valve-related events compared with mild-undersized annuloplasty (P = .002). Conclusions: Surgical edge-to-edge approximation in addition to a mild-undersizing annuloplasty offers similar durability compared with replacement, with a lower rate of hospitalization for heart failure, and may confer a survival advantage.

Cerebral microembolization after bioprosthetic aortic valve replacement: comparison of warfarin plus aspirin versus aspirin only.

BACKGROUND: No human physiological data exists on whether aspirin only is as effective as warfarin plus aspirin in preventing cerebral microembolization in the early postoperative period after bioprosthetic aortic valve replacement (bAVR). METHODS AND RESULTS: We prospectively enrolled 56 patients who had no other indication for oral anticoagulation, who underwent bAVR and received, in an open-label fashion, either daily warfarin (for INR 2.0-3.0) plus 81 mg of aspirin (n=28) or 325 mg of aspirin only (n=28). Cerebral microembolization was quantified at 4 hours (baseline) and at 1 month postoperatively, by recording 1-hour bilateral middle cerebral artery (MCA) microembolic signals (MES). Platelet-function analysis (PFA) of closure times (CT) on collagen was also used as a marker of platelet-dependent activation. Follow-up to 1 year was complete. Preoperative demographics and baseline platelet function were equivalent in both groups. There was no mortality, stroke, or transient ischemic attack at 1 year in either group. No significant differences were found in the proportion of patients with MES among those receiving warfarin plus aspirin versus aspirin only, at baseline (68% versus 82%, respectively; P=0.4) and at 1 month (46% versus 43%; P=1.0) after bAVR. The total MES and PFA were also equivalent between groups, at baseline and follow-up. CONCLUSIONS: Early after bAVR, the effects of these 2 antithrombotic regimens on cerebral microembolization and platelet function are equivalent. These data bring new mechanistic support to the premise that aspirin only may safely be used early after bAVR in patients who have no other indication for oral anticoagulation.

Does anemia impact hospital readmissions after coronary artery bypass surgery?

BACKGROUND: Anemia is one of the most common complications of coronary artery bypass graft (CABG) surgery and has been shown to be associated with increased morbidity and mortality. The impact of anemia on hospital readmission after CABG, a potential measure of delayed complications, has not been addressed. STUDY DESIGN AND METHODS: We conducted a single-center retrospective study of 2102 patients who had CABG in Ontario to determine whether anemia at hospital discharge was associated with increased 30-day hospital readmissions, readmission secondary to cardiac disease, and 30-day mortality using administrative data. RESULTS: Of the 2102 patients, 224 patients (11%) were readmitted within 30 days of hospital discharge. Infection was the leading cause of readmissions (24%), followed by heart failure (13%), pulmonary disease (7%), and hemorrhagic disease (7%). Overall, 2.6% of patients were readmitted because of cardiac disease. Of patients discharged, 48% were discharged with a hemoglobin (Hb) level between 8 and 10 g/dL and 42% between 10 and 12 g/dL. Predischarge Hb concentration was not a significant independent predictor of 30-day readmission to the hospital due to all causes, readmission to the hospital due to cardiac causes, or 30-day mortality. A higher comorbidity score, adjusted odds ratio (OR) of 2.1 (95% confidence interval [CI], 1.3-3.6), leg and sternal wound infections OR of 1.9 (95% CI, 1.2-3.0), and postoperative renal failure OR of 1.4 (95% CI, 1.2-2.0) were associated with increased 30-day readmission rates. CONCLUSIONS: The predischarge Hb concentration after CABG was not associated with 30-day readmissions.

Population Study of Sex-Based Outcomes After Surgical Aortic Valve Replacement.

Background: Surgical aortic valve replacement (SAVR) is a key strategy for the treatment of aortic valve disease. However, studies have involved primarily male patients, and whether the benefits of this approach can be extrapolated to female patients is unclear. Methods: Clinical and administrative datasets for 12,207 patients undergoing isolated SAVR in Ontario from 2008 to 2019 were linked. Male and female patients were balanced using inverse probability treatment weighting. Mortality, endocarditis, and major hemorrhagic and thrombotic events, as well as 2 composite outcomes-major adverse cerebral and cardiovascular events (MACCE) and patient-derived adverse cardiovascular and noncardiovascular events (PACE)-and their component events, were compared in the weighted groups with a stratified log-rank test. Results: A total of 7485 male patients and 4722 female patients were included in the study. Median follow-up was 5.2 years in both sexes. All-cause mortality did not differ between sexes (hazard ratio [HR] 0.949 [95% confidence interval {CI} 0.851-1.059]). Male sex was associated with an increased risk of new-onset dialysis (HR 0.689 [95% CI 0.488-0.974]). Female sex was associated with a significantly increased risk of both new-onset heart failure (HR 1.211 [95% CI 1.051-1.394], P = 0.0081) and heart failure hospitalization (HR 1.200 [95% CI 1.036-1.390], P = 0.015). No statistically significant differences were seen in any of the other secondary outcomes between sexes. Conclusions: This population health study demonstrated that survival did not differ between male and female patients undergoing SAVR. Significant sex-related differences were found in the risk of heart failure and new-onset dialysis, but these findings should be considered exploratory and require further study.

Contexte: La chirurgie de remplacement valvulaire aortique est une stratégie importante dans le traitement de la valvulopathie aortique. Cependant, les études ont été menées principalement auprès de patients masculins, et il est difficile d'affirmer si les avantages de cette approche peuvent être extrapolés aux patientes. Méthodologie: Les ensembles de données cliniques et administratives de 12 207 patients ayant subi uniquement une chirurgie de remplacement valvulaire aortique en Ontario entre 2008 et 2019 ont été regroupés. Les groupes de patients hommes et femmes ont été équilibrés à l'aide d'une pondération par probabilité inverse du traitement. La mortalité, l'endocardite et les événements hémorragiques et thrombotiques majeurs en plus de deux critères composés ­ les événements cérébrovasculaires et cardiovasculaires indésirables majeurs et les événements cardiovasculaires et non cardiovasculaires indésirables rapportés par les patients ­ et leurs événements constituants ont été comparés dans les groupes pondérés à l'aide d'un test logarithmique par rangs stratifié. Résultats: Au total, 7485 hommes et 4722 femmes ont été inclus dans l'étude. La durée médiane du suivi était de 5,2 ans chez les femmes comme chez les hommes. La mortalité toutes causes confondues ne différait pas entre les sexes (rapport de risques instantanés [RRI] : 0,949, intervalle de confiance [IC] à 95 % : 0,851 à 1,059). Le sexe masculin était associé à un risque accru d'instauration d'une dialyse (RRI : 0,689; IC à 95 % : 0,488 à 0,974). Le sexe féminin était associé à une augmentation significative du risque d'insuffisance cardiaque inaugurale (RRI : 1,211; IC à 95 % : 1,051 à 1,394; p = 0,0081) et d'hospitalisation pour une insuffisance cardiaque (RRI : 1,200; IC à 95 % : 1,036 à 1,390; p = 0,015). Aucune différence statistiquement significative n'a été notée entre les sexes pour les autres critères secondaires. Conclusions: Cette étude en santé des populations a montré que la survie chez les personnes subissant une chirurgie de remplacement valvulaire aortique ne diffère pas entre les hommes et les femmes. Des différences significatives fondées sur le sexe ont été notées dans le risque d'insuffisance cardiaque et de l'instauration d'une dialyse, mais ces constats doivent être considérés comme exploratoires et faire l'objet d'autres études.

Combining Aortic Size With Arterial Hemodynamics Enhances Assessment of Future Thoracic Aortic Aneurysm Expansion.

BACKGROUND: Thoracic aortic aneurysm (TAA) is a deadly disease whose current method for risk stratification (aneurysm size) is imperfect. We sought to evaluate whether combining aortic size with hemodynamic measures that reflect the aorta's function was superior to aortic size alone in the assessment of TAA expansion. METHODS: One hundred thirty-seven nonoperated participants with TAA were followed prospectively. Aortic stiffness and pulsatile hemodynamics were noninvasively assessed at baseline with a combination of arterial tonometry with echocardiography using validated methodology. Aneurysm growth was calculated from standard imaging modalities. Multivariable linear regression models adjusted for potential confounders evaluated the association of aneurysm size and arterial hemodynamics, alone and in combination, with TAA growth. RESULTS: Sixty-nine percent of participants were male. Mean ± SD age, baseline aneurysm size, follow-up, and aneurysm expansion were, respectively, 62.2 ± 11.4 years, 45.9 ± 4.0 mm, 4.5 ± 1.9 years, and 0.41 ± 0.46 mm/year. In the linear regression models, the standardised ß (ß∗) for the association of aneurysm size with aneurysm expansion was 0.178 (P = 0.044). This was improved by combining aortic size with most measures of aortic function, with ß∗ ranging from 0.192 (for aneurysm size combined with central diastolic blood pressure) to 0.484 (for aneurysm size combined with carotid-femoral pulse-wave velocity) (P ≤ 0.05 for each). CONCLUSIONS: Combining aneurysm size with measures of arterial function improves assessment of aneurysm growth over TAA size alone, which is the standard for clinical decisions in TAA. Thus, combining aneurysm size with measures of aortic function provides a clinical advantage in the assessment of TAA disease activity.

Influence of preoperative frailty on quality of life after cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Frailty has emerged as an important prognostic marker of increased mortality after cardiac surgery, but its association with quality of life (QoL) and patient-centered outcomes is not fully understood. We sought to evaluate the association between frailty and such outcomes in older patients undergoing cardiac surgery. METHODS: This systematic review included studies evaluating the effect of preoperative frailty on QoL outcomes after cardiac surgery amongst patients 65 years and older. The primary outcome was patient's perceived change in QoL following cardiac surgery. Secondary outcomes included residing in a long-term care facility for 1 year, readmission in the year following the intervention, and discharge destination. Screening, inclusion, data extraction, and quality assessment were performed independently by two reviewers. Meta-analyses based on the random-effects model were conducted. The evidential quality of findings was assessed with the GRADE profiler. RESULTS: After the identification of 3105 studies, 10 observational studies were included (1580 patients) in the analysis. Two studies reported on the change in QoL following cardiac surgery, which was higher for patients with frailty than for patients without. Preoperative frailty was associated with both hospital readmission (pooled odds ratio [OR] 1.48 [0.80-2.74], low GRADE level) as well as non-home discharge (pooled OR 3.02 [1.57-5.82], moderate GRADE level). CONCLUSION: While evidence in this field is limited by heterogeneity of frailty assessment and non-randomized data, we demonstrated that baseline frailty may possibly be associated with improved QoL, but with increased readmission as well as discharge to a non-home destination following cardiac surgery. These patient-centered outcomes are important factors when considering interventional options for older patients. STUDY REGISTRATION: OSF registries (https://osf.io/vm2p8).

Reoperation of left heart valve bioprostheses according to age at implantation.

BACKGROUND: Evidence supporting the use of bioprostheses for heart valve replacement in young adults is accumulating. However, reoperation data, which may help guide clinical decision making in young patients, remains poorly defined in the literature. METHODS AND RESULTS: We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823). There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259). The median interval to reoperation of contemporary, stented aortic bioprostheses was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years, and 12.93 years (95% CI 11.10 to 15.76 years) in patients between 40 and 60 years of age. Multivariable risk factors associated with reoperation following bioprosthetic AVR include age (hazard ratio [HR] 0.94 per year, 95% CI 0.91 to 0.96, P<0.001) and concomitant coronary artery bypass grafting (HR 0.34, 95% CI 0.11 to 0.99, P=0.04). The median interval to reoperation of contemporary mitral bioprostheses was 8.11 years (95% CI 5.79 to 16.50 years) in patients less than 40 years, and 10.14 years (95% CI 8.64 to 11.14 years) in patients between 40 and 60 years of age. As for AVR, age (HR 0.96 per year, 95% CI 0.95 to 0.98, P<0.001) and concomitant coronary artery bypass grafting (HR 0.55, 95% CI 0.32 to 0.93, P=0.03) were associated with decreased reoperation risk following bioprosthetic MVR. CONCLUSIONS: These data constitute clinically relevant age-specific prognostic information regarding reoperation in young patients, who may wish to select a bioprosthesis at initial left heart valve replacement.