Outcome After General Anesthesia Versus Monitored Anesthesia Care in Transfemoral Transcatheter Aortic Valve Replacement.

OBJECTIVE: To evaluate outcomes of monitored anesthesia care (MAC) compared with general anesthesia (GA) in patients undergoing transfemoral transcatheter aortic valve replacement (TAVR). DESIGN: Secondary analysis from the observational and prospective OBSERVANT (OBservational Study of Effectiveness of avR-taVi procedures for severe Aortic steNosis Treatment) study. SETTING: Multicenter study, including Italian hospitals performing TAVR interventions. PARTICIPANTS: One thousand four hundred ninety-four patients with severe and symptomatic aortic stenosis. INTERVENTIONS: Transfemoral TAVR under general or local anesthesia. MEASUREMENTS AND MAIN RESULTS: A propensity score procedure was applied, and 310 pairs were matched with similar baseline characteristics (EuroSCORE II: local anesthesia 6.6±5.9% v general anesthesia 7.0±7.7%, p = 0.430). MAC was associated with similar 30-day mortality compared with GA (3.9% v 4.8%, p = 0.564). TAVR was performed under MAC without any increased risk of other adverse events. The risk of paravalvular regurgitation≥mild was similar between the study groups (MAC 49.5% v general anesthesia 57.0%, p = 0.858). Two patients receiving on MAC had severe paravalvular regurgitation, whereas this complication was not observed after GA. Permanent pacemaker implantation was 19.1% in the MAC group v 14.8% in the GA group (p = 0.168). Mean intensive care unit stay was 3.5 days for the GA group v 2.9 days for the MAC group (p = 0.086). A similar 3-year survival rate was observed (MAC 69.4% v GA 69.9%, p = 0.966). CONCLUSIONS: Transfemoral TAVR can be performed under MAC with similar immediate and late outcomes as compared with GA. A possible risk of severe paravalvular regurgitation and pacemaker implantation with TAVR under MAC requires further investigation.

Does EuroSCORE II perform better than its original versions? A multicentre validation study.

AIMS: The European system for cardiac operation risk evaluation (EuroSCORE) is widely used for predicting in-hospital mortality after cardiac surgery. A new score (EuroSCORE II) has been recently developed to update the previously released versions. This study was undertaken to validate EuroSCORE II, to compare its performance with the original EuroSCOREs and to evaluate the effects of the removal of those factors that were included in the score even if they were statistically non-significant. METHODS AND RESULTS: Data on 12,325 consecutive patients who underwent major cardiac surgery in a 6-year period were retrieved from three prospective institutional databases. Discriminatory power was assessed using the c-index and comparison among the scores' performances was performed with Delong, bootstrap, and Venkatraman methods. Calibration was evaluated with calibration curves and associated statistics. The in-hospital mortality rate was 2.2%. The discriminatory power was high and similar in all algorithms (area under the curve 0.82, 95% CI: 0.79-0.84 for additive EuroSCORE; 0.82, 95% CI: 0.79-0.84 for logistic EuroSCORE; 0.82, 95% CI: 0.80-0.85 for EuroSCORE II). The EuroSCORE II had a fair calibration till 30%-predicted values and over-predicted beyond. The removal of non-significant factors from EuroSCORE II did not affect performance, being both the calibration and discrimination comparable. CONCLUSION: This validation study demonstrated that EuroSCORE II is a good predictor of perioperative mortality. It showed an optimal calibration until 30%-predicted mortality. Nonetheless, it does not seem to significantly improve the performance of older versions in the higher tertiles of risk. Moreover, it could be simplified, as the removal from the algorithm of non-significant factors does not alter its performance.

Hemoglobin trends in isolated coronary artery bypass grafting performed off-pump and with standard and mini circuits.

The comparison of hemodilution at the end of surgery is of limited use as it represents only a snapshot of a dynamic phenomenon. This study was undertaken to compare the perioperative hemoglobin curves of isolated coronary artery bypass grafting performed with minimized extracorporeal circulation, traditional cardiopulmonary bypass, and off-pump technique. The propensity score method was used to select three groups of patients, homogenous regarding preoperative and operative data, who underwent isolated coronary artery bypass grafting. A generalized linear mixed model was used for estimating differences in perioperative hemoglobin trends among groups. The three groups were each composed of 50 patients with no differences in demographic data, preoperative risk profile, preoperative hemoglobin, or type of surgery. There was no significant difference in major postoperative complications. The pattern of the hemodilution curves was similar in patients operated with mini-circuit and off-pump technique (P > 005). Mini-circuit led to a 3.1 ± 11.9% hemoglobin reduction, which was similar to the off-pump group (1.6 ± 8.9%, P = 0.99 at ANOVA) and significantly different from the standard extracorporeal circuit group (16.0 ± 10.3%, P < 0.001 at ANOVA). The generalized linear mixed model determined that the standard circuit was the only independent predictor for increased hemodilution. Its effect on hemodilution was time-dependent and the slope of the hemoglobin curve was more pronounced between systemic heparinization and the end of surgery. Perioperative hemoglobin trends of patients who underwent myocardial revascularization with mini-circuit were similar to those of off-pump surgery and significantly less pronounced than those of standard extracorporeal circulation.

[The PRIORITY study - PRedictIng long term Outcomes afteR Isolated coronary arTery bypass surgerY]. / Lo studio PRIORITY - PRedictIng long term Outcomes afteR Isolated coronary arTery bypass surgerY.

The allocation of clinical and economic resources is an emerging issue in health management. A useful update necessarily depends on the evaluation of long-term outcomes of clinical and surgical resources that can permit emphasis on all amendable fields, improve quality of care, and reduce health costs. The PRIORITY (PRedictIng long term Outcomes afteR Isolated coronary arTery bypass surgerY) study represents the first innovative step toward the updating of health management in a selected field, surgery for coronary artery disease, which is one of the most prevalent diseases and requires allocation of high-cost resources, although information on long-term outcomes is limited. The aims of the PRIORITY study are the identification of preoperative risk factors for long-term outcomes and the development of clinical and administrative preoperative scores that can guide clinicians and the national health system to more appropriate actions for increasing quality of care and reducing costs.

Impact of incomplete revascularization following OPCAB surgery.

BACKGROUND AND AIM OF THE STUDY: The aim of this study was to evaluate the early and mid-term off-pump coronary artery bypass surgery (OPCAB) results in a single surgical unit, assessing the impact of completeness of revascularization. METHODS: Three hundred and twelve patients underwent OPCAB between August 2000 and January 2005. In-hospital data were collected prospectively for all patients undergoing OPCAB. Complete revascularization (CR) was derived by comparing significantly stenotic vessels at cardiac catheterization with surgically grafted coronary vessels. Grafting of all the significantly stenotic coronary vessels was considered CR. In-hospital outcomes were compared between patients with CR and incomplete revascularization (IR). A multivariate analysis based on the Cox proportional hazards regression model was performed. RESULTS: Patients receiving IR (105 patients, 43.7%) presented a worse preoperative risk profile then those having CR (mean Euroscore 6.8 +/- 2.9 vs. 4.3 +/- 2.8, p < 0.0001). IR was not associated with a higher incidence of early adverse events. Five-year freedom from death and major adverse cardiac events (MACE) were 0.88 (0.02 SE) and 0.86 (0.03 SE), respectively. Complete revascularization was protective for mid-term unstable angina recurrence [heart rate (HR) = 0.24, 95% confidence interval (CI) 0.10 to 0.58], acute myocardial infarction (HR = 0.25, 95% CI 0.09 to 0.73), all-cause repeat revascularization (HR = 0.35, 95% CI 0.13 to 0.90), and MACE (HR = 0.2, 95% CI 0.1 to 0.5). CONCLUSION: Our study suggests that, although incomplete revascularization may not result in increased short-term morbidity and mortality, it increases the incidence of mid-term MACE.

High OPCAB surgical volume improves midterm event-free survival.

BACKGROUND: The aim of this study was to evaluate the midterm results of the initial phase of off-pump coronary artery bypass (OPCAB) surgery adoption in a single surgical unit, assessing the impact of procedural volume. METHODS: Study participants were 312 patients who underwent OPCAB during the period between August 2000 and January 2005 at S. Croce Hospital. Of these patients, 126 patients with an indication selected for comorbidities or 1-vessel disease underwent OPCAB performed by 4 low-volume surgeons, and 186 unselected patients underwent OPCAB performed by a single high-volume surgeon. RESULTS: OPCAB performed by low-volume surgeons was associated with less complete revascularization and less arterial conduit use. Early result analysis showed a low rate of in-hospital or 30-day adverse events. The 5-year survival was 0.88 (0.02 SE). OPCAB performance by a high-volume surgeon and complete revascularization were shown have a protective effect for midterm major adverse cardiac events (respectively, hazard ratio = 0.28, 95% confidence interval 0.11-0.74 and hazard ratio = 0.33, 95% confidence interval 0.15-0.73). CONCLUSION: Our study on the initial phase of OPCAB adoption suggests a benefit on midterm outcome from surgery performed by a high-volume surgeon.

The Impact of EuroSCORE II Risk Factors on Prediction of Long-Term Mortality.

BACKGROUND: The European System for Cardiac Operation Risk Evaluation (EuroSCORE) II has not been tested yet for predicting long-term mortality. This study was undertaken to evaluate the relationship between EuroSCORE II and long-term mortality and to develop a new algorithm based on EuroSCORE II factors to predict long-term survival after cardiac surgery. METHODS: Complete data on 10,033 patients who underwent major cardiac surgery during a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Mortality at follow-up was analyzed with time-to-event analysis. RESULTS: The Kaplan-Meier estimates of survival at 1 and 5 were, respectively, 95.0% ± 0.2% and 84.7% ± 0.4%. Both discrimination and calibration of EuroSCORE II decreased in the prediction of 1-year and 5-year mortality. Nonetheless, EuroSCORE II was confirmed to be an independent predictor of long-term mortality with a nonlinear trend. Several EuroSCORE II variables were independent risk factors for long-term mortality in a regression model, most of all very low ejection fraction (less than 20%), salvage operation, and dialysis. In the final model, isolated mitral valve surgery and isolated coronary artery bypass graft surgery were associated with improved long-term survival. CONCLUSIONS: The EuroSCORE II cannot be considered a direct estimator of long-term risk of death, as its performance fades for mortality at follow-up longer than 30 days. Nonetheless, it is nonlinearly associated with long-term mortality, and most of its variables are risk factors for long-term mortality. Hence, they can be used in a different algorithm to stratify the risk of long-term mortality after surgery.

Reliability of Modern Scores to Predict Long-Term Mortality After Isolated Aortic Valve Operations.

BACKGROUND: Contemporary scores for estimating perioperative death have been proposed to also predict also long-term death. The aim of the study was to evaluate the performance of the updated European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons Predicted Risk of Mortality score, and the Age, Creatinine, Left Ventricular Ejection Fraction score for predicting long-term mortality in a contemporary cohort of isolated aortic valve replacement (AVR). We also sought to develop for each score a simple algorithm based on predicted perioperative risk to predict long-term survival. METHODS: Complete data on 1,444 patients who underwent isolated AVR in a 7-year period were retrieved from three prospective institutional databases and linked with the Italian Tax Register Information System. Data were evaluated with performance analyses and time-to-event semiparametric regression. RESULTS: Survival was 83.0% ± 1.1% at 5 years and 67.8 ± 1.9% at 8 years. Discrimination and calibration of all three scores both worsened for prediction of death at 1 year and 5 years. Nonetheless, a significant relationship was found between long-term survival and quartiles of scores (p < 0.0001). The estimated perioperative risk by each model was used to develop an algorithm to predict long-term death. The hazard ratios for death were 1.1 (95% confidence interval, 1.07 to 1.12) for European System for Cardiac Operative Risk Evaluation II, 1.34 (95% CI, 1.28 to 1.40) for the Society of Thoracic Surgeons score, and 1.08 (95% CI, 1.06 to 1.10) for the Age, Creatinine, Left Ventricular Ejection Fraction score. CONCLUSIONS: The predicted risk generated by European System for Cardiac Operative Risk Evaluation II, The Society of Thoracic Surgeons score, and Age, Creatinine, Left Ventricular Ejection Fraction scores cannot also be considered a direct estimate of the long-term risk for death. Nonetheless, the three scores can be used to derive an estimate of long-term risk of death in patients who undergo isolated AVR with the use of a simple algorithm.

Early and Midterm Outcome of Propensity-Matched Intermediate-Risk Patients Aged ≥80 Years With Aortic Stenosis Undergoing Surgical or Transcatheter Aortic Valve Replacement (from the Italian Multicenter OBSERVANT Study).

The aim of this study was to analyze procedural and postprocedural outcomes of patients aged ≥80 years treated by transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) as enrolled in the OBservational Study of Effectiveness of SAVR-TAVR procedures for severe Aortic steNosis Treatment (OBSERVANT) Study. TAVI is offered to patients with aortic stenosis judged inoperable or at high surgical risk. Nevertheless, it is common clinical practice to treat elderly (≥80 years) patients by TAVI regardless of surgical risk for traditional SAVR. OBSERVANT is a multicenter, observational, prospective cohort study that enrolled patients with symptomatic severe aortic stenosis who underwent SAVR or TAVI from December 2010 to June 2012 in 93 Italian participating hospitals. Information on demographic characteristics, health status before intervention, therapeutic approach, and intraprocedural and 30-day outcomes was collected. An administrative follow-up was set up to collect data on midterm to long-term outcomes. We reviewed baseline and procedural data of patients aged ≥80 years, looking for different early and late outcome after TAVI or SAVR. Patients treated by TAVI were sicker than SAVR because of higher rate of co-morbidities, advanced illness, frailty, and Logistic EuroSCORE. After propensity matching, early and midterm mortality were comparable between the 2 groups. However, patients treated by TAVI had higher rate of vascular complications (6.0% vs 0.5%; p <0.0001), permanent pacemaker implantation (13.4% vs 3.7%; p <0.0001), and paravalvular leak (8.9% vs 2.4%; p <0.0001). Patients who underwent SAVR had more frequent bleedings needing transfusion (63.2% vs 34.5%; p <0.0001) and acute kidney injury (9.6% vs 3.9%; p = 0.0010). In conclusion, patients aged ≥80 years treated by TAVI or SAVR had similar early and midterm mortality.

Transcatheter Aortic Valve Implantation Compared With Surgical Aortic Valve Replacement in Low-Risk Patients.

BACKGROUND: The proven efficacy of transcatheter aortic valve implantation (TAVI) in high-risk patients is leading to the expansion of its indications toward lower-risk patients. However, this shift is not supported by meaningful evidence of its benefit over surgical aortic valve replacement (SAVR). This analysis aims to describe outcomes of TAVI versus SAVR in low-risk patients. METHODS AND RESULTS: We compared the outcome after TAVI and SAVR of low-risk patients (European System for Cardiac Operative Risk Evaluation II [EuroSCORE II] <4%) included in the Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment (OBSERVANT) study. The primary outcome was 3-year survival. Secondary outcomes were early events and major adverse cardiac and cerebrovascular events at 3 years. Propensity score matching resulted in 355 pairs of patients with similar baseline characteristics. Thirty-day survival was 97.1% after SAVR and 97.4% after TAVI (P=0.82). Cardiac tamponade, permanent pacemaker implantation, major vascular damage, and moderate-to-severe paravalvular regurgitation were significantly more frequent after TAVI compared with SAVR. Stroke rates were equal in the study groups. SAVR was associated with higher risk of cardiogenic shock, severe bleeding, and acute kidney injury. At 3 years, survival was 83.4% after SAVR and 72.0% after TAVI (P=0.0015), whereas freedom from major adverse cardiac and cerebrovascular events was 80.9% after SAVR and 67.3% after TAVI (P<0.001). CONCLUSIONS: In patients with low operative risk, significantly better 3-year survival and freedom from major adverse cardiac and cerebrovascular events were observed after SAVR compared with TAVI. Further studies on new-generation valve prostheses are necessary before expanding indications of TAVI toward lower-risk patients.

Immediate and Intermediate Outcome After Transapical Versus Transfemoral Transcatheter Aortic Valve Replacement.

A few studies recently reported controversial results with transfemoral transcatheter aortic valve replacement (TF-TAVR) versus transapical transcatheter aortic valve replacement (TA-TAVR), often without adequate adjusted analysis for baseline differences. Data on patients who underwent TF-TAVR and TA-TAVR from the Observational Study of Effectiveness of avR-tavI procedures for severe Aortic stenosis Treatment study were analyzed with propensity score 1-to-1 matching. From a cohort of 1,654 patients (1,419 patients underwent TF-TAVR and 235 patients underwent TA-TAVR), propensity score matching resulted in 199 pairs of patients with similar operative risk (EuroSCORE II: TF-TAVR 8.1 ± 7.1% vs TA-TAVR, 8.4 ± 7.3%, p = 0.713). Thirty-day mortality was 8.0% after TA-TAVR and 4.0% after TF-TAVR (p = 0.102). Postoperative rates of stroke (TA-TAVR, 2.0% vs TF-TAVR 1.0%, p = 0.414), cardiac tamponade (TA-TAVR, 4.1% vs TF-TAVR 1.5%, p = 0.131), permanent pacemaker implantation (TA-TAVR, 8.7% vs TF-TAVR 13.3%, p = 0.414), and infection (TA-TAVR, 6.7% vs TF-TAVR 3.6%, p = 0.180) were similar in the study groups but with an overall trend in favor of TF-TAVR. Higher rates of major vascular damage (7.2% vs 1.0%, p = 0.003) and moderate-to-severe paravalvular regurgitation (7.8% vs 5.2%, p = 0.008) were observed after TF-TAVR. On the contrary, TA-TAVR was associated with higher rates of red blood cell transfusion (50.0% vs 30.4%, p = 0.0002) and acute kidney injury (stages 1 to 3: 44.4% vs 21.9%, p <0.0001) compared with TF-TAVR. Three-year survival rate was 69.1% after TF-TAVR and 57.0% after TA-TAVR (p = 0.006), whereas freedom from major adverse cardiovascular and cerebrovascular events was 61.9% after TF-TAVR and 50.4% after TA-TAVR (p = 0.011). In conclusion, TF-TAVR seems to be associated with significantly higher early and intermediate survival compared with TA-TAVR. The transfemoral approach, whenever feasible, should be considered the route of choice for TAVR.

Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement for Severe Aortic Stenosis in Patients With Chronic Kidney Disease Stages 3b to 5.

BACKGROUND: There are scarce data on outcomes after transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in patients with renal failure. METHODS: We evaluated the impact of renal failure on outcomes after TAVI and SAVR and compared the results of these procedures in patients with chronic kidney disease stages 3b to 5 from the Observational Study of Effectiveness of AVR-TAVI Procedures for Severe Aortic Stenosis Treatment (OBSERVANT) study. RESULTS: Chronic kidney disease (CKD) stages 3b to 5 was associated with an increased risk of mortality after either TAVI or SAVR compared with CKD stages 1 to 3a. Among 170 propensity score-matched pairs with CKD stages 3b to 5, patients who underwent TAVI had a significantly higher rate of permanent pacemaker implantation, vascular damage, and mild to moderate paravalvular regurgitation, and tended to have a higher 30-day mortality (7.1% versus 2.9%; p = 0.09). Thirty-day mortality after transapical TAVI was 7.1%. SAVR had a significantly higher rate of blood transfusions, stroke, and acute kidney injury. At 2 years, patients undergoing TAVI had somewhat higher all-cause mortality (31.2% versus 23.4%; p = 0.118), major cardiac and cerebrovascular events (37.2% versus 31.0%; p = 0.270), and a lower risk of dialysis (12.4% versus 21.2%; p = 0.052) compared with SAVR. CONCLUSIONS: CKD stages 3b to 5 increases the risk of mortality after TAVI and SAVR. In this subset of patients, SAVR was associated with somewhat better early and late survival. The risk of acute kidney injury was higher after SAVR. These findings suggest that CKD stages 3b to 5 does not contraindicate SAVR. Strategies to prevent severe acute kidney injury should be implemented with either SAVR or TAVI.

[Cognitive and quality of life trajectory after either surgical or transcatheter aortic valve replacement in high-risk patients]. / Evoluzione dello stato cognitivo e della qualità di vita in pazienti con stenosi aortica ad alto rischio clinico sottoposti a sostituzione valvolare chirurgica o per via transcatetere.

RATIONALE: The impact of transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (AVR) on cognitive status and quality of life in high-risk patients has been incompletely investigated. METHODS: We conducted a prospective, multicenter study including all patients treated with TAVI and high-risk patients undergoing AVR (age ≥80 years or logistic EuroSCORE ≥15%) at participating centers. Multidimensional geriatric evaluation including Mini Mental State Examination (MMSE), EuroQol 5D (EQ5D) and Minnesota Living With Heart Failure Questionnaire (MLHFQ) were performed at baseline and at 3- and 12-month follow-up. RESULTS: A total of 518 patients (151 AVR and 367 TAVI) were enrolled in 10 Italian institutions. Patients receiving AVR were older (82.7 ± 2.4 years), with a lower logistic EuroSCORE (12.5 ± 7.1%) as compared with TAVI patients (81.5 ± 6.2 years and 19.6 ± 14.0%, respectively, p=0.001 and p<0.001). Overall, 35.5% of patients showed some degree of cognitive impairment at baseline, with no differences between groups. No significant changes in the cognitive status were observed between baseline and follow-up and between groups at any time point. TAVI patients had a lower quality of life at baseline as compared with AVR patients. Generic and heart failure-related quality of life improved significantly after either procedure. CONCLUSIONS: In high-risk patients, both TAVI and AVR are associated with a significant improvement of quality of life up to 1 year without a detrimental effect on cognitive function.

Surgical treatment of an aneurysm originating from a Kommerell's diverticulum in the right-sided aortic arch with retroesophageal component.

We report the case of a 41-year-old man presenting with a large Kommerell's diverticulum aneurysm in the right-sided aortic arch with retroesophageal component and moderate thoracic aortic dilation. Surgical treatment was performed through left thoracotomy and consisted of aneurysmectomy, closure of the distal aortic arch defect and aorta-left subclavian artery bypass. After 2 years computed tomography showed no modifications in the thoracic aortic morphology and the patency of the graft to the subclavian artery.

1-Year Outcomes After Transfemoral Transcatheter or Surgical Aortic Valve Replacement: Results From the Italian OBSERVANT Study.

BACKGROUND: There is a paucity of prospective and controlled data on the comparative effectiveness of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in a real-world setting. OBJECTIVES: This analysis aims to describe 1-year clinical outcomes of a large series of propensity-matched patients who underwent SAVR and transfemoral TAVR. METHODS: The OBSERVANT (Observational Study of Effectiveness of SAVR-TAVI Procedures for Severe Aortic Stenosis Treatment) trial is an observational prospective multicenter cohort study that enrolled patients with aortic stenosis (AS) who underwent SAVR or TAVR. The propensity score method was applied to select 2 groups with similar baseline characteristics. All outcomes were adjudicated through a linkage with administrative databases. The primary endpoints of this analysis were death from any cause and major adverse cardiac and cerebrovascular events (MACCE) at 1 year. RESULTS: The unadjusted enrolled population (N = 7,618) included 5,707 SAVR patients and 1,911 TAVR patients. The matched population had a total of 1,300 patients (650 per group). The propensity score method generated a low-intermediate risk population (mean logistic EuroSCORE 1: 10.2 ± 9.2% vs. 9.5 ± 7.1%, SAVR vs. transfemoral TAVR; p = 0.104). At 1 year, the rate of death from any cause was 13.6% in the surgical group and 13.8% in the transcatheter group (hazard ratio [HR]: 0.99; 95% confidence interval [CI]: 0.72 to 1.35; p = 0.936). Similarly, there were no significant differences in the rates of MACCE, which were 17.6% in the surgical group and 18.2% in the transcatheter group (HR: 1.03; 95% CI: 0.78 to 1.36; p = 0.831). The cumulative incidence of cerebrovascular events, and rehospitalization due to cardiac reasons and acute heart failure was similar in both groups at 1 year. CONCLUSIONS: The results suggest that SAVR and transfemoral TAVR have comparable mortality, MACCE, and rates of rehospitalization due to cardiac reasons at 1 year. These data need to be confirmed in longer term and dedicated ongoing randomized trials.

Giant coronary artery fistula connecting the left coronary sinus with the superior atriocaval junction.

A left Valsalva sinus-right atriocaval junction giant congenital fistula was diagnosed in a young man with recent bacterial endocarditis. Surgical closure of the fistula was performed to correct the left-to-right shunt, to reduce the risk of recurrence of endocarditis and to prevent aortic root distortion. Surgery was preferred to percutaneous treatment because of the perceived risk of coronary complications. The dimensions of the residual chamber connected with the aortic root appeared unchanged at the 1-year follow-up echocardiography. Simple closure, with no procedure on the proximal coronary tract of the fistula may offer an effective and definitive correction of giant fistulas.

Reliability of new scores in predicting perioperative mortality after mitral valve surgery.

OBJECTIVE: The study was designed to validate euroSCORE II and ACEF (age, creatinine, and ejection fraction) scores in patients undergoing isolated or associated mitral valve surgery and compare them with logistic euroSCORE and Society of Thoracic Surgeons scores. METHODS: Data on 3441 consecutive patients undergoing isolated or associated mitral valve surgery in a 6-year period were retrieved from 3 prospective institutional databases. Discriminatory power was assessed with the C index. Calibration was evaluated with calibration curves and associated statistics. RESULTS: In-hospital mortality was 3.4%. Discriminatory power was uniformly good (for euroSCORE II: area under curve, 0.79; 95% confidence interval, 0.74-0.84; for logistic euroSCORE: area under the curve, 0.78; 95% confidence interval, 0.74-0.83; for ACEF: area under the curve, 0.73; 95% confidence interval, 0.69-0.79) but significantly higher in euroSCORE models (P < .05 for Delong, bootstrap, Venkatraman methods). Calibration pattern was slightly better for the ACEF score, although related summary statistics (unreliability, Hosmer-Lemeshow test, Spiegelhalter z-test for calibration accuracy) were not significant even for euroSCORE II. The euroSCORE II demonstrated a performance similar to Society of Thoracic Surgeons score. Logistic euroSCORE confirmed the progressive trend toward overprediction previously demonstrated in the general cardiac surgical population (summary statistics P < .05). Analysis of score performances in the surgical group studied showed results comparable to the global population. CONCLUSIONS: The euroSCORE II and ACEF scores are good predictors of perioperative mortality in patients undergoing isolated or associated mitral valve surgery, with better discrimination for the first and better calibration for the second. No algorithm seems suitable for risk estimation in mid and high-risk patients.

In-hospital mortality risk assessment in elective and non-elective cardiac surgery: a comparison between EuroSCORE II and age, creatinine, ejection fraction score.

OBJECTIVES: Age, creatinine, ejection fraction (ACEF) score is a simplified algorithm for prediction of mortality after elective cardiac surgery. Although mainly conceived for elective cardiac surgery, no information is available on its performance in non-elective surgery and on comparison with the new EuroSCORE II. This study was undertaken to compare the performance of ACEF score and EuroSCORE II within classes of urgency. METHODS: Complete data on 13 871 consecutive patients who underwent major cardiac surgery in a 6-year period were retrieved from three prospective institutional databases. Discriminatory power was assessed using the c-index and h with Delong, bootstrap and Venkatraman methods. Calibration was evaluated with calibration curves and associated statistics. RESULTS: The in-hospital mortality rate was 2.5%. The discriminatory power of ACEF score within elective and non-elective surgery was similar (area under the curve (AUC) 0.71, 95% confidence interval (CI) 0.67-0.74 and AUC 0.68, 95% CI 0.62-0.73, respectively) but significantly lower than that of EuroSCORE II (AUC 0.80, 95% CI 0.77-0.83 for elective surgery; AUC 0.82, 95% CI 0.78-0.85 for non-elective surgery). The calibration patterns were different in the two subgroups, but the summary statistics underscored a miscalibration in both of them (U-statistic and Spiegelhalter Z-test P-values <0.05). Even the calibration of EuroSCORE II was insufficient, although it was demonstrated to be well calibrated in the first tertile of predicted risk. CONCLUSIONS: This study demonstrated that the performance of ACEF score in predicting in-hospital mortality in elective and non-elective cardiac surgery is comparable. Nonetheless, it is not as satisfactory as the new EuroSCORE II, as its discrimination is significantly lower and it is also miscalibrated.

Effect of severe left ventricular systolic dysfunction on hospital outcome after transcatheter aortic valve implantation or surgical aortic valve replacement: results from a propensity-matched population of the Italian OBSERVANT multicenter study.

OBJECTIVE: Despite demonstration of the superior outcomes of transcatheter aortic valve implantation (TAVI) versus optimal medical therapy for severe left ventricular systolic dysfunction, studies comparing TAVI and surgical aortic valve replacement (AVR) in this high-risk group have been lacking. METHODS: We performed propensity matching for age, gender, baseline comorbidities, previous interventions, priority at hospital admission, frailty score, New York Heart Association class, EuroSCORE, and associated cardiac diseases. Next, the 30-day mortality and procedure-related morbidity of 162 patients (81 TAVI vs 81 AVR) with severe left ventricular systolic dysfunction (ejection fraction ≤ 35%) were analyzed at the Italian National Institute of Health. RESULTS: The 30-day mortality was comparable (P = .37) between the 2 groups. The incidence of periprocedural acute myocardial infarction (P = .55), low output state (P = .27), stroke (P = .36), and renal dysfunction (peak creatinine level, P = .57) was also similar between the 2 groups. TAVI resulted in significantly greater postprocedural permanent pacemaker implantation (P = .01) and AVR in more periprocedural transfusions (P < .01) despite a similar transfusion rate per patient (2.8 ± 3.7 for TAVI vs 4.4 ± 3.8 for AVR; P = .08). The postprocedural intensive care unit stay (median, 2 days after TAVI vs 3 days after AVR; P = .34), intermediate care unit stay (median, 0 days after both TAVI and AVR; P = .94), and hospitalization (median, 11 days after TAVI vs 14 days after AVR; P = .51) were comparable. CONCLUSIONS: In patients with severe left ventricular systolic dysfunction, both TAVI and AVR are valid treatment options, with comparable hospital mortality and periprocedural morbidity. Comparisons of the mid- to long-term outcomes are mandatory.