ABSTRACT
OBJECTIVES: Minimally invasive cardiac surgery techniques are increasingly used but have longer cardiopulmonary bypass time, which may increase inflammatory response and negatively affect coagulation. Our aim was to compare biomarkers of inflammation and coagulation as well as transfusion rates after minimally invasive mitral valve repair and mitral valve surgery using conventional sternotomy. DESIGN: A prospective non-randomized study was performed enrolling 71 patients undergoing mitral valve surgery (35 right mini-thoracotomy and 36 conventional sternotomy procedures). Blood samples were collected pre- and postoperatively to assess inflammatory response. Thromboelastometry (ROTEM) was performed to assess coagulation, and transfusion rates were monitored. RESULTS: The minimally invasive group had longer cardiopulmonary bypass times compared to the sternotomy group: 127 min ([115-146] vs 79 min [65-112], p < 0.001) and were cooled to a lower temperature during cardiopulmonary bypass, 34 °C vs 36 °C (p = 0.04). IL-6 was lower in the minimally invasive group compared to the conventional sternotomy group when measured at the end of the surgical procedure, (38 [23-69] vs 61[41-139], p = 0.008), but no differences were found at postoperative day 1 or postoperative day 3. The transfusion rate was lower in the minimally invasive group (14%) compared to full sternotomy (35%, p = 0.04) and the chest tube output was reduced, (395 ml [190-705] vs 570 ml [400-1040], p = 0.04). CONCLUSIONS: Our data showed that despite the longer use of extra corporal circulation during surgery, minimally invasive mitral valve repair is associated with reduced inflammatory response, lower rates of transfusion, and reduced chest tube output.
Subject(s)
Biomarkers , Blood Coagulation , Blood Transfusion , Cardiopulmonary Bypass , Inflammation Mediators , Mitral Valve , Sternotomy , Thoracotomy , Humans , Prospective Studies , Female , Male , Biomarkers/blood , Middle Aged , Mitral Valve/surgery , Mitral Valve/physiopathology , Inflammation Mediators/blood , Cardiopulmonary Bypass/adverse effects , Aged , Treatment Outcome , Time Factors , Sternotomy/adverse effects , Thoracotomy/adverse effects , Thrombelastography , Interleukin-6/blood , Inflammation/blood , Inflammation/etiology , Inflammation/diagnosis , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Diseases/surgery , Heart Valve Diseases/blood , Risk FactorsABSTRACT
Background. Surgery for acute type A aortic dissection confers a risk for significant bleeding. We analyzed the impact of massive bleeding on complications after surgery for acute type A aortic dissection. Methods. Patients undergoing surgery for acute type A aortic dissection from the retrospective multicenter Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database 2005-2014 were eligible. Massive bleeding was defined according to the Universal Definition of Perioperative Bleeding. The primary outcome measure was early mortality and secondary outcome measures were perioperative stroke, mechanical ventilation more than 48 h, new-onset dialysis, and intensive care unit stay. Propensity score matching was performed to adjust for differences in covariates. Results. Nine hundred ninety-seven patients were included, of whom 403 (40.4%) had massive bleeding. In the propensity score-matched cohort (344 pairs), patients with massive bleeding had higher 30-day mortality (17.2 versus 7.6%, p < .001), mechanical ventilation more than 48 h (52.8 versus 22.6%, p < .001), perioperative stroke (24.3 versus 14.8%, p = .002), new-onset dialysis (22.5 versus 4.9%, p < .001), and longer intensive care unit stay (6 versus 3 days, p < .001), compared with patients without massive bleeding. Risk factors for massive bleeding were previous cardiac surgery, preoperative clopidogrel or ticagrelor therapy, DeBakey type I dissection, and localized or generalized malperfusion. Conclusions. Massive bleeding in surgery for acute type A aortic dissection is associated with a markedly increased risk for severe complications as well as early death. Further improvement of surgical technique and pharmacological optimization of coagulation is paramount to possibly improve outcomes in acute type A aortic dissection repair.
Subject(s)
Aortic Aneurysm , Aortic Dissection , Databases, Factual , Postoperative Hemorrhage , Respiration, Artificial , Humans , Aortic Dissection/surgery , Aortic Dissection/mortality , Aortic Dissection/complications , Male , Female , Retrospective Studies , Middle Aged , Risk Factors , Aged , Treatment Outcome , Time Factors , Aortic Aneurysm/surgery , Aortic Aneurysm/mortality , Aortic Aneurysm/complications , Risk Assessment , Postoperative Hemorrhage/mortality , Postoperative Hemorrhage/etiology , Acute Disease , Scandinavian and Nordic Countries/epidemiology , Length of Stay , Renal Dialysis , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/mortalityABSTRACT
OBJECTIVES: To investigate outcome after septal myectomy and to evaluate long-term hemodynamics with exercise echocardiography. METHODS: This study included 40 consecutive patients operated with septal myectomy for hypertrophic obstructive cardiomyopathy from January 1998 to August 2017 at Skane University Hospital, Lund, Sweden. Perioperative clinical data and echocardiography measurements were reviewed retrospectively. Patients (n = 36) who were alive and living in Sweden were invited for exercise echocardiography to evaluate exercise capacity and hemodynamics, of whom 19 patients performed exercise echocardiography. RESULTS: Overall survival was 100% at 1 year and 96% at 5 years following surgery. Preoperative median resting peak LVOT (left ventricular outflow tract) gradient was 80 mm Hg. Septum thickness was reduced from 22 ± 4 mm preoperatively to 16 ± 3 mm postoperatively (p < 0.001). During exercise echocardiography, the peak LVOT gradient was 8 mm Hg at rest, and increased to 13 mm Hg during exercise echocardiography (p = 0.002). None of the patients had dynamic LVOT obstruction during exercise echocardiography, and there was no clinically significant systolic anterior motion or severe mitral insufficiency during exercise. CONCLUSIONS: Long-term survival following septal myectomy is very good. At long-term follow-up, LVOT gradients were low and exercise echocardiography demonstrated good hemodynamics.
Subject(s)
Cardiomyopathy, Hypertrophic , Ventricular Outflow Obstruction , Cardiomyopathy, Hypertrophic/diagnostic imaging , Cardiomyopathy, Hypertrophic/surgery , Echocardiography , Heart Septum/diagnostic imaging , Heart Septum/surgery , Humans , Retrospective Studies , Treatment Outcome , Ventricular Outflow Obstruction/diagnostic imaging , Ventricular Outflow Obstruction/etiology , Ventricular Outflow Obstruction/surgeryABSTRACT
Patients undergoing surgical aortic valve replacement (SAVR) are at high risk for atrial fibrillation (AF) and stroke after surgery. There is an unmet clinical need to improve stroke prevention in this patient population. The LAA-CLOSURE trial aims to assess the efficacy and safety of prophylactic surgical closure of the left atrial appendage for stroke and cardiovascular death prevention in patients undergoing bioprosthetic SAVR. This randomized, open-label, prospective multicenter trial will enroll 1,040 patients at 13 European sites. The primary endpoint is a composite of cardiovascular mortality, stroke and systemic embolism at 5 years. Secondary endpoints include cardiovascular mortality, stroke, systemic embolism, bleed fulfilling academic research consortium (BARC) criteria, hospitalization for decompensated heart failure and health economic evaluation. Sample size is based on 30% risk reduction in time to event analysis of primary endpoint. Prespecified reports include 30-day safety analysis focusing on AF occurrence and short-term outcomes and interim analyses at 1 and 3 years for primary and secondary outcomes. Additionally, substudies will be performed on the completeness of the closure using transesophageal echocardiography/cardiac computed tomography and long-term ECG recording at one year after the operation.
Subject(s)
Atrial Appendage/surgery , Bioprosthesis/adverse effects , Cardiac Surgical Procedures/methods , Stroke/prevention & control , Aged , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/surgery , Atrial Fibrillation/complications , Atrial Fibrillation/surgery , Echocardiography, Transesophageal , Female , Follow-Up Studies , Heart Valve Prosthesis Implantation/adverse effects , Humans , Male , Prospective Studies , Stroke/diagnosis , Stroke/etiologyABSTRACT
BACKGROUND: Circulating soluble urokinase plasminogen activator receptor (suPAR) is a marker of inflammation with prognostic value for elevated risk of morbidity and mortality. It has not yet been shown how the inflammatory process induced by cardiac surgery affects suPAR concentrations postoperatively. METHODS: In a prospective observational study, plasma suPAR levels were measured in 30 patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), pre-, peri, post-operatively, and 3-5 days after surgery. Fifteen patients underwent coronary artery bypass grafting (CABG) and 15 underwent complex procedures with longer CPB duration. Concentrations of suPAR at each time point were compared to the preoperative levels and compared between the two groups. RESULTS: In both groups, plasma suPAR concentrations were significantly higher on the first postoperative day (3.27 (interquartile range (IQR) 2.75-3.86) µg/L compared to baseline (2.62 (1.98-3.86)) µg/L, p < .001. There were no significant differences in suPAR concentrations between the groups at any time point. Preoperatively, the median suPAR concentration was 2.57 (2.01-3.60) µg/L in the CABG group versus 2.67 (1.89-3.97) µg/L in the complex group (p = .567). At ICU arrival 2.48 (2.34-3.23) µg/L versus 2.73 (2.28-3.44) µg/L in CABG and complex patients, respectively (p = .914). There was no difference in suPAR concentrations between the groups on postoperative day 1 (3.34 (2.89-3.89) versus 3.19 (2.57-3.62) p = .967) or 3-5 days after surgery (2.72 (1.98-3.16) versus 2.96 (2.39-4.28) p = .085. CONCLUSIONS: After a transient rise on the first postoperative day, the suPAR levels returned to the preoperative levels by the third postoperative day. There was no significant difference in suPAR levels between the routine CABG and complex group with longer CPB time.
Subject(s)
Cardiac Surgical Procedures , Receptors, Urokinase Plasminogen Activator , Biomarkers , Cardiac Surgical Procedures/adverse effects , Cardiopulmonary Bypass/adverse effects , Humans , PrognosisABSTRACT
OBJECTIVES: To explore the preoperative, intraoperative, and postoperative dynamics of heparin-binding protein (HBP) in cardiothoracic surgery. DESIGN: This was a prospective, observational study. SETTING: The study was conducted at a single university hospital. PARTICIPANTS: Thirty patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) were included, 15 of whom underwent coronary artery bypass grafting surgery and 15 of whom underwent complex procedures. Ten patients undergoing lung surgery also were included as a conventional surgery reference group. INTERVENTIONS: No interventions were performed. MEASUREMENTS AND MAIN RESULTS: HBP was measured at nine different perioperative times. HBP levels increased immediately after heparin administration, further increased during CPB, but decreased rapidly after protamine administration. At arrival to the intensive care unit, median HBP levels were 24.8 (15.6-38.1) ng/mL for coronary artery bypass grafting patients and 51.2 (34.0-117.7) ng/mL for complex surgery patients (pâ¯=â¯0.011). One day after surgery, HBP levels in all three groups were below the proposed cutoff of 30 ng/mL, which previously was found to predict development of organ dysfunction in patients with infection. CONCLUSIONS: HBP levels are elevated by the administration of heparin and the use of CPB but reduced by protamine administration. At postoperative day one, HBP levels were less than the threshold for organ dysfunction in patients with infection. The usefulness of HBP for predicting postoperative infections in cardiothoracic surgery should be investigated in future studies.
Subject(s)
Cardiopulmonary Bypass , Heparin , Antimicrobial Cationic Peptides , Blood Proteins , Humans , Pilot Projects , Prospective StudiesABSTRACT
Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate.
Subject(s)
Aortic Aneurysm/surgery , Aortic Dissection/surgery , Blood Vessel Prosthesis Implantation , Endovascular Procedures , Acute Disease , Aortic Dissection/diagnostic imaging , Aortic Dissection/mortality , Aortic Dissection/physiopathology , Aortic Aneurysm/diagnostic imaging , Aortic Aneurysm/mortality , Aortic Aneurysm/physiopathology , Blood Vessel Prosthesis , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/mortality , Endovascular Procedures/adverse effects , Endovascular Procedures/instrumentation , Endovascular Procedures/mortality , Humans , Postoperative Complications/mortality , Risk Factors , Stents , Time Factors , Treatment OutcomeABSTRACT
Objectives. To evaluate the distribution and impact of ABO blood groups on postoperative outcomes in patients undergoing surgery for acute type A aortic dissection (ATAAD). Design. A total of 1144 surgical ATAAD patients from eight Nordic centres constituting the Nordic consortium for acute type A aortic dissection (NORCAAD) were analysed. Blood group O patients were compared to non-O subjects. The relative frequency of blood groups was assessed with t-distribution, modified for weighted proportions. Multivariable logistic regression was performed to identify independent predictors of 30-day mortality. Cox regression analyses were performed for assessing independent predictors of late mortality. Results. There was no significant difference in the proportions of blood group O between the study populations in the NORCAAD registry and the background population (40.6 (95% CI 37.7-43.4)% vs 39.0 (95% CI 39.0-39.0)%). ABO blood group was not associated with any significant change in risk of 30-day or late mortality, with the exception of blood group A being an independent predictor of late mortality. Prevalence of postoperative complications was similar between the ABO blood groups. Conclusions. In this large cohort of Nordic ATAAD patients, there were no associations between ABO blood group and surgical incidence or outcomes, including postoperative complications and survival.
Subject(s)
ABO Blood-Group System , Aortic Aneurysm/surgery , Aortic Dissection/surgery , Vascular Surgical Procedures , Acute Disease , Aged , Aortic Dissection/blood , Aortic Dissection/diagnostic imaging , Aortic Dissection/mortality , Aortic Aneurysm/blood , Aortic Aneurysm/diagnostic imaging , Aortic Aneurysm/mortality , Female , Humans , Incidence , Male , Middle Aged , Postoperative Cognitive Complications/mortality , Prevalence , Retrospective Studies , Risk Factors , Scandinavian and Nordic Countries/epidemiology , Time Factors , Treatment Outcome , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/mortalityABSTRACT
Shrunken pore syndrome (SPS) is a condition in which estimated glomerular filtration rate (eGFR) based upon cystatin C is lower than eGFR based upon creatinine. It has been associated with increased mortality even in the presence of normal GFR in both a cardiac surgical population and a general population. No systematic studies of the variation in eGFRcystatin C/eGFRcreatinine-ratio used for SPS diagnosis have been published. This study aims to evaluate whether early and midterm mortality following elective cardiac surgery varies with the ratio used to identify SPS. Preoperative levels of cystatin C and creatinine were analysed in 4007 patients undergoing elective coronary artery bypass grafting (CABG) and/or surgical aortic valve replacement (sAVR). The eGFRcystatin C/eGFRcreatinine-ratio was calculated based on the equation pairs CKD-EPIcystatin C/CKD-EPIcreatinine and CAPA/LMrev. The overall 1- and 3-year all-cause mortality was 2.9 and 6.8%, respectively. Mean follow-up time was 3.6 years. Mortality markedly and progressively increased with a decrease in the eGFRcystatin C/eGFRcreatinine-ratio for both equation pairs. An increase in mortality was noted already when the ratio decreased from 1.0 to 0.90. To facilitate the clinical decisions based upon the SPS-defining eGFRcystatin C/eGFRcreatinine-ratio, we calculated both the ratios defining the highest combined sensitivity and specificity and the ratios producing a high specificity of 95%, finding different cut-off for these scenarios.
Subject(s)
Cardiac Surgical Procedures/mortality , Creatinine/blood , Cystatin C/blood , Glomerular Filtration Rate , Adult , Aged , Cohort Studies , Female , Humans , Male , ROC Curve , Renal Insufficiency, Chronic/blood , Renal Insufficiency, Chronic/epidemiology , Sensitivity and Specificity , SyndromeABSTRACT
OBJECTIVE: To evaluate the hemostatic system in patients undergoing surgery for acute type A aortic dissection (ATAAD) compared with those undergoing elective aortic procedures. DESIGN: This was a prospective, observational study. SETTING: The study was performed at a single university hospital. PARTICIPANTS: Twenty-five patients with ATAAD were compared with 20 control patients undergoing elective surgery of the ascending aorta or the aortic root. INTERVENTIONS: No interventions were performed. MEASUREMENTS AND MAIN RESULTS: Platelet count and levels of fibrinogen, D-dimer, prothrombin time/international normalized ratio, activated partial thromboplastin time, and antithrombin were analyzed perioperatively and compared between the 2 groups. Patients with ATAAD had lower preoperative levels of platelets (188 [156-217]â¯×â¯109/L v 221 [196-240]â¯×â¯109/L; pâ¯=â¯0.018), fibrinogen (1.9 [1.6-2.4] g/L v 2.8 [2.2-3.0] g/L; pâ¯=â¯0.003), and antithrombin (0.81 [0.73-0.94] kIU/L v 0.96 [0.92-1.00] kIU/L; pâ¯=â¯0.003) and significantly higher levels of D-dimer (2.9 [1.7-9.7] mg/L v 0.1 [0.1-0.2] mg/L; p < 0.001) and prothrombin time/international normalized ratio (1.15 [1.1-1.2] v 1.0 [0.93-1.0]; pâ¯=â¯0.001). Surgery caused significant changes of the coagulation system in both groups. Intraoperative bleeding volumes were larger in the ATAAD group (2,407 [1,804-3,209] mL v 1,212 [917-1,920] mL; p < 0.001), and patients undergoing ATAAD surgery received significantly more transfusions of red blood cells (2.5 [0.25-4.75] U v 0 [0-2.75] U; pâ¯=â¯0.022), platelets (4 [3.25-6] U v 2 [2-4] U; pâ¯=â¯0.002), and plasma (2 [0-4] U v 0 [0-0] U; pâ¯=â¯0.004) compared with the elective group. CONCLUSIONS: This study demonstrates that ATAAD is associated with a coagulopathic state. Surgery causes additional damage to the hemostatic system in ATAAD patients, but also in patients undergoing elective surgery of the ascending aorta or the aortic root.
Subject(s)
Aortic Aneurysm, Thoracic/surgery , Aortic Dissection/surgery , Blood Coagulation Disorders/etiology , Vascular Grafting/adverse effects , Acute Disease , Aged , Aortic Dissection/blood , Aorta/surgery , Aortic Aneurysm, Thoracic/blood , Blood Coagulation Disorders/blood , Blood Coagulation Tests/methods , Blood Loss, Surgical , Blood Transfusion/methods , Blood Transfusion/statistics & numerical data , Case-Control Studies , Female , Fibrin Fibrinogen Degradation Products/metabolism , Fibrinogen/metabolism , Humans , Male , Middle Aged , Platelet Count , Postoperative Complications/blood , Postoperative Complications/etiology , Prospective Studies , Vascular Grafting/methodsABSTRACT
OBJECTIVE: In patients presenting with acute type-A aortic dissection (aTAAD), lactic acid measurement is a frequently used analysis for diagnosis of acute ischemia, which may have a dismal prognosis. The aim of the current study was to determine the performance of perioperative arterial lactic acid measurements in predicting outcome in aTAAD patients. DESIGN: Retrospective, observational study. SETTING: Cardiothoracic surgery unit at a tertiary-level hospital. PARTICIPANTS: The study involved 285 consecutive patients undergoing surgery for aTAAD. INTERVENTIONS: Preoperative and postoperative lactic acid levels were measured and evaluated together with clinical data related to outcome, including in-hospital and 1-year mortality. MEASUREMENTS AND MAIN RESULTS: Altogether, 37 patients (13%) died during the index hospital admission, and survival was 84.4 ± 2.2 at 1 year. Preoperative cardiac malperfusion (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.3-7.3) and cerebral malperfusion (OR 2.6; 95% CI 1.2-5.6) were associated significantly with poorer 1-year survival. The area under the curve (AUC) for in-hospital and 1-year mortality in relation to preoperative lactic acid levels was 0.684 and 0.673, respectively, corresponding to a lactic acid cut-off for in-hospital mortality of 2.75 mmol/L (sensitivity 56%; specificity 72%) and a cut-off for 1-year mortality of 2.85 mmol/L (sensitivity 48%; specificity 74%). The AUC for in-hospital and 1-year mortality in relation to lactic acid levels measured postoperatively on arrival at the intensive care unit was 0.582 and 0.498, respectively. CONCLUSION: Although hyperlactemia in aTAAD indicates an increased risk of postoperative mortality, the sole use of lactic acid levels as a tool for accurate assessment of postoperative mortality is inadvisable due to its poor discriminatory performance.
Subject(s)
Aortic Aneurysm, Thoracic/blood , Aortic Dissection/blood , Hyperlactatemia/blood , Vascular Surgical Procedures , Acute Disease , Aortic Dissection/mortality , Aortic Dissection/surgery , Aortic Aneurysm, Thoracic/mortality , Aortic Aneurysm, Thoracic/surgery , Biomarkers/blood , Female , Follow-Up Studies , Humans , Hyperlactatemia/epidemiology , Hyperlactatemia/etiology , Incidence , Lactic Acid/blood , Male , Middle Aged , Perioperative Period , Prognosis , Retrospective Studies , Survival Rate/trends , Sweden/epidemiology , Time FactorsABSTRACT
BACKGROUND: In the evolving field of transcatheter aortic valve replacements a new generation of valves have been introduced to clinical practice. With the complexity of the TAVR procedure and the unique aspects of each TAVR device, there is a perceived risk that changing or adding a new valve in a department could lead to a worse outcome for patients, especially during the learning phase. The objective was to study the safety aspect of introducing a second generation repositionable transcatheter valve (Boston Scientific Lotus valve besides Edwards Sapien valve) in a department. METHODS: In a retrospective study, 53 patients receiving the Lotus system, and 47 patients receiving the Sapien system over a period of three years were compared for short-term outcome according to VARC-2 definitions and 1-year survival. RESULTS: Outcome in terms VARC-2 criteria for early safety and clinical efficacy, stroke rate, and survival at 30 days and at 1 year were similar. The Lotus valve had less paravalvular leakage, where 90% had none or trace aortic insufficiency as compared to only 48% for the Sapien system. CONCLUSIONS: Introduction of a new generation valve can be done with early device success and safety, and without jeopardizing the outcome for patients up to one year. We found no adverse effects by changing valve type and observed improved outcome in terms of lower PVL-rates. Both existing and new centers starting a TAVR program can benefit from the use of a new generation device.
Subject(s)
Aortic Valve Stenosis/surgery , Heart Valve Prosthesis , Transcatheter Aortic Valve Replacement/instrumentation , Aged , Aged, 80 and over , Aortic Valve/surgery , Aortic Valve Stenosis/diagnosis , Equipment Design , Female , Humans , Male , Prosthesis Design , Retrospective Studies , Treatment OutcomeABSTRACT
OBJECTIVES: The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) is a collaborative effort of Nordic cardiac surgery centers to study acute type A aortic dissection (ATAAD). Here, we outline the overall objectives and the design of NORCAAD. DESIGN: NORCAAD currently consists of eight centers in Denmark, Finland, Iceland and Sweden. Data was collected for patients undergoing surgery for ATAAD from 2005 to 2014. A total of 194 variables were retrospectively collected including demographics, past medical history, preoperative medications, symptoms at presentation, operative variables, complications, bleeding and blood transfusions, need for late reoperations, 30-day mortality and long-term survival. RESULTS: Information was gathered in the database for 1159 patients, of which 67.6% were male. The mean age was 61.5 ± 12.1 years. The mean follow-up was 3.1 ± 2.9 years with a total of 3535 patient years. CONCLUSIONS: NORCAAD provides a foundation for close collaboration between cardiac surgery centers in the Nordic countries. Substudies in progress include: short-term outcomes, long-term survival, time interval from diagnosis until operation, effects of surgical techniques, malperfusion syndrome, renal failure, bleeding and neurological complications on outcomes and the rate of late reoperations.
Subject(s)
Aortic Aneurysm/surgery , Aortic Dissection/surgery , Research Design , Vascular Surgical Procedures , Acute Disease , Aged , Aortic Dissection/diagnosis , Aortic Dissection/mortality , Aortic Aneurysm/diagnosis , Aortic Aneurysm/mortality , Blood Transfusion , Databases, Factual , Female , Humans , International Cooperation , Male , Middle Aged , Postoperative Complications/etiology , Postoperative Complications/mortality , Postoperative Complications/surgery , Reoperation , Retrospective Studies , Risk Assessment , Risk Factors , Scandinavian and Nordic Countries/epidemiology , Time Factors , Treatment Outcome , Vascular Surgical Procedures/adverse effects , Vascular Surgical Procedures/mortalityABSTRACT
OBJECTIVES: Early identification of patients with infection and at risk of developing severe disease with organ dysfunction remains a difficult challenge. We aimed to evaluate and validate the heparin-binding protein, a neutrophil-derived mediator of vascular leakage, as a prognostic biomarker for risk of progression to severe sepsis with circulatory failure in a multicenter setting. DESIGN: A prospective international multicenter cohort study. SETTING: Seven different emergency departments in Sweden, Canada, and the United States. PATIENTS: Adult patients with a suspected infection and at least one of three clinical systemic inflammatory response syndrome criteria (excluding leukocyte count). INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Plasma levels of heparin-binding protein, procalcitonin, C-reactive protein, lactate, and leukocyte count were determined at admission and 12-24 hours after admission in 759 emergency department patients with suspected infection. Patients were defined depending on the presence of infection and organ dysfunction. Plasma samples from 104 emergency department patients with suspected sepsis collected at an independent center were used to validate the results. Of the 674 patients diagnosed with an infection, 487 did not have organ dysfunction at enrollment. Of these 487 patients, 141 (29%) developed organ dysfunction within the 72-hour study period; 78.0% of the latter patients had an elevated plasma heparin-binding protein level (>30 ng/mL) prior to development of organ dysfunction (median, 10.5 hr). Compared with other biomarkers, heparin-binding protein was the best predictor of progression to organ dysfunction (area under the receiver operating characteristic curve=0.80). The performance of heparin-binding protein was confirmed in the validation cohort. CONCLUSION: In patients presenting at the emergency department, heparin-binding protein is an early indicator of infection-related organ dysfunction and a strong predictor of disease progression to severe sepsis within 72 hours.
Subject(s)
Antimicrobial Cationic Peptides/blood , Carrier Proteins/blood , Cause of Death , Emergency Service, Hospital , Multiple Organ Failure/blood , Sepsis/blood , Adult , Aged , Area Under Curve , Biomarkers/blood , Blood Proteins , C-Reactive Protein/metabolism , Calcitonin/blood , Calcitonin Gene-Related Peptide , Canada , Cohort Studies , Critical Illness/mortality , Critical Illness/therapy , Female , Hospital Mortality/trends , Humans , Internationality , Male , Middle Aged , Multiple Organ Failure/mortality , Multiple Organ Failure/physiopathology , Predictive Value of Tests , Prospective Studies , Protein Precursors/blood , Risk Assessment , Sepsis/mortality , Sepsis/therapy , Survival Analysis , Sweden , Systemic Inflammatory Response Syndrome/blood , Systemic Inflammatory Response Syndrome/mortality , Systemic Inflammatory Response Syndrome/therapy , Treatment Outcome , United StatesABSTRACT
OBJECTIVE: Recent studies indicate acceptable survival rates in elderly patients treated surgically for acute type A aortic dissection (aTAAD). However, the impact of preoperative hemodynamic compromise or organ malperfusion on outcomes of such patients is still unclear. METHODS: In a retrospective study of 341 patients, 101 qualified as elderly (≥70 years old). Subjects were further grouped by clinical presentation, using the Penn classification. Univariate and multivariable analyses were conducted to identify variables reflecting in-hospital and long-term mortality. RESULTS: Relative to younger subjects, elderly patients showed significantly higher rates of in-hospital mortality (24.8% vs. 14.6%, p = 0.025) and DeBakey type 2 dissections at presentation (40% vs. 18% p < 0.001), with significantly fewer presenting as Penn class Ab (p = 0.010). Penn class Ac was identified as an independent predictor of in-hospital mortality at all ages. Estimated long-term survival was poorer in the elderly (log rank p < 0.001); but in-hospital mortality, based on Penn classification, was similar for both age groups. Survival rates of Penn class Aa subjects at one, five, and 10 years were lower in elderly (vs. younger) patients (79 ± 5.6% vs. 90 ± 2.7%, 68 ± 6.7% vs. 80 ± 3.9%, and 39 ± 10.3% vs. 75 ± 4.6%, respectively; log rank p < 0.001). CONCLUSION: Overall in-hospital mortality is higher in elderly patients surgically treated for aTAAD. Malperfusion and/or hemodynamic instability at presentation confer a dismal prognosis, independent of patient age.
Subject(s)
Aortic Aneurysm/physiopathology , Aortic Aneurysm/surgery , Aortic Dissection/physiopathology , Aortic Dissection/surgery , Blood Circulation , Hemodynamics , Age Factors , Aged , Analysis of Variance , Aortic Dissection/classification , Aortic Dissection/mortality , Aortic Aneurysm/classification , Aortic Aneurysm/mortality , Female , Hospital Mortality , Humans , Male , Middle Aged , Preoperative Period , Prognosis , Retrospective Studies , Survival Rate , Time Factors , Treatment OutcomeABSTRACT
BACKGROUND AND AIM OF THE STUDY: The logistic EuroSCORE and STS score have been used for the selection of suitable TAVI patients, but their predictive ability is unsatisfactory. The study aim was to evaluate the performance of the EuroSCORE II in predicting 30-day mortality after TAVI in comparison to the logistic EuroSCORE and STS scoring systems. METHODS: Between January 2008 and April 2013, a total of 123 consecutive patients underwent TAVI (transapical, n = 85; transfemoral, n = 38) at the authors' institution. Calibration and discriminatory ability was evaluated for three risk scores models (logistic EuroSCORE, STS score, and EuroSCORE II), and compared for the prediction of 30-day mortality using the Hosmer-Lemeshow test for goodness-of-fit and receiver operating characteristics curve analysis. RESULTS: The overall 30-day mortality was 4.1% (5/123). Predicted mortality was 25.0 ± 15.7% by logistic EuroSCORE, 7.3 ± 6.9% by STS score, and 7.8 ± 8.7% by EuroSCORE II. The observed/expected mortality ratio was 0.16 for logistic EuroSCORE, 0.56 for STS score, and 0.52 for EuroSCORE II. The area under the curve was 0.69 (95% CI 0.54-0.84) for the logistic EuroSCORE, 0.60 (95% CI 0.38-0.82) for the STS score, and 0.66 (95% CI 0.46-0.86) for the EuroSCORE II. CONCLUSION: In the present study, the EuroSCORE II was found to predict 30-day mortality more accurately for the TAVI cohort than did the more established logistic EuroSCORE, and also to compare (at present) on a par with the STS score. However, there were no differences in discriminatory power between the models. It is believed that, in the absence of a more TAVI-oriented risk stratification system, the EuroSCORE II may be a valuable adjunct in the clinical setting.
Subject(s)
Aortic Valve Stenosis/surgery , Risk Assessment/statistics & numerical data , Transcatheter Aortic Valve Replacement/mortality , Aged , Aged, 80 and over , Aortic Valve Stenosis/mortality , Cause of Death , Discriminant Analysis , Female , Humans , Logistic Models , Male , Retrospective Studies , Severity of Illness IndexABSTRACT
BACKGROUND: To assess whether retrograde cerebral perfusion reduces neurological injury and mortality in patients undergoing surgery for acute type A aortic dissection. METHODS: Single-center, retrospective, observational study including all patients undergoing acute type A aortic dissection repair with deep hypothermic circulatory arrest between January 1998 and December 2022 with or without the adjunct of retrograde cerebral perfusion. 515 patients were included: 257 patients with hypothermic circulatory arrest only and 258 patients with hypothermic circulatory arrest and retrograde cerebral perfusion. The primary endpoints were clinical neurological injury, embolic lesions, and watershed lesions. Multivariable logistic regression was performed to identify independent predictors of the primary outcomes. Survival analysis was performed using Kaplan-Meier estimates. RESULTS: Clinical neurological injury and embolic lesions were less frequent in patients with retrograde cerebral perfusion (20.2% vs. 28.4%, p = 0.041 and 13.7% vs. 23.4%, p = 0.010, respectively), but there was no significant difference in the occurrence of watershed lesions (3.0% vs. 6.1%, p = 0.156). However, after multivariable logistic regression, retrograde cerebral perfusion was associated with a significant reduction of clinical neurological injury (OR: 0.60; 95% CI 0.36-0.995, p = 0.049), embolic lesions (OR: 0.55; 95% CI 0.31-0.97, p = 0.041), and watershed lesions (OR: 0.25; 95%CI 0.07-0.80, p = 0.027). There was no significant difference in 30-day mortality (12.8% vs. 11.7%, p = ns) or long-term survival between groups. CONCLUSION: In this study, we showed that the addition of retrograde cerebral perfusion during hypothermic circulatory arrest in the setting of acute type A aortic dissection repair reduced the risk of clinical neurological injury, embolic lesions, and watershed lesions.
Subject(s)
Aortic Dissection , Cerebrovascular Circulation , Circulatory Arrest, Deep Hypothermia Induced , Perfusion , Humans , Aortic Dissection/surgery , Female , Male , Circulatory Arrest, Deep Hypothermia Induced/methods , Retrospective Studies , Middle Aged , Perfusion/methods , Cerebrovascular Circulation/physiology , Aged , Postoperative Complications/prevention & control , Aortic Aneurysm, Thoracic/surgeryABSTRACT
OBJECTIVES: It has been commonly accepted that untreated acute type A aortic dissection (ATAAD) results in an hourly mortality rate of 1-2% during the 1st 24 h after symptom onset. The data to support this statement rely solely on patients who have been denied surgical treatment after reaching surgical centres. The objective was to perform a total review of non-surgically treated (NST) ATAAD and provide contemporary mortality data. METHODS: This was a regional, retrospective, observational study. All patients receiving one of the following diagnoses: International Classification of Diseases (ICD)-9 4410, 4411, 4415, 4416 or ICD-10 I710, I711, I715, I718 in an area of 1.9 million inhabitants in Southern Sweden during a period of 23 years (January 1998 to November 2021) were retrospectively screened. The search was conducted using all available medical registries so that every patient diagnosed with ATAAD in our region was identified. The charts and imaging of each screened patient were subsequently reviewed to confirm or discard the diagnosis of ATAAD. RESULTS: Screening identified 2325 patients, of whom 184 NST ATAAD patients were included. The mortality of NST ATAAD was 47.3 ± 4.4%, 55.0 ± 4.4%, 76.7 ± 3.7% and 83.9 ± 4.3% at 24 h, 48 h, 14 days and 1 year, respectively. The hourly mortality rate during the 1st 24 h after symptom onset was 2.6%. CONCLUSIONS: This study observed higher mortality than has previously been reported. It emphasizes the need for timely diagnosis, swift management and emergent surgical treatment for patients suffering an acute type A aortic dissection.
Subject(s)
Aortic Aneurysm, Thoracic , Aortic Dissection , Humans , Retrospective Studies , Aortic Dissection/surgery , Treatment Outcome , Time Factors , Registries , Acute Disease , Aortic Aneurysm, Thoracic/diagnosis , Aortic Aneurysm, Thoracic/surgeryABSTRACT
Objective: Mitral valve reconstruction in the pediatric population is a challenge due to the frequent combination of annular dilatation and leaflet restriction and the need for growth. We present a novel strategy using leaflet expansion and subpartial annuloplasty with polytetrafluoroethylene reinforcement. Methods: From January 2014 through May 2021, 11 children aged 5 months to 14 years (median, 24 months) underwent elective mitral valve repair due to severe mitral valve regurgitation. The mitral valve abnormalities included congenital malformations (n = 7), postoperative leakage following commissurotomy (n = 1), and functional mitral valve regurgitation due to dilated cardiomyopathy (n = 3). Surgery consisted of leaflet expansions with autologous, untreated pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement. Results: All children survived their surgeries with uneventful postoperative courses, except for 1 patient who needed an early reoperation to resolve a functional stenosis due to a spinnaker phenomenon. At discharge, mean gradient was 3.5 ± 3.9 mm Hg, with trivial mitral regurgitation in 9 patients (82%). All patients were alive and asymptomatic during the median follow-up of 3 years (range, 1-7 years). Their echocardiographic data showed a mean transmitral gradient of 4.4 ± 1.7 mm Hg and remained unchanged. Residual mitral valve regurgitation was trivial or mild in 9 patients (82%) and moderate in 2 patients (18%). Conclusions: Leaflet expansion with autologous pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement for mitral regurgitation in the pediatric population gives stable and satisfactory results both early and at intermediate follow-up, permitting growth of the mitral valve.