Sex-related difference in outcomes after aortic root replacement.

PURPOSE: Poorer short-term outcomes have been described for females after cardiovascular surgery. We examined the influence of sex on the outcomes after aortic root replacement (ARR). METHODS: Medical records of 848 patients (females, n = 159/848, 19%) who underwent ARR at our center from 2005 to 2018 were retrospectively reviewed. Sex differences of the following outcomes were analyzed: the primary end point (in-hospital mortality or stro111ke), secondary end point (new requirement for permanent pacemaker), and long-term survival (median follow-up 21.4 months [interquartile range,1.3-60.0]). RESULTS: Females were significantly older (61.3 vs 58.7 [male]) with higher rates of pre-existing cerebrovascular disease (14% [22/159] vs 7% [52/689]) and previous valve intervention (20% [32/159] vs 13% [89/689]) but less myocardial infarction [1%(1/159) vs 7%(48/689)]. The surgical indication was different (aneurysm 75% [120/159] vs 87% [602/689], dissection 13% [21/159] vs 6% [41/689]; P < .01]). Females had larger average aneurysm size after controlling for body size (P ≤ .001). There was no sex difference in in-hospital mortality (3% [5/159] vs 2% [16/689]) or stroke (4% [7/159] vs 4% [29/689]). Multivariable logistic regression indicated that female sex was not an independent predictor of combined in-hospital stroke or death (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.28-1.25), confirmed by propensity score analysis. There was no difference in long-term survival (5-year survival, 90.96% vs 93.03%; P = .44). Females had higher incidence of permanent pacemaker requirement [11% (18/159) vs 6% (39/689), P = .03] and female sex was an independent predictor of permanent pacemaker requirement (OR, 2.01; 95% CI, 1.085-3.724; P = .03). CONCLUSIONS: While female patients have different baseline characteristics and indication for ARR, they are not exposed to an increased risk of in-hospital mortality or stroke. However, females experience increased incidence of permanent pacemaker requirement.

Assessing infant and maternal readiness for newborn discharge.

PURPOSE OF REVIEW: The review highlights the shift from prescribed length of stay (LOS) to mother-infant dyad readiness as the basis for making discharge decisions for healthy term newborns. We describe the components of readiness that should be considered in making the decision, focusing on infant clinical readiness, and maternal and familial readiness. RECENT FINDINGS: Although the Newborns' and Mothers' Health Protection Act of 1996 aimed to protect infants and mothers by establishing a minimum LOS, the American Academy of Pediatrics 2015 policy on newborn discharge acknowledges the shift from LOS-based to readiness-based discharge decision-making. Healthcare providers must consider a variety of infant and maternal characteristics in determining the appropriate time to discharge a dyad, and mothers should be actively involved in the decision-making process. Criteria for infant clinical readiness include the following: establishment of effective feeding, evaluation of jaundice risk, review and discussion of infant and household vaccination status, obtainment of specimen for metabolic screening, tests of hearing ability, assessment of sepsis risk factors, screening for congenital heart disease, and evaluation of parental knowledge about infant safety measures. Important consideration should also be given to the mother's sociodemographic vulnerabilities, maternal confidence and perception of discharge readiness, and availability of postdischarge care continuity. SUMMARY: The timing of newborn discharge should be a joint decision made by the mother and healthcare providers based on readiness. The decision should consider the infant's health status, the mother's health status, the mother's perception of readiness, and the availability of social and familial support for the mother and infant. Accessible and comprehensive support postdischarge is also important for helping infants achieve optimal health outcomes.

Vaccination during pregnancy: first line of defense for expecting mothers and vulnerable young infants.

PURPOSE OF REVIEW: Maternal vaccination is a well-tolerated and effective way to protect mothers, their developing fetuses, and their young infants from infectious diseases. Although influenza vaccine and diphtheria, tetanus, and acellular pertussis (Tdap) vaccine are recommended for all pregnant women, uptake rates in the United States remain low. This review will focus on the rationale, scientific evidence, and perceptions of vaccination during pregnancy. RECENT FINDINGS: Recent studies show that administration of influenza and Tdap vaccines during pregnancy is well tolerated and provides protection to the pregnant woman, her fetus, and young infant. Studies have shown that many pregnant women look to their obstetricians to guide their prenatal care. A strong provider recommendation remains the greatest impetus to increase vaccine uptake. Both healthcare providers and expectant mothers should continue to be educated on the importance and safety of the influenza and Tdap vaccines during pregnancy. SUMMARY: Providers play a central role in advising patients and their families about the importance of maternal vaccination. The strong recommendation of providers and the availability of maternal vaccines in OB/GYN offices are keys to improve vaccine uptake. Attention must be paid to further development of intervention techniques that address unique barriers such as vaccine cost, storage concerns, and misinformation about vaccine safety.

Incidence, Cause, and Outcome of Reinterventions After Aortic Root Replacement.

BACKGROUND: This study aims to comprehensively characterize details of aortic and aortic valve reinterventions after aortic root replacement (ARR). METHODS: Between 2005 and 2019, 882 patients underwent ARR. Indications were aneurysm in 666, aortic valve related in 116, aortic dissection in 64, and infective endocarditis (IE) in 36. Valve-sparing root replacement was performed in 290 patients, whereas a Bio-Bentall procedure was done in 528. Among them, 52 patients (5.9%) required reintervention. The incidence, cause, and time to reintervention and the outcomes after reintervention were investigated. A cause-specific Cox hazard model was performed to identify predictors for reintervention after ARR. RESULTS: The 10-year cumulative incidence of aortic and aortic valve reintervention after ARR was 10.3% (95% confidence interval, 7.3%-14.0%). Age per year decrease was the only independent predictor for reintervention (subdistribution hazard ratio, 0.97; 95% confidence interval, 0.95-0.99). The causes for 52 reinterventions were aortic valve causes in 29 patients (55.8%), including aortic stenosis/insufficiency, and prosthetic valve dysfunction; IE in 15 (28.9%); aortic-related causes in 7 (13.5%), including pseudoaneurysm, development of aneurysm, and residual dissection; and coronary button pseudoaneurysm in 1 (1.9%). Median time to reintervention was 11.0 months (interquartile range, 2.0-20.5) for IE, 24.0 months (interquartile range, 3.7-46.1) for aortic-related causes, and 77.0 months (interquartile range, 28.4-97.6) for aortic valve-related causes (P = .005). Overall in-hospital mortality after the reinterventions was 7.7% (4/52) with 20.0% for IE (3/15). CONCLUSIONS: Reintervention for IE occurred relatively early after ARR, whereas aortic valve- and aortic-related reinterventions gradually increased over time. In-hospital mortality after the reintervention was low, with the exception of IE.

Valve-Sparing Root Replacement Versus Bio-Bentall: Inverse Propensity Weighting of 796 Patients.

BACKGROUND: This large cohort, single-center study compared the 10-year survival and freedom from aortic valve reintervention between valve-sparing root replacement (VSRR) and bioprosthetic Bentall (bio-Bentall). METHODS: All patients undergoing elective VSRR or bio-Bentall for aortic root aneurysm between March 2005 through October 2019 were retrospectively reviewed (N = 796; n = 360 for VSRR). Inverse probability of treatment weighting (IPTW) balanced clinical variables between groups. Mean follow-up was 58.0 ± 45.4 months (range, 0-167 months). RESULTS: After IPTW adjustment, 10-year survival did not differ between VSRR (87.0%) and bio-Bentall (92.7%, P = 0.780). Cumulative incidence of aortic valve reintervention was 5.9% for VSRR (95% confidence interval [CI], 2.9%-10.4%) and 10.6% for bio-Bentall (95% CI, 6.2%-16.4%; P = .798). A Fine and Gray competing risk regression model identified age at operation (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99; P = .015), body surface area (sHR, 6.21; 95% CI, 1.97-19.59; P = .002), and bicuspid aortic valve (sHR, 2.15; 95% CI, 1.04-4.44; P = .038) as independently associated with aortic valve reintervention. For patients aged 50 years or younger, the cumulative incidence of aortic valve reintervention was 16.2% for VSRR (95% CI, 7.0%-28.8%) and 17.8% for bio-Bentall (95% CI, 6.9%-32.8%; P = .363). CONCLUSIONS: VSRR and bio-Bentall show similar excellent survival and freedom from aortic reintervention rates up to 10 years; however, a durable valve solution for young patients with bicuspid aortic valve remains a challenge.

Chronic kidney disease stage stratifies short- and long-term outcomes after aortic root replacement.

OBJECTIVES: Chronic kidney disease (CKD) is prevalent in patients undergoing cardiovascular surgery, and it negatively impacts procedural outcomes; however, its influence on the outcomes of aortic surgery has not been well studied. This study aims to elucidate the importance of CKD on the outcomes of aortic root replacement (ARR). METHODS: Patients who underwent ARR between 2005 and 2019 were retrospectively reviewed (n = 882). Patients were divided into 3 groups based on the Kidney Disease: Improving Global Outcomes criteria: Group 1 [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2, n = 421); Group 2 (eGFR = 30-59 ml/min/1.73 m2, n = 424); and Group 3 (eGFR < 30 ml/min/1.73 m2, n = 37). To reduce potential confounding, a propensity score matching was also performed between Group 1 and the combined group of Group 2 and Group 3. The primary end point was 10-year survival. Secondary end points were in-hospital mortality and perioperative morbidity. RESULTS: Severe CKD patients presented with more advanced overall chronic and acute illnesses. Kaplan-Meier analysis showed a significant correlation between CKD stage and 10-year survival (log-rank P < 0.001). The number of events for Group 1 was 15, Group 2 was 49 and Group 3 was 11 in 10 years. Group 3 had significantly higher in-hospital mortality (13.5% vs 3.5% in Group 2 vs 0.7% in Group 1, P < 0.001) and stroke (8.1% vs 7.1% vs 1.2%, P < 0.001) as well as introduction to new dialysis (27.0% vs 5.4% vs 1.7%, P < 0.001). eGFR was shown to be an independent predictor of mortality (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99). Comparison between propensity matched groups showed similar postoperative outcomes, and eGFR was still identified as a predictor of mortality (hazard ratio, 0.97; 95% confidence interval, 0.95-0.99). CONCLUSIONS: Higher stage in CKD negatively impacts the long-term survival in patients who are undergoing ARR.

Probability of Uneventful Recovery After Elective Aortic Root Replacement for Aortic Aneurysm.

BACKGROUND: Little is known about the chance of patients not experiencing complications (uneventful recovery) after aortic root replacement for aortic aneurysm. The aim of this study was to investigate the probability of uneventful recovery, identify its predictors, and address the association between the uneventful recovery and long-term survival. METHODS: Patients with aortic aneurysm who underwent elective aortic root replacement between 2005 and 2018 were retrospectively reviewed (N = 676). Uneventful recovery was defined as avoidance of all of the following complications during the index hospital stay (selected based on Cox proportional hazards regression for long-term survival): mortality, any stroke, reexploration for bleeding, respiratory failure, acute renal failure, deep sternal infection, and postcardiotomy shock. Permanent pacemaker implantation was included because of its clinical perspectives. Patients were divided into 4 different age groups (group <60 years of age, n = 299; group 60-69 years of age, n = 209; group 70-79 years of age, n = 125; group ≥80 years of age, n = 43), according to a restricted cubic spline analysis on in-hospital mortality and postoperative stroke. RESULTS: Uneventful recovery was 78.1%. The probability of uneventful recovery decreased in a linear fashion as the age increases (82.6% in the group <60 years of age, 79.0% in the group 60-69 years of age, 70.4% in the group 70-79 years of age, 65.1% in the group ≥80 years of age; P = .007). A multivariable logistic regression showed age, left ventricular ejection fraction, previous cardiac surgery, and peripheral artery disease were independent predictors of uneventful recovery. Uneventful recovery resulted in significantly better 5-year survival (log-rank P = .039). CONCLUSIONS: This study provides novel information regarding the probability of uneventful recovery while confirming low in-hospital mortality and stroke rates after elective aortic root replacement for aortic aneurysm. Importantly, uneventful recovery ensures excellent long-term survival.

Improving Outcomes of Iatrogenic Type A Aortic Dissection during Cardiac Surgery.

BACKGROUND: Iatrogenic Type A aortic dissection (IAD) is a rare but devastating complication of cardiac and aortic surgery with reported operative mortality of 30 to 50%. In this study, we report our experience with IAD and propose a standardized approach to management. METHODS: From January 1, 2000 through December 31, 2016, 23,275 patients underwent cardiac surgery at our institution. We identified 15 patients who developed IAD. Our approach to management included (1) immediate repair, (2) involvement of a second attending surgeon, (3) aggressive monitoring of malperfusion, (4) securing true lumen arterial perfusion access and systemic cooling, and (5) performance of hemiarch or total arch replacement based on the presence of suspected brain malperfusion. The index operation was also completed at the same time. Patient preoperative characteristics, operative sequence and technique, complications, and outcomes were analyzed with chart review. RESULTS: The incidence of IAD at our institution was 0.06% (n = 15). A disproportionate percentage of patients had aneurysmal ascending aortas (33.3%). The index surgery consisted of aortic surgery in five patients (33.3%), coronary bypass in three patients, valve surgery in five patients, and transplantation in one patient. The mechanism of dissection was aortic cannulation in 66.7% and aortic root vent site cannulation in 13.3%. In 46.7% of patients, the IAD was first recognized based on clinical evidence such as aortic hematoma, pericardial bleeding, or abnormal perfusion line pressures. In 40.0%, the diagnosis was made with intraoperative echocardiography without any clinical manifestations. The timing of the diagnosis was at the initiation of cardiopulmonary bypass initiation in 60.0%, while in 40.0% it was recognized after discontinuation of bypass. Hemiarch was done in 73.3% and total arch replacement performed in 13.3%. Isolated ascending repairs were done in two patients. Bypass and cross-clamp times were 229.5 ± 212.7 minutes and 130.5 ± 109.5 minutes, respectively. In-hospital mortality in our cohort was 6.7%. While stroke occurred in one patient, no visceral organ malperfusion was recognized. CONCLUSIONS: Incidence of IAD is low with cannulation of an aneurysmal aorta being a risk factor. A standardized approach may result in reduced operative mortality.