Risk factors associated with long-term mortality and complications after thoracoabdominal aortic aneurysm repair.

OBJECTIVE: We sought to determine the risk factors associated with late mortality or complications (thoracoabdominal aortic aneurysm [TAAA] life-altering events [TALE]: a composite of mortality, permanent paraplegia, permanent dialysis, and stroke) for patients who had undergone endovascular or open TAAA repair. METHODS: We performed a population-based study of patients who had undergone TAAA repair in Ontario, Canada, from 2006 to 2017. The association of baseline risk factors with mortality and complications after repair was examined using Cox hazards models with hospital-specific random effects. The survival of patients who had undergone TAAA repair was compared with that of controls without TAAAs. The two groups were matched by age, sex, area of residence, and average annual household income. The type of repair (endovascular vs open) was included in all models. RESULTS: We identified 664 adults (mean age, 69.3 ± 10.6 years; 71% men) who had undergone TAAA repair. At 5 and 8 years, survival was 55.0% (95% confidence interval [CI], 49.8%-60.1%) and 44.6% (95% CI, 40.4%-49.6%) for patients who had undergone TAAA repair vs 85.6% (95% CI, 83.9%-87.1%) and 76.3% (95% CI, 73.8%-78.8%) for the control population, respectively (hazard ratio [HR], 1.97; 95% CI, 1.67-2.32; P < .01). For the TAAA group, freedom from TALE was 49.2% (95% CI, 44.7%-53.7%) and 37.3% (95% CI, 33.1%-42.4%) at 5 and 8 years of follow-up, respectively. On multivariable analysis, the risk factors associated with mortality during follow-up included older age (HR, 1.21 per 5-year increase; 95% CI, 1.13-1.28), peripheral artery disease (HR, 1.46; 95% CI, 1.03-2.09), hypertension (HR, 1.58; 95% CI, 1.03-2.43), congestive heart failure (HR, 1.78; 95% CI, 1.34-2.36), and urgent procedures (HR, 2.27; 95% CI, 1.74-3.00). A lower rate of death was observed for those with previous coronary revascularization (HR, 0.63; 95% CI, 0.41-0.96) and those who had undergone repair at high-volume institutions (>60 TAAA repairs during the study period; HR, 0.71; 95% CI, 0.55-0.91). Older age, chronic kidney disease, congestive heart failure, and urgent procedures were associated with a higher rate of TALE. The type of repair (endovascular vs open) was not associated with mortality or TALE. CONCLUSIONS: TAAA repair was associated with reduced long-term survival compared with the general population, regardless of the mode of treatment. Urgent or emergent repair was the most profound risk factor for late adverse events. The type of repair (endovascular vs open) was not a predictor of long-term death or complications. Previous coronary revascularization and treatment performed at a high-volume institution were associated with improved late outcomes for patients undergoing TAAA repair.

Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair.

OBJECTIVE: To compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). METHODS: Population-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. RESULTS: Overall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). CONCLUSIONS: TAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.

Systematic review of contemporary outcomes of endovascular and open thoracoabdominal aortic aneurysm repair.

OBJECTIVE: The purpose of the study was to provide a systematic review of the literature reporting the contemporary early outcomes after endovascular and open repair of thoracoabdominal aortic aneurysms (TAAAs). METHODS: MEDLINE and Embase were searched for studies from January 2006 to March 2018 that reported either endovascular (using branched or fenestrated endografts) or open repair of TAAA in at least 10 patients. Outcomes of interest included perioperative mortality, spinal cord injury (SCI), renal failure requiring dialysis, and stroke. Pooled proportions were determined using a random-effects model. RESULTS: The analysis included 71 studies, of which 24 and 47 reported outcomes after endovascular and open TAAA repair, respectively. Endovascular cohort patients were older and had higher rates of coronary artery disease, chronic obstructive pulmonary disease, and diabetes. Endovascular repair was associated with higher rates of SCI (13.5%; 95% confidence interval [CI], 10.5%-16.7%) compared with open repair (7.4%; 95% CI, 6.2%-8.7%; P < .01) but similar rates of permanent paralysis (5.2% [95% CI, 3.8%-6.7%] vs 4.4% [95% CI, 3.3%-5.6%]; P = .39), lower rates of postoperative dialysis (6.4% [95% CI, 3.2%-9.5%] vs 12.0% [95% CI, 8.2%-16.3%]; P = .03) but similar rates of being discharged on permanent dialysis (3.7% [95% CI, 2.0%-5.9%] vs 3.8% [95% CI, 2.9%-5.3%]; P = .93), a trend to lower stroke (2.7% [95% CI, 1.9%-3.6%] vs 3.9% [95% CI, 3.0%-4.9%]; P = .06), and similar perioperative mortality (7.4% [95% CI, 5.9%-9.1%] vs 8.9% [95% CI, 7.2%-10.9%]; P = .21). CONCLUSIONS: This systematic review summarizes the contemporary literature results of endovascular and open TAAA repair. Endovascular repair studies included patients with more comorbidities and were associated with higher rates of SCI but similar rates of permanent paraplegia, whereas open repair studies had higher rates of postoperative dialysis but similar rates of being discharged on permanent dialysis. Perioperative mortality rates were similar. Universally adopted reporting standards for patient characteristics, outcomes, and the conduct of contemporary comparative studies will allow better assessment and comparisons of the risks associated with the two surgical treatment options for TAAA.

Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement.

BACKGROUND: Surgical aortic root enlargement (ARE) during aortic valve replacement (AVR) allows for larger prosthesis implantation and may be an important adjunct to surgical AVR in the transcatheter valve-in-valve era. The incremental operative risk of adding ARE to AVR has not been established. We aimed to evaluate the early outcomes of patients undergoing AVR with or without ARE. METHODS: From January 1990 to August 2014, 7039 patients underwent AVR (AVR+ARE, n=1854; AVR, n=5185) at a single institution. Patients with aortic dissection and active endocarditis were excluded. Mean age was 65±14 years and 63% were male. Logistic regression and propensity score matching were used to adjust for unbalanced variables in group comparisons. RESULTS: Patients undergoing AVR+ARE were more likely to be female (46% versus 34%, P<0.001) and had higher rates of previous cardiac surgery (18% versus 12%, P<0.001), chronic obstructive pulmonary disease (5% versus 3%, P=0.004), urgent/emergent status (6% versus 4%, P=0.01), and worse New York Heart Association status (P<0.001). Most patients received bioprosthetic valves (AVR+ARE: 73.4% versus AVR: 73.3%, P=0.98) and also underwent concomitant cardiac procedures (AVR+ARE: 68% versus AVR: 67%, P=0.31). Mean prosthesis size implanted was slightly smaller in patients requiring AVR+ARE versus AVR (23.4±2.1 versus 24.1±2.3, P<0.001). In-hospital mortality was higher after AVR+ARE (4.3% versus 3.0%, P=0.008), although when the cohort was restricted to patients undergoing isolated aortic valve replacement with or without root enlargement, mortality was not statistically different (AVR+ARE: 1.7% versus AVR: 1.1%, P=0.29). After adjustment for baseline characteristics, AVR+ARE was not associated with an increased risk of in-hospital mortality when compared with AVR (odds ratio, 1.03; 95% confidence interval, 0.75-1.41; P=0.85). Furthermore, AVR+ARE was not associated with an increased risk of postoperative adverse events. Results were similar if propensity matching was used instead of multivariable adjustments for baseline characteristics. CONCLUSIONS: In the largest analysis to date, ARE was not associated with increased risk of mortality or adverse events. Surgical ARE is a safe adjunct to AVR in the modern era.

Multiple Arterial Grafting Is Associated With Better Outcomes for Coronary Artery Bypass Grafting Patients.

BACKGROUND: Observational studies have shown better survival in patients undergoing coronary artery bypass grafting (CABG) with 2 arterial grafts compared with 1. However, whether a third arterial graft is associated with incremental benefit remains uncertain. We sought to analyze the outcomes of 3 versus 2 arterial grafts during CABG. As a secondary objective, we compared CABG with 2 or 3 arterial grafts (multiple arterial grafts [MAG]) with CABG using a single arterial graft (SAG). METHODS: Retrospective cohort analyses of all patients undergoing primary isolated CABG in Ontario, Canada, from October 2008 to March 2016. Propensity score matching was performed between patients with 3 arterial grafts (3Art group) versus 2 (2Art group). The primary outcome was time to first event of a composite of death, myocardial infarction, stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events). Additional analyses were performed to evaluate the association between MAG versus SAG and long-term outcomes using propensity score matching. RESULTS: Fifty thousand, two hundred thirty patients underwent isolated CABG during our study period; 3044 (6.1%) and 8253 (16.4%) patients had 3 and 2 arterial grafts, respectively, resulting in 2789 propensity score matching pairs for the primary analyses. Mean and maximum follow-up was 4.2 and 8.5 years, respectively. Radial artery grafting was more common in the 3Art versus 2Art group (79.3% versus 65.6%, P<0.01). In-hospital outcomes were not significantly different, including death (3Art 0.8% versus 2Art 0.5%, P=0.26). Up to 8 years, there were no differences in major adverse cardiac and cerebrovascular events (3Art 27%, 95% confidence interval [CI], 24% to 30% versus 2Art 25%, 95% CI, 22% to 28%; hazard ratio [HR], 1.08, 95% CI, 0.94-1.25), death (HR, 1.08; 95% CI, 0.90-1.29), myocardial infarction (HR, 1.15; 95% CI, 0.87-1.51), stroke (HR, 1.39; 95% CI, 0.95-2.06), or repeat revascularization (HR, 1.04; 95% CI, 0.82-1.32). When evaluating MAG versus SAG, 8629 patient pairs were formed using propensity score matching. At 8 years, cumulative incidences of major adverse cardiac and cerebrovascular events (HR, 0.82, 95% CI, 0.77-0.88), survival (HR, 0.80; 95% CI, 0.73-0.88), repeat revascularization (HR, 0.79; 95% CI, 0.69-0.90), and myocardial infarction (HR, 0.83; 95% CI, 0.72-0.97) were superior in the MAG group. CONCLUSIONS: CABG with 3 arterial grafts was not associated with increased in-hospital death nor with better clinical outcomes at 8-year follow-up, compared with CABG with 2 arterial grafts. MAG was associated with superior outcomes compared with SAG.

Validation of endovascular and open thoracoabdominal aortic aneurysm repair in Ontario health administrative databases.

PURPOSE: The positive predictive value (PPV) of endovascular and open thoracoabdominal aortic aneurysm (TAAA) repair coding was assessed in Ontario health administrative databases. METHODS: Between 1 January 2006 and 31 March 2016, a random sample of 192 patients was identified using Canadian Classification of Health Intervention (CCI) procedure codes and Ontario Health Insurance Plan (OHIP) billing codes from administrative data. Blinded chart reviews were conducted at two cardiovascular centers to assess the level of agreement between the administrative records and the corresponding patients' hospital charts. The PPV was calculated with 95% confidence intervals using hospital charts as the gold standard. RESULTS: The PPV for the single endovascular TAAA repair code, 1ID80GQNRN, was 0.90 (0.78, 0.97). A combination of all nine CCI open TAAA repair codes was performed, with a PPV of 0.62 (0.47, 0.76). The combination of any one of the nine CCI codes AND the single OHIP code for open TAAA repair (R803) rendered a PPV of 0.98 (0.90, 1.00). CONCLUSIONS: Endovascular TAAA repair may be identified using a single CCI code (1ID80GQNRN). Open TAAA repair may be identified using a combination of CCI and OHIP codes. Researchers may therefore use administrative data to conduct population-based studies of endovascular and open repair of TAAA.

Aortic valve replacement with pulmonary hypertension: Meta-analysis of 70 676 patients.

BACKGROUND AND AIM OF THE STUDY: We compared early and late outcomes of surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) and pulmonary hypertension (PHT). METHODS: We searched MEDLINE and EMBASE databases until July 2018 for studies comparing patients with AS and none, mild-moderate, or severe PHT undergoing SAVR. Random-effects meta-analysis was performed. RESULTS: There were 12 observational studies with 70 676 patients with median follow-up 4.0 years (interquartile range, 2.6-4 years). Compared to patients with no PHT, patients with any PHT undergoing SAVR were older (mean difference [MD], 2.31 years; 95% confidence interval [CI], 1.38-3.23 years; P < .01), with greater comorbidities and reduced ejection fraction (MD, -4.36; 95%CI, -5.94 to -2.78; P < .01). Patients with any PHT had higher unadjusted (5.2% vs 2.4%; risk ratio [RR], 2.27; 95%CI, 2.04-2.53; P < .01) and adjusted (RR, 1.65; 95%CI, 1.28-2.14; P < .01) in-hospital mortality compared with no PHT. Severe (RR, 3.53; 95%CI, 1.46-8.54; P < .01) and mild-moderate PHT (RR, 2.13; 95%CI, 1.28-3.55; P < .01) were associated with higher unadjusted in-hospital mortality compared with no PHT. Any PHT was associated with a higher unadjusted risk of stroke (RR, 1.64; 95%CI, 1.42-1.90; P < .01), acute kidney injury (RR, 2.02; 95%CI, 1.50-2.72; P < .01), prolonged ventilation (RR, 1.62; 95%CI, 1.04-2.52; P = .03), and longer hospital stay (MD, 1.76 days; 95%CI, 0.57-2.95; P < .01). Severe (HR, 2.44; 95%CI, 1.60-3.72; P < .01) but not mild-moderate PHT (HR, 2.25; 95%CI, 0.91-5.59; P = .08) was associated with higher adjusted long-term mortality compared with no PHT. CONCLUSIONS: Patients with severe AS and severe PHT had a significant increase in operative mortality and more than double the risk of long-term mortality following SAVR compared with patients with no PHT. Such patients may benefit from a less invasive transcatheter aortic valve intervention.

A systematic review and meta-analysis of early outcomes after endovascular versus open repair of thoracoabdominal aortic aneurysms.

OBJECTIVE: The objective of this study was to compare the early results of endovascular vs open thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: MEDLINE and Embase were searched for studies from January 2006 to March 2018 that compared endovascular vs open repair of TAAA using branched or fenestrated endografts. Data were subjected to a meta-analysis using a random-effects model. The outcomes of interest included early mortality, spinal cord injury, renal failure requiring dialysis, stroke, and hospital length of stay. RESULTS: Eight comparative studies met inclusion criteria. There were two retrospective propensity-matched studies, two unadjusted single-center retrospective studies, and four unadjusted national population-based studies. Mortality in the matched studies was equivalent in both groups. Pooled analysis of all unmatched observational studies revealed a survival benefit for endovascular over open repair (relative risk [RR], 0.63; 95% confidence interval [CI],0.45-0.87); P < .01, I2 = 47%). Endovascular repair was also associated with lower incidence of spinal cord injury (RR, 0.65; 95% CI, 0.42-1.01; P = .05; I2 = 28%). For unmatched studies, pooled RR of renal failure requiring dialysis significantly favored endovascular repair (RR, 0.44; 95% CI, 0.23-0.85; P = .01; I2 = 0%), although in the adjusted cohort, risk of dialysis was not different (RR, 1.00; 95% CI, 0.06-15.65; P = 1.00). Postoperative stroke rate was reported in three unadjusted studies and was not different between groups (RR, 0.81; 95% CI, 0.28-2.40; P = .71; I2 = 77%). Hospital length of stay was reported in four studies and was shorter in the endovascular group (mean difference, -4.4 days; 95% CI, -6.6 to -1.7; P < .01; I2 = 73%). CONCLUSIONS: There are few reports comparing endovascular vs open repair of TAAAs. Short-term outcomes may be improved in patients undergoing endovascular treatment of TAAA on the basis of a limited number of studies with high risk of bias. These findings highlight the need for larger comparative studies with standardization of reporting.

Adipose tumors of the heart.

BACKGROUND: Primary cardiac adipose tumors are rare. There are two distinct pathologically defined entities that represent this tumor type: lipoma and lipomatous hypertrophy of the interatrial septum (LHIS). We present a single-center experience with these tumors and demonstrate that the location may not correspond to the pathologic diagnosis. METHODS: A retrospective review of a prospectively collected cardiac surgery database from January 1990 to July 2016 identified 254 cases of surgically treated primary cardiac tumors at our Institution. Of these, 06/254 (2%) were primary adipose tumors. RESULTS: In 3/6 (50%) cases, patients were asymptomatic or had symptoms referable to other known intracardiac lesions. Five patients (83%) had preserved ventricular function. In 4/6 cases (67%), the tumor was identified preoperatively. All patients presented in New York Heart Association functional class ≤2. Pathologic diagnosis of LHIS was made in 5/6 cases (83%), with 2/5 LHIS (40%) located in the interatrial septum. A bovine pericardial patch was utilized for reconstruction following tumor resection in 3/6 cases (50%). Mean cardiopulmonary bypass time was 88 ± 43 min. All the patients tolerated the procedure well without any postoperative complications. CONCLUSIONS: Primary cardiac adipose tumors are responsible for a small portion of all primary heart tumors. Surgical resection provided excellent outcomes, and did not affect cardiac performance, in spite of the need for extensive resections. LHIS was identified in locations other than the interatrial septum and was usually symptomatic.

Do Non-fatal MACCE In The First 5-years Post CABG Affect 10-year Outcomes?

OBJECTIVE: Few have examined the impact of early adverse events post coronary artery bypass grafting (CABG) on long-term survival. We sought to determine if the occurrence of non-fatal major adverse cardiac and cerebrovascular events (MACCE) in the first 5 years after CABG impacts survival and adverse events at 10 years. METHODS: All patients who underwent isolated CABG from 1990-2014 at a single center in Ontario, Canada were included. Primary endpoint was all-cause mortality. The secondary endpoint of interest was MACCE, a composite of mortality, non-fatal myocardial infarction, stroke, and repeat revascularization. RESULTS: 20,444 cases of elective primary isolated CABG were identified as being alive at 5-years, with 11% patients developing non-fatal MACCE within the first 5 years post CABG (MACCE group) and the remaining 89% were alive without a MACCE event at 5-years (non-MACCE group). Following propensity score matching, 2,167 patient-pairs were formed. Among the MACCE group, 972/2,167 (44.9%) developed an MI, 519/2,167 (24.0%) had a stroke, and 946/2,167 (43.7%) required a repeat revascularization within the first 5 years post CABG. Non-MACCE was associated with better overall survival (HR 1.42 [95% confidence interval (CI) 1.25-1.63], p<0.01) and freedom from MACCE (HR 1.61 [95% CI 1.45-1.79], p<0.01) up to 10-years post CABG compared to MACCE cases. CONCLUSIONS: Patients who experienced non-fatal MACCE in the first 5-year after CABG experienced worse survival and more MACCE at 10 years. Prevention of major adverse events in the first five years after surgical revascularization may be an important strategy to improve late outcomes.