Outcomes of procedural complications in transfemoral transcatheter aortic valve replacement.

OBJECTIVES: As the application of transcatheter aortic valve replacement (TAVR) expands, the longitudinal implications of periprocedural complications are increasingly relevant. We examine the influence of TAVR complications on midterm survival. METHODS: Patients undergoing transfemoral TAVR at our institution between November 2011 and June 2018 were reviewed. Stroke severity was classified according to the National Institutes of Health stroke score. Kaplan-Meier analysis was used to assess survival, and a Cox proportional hazards model was created to examine independent associations with survival. The median follow-up time was 36 months for a total of 2789 patient-years. RESULTS: Overall, 866 patients were included. The mean age was 80 ± 9.5 years and mean Society of Thoracic Surgeons score was 4.8% ± 2.7%. The mortality rate at 30-days was 2.8% and 11.8% at 1 year. In-hospital left bundle branch block and 30-day permanent pacemaker insertion occurred in 14.8% and 7.9%, respectively. Postprocedural greater-than-mild paravalvular leak was present in 4.4% and stroke occurred in 3.8% at 30-days. Greater-than-mild paravalvular leak was associated with decreased survival at 2 years (P = .02), but not at 5 years. Severe stroke was independently associated with decreased survival at 5 years (hazard ratio, 5.73; 95% confidence interval, 2.29-14.36; P ≤ .001); however, the effect of nonsevere stroke did not reach significance (hazard ratio, 1.69; 95% confidence interval, 0.82-3.47; P = .152). CONCLUSIONS: Severe stroke was independently associated with decreased 5-year survival and initial risks associated with paravalvular leak may be attenuated over the midterm following transfemoral TAVR. Strategies to minimize the incidence of stroke and paravalvular leak must be prioritized to improve longitudinal outcomes after TAVR.

Observed versus expected morbidity and mortality in patients undergoing mitral valve repair.

OBJECTIVES: Mitral valve repair (MVP) is the gold standard treatment for degenerative mitral regurgitation. With the expansion of transcatheter technologies, this study compares the outcome of MVP in low-risk and non-low-risk patients to serve as a benchmark. METHODS: This retrospective, single-institution study examined all patients who underwent MVP for primary mitral regurgitation from 2005 to 2018. Patients were stratified into 2 risk categories: low-risk [Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (STS-PROM) ≤2%] and non-low risk (STS-PROM > 2% or age > 75), with a subgroup of very low risk (STS-PROM ≤1%, age <75). RESULTS: A total of 1207 patients were included, and 1053 patients were classified as low risk and 154 as non-low risk. The non-low-risk group was significantly older, more likely to be female, and had a higher comorbidity burden than the low-risk group (all P < 0.01). For the low-risk group, the observed-to-expected (O:E) STS mortality ratio was 0.4 and the composite morbidity and mortality ratio was 0.6, whereas for the non-low risk, the O:E mortality was 1.5 and the composite morbidity and mortality was 0.9. When the subgroup of very low-risk group was assessed, the mortality O:E ratio was 0. CONCLUSIONS: The observed composite morbidity and mortality of patients undergoing MVP were persistently lower in low-risk patients, mainly driven by the very low-risk group. The excellent outcome of MVP in low-risk patients should be validated on a national level to determine how transcatheter technologies can be utilized in these patients.

National Outcomes of Surgical Embolectomy for Acute Pulmonary Embolism.

BACKGROUND: Guidelines outlining the role of surgical embolectomy for acute pulmonary embolism remain consensus based; however, recent outcomes have improved compared with traditional experiences. This study examined contemporary outcomes of patients treated for acute pulmonary embolism on a nationwide scale. METHODS: Patients undergoing systemic thrombolysis, catheter-directed therapy, and surgical embolectomy for acute pulmonary embolism from 2010 to 2014 in the National Inpatient Sample were included. RESULTS: The study included 58,974 patients with acute pulmonary embolism; of these, 33,553 were treated with systemic thrombolysis, 22,336 with catheter-directed therapy, and 3085 underwent surgical embolectomy. Thrombolysis was the most common, with a substantial increase after 2012, while surgical volumes remained stable. Patients in the surgical group, compared with systemic thrombolysis and catheter-directed therapy, had more saddle emboli (22% vs 10% vs 10%) and were more frequently at severe risk of death (56% vs 42% vs 26%; both P < .01). Surgical embolectomy patients had higher in-hospital mortality (20% vs 16% vs 7%), stroke (7% vs 6% vs 3%), and blood transfusion (32% vs 16% vs 10%; all P < .01). Rates of major bleeding and intracranial hemorrhage were highest in the systemic thrombolysis group. Among surgical patients, age older than 60 years, atrial fibrillation and nonsaddle embolus were associated with increased odds of mortality. CONCLUSIONS: In this contemporary, real-world study, mortality occurred in 19.8% of patients undergoing surgical embolectomy for acute pulmonary embolism. This represents a significant improvement compared with traditional outcomes and supports the role of surgery in the multidisciplinary treatment of this high-risk condition.

Natural history of cranial fibrous dysplasia revealed during long-term follow-up: Case report and literature review.

BACKGROUND: Fibrous dysplasia (FD) is a rare developmental disease characterized by the replacement of bone marrow with proliferating fibro-osseous tissue. There exist three forms of FD-monostotic, polyostotic, and that associated with McCune-Albright syndrome. The disease can present in different locations and with a variety of symptoms. One of the more common locations of FD occurrence is the craniofacial region. Treatment of asymptomatic FD often involves conservative management with serial imaging. Medical management with bisphosphonates is an option, though long-term efficacy data are lacking. Surgical resection is usually reserved for very large or symptomatic lesions. CASE DESCRIPTION: We discuss the most unusual case of a 52-year-old male found to have a left pterional mass while being worked up for sinus headaches. The patient elected to follow this lesion conservatively, and imaging several years later showed obvious growth which accelerated in the last 4 years during an 18-year observational period. He ultimately underwent successful resection of an extradural and intradural FD. CONCLUSIONS: The significant growth potential of these lesions was revealed in this patient, in whom conservative management had been adopted. Despite optimal surgical resection and outcome in this case, the importance of surveillance imaging and perhaps earlier intervention cannot be underestimated when managing cranial FD.