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BACKGROUND: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications. METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models. RESULTS: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar. CONCLUSIONS: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.
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Aorta , Oxigenación por Membrana Extracorpórea , Arteria Femoral , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Oxigenación por Membrana Extracorpórea/métodos , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Anciano , Enfermedades del Sistema Nervioso/etiología , Enfermedades del Sistema Nervioso/epidemiología , Adulto , Arteria Subclavia , Cateterismo/métodos , Cateterismo/efectos adversos , Cateterismo/estadística & datos numéricos , Cateterismo Periférico/métodos , Cateterismo Periférico/efectos adversos , Cateterismo Periférico/estadística & datos numéricos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Mortalidad Hospitalaria/tendenciasRESUMEN
OBJECTIVES: Post-cardiotomy extracorporeal life support (ECLS) cannulation might occur in a general post-operative ward due to emergent conditions. Its characteristics have been poorly reported and investigated This study investigates the characteristics and outcomes of adult patients receiving ECLS cannulation in a general post-operative cardiac ward. METHODS: The Post-cardiotomy Extracorporeal Life Support (PELS) is a retrospective (2000-2020), multicenter (34 centers), observational study including adult patients who required ECLS for post-cardiotomy shock. This PELS sub-analysis analyzed patients´ characteristics, in-hospital outcomes, and long-term survival in patients cannulated for veno-arterial ECLS in the general ward, and further compared in-hospital survivors and non-survivors. RESULTS: The PELS study included 2058 patients of whom 39 (1.9%) were cannulated in the general ward. Most patients underwent isolated coronary bypass grafting (CABG, n = 15, 38.5%) or isolated non-CABG operations (n = 20, 51.3%). The main indications to initiate ECLS included cardiac arrest (n = 17, 44.7%) and cardiogenic shock (n = 14, 35.9%). ECLS cannulation occurred after a median time of 4 (2-7) days post-operatively. Most patients' courses were complicated by acute kidney injury (n = 23, 59%), arrhythmias (n = 19, 48.7%), and postoperative bleeding (n = 20, 51.3%). In-hospital mortality was 84.6% (n = 33) with persistent heart failure (n = 11, 28.2%) as the most common cause of death. No peculiar differences were observed between in-hospital survivors and nonsurvivors. CONCLUSIONS: This study demonstrates that ECLS cannulation due to post-cardiotomy emergent adverse events in the general ward is rare, mainly occurring in preoperative low-risk patients and after a postoperative cardiac arrest. High complication rates and low in-hospital survival require further investigations to identify patients at risk for such a complication, optimize resources, enhance intervention, and improve outcomes.
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BACKGROUND: The outcomes after prolonged treatment in the intensive care unit (ICU) after surgery for Stanford type A aortic dissection (TAAD) have not been previously investigated. METHODS: This analysis included 3538 patients from a multicenter study who underwent surgery for acute TAAD and were admitted to the cardiac surgical ICU. RESULTS: The mean length of stay in the cardiac surgical ICU was 9.9±9.5 days. The mean overall costs of treatment in the cardiac surgical ICU 24086±32084 . In-hospital mortality was 14.8% and 5-year mortality was 30.5%. Adjusted analyses showed that prolonged ICU stay was associated with significantly lower risk of in-hospital mortality (adjusted OR 0.971, 95%CI 0.959-0.982), and of five-year mortality (adjusted OR 0.970, 95%CI 0.962-0.977), respectively. Propensity score matching analysis yielded 870 pairs of patients with short ICU stay (2-5 days) and long ICU stay (>5 days) with balanced baseline, operative and postoperative variables. Patients with prolonged ICU stay (>5 days) had significantly lower in-hospital mortality (8.9% vs. 17.4%, <0.001) and 5-year mortality (28.2% vs. 30.7%, P=0.007) compared to patients with short ICU-stay (2-5 days). CONCLUSIONS: Prolonged ICU stay was common after surgery for acute TAAD. However, when adjusted for multiple baseline and operative variables as well as adverse postoperative events and the cluster effect of hospitals, it was associated with favorable survival up to 5 years after surgery.
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Disección Aórtica , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Tiempo de Internación , Humanos , Masculino , Femenino , Disección Aórtica/cirugía , Disección Aórtica/economía , Disección Aórtica/mortalidad , Tiempo de Internación/economía , Persona de Mediana Edad , Unidades de Cuidados Intensivos/economía , Anciano , Pronóstico , Aneurisma de la Aorta/cirugía , Aneurisma de la Aorta/economía , Aneurisma de la Aorta/mortalidadRESUMEN
The introduction of the Y(ang)-technique for aortic root enlargement has sparked a renewed interest in annular and root enlargement procedures world-wide. In order to execute these procedures proficiently however, it's important to understand the complex three-dimensional structure of the aortic root and left ventricular outflow tract, and also be familiar with the different enlargement techniques. Herein, we are providing a description of the aortic root anatomy and the most commonly utilized root enlargement procedures. This should facilitate clinical decision making and guidance of patients towards the most appropriate procedure, which should not only treat the patients' acute symptoms, but should also set the patient up for potentially needed future procedures and respective life-time management of aortic valve disease.
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OBJECTIVES: Most post-cardiotomy (PC) extracorporeal membrane oxygenation (ECMO) runs last less than 7 days. Studies on the outcomes of longer runs have provided conflicting results. This study investigates patient characteristics and short- and long-term outcomes in relation to PC ECMO duration, with a focus on prolonged (> 7 d) ECMO. DESIGN: Retrospective observational cohort study. SETTING: Thirty-four centers from 16 countries between January 2000 and December 2020. PATIENTS: Adults requiring post PC ECMO between 2000 and 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Characteristics, in-hospital, and post-discharge outcomes were compared among patients categorized by ECMO duration. Survivors and nonsurvivors were compared in the subgroup of patients with ECMO duration greater than 7 days. The primary outcome was in-hospital mortality. Two thousand twenty-one patients were included who required PC ECMO for 0-3 days (n = 649 [32.1%]), 4-7 days (n = 776 [38.3%]), 8-10 days (n = 263 [13.0%]), and greater than 10 days (n = 333 [16.5%]). There were no major differences in the investigated preoperative and procedural characteristics among ECMO duration groups. However, the longer ECMO duration category was associated with multiple complications including bleeding, acute kidney injury, arrhythmias, and sepsis. Hospital mortality followed a U-shape curve, with lowest mortality in patients with ECMO duration of 4-7 days (n = 394, 50.8%) and highest in patients with greater than 10 days ECMO support (n = 242, 72.7%). There was no significant difference in post-discharge survival between ECMO duration groups. In patients with ECMO duration greater than 7 days, age, comorbidities, valvular diseases, and complex procedures were associated with nonsurvival. CONCLUSIONS: Nearly 30% of PC ECMO patients were supported for greater than 7 days. In-hospital mortality increased after 7 days of support, especially in patients undergoing valvular and complex surgery, or who had complications, although the long-term post-discharge prognosis was comparable to PC ECMO patients with shorter support duration.
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OBJECTIVES: Gender difference in the outcome after type A aortic dissection (TAAD) surgery remains an issue of ongoing debate. In this study, we aimed to evaluate the impact of gender on the short- and long-term outcome after surgery for TAAD. METHODS: A multicentre European registry retrospectively included all consecutive TAAD surgery patients between 2005 and 2021 from 18 hospitals across 8 European countries. Early and late mortality, and cumulative incidence of aortic reoperation were compared between genders. RESULTS: A total of 3902 patients underwent TAAD surgery, with 1185 (30.4%) being females. After propensity score matching, 766 pairs of males and females were compared. No statistical differences were detected in the early postoperative outcome between genders. Ten-year survival was comparable between genders (47.8% vs 47.1%; log-rank test, P = 0.679), as well as cumulative incidences of distal or proximal aortic reoperations. Ten-year relative survival compared to country-, year-, age- and sex-matched general population was higher among males (0.65) compared to females (0.58). The time-period subanalysis revealed advancements in surgical techniques in both genders over the years. However, an increase in stroke was observed over time for both populations, particularly among females. CONCLUSIONS: The past 16 years have witnessed marked advancements in surgical techniques for TAAD in both males and females, achieving comparable early and late mortality rates. Despite these findings, late relative survival was still in favour of males.
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Disección Aórtica , Sistema de Registros , Humanos , Masculino , Femenino , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Estudios Retrospectivos , Europa (Continente)/epidemiología , Persona de Mediana Edad , Anciano , Factores Sexuales , Resultado del Tratamiento , Reoperación/estadística & datos numéricos , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Complicaciones Posoperatorias/epidemiología , Puntaje de PropensiónRESUMEN
OBJECTIVES: Although cardiogenic shock requiring extracorporeal life support after cardiac surgery is associated with high mortality, the impact of sex on outcomes of postcardiotomy extracorporeal life support remains unclear with conflicting results in the literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring postcardiotomy extracorporeal life support. METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy extracorporeal life support between 2000 and 2020. Preoperative, procedural, and extracorporeal life support characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed Cox proportional hazard models. RESULTS: This analysis included 1823 patients (female: 40.8%; median age: 66.0 years [interquartile range, 56.2-73.0 years]). Females underwent more mitral valve surgery (females: 38.4%, males: 33.1%, P = .019) and tricuspid valve surgery (feamales: 18%, males: 12.4%, P < .001), whereas males underwent more coronary artery surgery (females: 45.9%, males: 52.4%, P = .007). Extracorporeal life support implantation was more common intraoperatively in feamales (females: 64.1%, females: 59.1%) and postoperatively in males (females: 35.9%, males: 40.9%, P = .036). Ventricular unloading (females: 25.1%, males: 36.2%, P < .001) and intra-aortic balloon pumps (females: 25.8%, males: 36.8%, P < .001) were most frequently used in males. Females had more postoperative right ventricular failure (females: 24.1%, males: 19.1%, P = .016) and limb ischemia (females: 12.3%, males: 8.8%, P = .23). In-hospital mortality was 64.9% in females and 61.9% in males (P = .199) with no differences in 5-year survival (females: 20%, 95% CI, 17-23; males: 24%, 95% CI, 21-28; P = .069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95% CI, 0.99-1.27; P = .069) and did not change after adjustments. CONCLUSIONS: This study demonstrates that female and male patients requiring postcardiotomy extracorporeal life support have different preoperative and extracorporeal life support characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survivals.
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BACKGROUND: Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study. METHODS: The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta. RESULTS: Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172). CONCLUSIONS: In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073.
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Aorta Torácica , Disección Aórtica , Implantación de Prótesis Vascular , Complicaciones Posoperatorias , Reoperación , Humanos , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Aorta Torácica/cirugía , Reoperación/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Implantación de Prótesis Vascular/métodos , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Adulto , Estudios Retrospectivos , Resultado del Tratamiento , Europa (Continente)/epidemiología , Puntaje de PropensiónRESUMEN
BACKGROUND: The benefits and harms associated with femoral artery cannulation over other sites of arterial cannulation for surgical repair of acute Stanford type A aortic dissection (TAAD) are not conclusively established. METHODS: We evaluated the outcomes after surgery for TAAD using femoral artery cannulation, supra-aortic arterial cannulation (i.e., innominate/subclavian/axillary artery cannulation), and direct aortic cannulation. RESULTS: 3751 (96.1%) patients were eligible for this analysis. In-hospital mortality using supra-aortic arterial cannulation was comparable to femoral artery cannulation (17.8% vs. 18.4%; adjusted OR 0.846, 95% CI 0.799-1.202). This finding was confirmed in 1028 propensity score-matched pairs of patients with supra-aortic arterial cannulation or femoral artery cannulation (17.5% vs. 17.0%, p = 0.770). In-hospital mortality after direct aortic cannulation was lower compared to femoral artery cannulation (14.0% vs. 18.4%, adjusted OR 0.703, 95% CI 0.529-0.934). Among 583 propensity score-matched pairs of patients, direct aortic cannulation was associated with lower rates of in-hospital mortality (13.4% vs. 19.6%, p = 0.004) compared to femoral artery cannulation. Switching of the primary site of arterial cannulation was associated with increased rate of in-hospital mortality (36.5% vs. 17.0%; adjusted OR 2.730, 95% CI 1.564-4.765). Ten-year mortality was similar in the study cohorts. CONCLUSIONS: In this study, the outcomes of surgery for TAAD using femoral arterial cannulation were comparable to those using supra-aortic arterial cannulation. However, femoral arterial cannulation was associated with higher in-hospital mortality than direct aortic cannulation. TRIAL REGISTRATION: ClinicalTrials.gov registration code: NCT04831073.
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Disección Aórtica , Arteria Femoral , Mortalidad Hospitalaria , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Cateterismo/métodos , Cateterismo Periférico/métodos , Arteria Femoral/cirugía , Puntaje de Propensión , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVES: The progressive increase in the use of implantable electronic devices, vascular access for dialysis and the increased life expectancy of patients with congenital heart diseases has led in recent years to a considerable number of right-side infective endocarditis, especially of the tricuspid valve (TV). Although current guidelines recommend TV repair for native tricuspid valve endocarditis (TVE), the percentage of valve replacements remains very high in numerous studies. The aim of our study is to analyse our experience in the treatment of TVE with a reparative approach. METHODS: This case series includes all the patients who underwent surgery for acute or healed infective endocarditis on the native TV, at the Cliniques Universitaires Saint-Luc (Bruxelles, Belgium) between February 2001 and December 2020. RESULTS: Thirty-one patients were included in the study. Twenty-eight (90.3%) underwent TV repair and 3 (9.7%) had a TV replacement with a mitral homograft. The repair group was divided into 2 subgroups, according to whether a patch was used during surgery or not. Hospital mortality was 33.3% (n = 1) for the replacement group and 7.1% (n = 2) for repair (P = 0.25). Overall survival at 10 years was 75.6% [95% confidence interval (CI): 52-89%]. Further, freedom from reoperation on the TV at 10 years was 59.3% (95% CI: 7.6-89%) vs 93.7% (95% CI: 63-99%) (P = 0.4) for patch repair and no patch use respectively. Freedom from recurrent endocarditis at 10 years was 87% (95% CI: 51-97%). CONCLUSIONS: Considering that TVE is more common in young patients, a repair-oriented approach should be considered as the first choice. In the case of extremely damaged valves, the use of pericardial patch is a valid option. If repair is not feasible, the use of a mitral homograft is an additional useful solution to reduce the prosthetic material.
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Surgery for type A aortic dissection (TAAD) is frequently complicated by neurologic complications. The prognostic impact of neurologic complications of different nature has been investigated in this study. The subjects of this analysis were 3,902 patients who underwent surgery for acute TAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD). During the index hospitalization, 722 patients (18.5%) experienced stroke/global brain ischemia. Ischemic stroke was detected in 539 patients (13.8%), hemorrhagic stroke in 76 patients (1.9%) and global brain ischemia in 177 patients (4.5%), with a few patients having had findings of more than 1 of these conditions. In-hospital mortality was increased significantly in patients with postoperative ischemic stroke (25.6%, adjusted odds ratio [OR] 2.422, 95% confidence interval [CI] 1.825 to 3.216), hemorrhagic stroke (48.7%, adjusted OR 4.641, 95% CI 2.524 to 8.533), and global brain ischemia (74.0%, adjusted OR 22.275, 95% CI 14.537 to 35.524) compared with patients without neurologic complications (13.5%). Similarly, patients who experienced ischemic stroke (46.3%, adjusted hazard ratio [HR] 1.719, 95% CI 1.434 to 2.059), hemorrhagic stroke (62.8%, adjusted HR 3.236, 95% CI 2.314 to 4.525), and global brain ischemia (83.9%, adjusted HR 12.777, 95% CI 10.325 to 15.810) had significantly higher 5-year mortality than patients without postoperative neurologic complications (27.5%). The negative prognostic effect of neurologic complications on survival vanished about 1 year after surgery. In conclusion, postoperative ischemic stroke, hemorrhagic stroke, and global cerebral ischemia increased early and midterm mortality after surgery for acute TAAD. The magnitude of risk of mortality increased with the severity of the neurologic complications, with postoperative hemorrhagic stroke and global brain ischemia being highly lethal complications.
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Aneurisma de la Aorta Torácica , Disección Aórtica , Mortalidad Hospitalaria , Accidente Cerebrovascular Isquémico , Complicaciones Posoperatorias , Sistema de Registros , Humanos , Disección Aórtica/cirugía , Disección Aórtica/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Aneurisma de la Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Mortalidad Hospitalaria/tendencias , Anciano , Accidente Cerebrovascular Isquémico/epidemiología , Pronóstico , Accidente Cerebrovascular Hemorrágico/epidemiología , Isquemia Encefálica/etiología , Isquemia Encefálica/epidemiología , Factores de Riesgo , Europa (Continente)/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendenciasRESUMEN
BACKGROUND: Surgery for Stanford type A aortic dissection (TAAD) is associated with an increased risk of late aortic reoperations due to degeneration of the dissected aorta. METHODS: The subjects of this analysis were 990 TAAD patients who survived surgery for acute TAAD and had complete data on the diameter and dissection status of all aortic segments. RESULTS: After a mean follow-up of 4.2 ± 3.6 years, 60 patients underwent 85 distal aortic reoperations. Ten-year cumulative incidence of distal aortic reoperation was 9.6%. Multivariable competing risk analysis showed that the maximum preoperative diameter of the abdominal aorta (SHR 1.041, 95%CI 1.008-1.075), abdominal aorta dissection (SHR 2.133, 95%CI 1.156-3.937) and genetic syndromes (SHR 2.840, 95%CI 1.001-8.060) were independent predictors of distal aortic reoperation. Patients with a maximum diameter of the abdominal aorta >30 mm and/or abdominal aortic dissection had a cumulative incidence of 10-year distal aortic reoperation of 12.0% compared to 5.7% in those without these risk factors (adjusted SHR 2.076, 95%CI 1.062-4.060). CONCLUSION: TAAD patients with genetic syndromes, and increased size and dissection of the abdominal aorta have an increased the risk of distal aortic reoperations. A policy of extensive surgical or hybrid primary aortic repair, completion endovascular procedures for aortic remodeling and tight surveillance may be justified in these patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073.
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Aneurisma de la Aorta Torácica , Aneurisma de la Aorta , Disección Aórtica , Azidas , Implantación de Prótesis Vascular , Desoxiglucosa/análogos & derivados , Humanos , Aorta Abdominal/diagnóstico por imagen , Aorta Abdominal/cirugía , Aneurisma de la Aorta/cirugía , Reoperación , Implantación de Prótesis Vascular/efectos adversos , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/cirugía , Factores de Riesgo , Aneurisma de la Aorta Torácica/cirugía , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.
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Disección Aórtica , Azidas , Desoxiglucosa/análogos & derivados , Humanos , Estudios Retrospectivos , Estudios de Cohortes , Disección Aórtica/cirugía , Pronóstico , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs. METHODS: Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. RESULTS: The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p < 0.001) and postoperative LCOS (p < 0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P = 0.022). CONCLUSIONS: Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429.
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INTRODUCTION: Patients requiring postcardiotomy veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) have a high risk of early mortality. In this analysis, we evaluated whether any interinstitutional difference exists in the results of postcardiotomy V-A-ECMO. METHODS: Studies on postcardiotomy V-A-ECMO were identified through a systematic review for individual patient data (IPD) meta-analysis. Analysis of interinstitutional results was performed using direct standardization, estimation of observed/expected in-hospital mortality ratio and propensity score matching. RESULTS: Systematic review of the literature yielded 31 studies. Data from 10 studies on 1269 patients treated at 25 hospitals were available for the present analysis. In-hospital mortality was 66.7%. The relative risk of in-hospital mortality was significantly higher in six hospitals. Observed versus expected in-hospital mortality ratio showed that four hospitals were outliers with significantly increased mortality rates, and one hospital had significantly lower in-hospital mortality rate. Participating hospitals were classified as underperforming and overperforming hospitals if their observed/expected in-hospital mortality was higher or lower than 1.0, respectively. Among 395 propensity score matched pairs, the overperforming hospitals had significantly lower in-hospital mortality (60.3% vs 71.4%, p = 0.001) than underperforming hospitals. Low annual volume of postcardiotomy V-A-ECMO tended to be predictive of poor outcome only when adjusted for patients' risk profile. CONCLUSIONS: In-hospital mortality after postcardiotomy V-A-ECMO differed significantly between participating hospitals. These findings suggest that in many centers there is room for improvement of the results of postcardiotomy V-A-ECMO.
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Procedimientos Quirúrgicos Cardíacos , Oxigenación por Membrana Extracorpórea , Humanos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Oxigenación por Membrana Extracorpórea/efectos adversos , Oxigenación por Membrana Extracorpórea/métodos , Mortalidad Hospitalaria , Estudios Retrospectivos , Choque Cardiogénico/terapiaRESUMEN
Background: Acute type A aortic dissection (TAAD) is associated with significant mortality and morbidity. In this study we evaluated the prognostic significance of preoperative arterial lactate concentration on the outcome after surgery for TAAD. Methods: The ERTAAD registry included consecutive patients who underwent surgery for acute type A aortic dissection (TAAD) at 18 European centers of cardiac surgery. Results: Data on arterial lactate concentration immediately before surgery were available in 2798 (71.7 %) patients. Preoperative concentration of arterial lactate was an independent predictor of in-hospital mortality (mean, 3.5 ± 3.2 vs 2.1 ± 1.8 mmol/L, adjusted OR 1.181, 95%CI 1.129-1.235). The best cutoff value preoperative arterial lactate concentration was 1.8 mmol/L (in-hospital mortality, 12.0 %, vs. 26.6 %, p < 0.0001). The rates of in-hospital mortality increased along increasing quintiles of arterial lactate and it was 12.1 % in the lowest quintile and 33.6 % in the highest quintile (p < 0.0001). The difference between multivariable models with and without preoperative arterial lactate was statistically significant (p = 0.0002). The NRI was 0.296 (95%CI 0.200-0.391) (p < 0.0001) with -17 % of events correctly reclassified (p = 0.0002) and 46 % of non-events correctly reclassified (p < 0.0001). The IDI was 0.025 (95%CI 0.016-0.034) (p < 0.0001). Six studies from a systematic review plus the present one provided data for a pooled analysis which showed that the mean difference of preoperative arterial lactate between 30-day/in-hospital deaths and survivors was 1.85 mmol/L (95%CI 1.22-2.47, p < 0.0001, I2 64 %). Conclusions: Hyperlactatemia significantly increased the risk of mortality after surgery for acute TAAD and should be considered in the clinical assessment of these critically ill patients.
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Objective: Current guidelines advise using prophylactic tricuspid valve annuloplasty during mitral valve surgery, especially in the presence of annular diameter enlargement. However, several retrospective studies and a prospective randomized study from our department could not confirm that diameter enlargement is predictive of late regurgitation. We examined whether 2- and 3-dimensional echocardiographic and clinical characteristics could identify patients who will develop moderate or severe recurrent tricuspid regurgitation. Methods: Patients with less than severe functional tricuspid regurgitation (FTR) were randomized not to receive tricuspid annuloplasty, and 11 of 53 of them were excluded from the study because 3-dimensional echocardiographic analysis was not possible. Cox regression was used to estimate the model-based probability of moderate or severe FTR (vena contracta ≥3 mm) or progression of TR and FTR regression using valve dimensions (annulus area, diameter perimeter, nonplanar angle, and sphericity index), dynamics (annulus contraction, annulus displacement, and displacement velocity), and clinical parameters as possible predictors. Results: At a median follow-up of 3.8 years (range, 3-5.6 years), 17 patients had moderate or severe FTR or progression, and 13 had FTR regression. Our models identified annular displacement velocity as a significant predictor for FTR recurrence and nonplanar angle as a significant predictor for FTR regression. Conclusions: Annular dynamics, not the dimension, predict recurrence and regression of FTR. Annular contraction should be systematically investigated as a possible surrogate of right ventricle function to prophylactically treat the tricuspid valve.
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AIMS: In this study we evaluated the impact of direct aortic cannulation versus innominate/subclavian/axillary artery cannulation on the outcome after surgery for type A aortic dissection. METHODS: The outcomes of patients included in a multicenter European registry (ERTAAD) who underwent surgery for acute type A aortic dissection with direct aortic cannulation versus those with innominate/subclavian/axillary artery cannulation, i.e. supra-aortic arterial cannulation, were compared using propensity score matched analysis. RESULTS: Out of 3902 consecutive patients included in the registry, 2478 (63.5%) patients were eligible for this analysis. Direct aortic cannulation was performed in 627 (25.3%) patients, while supra-aortic arterial cannulation in 1851 (74.7%) patients. Propensity score matching yielded 614 pairs of patients. Among them, patients who underwent surgery for TAAD with direct aortic cannulation had significantly decreased in-hospital mortality (12.7% vs. 18.1%, p = 0.009) compared to those who had supra-aortic arterial cannulation. Furthermore, direct aortic cannulation was associated with decreased postoperative rates of paraparesis/paraplegia (2.0 vs. 6.0%, p < 0.0001), mesenteric ischemia (1.8 vs. 5.1%, p = 0.002), sepsis (7.0 vs. 14.2%, p < 0.0001), heart failure (11.2 vs. 15.2%, p = 0.043), and major lower limb amputation (0 vs. 1.0%, p = 0.031). Direct aortic cannulation showed a trend toward decreased risk of postoperative dialysis (10.1 vs. 13.7%, p = 0.051). CONCLUSIONS: This multicenter cohort study showed that direct aortic cannulation compared to supra-aortic arterial cannulation is associated with a significant reduction of the risk of in-hospital mortality after surgery for acute type A aortic dissection. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04831073.
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Disección Aórtica , Cateterismo , Humanos , Estudios de Cohortes , Resultado del Tratamiento , Aorta , Disección Aórtica/cirugía , Estudios RetrospectivosRESUMEN
This data article presents the details of the Live Road Assessment Custom Dataset (LiRA-CD), an open-source dataset for road condition modelling and research. The dataset captures GPS trajectories of a fleet of electric vehicles and their time-series data from 50 different sensors collected on 230 km of highway and urban roads in Copenhagen, Denmark. Additionally, road condition measurements were collected by standard survey vehicles, which serve as high-quality reference data. The in-vehicle measurements were collected onboard with an Internet-of-Things (IoT) device, then periodically transmitted before being saved in a database. Researchers can use the dataset for prediction modelling related to standard road condition parameters such as surface friction and texture, road roughness, road damages, and energy consumption. Furthermore, researchers and pavement engineers can use the dataset as a template for future studies and projects, benchmarking the performance of different algorithms and solving problems of the same type. LiRA-CD is freely available and can be accessed at https://doi.org/10.11583/DTU.c.6659909.