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(1) Background: Type A acute aortic dissection (TAAAD) almost always requires emergency surgery, and postoperative complications are common. Quality assurance systems tend to measure only the hard outcomes, e.g., complications and mortality. Our aim was to assess the health-related quality of life of TAAAD survivors. (2) Methods: An anonymized, Dutch language, web-based survey was sent out to all of the participants of the 2022 Annual Meeting of the Dutch National Aortic Dissection (DNAD) advocacy group via their own representatives. The survey was divided into five sections: patient information, global satisfaction, surgery, including complications, and the recovery period. (3) Results: Ninety members of the DNAD group attended the meeting. Seventy-five (83%) participated in the survey, and the responses from 61 (81%) were available for analysis. Despite hindrances in their daily life (complications, changes in physical, cognitive, and social functioning), patients were satisfied with their treatment, and all would undergo the procedure again. In addition they requested better post-discharge guidance and communication (4) Conclusion: The emphasis lies in equipping patients with knowledge about potential outcomes and effective coping strategies. This underscores the importance of communication and expectation management, in line with established literature.
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OBJECTIVES: We investigated the predictive value of aortic valve cusp retraction, calcification, and fenestration for aortic valvuloplasty feasibility. METHODS: Multicenter data were collected for 2082 patients who underwent surgical aortic valvuloplasty or aortic valve replacement. The study population had retraction, calcification, or fenestration in at least one aortic valve cusp. Controls had normal or prolapsed cusps. RESULTS: All cusp characteristics demonstrated significantly increased odds ratios [ORs] for switch to valve replacement. This effect was strongest for cusp retraction, followed by calcification and fenestration (OR, 25.14; P ≤ .001; OR, 13.50, P ≤ .001; OR, 12.32, P ≤ .001). Calcification and retraction displayed increased odds for developing grade 4 aortic regurgitation compared with grade 0 or 1 combined on average over time (OR, 6.67; P ≤ .001; OR, 4.13; P = .038). Patients with cusp retraction showed increased risk for reintervention at 1- and 2-year follow-up after aortic valvuloplasty (hazard ratio, 5.66; P ≤ .001; hazard ratio, 3.22, P = .007). Cusp fenestration was the only group showing neither an increased risk of postoperative severe aortic regurgitation (P = .57) or early reintervention (P = .88) compared with the control group. CONCLUSIONS: Aortic valve cusp retraction, calcification, and fenestration were all related to increased rates of switch to valve replacement. Calcification and retraction were associated with recurrence of severe aortic regurgitation. Retraction was related to early reintervention. Fenestration was neither associated with recurrence of severe aortic regurgitation or reintervention. This indicates that surgeons are well able to distinguish aortic valve repair candidates in patients with cusp fenestration.
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Insuficiencia de la Válvula Aórtica , Estenosis de la Válvula Aórtica , Calcinosis , Procedimientos Quirúrgicos Cardíacos , Humanos , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/etiología , Calcinosis/diagnóstico por imagen , Calcinosis/cirugía , Resultado del TratamientoRESUMEN
OBJECTIVES: Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve-graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients. METHODS: The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR. RESULTS: We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1-5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94-97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82-92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95-98%) with VSRR and 95.4% (95% CI 91-99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02). CONCLUSIONS: This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres.
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Aneurisma de la Aorta Torácica , Aneurisma de la Raíz de la Aorta , Insuficiencia de la Válvula Aórtica , Implantación de Prótesis Vascular , Endocarditis , Enfermedades de las Válvulas Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Pilotos , Humanos , Persona de Mediana Edad , Válvula Aórtica/cirugía , Puntaje de Propensión , Constricción Patológica/etiología , Implantación de Prótesis Vascular/métodos , Aneurisma de la Aorta Torácica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/métodos , Endocarditis/cirugía , Resultado del Tratamiento , Estudios Retrospectivos , Insuficiencia de la Válvula Aórtica/cirugíaRESUMEN
BACKGROUND: In response to an increased need for patient information in congenital heart disease, we previously developed an online, evidence-based information portal for patients with congenital aortic and pulmonary valve disease. To assess its effectiveness, a stepped-wedge cluster randomised trial was conducted. METHODS: Adult patients and caregivers of paediatric patients with congenital aortic and/or pulmonary valve disease and/or tetralogy of Fallot who visited the outpatient clinic at any of the four participating centres in the Netherlands between 1 March 2016-1 July 2017 were prospectively included. The intervention (information portal) was introduced in the outpatient clinic according to a stepped-wedge randomised design. One month after outpatient clinic visit, each participant completed a questionnaire on disease-specific knowledge, anxiety, depression, mental quality of life, involvement and opinion/attitude concerning patient information and involvement. RESULTS: 343 participants were included (221 control, 122 intervention). Cardiac diagnosis (p=0.873), educational level (p=0.153) and sex (p=0.603) were comparable between the two groups. All outcomes were comparable between groups in the intention-to-treat analyses. However, only 51.6% of subjects in the intervention group (n=63) reported actually visiting the portal. Among these subjects (as-treated), disease-specific knowledge (p=0.041) and mental health (p=0.039) were significantly better than in control subjects, while other baseline and outcome variables were comparable. CONCLUSION: Even after being invited by their cardiologists, only half of the participants actually visited the information portal. Only in those participants that actually visited the portal, knowledge of disease and mental health were significantly better. This underlines the importance of effective implementation of online evidence-based patient information portals in clinical practice.
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Válvula Aórtica , Cuidadores/estadística & datos numéricos , Enfermedades de las Válvulas Cardíacas/epidemiología , Portales del Paciente/estadística & datos numéricos , Válvula Pulmonar , Calidad de Vida , Adolescente , Adulto , Femenino , Humanos , Masculino , Morbilidad/tendencias , Países Bajos/epidemiología , Encuestas y Cuestionarios , Adulto JovenRESUMEN
Selecting the optimal surgical treatment strategy in patients below the age of 65 years (i.e., non-elderly patients) with aortic valve or aortic root disease remains challenging. The objective of the current study is to summarize contemporary research on clinical and quality of life outcomes after aortic valve replacement (AVR) and aortic root surgery in non-elderly patients. Recent systematic reviews on clinical outcome after biological and mechanical AVR, the Ross procedure and aortic root surgery show that event occurrence is considerable after any type of AVR or aortic root surgery and-with the exception of the Ross procedure-survival is suboptimal. Although thromboembolism and bleeding events are more common after mechanical AVR and root surgery, these events are also considerably present after biological AVR, the Ross procedure and valve-sparing aortic root surgery (VSRR). Similarly, reoperation is more common after biological AVR, the Ross procedure and VSRR, but also occurs frequently after mechanical AVR and root replacement. Published evidence in AVR patients points to the direction of better health-related quality of life (HRQoL) outcomes with a biological solutions, while the HRQoL after aortic root surgery is limited and contradictory. This review illustrates that treatment for non-elderly aortic valve and aortic root disease patients needs to be tailored to the individual patient, considering both clinical and HRQoL outcomes as crucial factors to reach a treatment decision that best reflects the patient's values and goals in life.
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Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.
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Válvula Aórtica/cirugía , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Adulto , Factores de Edad , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Bioprótesis , Medicina Basada en la Evidencia , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/fisiopatología , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Esperanza de Vida , Persona de Mediana Edad , Falla de Prótesis , Recuperación de la Función , Sistema de Registros , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Resultado del TratamientoRESUMEN
OBJECTIVES: Current national registries are lacking detailed pathology-driven analysis and long-term patients outcomes. The Heart Valve Society (HVS) aortic valve (AV) repair research network started the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) to evaluate long-term patient outcomes of AV repair and replacement. The purpose of the current report is to describe the AVIATOR initiative and report in a descriptive manner the patients included. METHODS: The AV repair research network includes surgeons, cardiologists, and scientists and established an online database compliant with the guidelines for reporting valve-related events. Prospective inclusion started from January 2013. Adult patients (18 years or older) who were operated on between 1995 and 2017 with complete procedural specification of the type of repair/replacement were selected for descriptive analysis. RESULTS: Currently 58 centers from 17 countries include 4896 patients with 89% AV repair (n = 4379) versus 11% AV replacement (n = 517). AV repair was either isolated (28%), or associated with tubular/partial root replacement (22%) or valve-sparing root replacement (49%) with an in-hospital mortality of 0.5%, 1.7%, and 1.2%, respectively. AV replacement was either isolated (24%), associated with tubular/partial root replacement (17%) or root replacement (59%) with an in-hospital mortality of 1%, 2.6%, and 2.0%, respectively. CONCLUSIONS: The multicenter surgical AVIATOR registry, by applying uniform definitions, should provide a solid evidence base to evaluate the place of repair versus replacement on the basis of long-term patient outcomes. Obtaining data completeness and adequate representation of all surgery types remain challenging. Toward the near future AVIATOR-medical will start to study natural history, as will AVIATOR-kids, with a focus on pediatric disease.
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Aneurisma de la Aorta/cirugía , Insuficiencia de la Válvula Aórtica/cirugía , Adolescente , Adulto , Anciano , Disección Aórtica/cirugía , Aorta/cirugía , Aneurisma de la Aorta/complicaciones , Insuficiencia de la Válvula Aórtica/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Sistema de Registros , Resultado del Tratamiento , Adulto JovenRESUMEN
With improved outcomes following cardiac surgery, health related quality of life (HRQoL) gains increasing importance for the better judgement of choosing the preferred treatment strategy in the individual patient. The physician perception of patient preferences can differ considerably from actual patient preferences, underlining the importance of gathering evidence of actual patient preferences before and quality of life after cardiac surgery. The objective of the current review is to provide an overview of current insights into the quality of life measurements after aortic valve and thoracic aortic surgery and to provide starting points for the application of HRQoL measurements toward the future. The amount and level of evidence on HRQoL outcomes after aortic valve and thoracic aortic surgery seems to be insufficient. Little has been investigated about the natural course of HRQoL after cardiac surgery, HRQoL outcomes between different surgical strategies, HRQoL outcomes between surgical patients and the general population, the different factors influencing HRQoL after cardiac surgery, and the effect of HRQoL on healthcare costs. More prospective studies should be performed, taking into account the knowledge gaps that need to be filled. Computerized adaptive testing methods through open source programs can be implemented to keep the burden to the patient as low as possible and catalyze the use of these tools. Our cardiovascular surgery community has the responsibility to deliberate how it can proceed to effectively fill in these knowledge gaps, and use this newfound knowledge to improve shared treatment decision making, patient outcomes, and ultimately optimize health care efficiency.
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Enfermedades de la Aorta/cirugía , Válvula Aórtica/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Estado de Salud , Calidad de Vida , Procedimientos Quirúrgicos Vasculares/métodos , Humanos , Periodo PosoperatorioRESUMEN
OBJECTIVES: Surgical repair of coarctation of the aorta (CoA) is often possible through left thoracotomy and without the use of cardiopulmonary bypass. Recent studies reporting the outcome after CoA repair through left thoracotomy are limited. Therefore, the aim of this study is to evaluate the results of CoA repair through left thoracotomy in children who were operated on in our centre over the past 21 years. METHODS: From January 1995 to December 2016, 292 patients younger than 18 years underwent primary CoA repair through left thoracotomy at our 2 institutions. Peri- and postoperative data and follow-up data collected from our hospital and the referring hospitals were retrospectively reviewed. RESULTS: Median age at operation was 64 days (range 2 days-17 years). Most patients underwent the resection of the CoA followed by an (extended) end-to-end anastomosis (93%). Six patients died perioperatively and 2 more patients died during the follow-up, of which 7 patients had other major comorbidities. Actuarial survival was 97% at 5 years, 96% at 10 years and 96% at 15 years. Second arch interventions due to recoarctation were performed in 9.9% (n = 29) of patients, consisting of balloon dilatation in all but 2 patients. Recoarctation occurred significantly more often after initial repair in the neonatal period (21%) and could occur as late as 14 years after initial surgery. There were 7 re-recoarctations, and 14% of patients were on hypertensive medication during the follow-up. CONCLUSIONS: Repair of CoA through left thoracotomy is a safe procedure with low rates of mortality. The long-term follow-up is necessary due to the significant risk of recoarctation requiring reintervention.
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Coartación Aórtica , Toracotomía , Coartación Aórtica/mortalidad , Coartación Aórtica/cirugía , Preescolar , Femenino , Humanos , Hipertensión , Lactante , Recién Nacido , Estimación de Kaplan-Meier , Masculino , Complicaciones Posoperatorias , Reoperación/efectos adversos , Reoperación/mortalidad , Estudios Retrospectivos , Toracotomía/efectos adversos , Toracotomía/mortalidad , Resultado del TratamientoRESUMEN
OBJECTIVES: Supravalvar aortic stenosis (SVAS) is a rare congenital anomaly. The "single-patch technique," "'two sinus augmentation with an inverted Y-patch" (both nonsymmetrical corrections), "three-patch technique," and the "slide aortoplasty" (both symmetrical corrections) are the techniques implemented by the majority of surgeons for the correction of SVAS. In the few studies that compared these techniques, no technique was shown to be superior over another. The aim of the present study is to review the 52-year experience with the surgical correction of SVAS in two of four congenital cardiothoracic surgical centers in the Netherlands. METHODS: We retrospectively reviewed all patient files of those who underwent an operation to correct their SVAS, between 1962 and 2014 in our centers. Patients were divided according to their operating technique. These groups were compared using the end points freedom from reoperation and mortality. RESULTS: A total of 49 patients were included, 23 (46.9%) patients in the nonsymmetrical group and 26 (53.1%) patients in the symmetrical group. Survival after 20 years in the nonsymmetrical group was 80% (standard error [SE]: 0.091) and in the symmetrical group was 85% (SE: 0.085; P = .163). Freedom from reoperation after 20 years in the nonsymmetrical group was 88% (SE: 0.079) and in the symmetrical group was 71% (SE: 0.107; P = 0.313). CONCLUSION: In this patient group, there is no significant difference in survival and freedom from reoperation between the different surgical techniques for SVAS repair. Compared to the survival in the general population, the survival of SVAS patients is remarkably low. Apparently, SVAS is not a benign disease and probably patients should be followed more closely for the rest of their lives.
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Aorta/cirugía , Estenosis Aórtica Supravalvular/cirugía , Procedimientos Quirúrgicos Vasculares/métodos , Adolescente , Adulto , Estenosis Aórtica Supravalvular/congénito , Estenosis Aórtica Supravalvular/mortalidad , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Reoperación , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Use of 4-dimensional flow magnetic resonance imaging (4D-flow MRI) derived wall shear stress (WSS) heat maps enables identification of regions in the ascending aorta with increased WSS. These regions are subject to dysregulation of the extracellular matrix and elastic fiber degeneration, which is associated with aortic dilatation and dissection. PURPOSE: To evaluate the effect of the presence of aortic valve stenosis and the aortic diameter on the peak WSS and surface area of increased WSS in the ascending aorta. STUDY TYPE: Prospective. SUBJECTS: In all, 48 bicuspid aortic valve (BAV) patients (38.1 ± 12.4 years) and 25 age- and gender-matched healthy individuals. FIELD STRENGTH/SEQUENCE: Time-resolved 3D phase contrast MRI with three-directional velocity encoding at 3.0T. ASSESSMENT: Peak systolic velocity, WSS, and aortic diameters were assessed in the ascending aorta and 3D heat maps were used to identify regions with elevated WSS. STATISTICAL TESTS: Comparisons between groups were performed by t-tests. Correlations were investigated by univariate and multivariate regression analysis. RESULTS: Elevated WSS was present in 15 ± 11% (range; 1-35%) of the surface area of the ascending aorta of BAV patients with aortic valve stenosis (AS) (n = 10) and in 6 ± 8% (range; 0-31%) of the ascending aorta of BAV patients without AS (P = 0.005). The mid-ascending aortic diameter negatively correlated with the peak ascending aortic WSS (R = -0.413, P = 0.004) and the surface area of elevated WSS (R = -0.419, P = 0.003). Multivariate linear regression analysis yielded that the height of peak WSS and the amount of elevated WSS depended individually on the presence of aortic valve stenosis and the diameter of the ascending aorta. DATA CONCLUSION: The extent of increased WSS in the ascending aorta of BAV patients depends on the presence of aortic valve stenosis and aortic dilatation and is most pronounced in the presence of AS and a nondilated ascending aorta. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2018;48:522-530.
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Aorta/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/diagnóstico por imagen , Imagen por Resonancia Magnética , Adulto , Estudios de Casos y Controles , Constricción Patológica , Dilatación , Ecocardiografía , Elasticidad , Matriz Extracelular/metabolismo , Femenino , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Resistencia al Corte , Estrés Mecánico , SístoleRESUMEN
BACKGROUND: A Dutch online patient decision aid to support prosthetic heart valve selection was recently developed. A multicenter randomized controlled trial was conducted to assess whether use of the patient decision aid results in optimization of shared decision making in prosthetic heart valve selection. METHODS AND RESULTS: In a 5-center randomized controlled trial, patients were allocated to receive either standard preoperative care (control group) or additional access to the patient decision aid (intervention group). Legally capable adult patients accepted for elective isolated or combined aortic and mitral valve replacement were included. Primary outcome was preoperative decisional conflict (Decisional Conflict Scale); secondary outcomes included patient knowledge, involvement in valve selection, anxiety and depression, (valve-specific) quality of life, and regret. Out of 306 eligible patients, 155 were randomized (78 control and 77 intervention). Preoperative decisional conflict did not differ between the groups (34% versus 33%; P=0.834). Intervention patients felt better informed (median Decisional Conflict Scale informed subscore: 8 versus 17; P=0.046) and had a better knowledge of prosthetic valves (85% versus 68%; P=0.004). Intervention patients experienced less anxiety and depression (median Hospital Anxiety and Depression Scale score: 6 versus 9; P=0.015) and better mental well-being (mean Short Form Health Survey score: 54 versus 50; P=0.032). Three months postoperatively, valve-specific quality of life and regret did not differ between the groups. CONCLUSIONS: A patient decision aid to support shared decision making in prosthetic heart valve selection does not lower decisional conflict. It does result in more knowledgeable, better informed, and less anxious and depressed patients, with a better mental well-being. CLINICAL TRIAL REGISTRATION: http://www.trialregister.nl. Unique identifier: NTR4350.
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Válvula Aórtica/cirugía , Toma de Decisiones Clínicas , Técnicas de Apoyo para la Decisión , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Válvula Mitral/cirugía , Selección de Paciente , Diseño de Prótesis , Adulto , Anciano , Anciano de 80 o más Años , Ansiedad/etiología , Ansiedad/prevención & control , Válvula Aórtica/fisiopatología , Depresión/etiología , Depresión/prevención & control , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/fisiopatología , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Internet , Masculino , Salud Mental , Persona de Mediana Edad , Válvula Mitral/fisiopatología , Países Bajos , Educación del Paciente como Asunto , Satisfacción del Paciente , Valor Predictivo de las Pruebas , Estudios Prospectivos , Calidad de Vida , Medición de Riesgo , Factores de Riesgo , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Liver cirrhosis is a known risk factor for postoperative mortality in patients undergoing cardiac surgery. Clinical assessment of liver cirrhosis using the widely accepted Child-Pugh (CP) score is thus vital for evaluation of surgical options and perioperative care. However, detailed mortality rates as a consequence of liver cirrhosis are unclear. This review aimed to stratify the risk of short-term (<30 days) and overall (up to 10 years) mortality after cardiac surgery in patients with liver cirrhosis, classified by the CP score. Thus, PubMed, Embase, CINAHL and the Cochrane Library were systematically reviewed by two independent investigators for studies published up to February 2014, in which mortality in cirrhotic patients, classified by the CP classification, undergoing cardiac surgery was evaluated postoperatively. A total of 993 articles were identified. After critical appraisal of 21 articles, 19 were selected for final analysis. Weighted short-term mortality of cirrhotic patients undergoing cardiac surgery was 19.3% [95% confidence interval (CI): 16.4-22.5%]. Across the different CP groups, short-term mortality appeared to be 9.0% (95% CI: 6.6-12.2%), 37.7% (95% CI: 30.8-44.3%) and 52.0% (95% CI: 33.5-70.0%) in Groups A, B and C, respectively. Weighted overall mortality within 1 year was 42.0% (95% CI: 36.0-48.3%) in all cirrhotic patients. Subdivided in groups, overall mortality within that 1 year was 27.2% (95% CI: 20.9-34.7%), 66.2% (95% CI: 54.3-76.3%) and 78.9% (95% CI: 56.1-92.1%) in Groups A, B and C, respectively. In conclusion, short-term mortality is considerably increased in patients with liver cirrhosis CP class B and C. Overall mortality is significantly high in all classes of liver cirrhosis.
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Procedimientos Quirúrgicos Cardíacos/mortalidad , Cirrosis Hepática/mortalidad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
In the past decades, more than 40 mitral valve annuloplasty rings of various shapes and consistency were marketed for mitral regurgitation (MR), although the effect of ring type on clinical outcome remains unclear. Our objective was to review the literature and apply a simplification method to make rings of different shapes and rigidity more comparable. We studied relevant literature from MEDLINE and EMBASE databases related to clinical studies as well as animal and finite element models. Annuloplasty rings were clustered into 3 groups as follows: rigid (R), flexible (F), and semirigid (S). Only clinical articles regarding degenerative (DEG) or ischemic/dilated cardiomyopathy (ICM) MR were included and stratified into these groups. A total of 37 rings were clustered into R, F, and S subgroups. Clinical studies with a mean follow-up of less than 1 year and a reported mean etiology of valve incompetence of less than 60% were excluded from the analysis. Forty-one publications were included. Preimplant and postimplant end points were New York Heart Association class, left ventricular ejection fraction (LVEF), left ventricular end-systolic dimension (LVESD), and left ventricular end-diastolic dimension (LVEDD). Statistical analysis included paired-samples t test and analysis of variance with post hoc Bonferroni correction. P < 0.05 indicated statistical difference. Mean ± SD follow-up was 38.6 ± 27 and 29.7 ± 13.2 months for DEG and ICM, respectively. In DEG, LVEF remained unchanged, and LVESD decreased in all subgroups. In our analysis, LVEDD decreased only in F and R, and S did not change; however, the 4 individual studies showed a significant decline. In ICM, New York Heart Association class improved in all subgroups, and LVEF increased. Moreover, LVESD and LVEDD decreased only in F and S; R was underpowered (1 study). No statistical difference among R, F, and S in either ICM or DEG could be detected for all end points. Overall, owing to underpowered data sets derived from limited available publications, major statistical differences in clinical outcome between ring types could not be substantiated. Essential end points such as recurrent MR and survival were incomparable. In conclusion, ring morphology and consistency do not seem to play a major clinical role in mitral valve repair based on the present literature. Hence, until demonstrated otherwise, surgeons may choose their ring upon their judgment, tailored to specific patient needs.
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Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral/cirugía , Diseño de Prótesis , Cardiomiopatía Dilatada/complicaciones , Humanos , Anuloplastia de la Válvula Mitral/métodos , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/fisiopatología , Ajuste de Prótesis , Recuperación de la Función , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
OBJECTIVES: The aim was to describe procedural volumes, patient risk profile and outcomes of heart valve surgery in the past 16 years in Netherlands. METHODS: The Dutch National Database for Cardio-Thoracic Surgery includes approximately 200 000 cardiac operations performed between 1995 and 2010. Information on all valve surgeries (56 397 operations) was extracted. We determined trends for changes in procedural volume, demographics, risk profile and in-hospital mortality of valve operations. Because of incomplete data in the first years of registration, the total number of operations in those years was estimated using Poisson regression. For a subset from 2007 to 2010, follow-up data were available. Survival status was obtained through linkage with the national Cause of Death Registry, and survival analysis was performed using Kaplan-Meier method. Information on discharge and readmissions was obtained from the National Hospital Discharge Registry. RESULTS: The annual volume of heart valve operations increased by more than 100% from an estimated 2431 in 1995 to 5906 in 2010. Adjusted for population size in Netherlands, the number of operations per 100 000 adults increased from 20 in 1995 to 43 in 2010. In 2010, frequently performed valve surgery included the following: 34.6% isolated aortic valve (AoV) replacement, 21.8% AoV replacement and coronary artery bypass grafting (CABG), 14.6% isolated mitral valve surgery (repair or replacement) and 9.1% mitral valve and CABG. In AoV surgery, an increasing use of bioprostheses in all age categories is observed. In mitral valve surgery, 75.4% was performed by repair rather than replacement in 2010. In-hospital mortality for all valve surgery decreased significantly from 4.6% in 2007 to 3.6% in 2010, whereas the mean logistic EuroSCORE remained stable (median 5.8, P = 1.000). Thirty-day mortality after all valve surgery was 3.9% and 120-day mortality was 6.5%. At 1 year, survival after all valve surgery was 91.6% and a reoperation had been performed in 1.6%. The median postoperative length of stay was 7 days (interquartile range (IQR) 5-11) in the primary hospital and 11 days (IQR 8-16), including subsequent stay, in the secondary hospital. CONCLUSIONS: The results of this study provide a comprehensive overview of valve surgery trends and outcomes in Netherlands. The number of heart valve operations performed in Netherlands has increased since 1995. The significant decrease in mortality and unchanged EuroSCORE between 2007 and 2010 might reflect a general improvement of the safety of valve surgery.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas/métodos , Válvulas Cardíacas/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Bases de Datos Factuales , Femenino , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Países Bajos/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Inspiratory muscle training (IMT) before cardiac surgery has proved to be a promising intervention to reduce postoperative pneumonia in a randomized controlled trial setting. Effects of IMT in routine care have not been reported. OBJECTIVE: The purpose of this study was to investigate the effect of IMT before cardiac surgery on postoperative pneumonia in routine care at a Dutch university medical center using propensity scoring. DESIGN: This was an observational cohort study. METHODS: All candidates for cardiac surgery were preoperatively stratified by a physical therapist for low risk or high risk for postoperative pulmonary complications. Patients at high risk either engaged in an unsupervised IMT program (20 minutes a day) at home for at least 2 weeks before surgery (group 1) or received usual care (no IMT) (group 2). Results in terms of outcome measures were adjusted with propensity scores to reduce bias caused by nonrandom treatment assignment. RESULTS: The results showed that of the 94 patients at high risk in group 1, 1 patient (1.1%) developed a postoperative pneumonia. In group 2, 8 out of the 252 patients at high risk (3.2%) developed this pulmonary complication (adjusted odds ratio=0.34, 95% confidence interval=0.04-3.38). No significant differences were found regarding median (25th-75th percentile) ventilation time (7 [5-9] hours versus 7 [5-10] hours), length of stay in the intensive care unit (23 [21-24] hours versus 23 [21-25] hours), or total postoperative length of stay (7 [6-11] days versus 7 [5-9] days). LIMITATIONS: The most important limitations of this study were confounding, incomplete data collection, and a low incidence of the primary outcome. CONCLUSIONS: Propensity scoring is believed to be a valuable tool of great potential interest to researchers in the field of observational studies. Whether IMT in routine care resulted in less postoperative pneumonia cannot be concluded.
Asunto(s)
Ejercicios Respiratorios , Cuidados Preoperatorios , Procedimientos Quirúrgicos Cardíacos , Estudios de Cohortes , Humanos , Neumonía/prevención & control , Cuidados Preoperatorios/métodos , Cuidados Preoperatorios/normas , Puntaje de Propensión , Medición de RiesgoRESUMEN
The European system for cardiac operative risk evaluation (EuroSCORE) is a commonly used risk score for operative mortality following cardiac surgery. We aimed to conduct a systematic review of the performance of the additive and logistic EuroSCORE. A literature search resulted in 67 articles. Studies applying the EuroSCORE on patients undergoing cardiac surgery and which reported early mortality were included. Weighted meta-regression showed that the EuroSCORE overestimated mortality. However, this performance depended on the risk profile of patients: in high-risk patients, the additive model actually underestimated mortality. Discriminative performance was good. Given the poor predictive performance, the EuroSCORE may not be suitable as a tool for patient selection nor for benchmarking.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/mortalidad , Índice de Severidad de la Enfermedad , Calibración , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Pronóstico , Medición de Riesgo/métodos , Resultado del TratamientoRESUMEN
Viewing static photographs of objects in motion evokes higher fMRI activation in the human medial temporal complex (MT+) than looking at similar photographs without this implied motion. As MT+ is traditionally thought to be involved in motion perception (and not in form perception), this finding suggests feedback from object-recognition areas onto MT+. To investigate this hypothesis, we recorded extracranial potentials evoked by the sight of photographs of biological agents with and without implied motion. The difference in potential between responses to pictures with and without implied motion was maximal between 260 and 400 msec after stimulus onset. Source analysis of this difference revealed one bilateral, symmetrical dipole pair in the occipital lobe. This area also showed a response to real motion, but approximately 100 msec earlier than the implied motion response. The longer latency of the implied motion response in comparison to the real motion response is consistent with a feedback projection onto MT+ following object recognition in higher-level temporal areas.