ABSTRACT
BACKGROUND: Functional tricuspid regurgitation (TR) is a common pathophysiologic condition in adults with ostium secundum atrial septal defect (ASD). The aim of this study was to evaluate long-term outcomes following transcatheter ASD closure, which have not been well studied among patients with significant TR. METHODS: We reviewed consecutive adult patients who underwent transcatheter ASD closure at Toronto General Hospital, Ontario, Canada, from 1998 to 2016. We linked our hospital registry with Ontario population-based health administrative databases to collect longitudinal data on inpatient and outpatient health care utilisation and vital status. RESULTS: In this cohort study of 949 patients, 199 (22%) had moderate to severe TR before transcatheter ASD closure. A significant proportion of patients (61%) showed improvement in TR severity to at least mild TR after ASD intervention. At a median follow-up of 10.9 years, patients with baseline mild or no TR, compared with those with greater than moderate TR, had significantly lower rates of all-cause mortality (6.8 vs 22.5 per 1000 person-years [PY]; P < 0.001), composite hospitalisation for atrial fibrillation (AF) or heart failure (HF) (22.3 vs 49.1 per 1000 PY; P < 0.001), and new onset of AF (10.4 vs 20.2 per 1000 PY; P = 0.002) and HF (5.0 vs 9.2 per 1000 PY; P = 0.039). Preprocedural TR was independently associated with higher all-cause mortality (adjusted hazard ratio 1.69, 95% confidence interval 1.08-2.62). CONCLUSIONS: TR severity was independently associated with a higher risk of mortality and morbidity. Further investigation of earlier device closure or concomitant tricuspid valve intervention may be of interest.
Subject(s)
Cardiac Catheterization , Heart Septal Defects, Atrial , Long Term Adverse Effects , Prosthesis Implantation , Tricuspid Valve Insufficiency , Atrial Fibrillation/epidemiology , Atrial Fibrillation/etiology , Atrial Fibrillation/therapy , Cardiac Catheterization/adverse effects , Cardiac Catheterization/methods , Echocardiography/methods , Female , Heart Failure/epidemiology , Heart Failure/etiology , Heart Failure/therapy , Heart Septal Defects, Atrial/complications , Heart Septal Defects, Atrial/diagnosis , Heart Septal Defects, Atrial/surgery , Hospitalization/statistics & numerical data , Humans , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Long Term Adverse Effects/therapy , Male , Middle Aged , Mortality , Ontario/epidemiology , Prosthesis Implantation/adverse effects , Prosthesis Implantation/methods , Retrospective Studies , Septal Occluder Device , Tricuspid Valve Insufficiency/complications , Tricuspid Valve Insufficiency/diagnosisABSTRACT
BACKGROUND: The choice between mechanical valves (MVs) and bioprosthetic valves (BVs) in patients undergoing aortic valve surgery is complex, requiring a balance between the inferior durability of BV and the indicated long-term anticoagulation therapy with MV. This is especially challenging in the middle age group (< 70 years), which has seen an increased use of BV over recent years. METHODS: A meta-analysis of randomised controlled trials (RCTs), observational studies using propensity score matching (PSM) and inverse probability weighting (IPW) was conducted to examine the clinical outcomes of patients < 70 years of age undergoing aortic valve replacement. The primary outcome was overall long-term mortality. Secondary outcomes included bleeding events, reoperation, systemic thromboembolism, and cerebrovascular accident. RESULTS: Fifteen studies (1 RCT, 12 PSM studies, and 2 IPW studies; aggregated sample size 16,876 patients) were included. Median follow-up was 7.8 years. Mortality was higher with BVs vs MVs (hazard ratio [HR] 1.22, 95% confidence interval [CI] 1.00-1.49), as was reoperation (HR 3.05, 95% CI 2.22-4.19). Bleeding risk was lower with BVs (HR 0.58, 95% CI 0.48-0.69), and the risk of stroke was similar in both valve types (HR 0.96, 95% CI 0.83-1.11) CONCLUSIONS: This broadest meta-analysis comparing BV and MV suggests a survival benefit for MVs in patients < 70 years of age. This should lead to reassessment of current patterns used in the choice of valves for patients < 70 among the cardiothoracic surgery community.
Subject(s)
Aortic Valve/surgery , Bioprosthesis/adverse effects , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis/adverse effects , Long Term Adverse Effects , Postoperative Complications , Reoperation/statistics & numerical data , Aortic Valve Disease/surgery , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/instrumentation , Heart Valve Prosthesis Implantation/methods , Humans , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Middle Aged , Mortality , Postoperative Complications/classification , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgeryABSTRACT
OBJECTIVES: To evaluate the association between low left ventricular ejection fraction (LVEF), complication rescue, and long-term survival after isolated coronary artery bypass grafting. METHODS: National cohort study of patients who underwent isolated coronary artery bypass grafting (2000-2016) using Veterans Affairs Surgical Quality Improvement Program data. Left ventricular ejection fraction was categorized as ≥35% (n = 55,877), 25%-34% (n = 3893), or <25% (n = 1707). Patients were also categorized as having had no complications, 1 complication, or more than 1 complication. The association between LVEF, complication rescue, and risk of death was evaluated with multivariable Cox regression. RESULTS: Among 61,477 patients, 6586 (10.7%) had a perioperative complication and 2056 (3.3%) had multiple complications. Relative to LVEF ≥35%, decreasing ejection fraction was associated with greater odds of complications (25%-34%, odds ratio, 1.30 [1.18-1.42]; <25%, odds ratio, 1.65 [1.43-1.92]). There was a dose-response relationship between decreasing LVEF and overall risk of death (≥35% [ref]; 25%-35%, hazard ratio, 1.46 [1.37-1.55]; <25%, hazard ratio, 1.68 [1.58-1.79]). Among patients who were rescued from complications, there were decreases in 10-year survival, regardless of LVEF. Among those rescued after multiple complications, LVEF was no longer associated with risk of death. CONCLUSIONS: While decreasing LVEF is associated with post-coronary artery bypass grafting complications, patients rescued from complications have worse long-term survival, regardless of left ventricular function. Prevention and timely treatment of complications should remain a focus of quality improvement initiatives, and future work is needed to mitigate their long-term detrimental impact on survival.
Subject(s)
Coronary Artery Bypass , Coronary Artery Disease , Long Term Adverse Effects , Postoperative Complications , Ventricular Dysfunction, Left , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/methods , Coronary Artery Disease/complications , Coronary Artery Disease/diagnosis , Coronary Artery Disease/physiopathology , Coronary Artery Disease/surgery , Early Medical Intervention/standards , Female , Humans , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/mortality , Long Term Adverse Effects/physiopathology , Long Term Adverse Effects/prevention & control , Male , Middle Aged , Postoperative Complications/diagnosis , Postoperative Complications/etiology , Postoperative Complications/physiopathology , Postoperative Complications/therapy , Preventive Health Services , Quality Improvement , Risk Assessment , Stroke Volume , Survival Analysis , Time-to-Treatment/standards , United States , United States Department of Veterans Affairs , Ventricular Dysfunction, Left/complications , Ventricular Dysfunction, Left/diagnosis , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Left/therapyABSTRACT
OBJECTIVE: In this study, we sought to identify independent risk factors for mortality and reintervention after early surgical correction of truncus arteriosus using a novel statistical method. METHODS: Patients undergoing neonatal/infant truncus arteriosus repair between January 1984 and December 2018 were reviewed retrospectively. An innovative statistical strategy was applied integrating competing risks analysis with modulated renewal for time-to-event modeling. RESULTS: A total of 204 patients were included in the study. Mortality occurred in 32 patients (15%). Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were significantly associated with overall mortality (right ventricle to pulmonary artery conduit size: hazard ratio, 1.34; 95% confidence interval, 1.08-1.66, P = .008; truncal valve insufficiency: hazard ratio, 2.5; 95% confidence interval, 1.13-5.53, P = .024). truncal valve insufficiency at birth, truncal valve intervention at index repair, and number of cusps (4 vs 3) were associated with truncal valve reoperations (truncal valve insufficiency: hazard ratio, 2.38; 95%, confidence interval, 1.13-5.01, P = .02; cusp number: hazard ratio, 6.62; 95% confidence interval, 2.54-17.3, P < .001). Right ventricle to pulmonary artery conduit size 11 mm or less was associated with a higher risk of early catheter-based reintervention (hazard ratio, 1.54; 95% confidence interval, 1.04-2.28, P = .03) and reoperation (hazard ratio, 1.96; 95% confidence interval, 1.33-2.89, P = .001) on the right ventricle to pulmonary artery conduit. CONCLUSIONS: Smaller right ventricle to pulmonary artery conduit size and truncal valve insufficiency at birth were associated with overall mortality after truncus arteriosus repair. Quadricuspid truncal valve, the presence of truncal valve insufficiency at the time of diagnosis, and truncal valve intervention at index repair were associated with an increased risk of reoperation. The size of the right ventricle to pulmonary artery conduit at index surgery is the single most important factor for early reoperation and catheter-based reintervention on the conduit.
Subject(s)
Cardiovascular Surgical Procedures , Heart Valves , Heart Ventricles , Long Term Adverse Effects , Postoperative Complications , Reoperation , Risk Assessment , Truncus Arteriosus, Persistent/surgery , Adult , Cardiovascular Surgical Procedures/adverse effects , Cardiovascular Surgical Procedures/methods , Cardiovascular Surgical Procedures/mortality , Causality , Female , Heart Valves/abnormalities , Heart Valves/physiopathology , Heart Valves/surgery , Heart Ventricles/abnormalities , Heart Ventricles/physiopathology , Humans , Infant , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Long Term Adverse Effects/surgery , Male , Mortality , Postoperative Complications/diagnosis , Postoperative Complications/mortality , Postoperative Complications/surgery , Pulmonary Artery/abnormalities , Pulmonary Artery/surgery , Reoperation/methods , Reoperation/standards , Reoperation/statistics & numerical data , Retrospective Studies , Risk Assessment/methods , Risk Assessment/statistics & numerical data , Truncus Arteriosus, Persistent/diagnosis , Truncus Arteriosus, Persistent/physiopathology , United States/epidemiologySubject(s)
Cardiovascular Surgical Procedures , Long Term Adverse Effects , Postoperative Complications , Reoperation , Risk Assessment , Truncus Arteriosus, Persistent/surgery , Adult , Cardiovascular Surgical Procedures/adverse effects , Cardiovascular Surgical Procedures/methods , Cardiovascular Surgical Procedures/mortality , Female , Humans , Infant , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Long Term Adverse Effects/surgery , Male , Postoperative Complications/diagnosis , Postoperative Complications/mortality , Postoperative Complications/surgery , Reoperation/methods , Reoperation/standards , Reoperation/statistics & numerical data , Risk Assessment/methods , Risk Assessment/statistics & numerical data , Risk Factors , Survival Analysis , Truncus Arteriosus, Persistent/diagnosis , Truncus Arteriosus, Persistent/physiopathologyABSTRACT
BACKGROUND: The public is placing increased emphasis on specialty specific rankings, thereby affecting patients' choices of clinical care programs. In the spirit of transparency, public reporting initiatives are underway or being considered by various surgical specialties whose databases rank programs based on short-term outcomes. Of concern, short-term risk avoidance excludes important comparative cases from surgical database participation and may adversely affect overall long-term oncologic treatment team results. To assess the validity of comparing short-term perioperative and long-term survival outcomes of all patients treated at major centers, we studied the correlations between these variables. METHODS: The National Cancer Database was queried for patients diagnosed with non-small cell lung carcinoma (NSCLC) between 2008 and 2012, yielding 5-year follow-up data for all patients at centers treating at least 100 patients annually. Mortality (30- and 90-day), unplanned 30-day readmissions, and hospital length of stay were modeled using logistic regression with sex, race, age, Charlson-Deyo combined comorbidity, extent of surgery, income, insurance status, histology, grade, and analytic stage as predictors, all with 2-way interaction terms. The differences between the predicted rates and observed rates were calculated for each short-term outcome, and the average of these was used to create a short-term metric (STM). A similar approach was used to create a long-term metric (LTM) that used overall survival as a single dependent variable. Centers were ranked into deciles based on these metrics. Visual plotting as well as correlation coefficients were used to judge correlation between STM and LTM. RESULTS: A total of 298,175 patients from 541 centers were included in this analysis, of whom 102,860 underwent surgical resection for NSCLC. The correlation between STM and LTM was negative using parametric estimates (Pearson correlation coefficient = -0.09 [P = .03] and -0.22 [P < .01]) and nonparametric estimates (Spearman rank correlation coefficient = -0.09 [P = .02] and -0.22 [P < .01]) for squamous cell carcinoma and adenocarcinoma, respectively. CONCLUSIONS: Short-term perioperative outcome rankings correlate poorly with long-term survival outcome rankings when cancer treatment centers are compared. Factors explaining this discrepancy merit further study. Rankings based on short-term outcomes alone may be incomplete for public reporting.
Subject(s)
Carcinoma, Non-Small-Cell Lung , Long Term Adverse Effects/mortality , Lung Neoplasms , Outcome Assessment, Health Care , Pneumonectomy , Postoperative Complications , Public Reporting of Healthcare Data , Carcinoma, Non-Small-Cell Lung/mortality , Carcinoma, Non-Small-Cell Lung/pathology , Carcinoma, Non-Small-Cell Lung/surgery , Female , Hospitals, High-Volume/statistics & numerical data , Humans , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Lung Neoplasms/surgery , Male , Middle Aged , Neoplasm Grading , Neoplasm Staging , Outcome Assessment, Health Care/methods , Outcome Assessment, Health Care/statistics & numerical data , Pneumonectomy/adverse effects , Pneumonectomy/methods , Pneumonectomy/statistics & numerical data , Postoperative Complications/mortality , Postoperative Complications/therapy , Risk Factors , Survival Analysis , United States/epidemiologyABSTRACT
BACKGROUND: Transcatheter mitral valve replacement (TMVR) is feasible for selected patients with severe mitral regurgitation (MR) who are poor candidates for valve surgery. Intermediate-term to long-term TMVR outcomes have not been reported. OBJECTIVES: This study sought to evaluate the safety and effectiveness through 2-year follow-up of TMVR in high-surgical-risk patients with severe MR. METHODS: The first 100 patients enrolled in the Expanded Clinical Study of the Tendyne Mitral Valve System, an open-label, nonrandomized, prospective study of transapical TMVR, were followed for 2 years. RESULTS: The patients (aged 74.7 ± 8.0 years, 69.0% male) had symptomatic (66.0% New York Heart Association [NYHA] functional class III or IV) grade 3+ or 4+ MR that was secondary or mixed in 89 (89.0%). Prostheses were successfully implanted in 97 (97.0%) patients. At 2 years, all-cause mortality was 39.0%; 17 (43.6%) of 39 deaths occurred during the first 90 days. Heart failure hospitalization (HFH) fell from 1.30 events per year preprocedure to 0.51 per year in the 2 years post-TMVR (P < 0.0001). At 2 years, 93.2% of surviving patients had no MR. No patient had >1+ MR. The improvement in symptoms at 1 year (88.5% NYHA functional class I or II) was sustained to 2 years (81.6% NYHA functional class I or II). Among survivors, the left ventricular ejection fraction was 45.6 ± 9.4% at baseline and 39.8 ± 9.5% at 2 years (P = 0.0012). Estimated right ventricular systolic pressure decreased from 47.6 ± 8.6 mm Hg to 32.5 ± 10.4 mm Hg (P < 0.005). CONCLUSIONS: In this study, the impact of TMVR on severity of MR, reduction in HFH rate, and improvement in symptoms was sustained through 2 years. All-cause mortality and the need for HFH was highest in the first 3 months postprocedure. (Expanded Clinical Study of the Tendyne Mitral Valve System; NCT02321514).
Subject(s)
Cardiac Catheterization/methods , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Long Term Adverse Effects/mortality , Mitral Valve Insufficiency , Mitral Valve , Postoperative Complications , Ventricular Dysfunction, Left , Aged , Echocardiography/methods , Female , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis Implantation/methods , Humans , Male , Mitral Valve/diagnostic imaging , Mitral Valve/surgery , Mitral Valve Insufficiency/diagnosis , Mitral Valve Insufficiency/mortality , Mitral Valve Insufficiency/physiopathology , Mitral Valve Insufficiency/surgery , Postoperative Complications/diagnosis , Postoperative Complications/epidemiology , Severity of Illness Index , Stroke Volume , Treatment Outcome , Ventricular Dysfunction, Left/diagnosis , Ventricular Dysfunction, Left/etiology , Ventricular Dysfunction, Left/physiopathologyABSTRACT
BACKGROUND: There is limited evidence that fractional flow reserve (FFR) is effective in guiding therapeutic strategy in multivessel coronary artery disease (CAD) beyond prespecified percutaneous coronary intervention or coronary graft surgery candidates. OBJECTIVES: The FUTURE (FUnctional Testing Underlying coronary REvascularization) trial aimed to evaluate whether a treatment strategy based on FFR was superior to a traditional strategy without FFR in the treatment of multivessel CAD. METHODS: The FUTURE trial is a prospective, randomized, open-label superiority trial. Multivessel CAD candidates were randomly assigned (1:1) to treatment strategy based on FFR in all stenotic (≥50%) coronary arteries or to a traditional strategy without FFR. In the FFR group, revascularization (percutaneous coronary intervention or surgery) was indicated for FFR ≤0.80 lesions. The primary endpoint was a composite of major adverse cardiac or cerebrovascular events at 1 year. RESULTS: The trial was stopped prematurely by the data safety and monitoring board after a safety analysis and 927 patients were enrolled. At 1-year follow-up, by intention to treat, there were no significant differences in major adverse cardiac or cerebrovascular events rates between groups (14.6% in the FFR group vs 14.4% in the control group; hazard ratio: 0.97; 95% confidence interval: 0.69-1.36; P = 0.85). The difference in all-cause mortality was nonsignificant, 3.7% in the FFR group versus 1.5% in the control group (hazard ratio: 2.34; 95% confidence interval: 0.97-5.18; P = 0.06), and this was confirmed with a 24 months' extended follow-up. FFR significantly reduced the proportion of revascularized patients, with more patients referred to exclusively medical treatment (P = 0.02). CONCLUSIONS: In patients with multivessel CAD, we did not find evidence that an FFR-guided treatment strategy reduced the risk of ischemic cardiovascular events or death at 1-year follow-up. (Functional Testing Underlying Coronary Revascularisation; NCT01881555).
Subject(s)
Coronary Artery Bypass , Coronary Artery Disease , Coronary Stenosis , Coronary Vessels , Fractional Flow Reserve, Myocardial/physiology , Percutaneous Coronary Intervention , Postoperative Complications/mortality , Aged , Coronary Angiography/methods , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/methods , Coronary Artery Disease/diagnosis , Coronary Artery Disease/mortality , Coronary Artery Disease/physiopathology , Coronary Artery Disease/surgery , Coronary Stenosis/diagnostic imaging , Coronary Stenosis/etiology , Coronary Stenosis/surgery , Coronary Vessels/diagnostic imaging , Coronary Vessels/physiopathology , Early Termination of Clinical Trials , Female , Humans , Long Term Adverse Effects/mortality , Male , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/methods , Predictive Value of Tests , Risk Assessment/methods , Severity of Illness IndexSubject(s)
Aftercare/methods , Long Term Adverse Effects , Mass Screening , Myocardial Infarction , Patient Care Management , Risk Adjustment , Age Factors , Aged , Australia/epidemiology , Awareness , Female , Health Services Needs and Demand , Heart Disease Risk Factors , Humans , Long Term Adverse Effects/mortality , Long Term Adverse Effects/prevention & control , Male , Mass Screening/methods , Mass Screening/psychology , Mass Screening/standards , Middle Aged , Myocardial Infarction/diagnosis , Myocardial Infarction/epidemiology , Myocardial Infarction/therapy , Patient Care Management/methods , Patient Care Management/standards , Risk Adjustment/methods , Risk Adjustment/organization & administrationABSTRACT
BACKGROUND: Survivors of acute type A aortic dissection (ATAAD) repair remain at risk for long-term complications. Guidelines recommend postoperative imaging surveillance, but adherence is uncertain. OBJECTIVES: The aim of this study was to define the real-world frequency of postoperative imaging and characterize long-term outcomes of ATAAD. METHODS: Population-based administrative health databases for Ontario, Canada, were linked to identify patients who underwent ATAAD repair and survived at least 90 days. Guideline-directed imaging surveillance (GDIS) was defined as undergoing a computed tomographic or magnetic resonance imaging scan at 6 and 12 months postoperatively and then annually thereafter. Multivariable time-to-event analysis explored the associations between GDIS and all-cause mortality and reintervention. RESULTS: A total of 888 patients who survived urgent ATAAD repair between April 1, 2005, and March 31, 2018, were included. Median follow-up after ATAAD repair was 5.2 years (interquartile range: 2.4-7.9 years). A total of 14% patients received GDIS throughout follow-up. At 6 years, 3.9% of patients had received GDIS. The mortality rate was 4% at 1 year, 14% at 5 years, and 29% at 10 years. Incidence of aortic reintervention was 3% at 1 year, 9% at 5 years, and 17% at 10 years; the majority of these were urgent (68%), and they carried a 9% 30-day mortality rate. Greater adherence to GDIS was associated with mortality (hazard ratio: 1.08; 95% confidence interval: 1.05-1.11) and reintervention (hazard ratio: 1.04; 95% confidence interval: 1.01-1.07). CONCLUSIONS: Adherence to GDIS following ATAAD repair is poor, while long-term mortality and reinterventions remain substantial. Further research is needed to determine if guidelines should be modified.
Subject(s)
Aortic Aneurysm , Aortic Dissection , Long Term Adverse Effects , Magnetic Resonance Imaging , Postoperative Complications , Reoperation , Tomography, X-Ray Computed , Vascular Surgical Procedures/adverse effects , Aortic Dissection/epidemiology , Aortic Dissection/surgery , Aortic Aneurysm/diagnostic imaging , Aortic Aneurysm/etiology , Aortic Aneurysm/surgery , Female , Guideline Adherence , Humans , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Long Term Adverse Effects/surgery , Magnetic Resonance Imaging/methods , Magnetic Resonance Imaging/statistics & numerical data , Male , Middle Aged , Needs Assessment , Ontario/epidemiology , Patient Care Planning/standards , Postoperative Complications/diagnosis , Postoperative Complications/etiology , Postoperative Complications/mortality , Postoperative Complications/surgery , Postoperative Period , Reoperation/adverse effects , Reoperation/methods , Reoperation/mortality , Tomography, X-Ray Computed/methods , Tomography, X-Ray Computed/statistics & numerical data , Vascular Surgical Procedures/methodsABSTRACT
Background Heart failure might be an important determinant in choosing coronary revascularization modalities. There was no previous study evaluating the effect of heart failure on long-term clinical outcomes after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG). Methods and Results Among 14 867 consecutive patients undergoing first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, we identified the current study population of 3380 patients with three-vessel or left main coronary artery disease, and compared clinical outcomes between PCI and CABG stratified by the subgroup based on the status of heart failure. There were 827 patients with heart failure (PCI: N=511, and CABG: N=316), and 2553 patients without heart failure (PCI: N=1619, and CABG: N=934). In patients with heart failure, the PCI group compared with the CABG group more often had advanced age, severe frailty, acute and severe heart failure, and elevated inflammatory markers. During a median 5.9 years of follow-up, there was a significant interaction between heart failure and the mortality risk of PCI relative to CABG (interaction P=0.009), with excess mortality risk of PCI relative to CABG in patients with heart failure (HR, 1.75; 95% CI, 1.28-2.42; P<0.001) and no excess mortality risk in patients without heart failure (HR, 1.04; 95% CI, 0.80-1.34; P=0.77). Conclusions There was a significant interaction between heart failure and the mortality risk of PCI relative to CABG with excess risk in patients with heart failure and neutral risk in patients without heart failure.
Subject(s)
Coronary Artery Bypass , Coronary Artery Disease , Heart Failure , Long Term Adverse Effects , Percutaneous Coronary Intervention , Aged , Comorbidity , Coronary Artery Bypass/adverse effects , Coronary Artery Bypass/methods , Coronary Artery Disease/diagnosis , Coronary Artery Disease/epidemiology , Coronary Artery Disease/surgery , Female , Frailty/diagnosis , Frailty/epidemiology , Heart Failure/diagnosis , Heart Failure/epidemiology , Heart Failure/physiopathology , Humans , Japan/epidemiology , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Male , Outcome Assessment, Health Care , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/methods , Risk Factors , Severity of Illness Index , Treatment OutcomeABSTRACT
BACKGROUND: Tricuspid regurgitation (TR) is associated with adverse prognosis in various patient populations but currently no data is available about the prevalence and prognostic implication of TR in ST-segment elevation myocardial infarction (STEMI) patients. OBJECTIVES: To investigate the possible implication of TR among STEMI patients. METHODS: We conducted a retrospective study of STEMI patients undergoing primary percutaneous coronary intervention (PCI), and its relation to major clinical and echocardiographic parameters. Patient records were assessed for the prevalence and severity of TR as well as the relation to the clinical profile, key echocardiographic parameters, in-hospital outcomes, and long-term mortality. Patients with previous myocardial infarction or known previous TR were excluded. RESULTS: The study included 1071 STEMI patients admitted between September 2011 and May 2016 (age 61 ± 13 years; predominantly male). A total of 205 patients (19%) had mild TR while another 32 (3%) had moderate or greater TR. Patients with significant TR demonstrated worse echocardiographic parameters, were more likely to have in-hospital complications, and had higher long-term mortality (28% vs. 6%, P < 0.001). Following adjustment for significant clinical and echocardiographic parameters, mortality hazard ratio of at least moderate to severe TR remained significant (2.44, 95% confidence interval 1.06-5.6, P = .036) for patients with moderate to severe TR. CONCLUSIONS: Among STEMI patients after primary PCI, the presence of moderate to severe TR was independently associated with adverse outcomes and significantly lower survival rate.
Subject(s)
Echocardiography , Long Term Adverse Effects , Percutaneous Coronary Intervention , ST Elevation Myocardial Infarction , Tricuspid Valve Insufficiency , Aged , Echocardiography/methods , Echocardiography/statistics & numerical data , Female , Humans , Israel/epidemiology , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Male , Middle Aged , Outcome and Process Assessment, Health Care , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/methods , Percutaneous Coronary Intervention/statistics & numerical data , Prognosis , Registries/statistics & numerical data , Retrospective Studies , Risk Assessment , Risk Factors , ST Elevation Myocardial Infarction/complications , ST Elevation Myocardial Infarction/diagnosis , ST Elevation Myocardial Infarction/mortality , ST Elevation Myocardial Infarction/surgery , Severity of Illness Index , Survival Rate , Tricuspid Valve Insufficiency/diagnosis , Tricuspid Valve Insufficiency/epidemiology , Tricuspid Valve Insufficiency/etiology , Tricuspid Valve Insufficiency/physiopathologyABSTRACT
BACKGROUND: Transcatheter aortic-valve replacement (TAVR) reduces mortality and improves quality of life in patients with severe aortic valve stenosis. One third of patients have no benefit one year after TAVR. Sarcopenia, an age-related loss of skeletal muscle mass, is associated with increased physical disability and mortality. The main purpose was to evaluate the impact of severe sarcopenia on rehospitalization one year after TAVR in older patients. METHODS: All patients aged ≥75 referred for a TAVR in 2018 were included. Severe sarcopenia was defined by a loss of skeletal muscle mass defined on CT-scan measurement associated with a gait speed ≤0.8m/s. The main outcome was rehospitalization one year after TAVR. RESULTS: Median age of the 182 included patients was 84, and 35% had an unplanned hospitalization at one year. Severe sarcopenia was diagnosed in 9 patients (4.9%). Univariable analysis showed that gait speed was a factor associated with readmission [HR=0.32, 95% CI (0.10-0.97), p=0.04] but not severe sarcopenia. In multivariable analysis, only diabetes was significantly associated with rehospitalization [HR=2.06, 95% CI (1.11-3.84), p=0.02]. Prevalence of severe sarcopenia varied according to different thresholds of skeletal muscle mass on CT-scan. CONCLUSION: Even though severe sarcopenia was not correlated with rehospitalization and mortality at one year after TAVR, our results emphasize the changes in the prevalence according to cutoff used. It highlights the need to define standardized methods and international threshold for sarcopenia diagnosis by CT-scan measurements, in general population and for patients with valvular heart disease.
Subject(s)
Aortic Valve Stenosis , Muscle, Skeletal/diagnostic imaging , Quality of Life , Sarcopenia , Transcatheter Aortic Valve Replacement/adverse effects , Walking Speed , Aged, 80 and over , Aortic Valve Stenosis/diagnosis , Aortic Valve Stenosis/epidemiology , Aortic Valve Stenosis/psychology , Aortic Valve Stenosis/surgery , Female , Humans , Long Term Adverse Effects/mortality , Long Term Adverse Effects/therapy , Male , Patient Readmission/statistics & numerical data , Risk Assessment , Risk Factors , Sarcopenia/epidemiology , Severity of Illness Index , Tomography, X-Ray Computed/methodsABSTRACT
BACKGROUND: The role of perioperative radiotherapy in the management of resectable extremity soft tissue sarcoma (ESTS) is widely recognised for local tumour control, wound complications (WC) and long-term function. However, debate continues regarding its implications on long-term survival. This study aimed to determine whether the timing of perioperative radiotherapy affects long-term survival outcomes in adults with ESTS. METHODS: A systematic literature search of MEDLINE, EMBASE, Web of Science and Cochrane was performed. The primary outcome measure was the pooled hazard ratio (HR) at 95% confidence intervals. Secondary outcomes and subgroup analyses were presented as cumulative odds ratios (OR). A random-effects, generic inverse variance method and sensitivity analysis were performed to minimise heterogeneity. RESULTS: Six studies (nâ¯=â¯4192 patients) were identified. Time-to-event analysis demonstrated a statistically significant advantage in post-operative radiotherapy for overall survival (HR 1.15 and pâ¯=â¯0.05). Combined HRs for disease-free (1.25 and pâ¯=â¯0.22) and disease-specific (1.06 and pâ¯=â¯0.43) survival also favoured post-operative radiotherapy but did not achieve statistical significance. Post-operative radiotherapy was shown to confer an overall (OR 1.19 and pâ¯=â¯0.01), disease-free (OR 1.19 and pâ¯=â¯0.01) and disease-specific (OR 1.19 and pâ¯=â¯0.01) survival advantage on subgroup analysis. This survival benefit was best observed at three years in the disease-free survival comparison (OR 1.55 and pâ¯=â¯0.003). Preoperative radiotherapy was associated with more WC (OR 2.74 and p<0.00001). CONCLUSIONS: Pooled analysis of published literature suggests that post-operative radiotherapy confers a significant long-term survival advantage with fewer WC. Further large multicentre randomised controlled trials with long-term follow-up are required to determine the optimal perioperative radiotherapy regime in adult ESTS.
Subject(s)
Extremities , Long Term Adverse Effects , Perioperative Care , Radiotherapy/methods , Sarcoma/radiotherapy , Soft Tissue Neoplasms/radiotherapy , Adult , Cancer Survivors/statistics & numerical data , Extremities/pathology , Extremities/surgery , Humans , Long Term Adverse Effects/mortality , Long Term Adverse Effects/prevention & control , Perioperative Care/methods , Perioperative Care/standards , Sarcoma/mortality , Sarcoma/pathology , Sarcoma/surgery , Soft Tissue Neoplasms/mortality , Soft Tissue Neoplasms/pathology , Soft Tissue Neoplasms/surgery , Time-to-Treatment/standardsABSTRACT
Background Percutaneous coronary intervention with radial arterial access has been associated with fewer occurrences of major bleeding. However, published data on the long-term mortality and major adverse cardiac events after percutaneous coronary intervention with radial or femoral arterial access are inconclusive. Method and Results This was a territory-wide retrospective cohort study including 26 022 patients who underwent first-ever percutaneous coronary intervention between January 1, 2010 and December 31, 2017 in Hong Kong. Among the 14 614 patients matched by propensity score (7307 patients in each group), 558 (7.6%) and 787 (10.8%) patients died during the observation period in the radial group and femoral group, respectively, resulting in annualized all-cause mortality rates of 2.69% and 3.87%, respectively. The radial group had a lower risk of all-cause mortality compared with the femoral group up to 3 years after percutaneous coronary intervention (hazard ratio [HR], 0.70; 95% CI, 0.63-0.78; P<0.001). Radial access was associated with a lower risk of major adverse cardiac events (HR, 0.78; 95% CI, 0.73-0.83, P<0.001), myocardial infarction after hospital discharge (HR, 0.78; 95% CI, 0.70-0.87, P<0.001), and unplanned revascularization (HR, 0.76; 95% CI, 0.68-0.85, P<0.001). The risks of stroke were similar across the 2 groups (HR, 0.96; 95% CI, 0.82-1.13, P=0.655). Conclusions Radial access was associated with a significant reduction in all-cause mortality at 3 years compared with femoral access. Radial access was associated with reduced risks of myocardial infarction and unplanned revascularization, but not stroke. The benefits were sustained beyond the early postoperative period.
Subject(s)
Acute Coronary Syndrome , Catheterization, Peripheral , Femoral Artery/surgery , Long Term Adverse Effects , Radial Artery/surgery , Acute Coronary Syndrome/diagnosis , Acute Coronary Syndrome/epidemiology , Acute Coronary Syndrome/surgery , Catheterization, Peripheral/adverse effects , Catheterization, Peripheral/methods , Cohort Studies , Coronary Angiography/methods , Female , Hemorrhage/diagnosis , Hemorrhage/etiology , Hong Kong/epidemiology , Humans , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Long Term Adverse Effects/surgery , Male , Middle Aged , Mortality , Outcome and Process Assessment, Health Care , Percutaneous Coronary Intervention/adverse effects , Percutaneous Coronary Intervention/methods , Reoperation/methods , Reoperation/statistics & numerical data , Retrospective StudiesABSTRACT
BACKGROUND: There has recently been considerable interest in better understanding how blood pressure should be managed after an episode of hospitalized AKI, but there are scant data regarding the associations between blood pressure measured after AKI and subsequent adverse outcomes. We hypothesized that among AKI survivors, higher blood pressure measured three months after hospital discharge would be associated with worse outcomes. We also hypothesized these associations between blood pressure and outcomes would be similar among those who survived non-AKI hospitalizations. METHODS: We quantified how systolic blood pressure (SBP) observed three months after hospital discharge was associated with risks of subsequent hospitalized AKI, loss of kidney function, mortality, and heart failure events among 769 patients in the prospective ASSESS-AKI cohort study who had hospitalized AKI. We repeated this analysis among the 769 matched non-AKI ASSESS-AKI enrollees. We then formally tested for AKI interaction in the full cohort of 1538 patients to determine if these associations differed among those who did and did not experience AKI during the index hospitalization. RESULTS: Among 769 patients with AKI, 42 % had subsequent AKI, 13 % had loss of kidney function, 27 % died, and 18 % had heart failure events. SBP 3 months post-hospitalization did not have a stepwise association with the risk of subsequent AKI, loss of kidney function, mortality, or heart failure events. Among the 769 without AKI, there was also no stepwise association with these risks. In formal interaction testing using the full cohort of 1538 patients, hospitalized AKI did not modify the association between post-discharge SBP and subsequent risks of adverse clinical outcomes. CONCLUSIONS: Contrary to our first hypothesis, we did not observe that higher stepwise blood pressure measured three months after hospital discharge with AKI was associated with worse outcomes. Our data were consistent with our second hypothesis that the association between blood pressure measured three months after hospital discharge and outcomes among AKI survivors is similar to that observed among those who survived non-AKI hospitalizations.
Subject(s)
Acute Kidney Injury , Heart Failure , Hypertension , Long Term Adverse Effects , Risk Assessment , Acute Kidney Injury/complications , Acute Kidney Injury/diagnosis , Acute Kidney Injury/therapy , Blood Pressure , Blood Pressure Determination/methods , Blood Pressure Determination/statistics & numerical data , Cohort Studies , Female , Heart Failure/diagnosis , Heart Failure/etiology , Heart Failure/mortality , Hospitalization/statistics & numerical data , Humans , Hypertension/diagnosis , Hypertension/epidemiology , Hypertension/etiology , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Male , Middle Aged , Mortality , North America/epidemiology , Outcome and Process Assessment, Health Care , Prognosis , Risk Assessment/methods , Risk Assessment/statistics & numerical data , Risk Factors , SurvivorsABSTRACT
BACKGROUND: Survivors of critical illness have poor long-term outcomes with subsequent increases in health care utilization. Less is known about the interplay between multimorbidity and long-term outcomes. RESEARCH QUESTION: How do baseline patient demographics impact mortality and health care utilization in the year after discharge from critical care? STUDY DESIGN AND METHODS: Using data from a prospectively collected cohort, we used propensity score matching to assess differences in outcomes between patients with a critical care encounter and patients admitted to the hospital without critical care. Long-term mortality was examined via nationally linked data as was hospital resource use in the year after hospital discharge. The cause of death was also examined. RESULTS: This analysis included 3,112 participants. There was no difference in long-term mortality between the critical care and hospital cohorts (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .39). Prehospitalization emotional health issues (eg, clinical diagnosis of depression) were associated with increased long-term mortality (hazard ratio, 1.49; 95% CI, 1.14-1.96; P < .004). Health care utilization was different between the two cohorts in the year after discharge with the critical care cohort experiencing a 29% increased risk of hospital readmission (OR, 1.29; 95% CI, 1.11-1.50; P = .001). INTERPRETATION: This national cohort study has demonstrated increased resource use for critical care survivors in the year after discharge but fails to replicate past findings of increased longer-term mortality. Multimorbidity, lifestyle factors, and socioeconomic status appear to influence long-term outcomes and should be the focus of future research.
Subject(s)
Critical Care , Critical Illness , Depression , Long Term Adverse Effects , Risk Assessment , Social Class , Aged , Cohort Studies , Critical Care/methods , Critical Care/statistics & numerical data , Critical Illness/mortality , Critical Illness/therapy , Depression/diagnosis , Depression/epidemiology , Female , Humans , Life Style , Long Term Adverse Effects/diagnosis , Long Term Adverse Effects/mortality , Male , Multimorbidity , Patient Discharge , Patient Readmission , Risk Factors , Scotland/epidemiology , Subacute Care/statistics & numerical data , Survivors/statistics & numerical dataABSTRACT
BACKGROUND: Long-term outcomes are poorly understood, and data in patients undergoing transvenous lead extraction (TLE) are lacking. OBJECTIVE: The purpose of this study was to evaluate factors influencing survival in patients undergoing TLE depending on extraction indication. METHODS: Clinical data from consecutive patients undergoing TLE in the reference center between 2000 and 2019 were prospectively collected. The total cohort was divided into groups depending on whether there was an infective or noninfective indication for TLE. We evaluated the association of demographic, clinical, and device-related and procedure-related factors on mortality. RESULTS: A total of 1151 patients were included. Mean follow-up was 66 months, and mortality was 34.2% (n = 392). Of these patients, 632 (54.9%) and 519 (45.1%) were for infective and noninfective indications, respectively. A higher proportion in the infection group died (38.6% vs 28.5%; P <.001). In the total cohort, multivariable analysis demonstrated increased mortality risk with age >75 years (hazard ratio [HR] 2.98; 95% confidence interval [CI] 2.35-3.78; P <.001), estimated glomerular filtration rate <60 mL/min/1.73 m2 (HR 1.67; 95% CI 1.31-2.13; P <.001), higher cumulative comorbidity (HR 1.17; 95% CI 1.09-1.26; P <.001), reduced risk per percentage increase in left ventricular ejection fraction (HR 0.98; 95% CI 0.97-0.99; P <.001), and near unity per year of additional lead dwell time (HR 0.98; 95% CI 0.96-1.00; P = .037). Kaplan-Meier survival curves demonstrated worse prognosis, with a higher number of leads extracted and increasing comorbidities. CONCLUSION: Long-term mortality for patients undergoing TLE remains high. Consensus guidelines recommend evaluating risk for major complications when determining whether to proceed with TLE. This study suggests also assessing longer-term outcomes when considering TLE in those with a high risk of medium- and long-term mortality, particularly for noninfective indications.
Subject(s)
Defibrillators, Implantable/adverse effects , Device Removal , Long Term Adverse Effects/mortality , Multiple Chronic Conditions/epidemiology , Pacemaker, Artificial/adverse effects , Prosthesis-Related Infections , Aged , Catheterization, Peripheral/methods , Comorbidity , Device Removal/adverse effects , Device Removal/methods , Device Removal/mortality , Female , Humans , Kaplan-Meier Estimate , Male , Prognosis , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/etiology , Prosthesis-Related Infections/surgery , Renal Insufficiency, Chronic/epidemiology , Risk Assessment/statistics & numerical data , Risk Factors , Stroke VolumeABSTRACT
BACKGROUND: Contrast-associated acute kidney injury (CA-AKI) is a common complication in patients undergoing coronary angiography (CAG). However, few studies demonstrate the association between the prognosis and developed CA-AKI in the different periods after the operation. METHODS: We retrospectively enrolled 3206 patients with preoperative serum creatinine (Scr) and at least twice SCr measurement after CAG. CA-AKI was defined as an increase ≥50% or ≥0.3 mg/dL from baseline in the 72 hours after the procedure. Early CA-AKI was defined as having the first increase in SCr within the early phase (<24 hours), and late CA-AKI was defined as an increase in SCr that occurred for the first time in the late phase (24-72 hours). The first endpoint of this study was long-term all-cause mortality. Kaplan-Meier analysis was used to count the cumulative mortality, and the log-rank test was used to assess differences between curves. Univariate and multivariate cox regression analyses were performed to assess whether patients who developed different type CA-AKI were at increased risk of long-term mortality. RESULTS: The number of deaths in the 3 groups was 407 for normal (12.7%), 106 for early CA-AKI (32.7%) and 57 for late CA-AKI (17.7%), during a median follow-up period of 3.95 years. After adjusting for important clinical variables, early CA-AKI (HR = 1.33, 95% CI: 1.02-1.74, P=0.038) was significantly associated with mortality, while late CA-AKI (HR = 0.92, 95% CI: 0.65-1.31, P=0.633) was not. The same results were found in patients with coronary artery disease, chronic kidney disease, diabetes mellitus, and percutaneous coronary intervention. CONCLUSIONS: Early increases in Scr, i.e., early CA-AKI, have better predictive value for long-term mortality. Therefore, in clinical practice, physicians should pay more attention to patients with early renal injury related to long-term prognosis and give active treatment.
Subject(s)
Acute Kidney Injury , Contrast Media/adverse effects , Coronary Angiography , Coronary Artery Disease , Long Term Adverse Effects , Acute Kidney Injury/chemically induced , Acute Kidney Injury/diagnosis , China/epidemiology , Coronary Angiography/adverse effects , Coronary Angiography/methods , Coronary Angiography/mortality , Coronary Artery Disease/blood , Coronary Artery Disease/diagnosis , Coronary Artery Disease/mortality , Creatinine/blood , Female , Humans , Long Term Adverse Effects/etiology , Long Term Adverse Effects/mortality , Male , Middle Aged , Prognosis , Retrospective Studies , Risk Adjustment/methods , Risk FactorsABSTRACT
BACKGROUND: Data on long-term cardiovascular outcomes in systemic lupus erythematosus (SLE) are sparse. OBJECTIVES: This study sought to examine the long-term risk and prognosis associated with cardiovascular outcomes, including heart failure (HF), in patients with SLE. METHODS: Using Danish administrative registries, risks of outcomes were compared between SLE patients (diagnosed 1996 to 2018, no history of cardiovascular disease) and age-, sex-, and comorbidity-matched control subjects from the background population (matched 1:4). Furthermore, mortality following HF diagnosis was compared between SLE patients developing HF and age- and sex-matched non-SLE control subjects with HF (matched 1:4). RESULTS: A total of 3,411 SLE patients (median age: 44.6 years [25th to 75th percentile: 31.9 to 57.0 years]; 14.1% men) were matched with 13,644 control subjects. The median follow-up was 8.5 years (25th to 75th percentile: 4.0 to 14.4 years). Absolute 10-year risks of outcomes were: HF, 3.71% (95% confidence interval [CI]: 3.02% to 4.51%) for SLE patients, 1.94% (95% CI: 1.68% to 2.24%) for control subjects; atrial fibrillation, 4.35% (95% CI: 3.61% to 5.18%) for SLE patients, 2.82% (95% CI: 2.50% to 3.16%) for control subjects; ischemic stroke, 3.75% (95% CI: 3.06% to 4.54%) for SLE patients, 1.92% (95% CI: 1.66% to 2.20%) for control subjects; myocardial infarction, 2.17% (95% CI: 1.66% to 2.80%) for SLE patients, 1.49% (95% CI: 1.26% to 1.75%) for control subjects; venous thromboembolism, 6.03% (95% CI: 5.17% to 6.98%) for SLE patients, 1.68% (95% CI: 1.44% to 1.95%) for control subjects; and the composite of implantable cardioverter-defibrillator implantation/ventricular arrhythmias/cardiac arrest, 0.89% (95% CI: 0.58% to 1.31%) for SLE patients, 0.30% (95% CI: 0.20% to 0.43%) for control subjects. SLE with subsequent HF was associated with higher mortality compared with HF without SLE (adjusted hazard ratio: 1.50; 95% CI: 1.08 to 2.08). CONCLUSIONS: SLE patients had a higher associated risk of HF and other cardiovascular outcomes compared with matched control subjects. Among patients developing HF, a history of SLE was associated with higher mortality.