Risk Factor Analysis for 30-day Mortality After Surgery for Infective Endocarditis.

BACKGROUND: Infective endocarditis (IE) remains a challenging disease associated with high mortality. Several scores have been suggested to assess surgical risk. None was sufficiently adequate. We therefore analyzed risk factors for 30-day mortality. METHODS: A total of 438 consecutive patients had surgery for IE in our department between 2002 and 2020. Patients were divided into two groups, one consisting of 30-day survivors (362 patients; 82.6%) and one of nonsurvivors (76 patients; 17.4%). Logistic regression analysis on pre- and intraoperative risk factors was performed and the groups were compared by univariable analyses. RESULTS: Patients in mortality group were older (69 [58, 77] vs. 63 [50, 72] years; p < 0.001), EuroSCORE II was higher (24.5 [12.1, 49.0] vs. 8.95 [3.7, 21.2]; p < 0.001) and there were more females. More frequently left ventricular function (below 30%), preoperative acute renal insufficiency, chronic dialysis, insulin-dependent diabetes mellitus, NYHA-class IV (New York Heart Association heart failure class IV), and cardiogenic shock occurred. Patients in the mortality group were often intensive care unit patients (40.8 vs. 22.4%; p < 0.001) or had a preoperative stroke (26.3 vs. 16.0%; p = 0.033). In the nonsurvivor group Staphylococcus aureus was prevalent. Streptococcus viridans was common in the survivor group as was isolated aortic valve endocarditis (32.9 vs. 17.1%; p = 0.006). Prosthetic valve endocarditis (PVE) and abscesses occurred more often in nonsurvivors. In the logistic regression analysis, female gender, chronic dialysis, cardiogenic shock, and NYHA IV and from intraoperative variables PVE, cardiopulmonary bypass time, and mitral valve surgery were the strongest predictors for 30-day mortality. CONCLUSION: This study indeed clearly indicates that significant risk factors for 30-day mortality cannot be changed. Nevertheless, they should be taken into account for preoperative counselling, and they will alert the surgical team for an even more careful management.

Pulmonary valve reconstruction for acquired pulmonary regurgitation in patients with treated congenital heart disease.

OBJECTIVES: Pulmonary valve regurgitation is a common problem after relief of right ventricular outflow tract (RVOT) obstruction with a transannular patch. Pulmonary valve replacement with a homograft or xenograft is the routine treatment. Longevity of biological valves and the availability of homografts are limited. Alternatives to restore RVOT competence are evaluated. The goal of this study was to present intermediate-term results for pulmonary valve reconstruction (PVr) in patients with severe regurgitation. METHODS: PVr was performed in 24 patients (August 2006‒July 2018). We analysed perioperative data, pre- and postoperative cardiac magnetic resonance (CMR) imaging studies, freedom from valve replacement and risk factors for pulmonary valve dysfunction. RESULTS: The underlying diagnoses were tetralogy of Fallot (n = 18, 75%), pulmonary stenosis (n = 5, 20.8%) and the double outlet right ventricle post banding procedure (n = 1, 4.2%). The median age was 21.5 (14.8-23.7) years. Main (n = 9, 37.5%) and branch pulmonary artery procedures (n = 6, 25%) and surgery of the RVOT (n = 16, 30.2%) were often part of the reconstruction. The median follow-up after the operation was 8.0 (4.7-9.7) years. Freedom from valve failure was 96% at 2 and 90% at 5 years. The mean longevity of the reconstructive surgery was 9.9 years (95% confidence interval: 8.8-11.1 years). CMR before and 6 months after surgery showed a reduction in the regurgitation fraction [41% (33-55) vs 20% (18-27) P = 0.00] and of the indexed right ventricular end-diastolic volume [156 ml/m2 (149-175) vs 116 ml/m2 (100-143), P = 0.004]. Peak velocity across the pulmonary valve (determined by CMR) half a year after surgery was 2.0, unchanged. CONCLUSIONS: PVr can be achieved with acceptable intermediate-term results and may delay pulmonary valve replacement.

Mid- and Long-Term Surgical Outcomes Due to Infective Endocarditis in Elderly Patients: A Retrospective Cohort Study.

BACKGROUND: Infective endocarditis (IE) is one of the true remaining dreaded situations in cardiovascular medicine. Current international guidelines do not include specific recommendations for treatment options of infective endocarditis (conventional vs. surgical) based on the patient's age, functional status or comorbidities. Elderly patients have less invasive and often delayed surgeries compared to younger patients due to their shorter long-term survival probabilities. In the setting of IE, this might not be the right treatment, as surgery is the only curative option in up to 50% of all endocarditis patients. The aim of our study was to evaluate the mid- and long-term surgical outcomes due to infective endocarditis of patients aged ≥70 years. METHODS: Between 2002 and 2020, a retrospective study with 137 patients aged 70 years and older and 276 patients aged below 70 years was conducted. Altogether, 413 consecutive patients who received surgery due to infective native or prosthetic valve endocarditis were assigned to either the elderly (E)-Group or the control (C)-Group. Primary endpoints were short- and long-term MACCEs (Major Adverse Cardiac and Cerebrovascular Events) as a composite of death or major adverse events, and secondary endpoints were intraoperative variables and postoperative course. RESULTS: Preoperative risk factors differed significantly. Elderly patients had more arterial hypertension, atrial fibrillation, diabetes, chronic renal insufficiency and coronary heart disease. Fewer of them were in a state of emergency. Time from diagnosis to OR, antibiotic pretreatment, length of surgery and cardiopulmonary bypass time were significantly longer in the E-Group. Furthermore, 44.5% of patients in the E-Group had prosthesis endocarditis as opposed to 29.7% in the C-group. During postoperative follow-up, new onset of hemodialysis, duration of ventilation, delirium, reintubation and tracheotomy rates were significantly higher in the E-Group. There were significant differences in 7- and 30-day mortality. One- year survival was 62% for the E-Group and 79% for the C-Group. Five-year survival was 47% for the E-Group and 67% for the C-Group. CONCLUSIONS: This study demonstrates that surgery for infective endocarditis is a high-risk procedure, especially for elderly people. Nevertheless, as it is more or less the only concept to increase long-term survival, it should be offered generously to all patients who are still able to take care of themselves.

Right ventricular outflow tract reconstruction with the Labcor® stentless valved pulmonary conduit.

OBJECTIVES: The right ventricular outflow tract reconstruction is a common necessity in congenital cardiac surgery. As homograft availability is limited, alternatives need to be evaluated. The Labcor® conduit consists of a porcine tricomposite valve assembled inside a bovine pericardium tube. This study presents intermediate-term results for its utilization for right ventricular outflow tract reconstruction. METHODS: Labcor conduits were implanted in 53 patients (February 2009-July 2016). We analysed perioperative data, freedom from conduit failure and risk factors for conduit dysfunction. RESULTS: The most common diagnosis was Tetralogy of Fallot (n = 20, 37.7%). The median age at surgery was 10.0 [interquartile range (IQR) 4.9-14.3] years. Pulmonary artery plasty (n = 37, 69.8%) and augmentation of the right ventricular outflow tract (n = 16, 30.2%) were often part of the procedure. The median conduit size was 21 (range 11-25) mm. There was no in-hospital death. The median follow-up after surgery was 4.6 (IQR 3.4-5.6) years. Fourteen patients (27.5%) developed conduit failure with stenosis being the main cause. Freedom from conduit failure was 98.0% at 2 and 80.5% at 5 years. The median longevity of the conduit was 7.4 years (95% confidence interval 5.1-9.8 years). Younger age and smaller conduit size were related to conduit failure. CONCLUSIONS: Utilization of the Labcor conduit revealed acceptable intermediate-term results. The conduit appeared to be functioning sufficiently well within the first 5 years in the majority of patients. The higher rate of failure concerning smaller conduits might be associated with somatic outgrowth; however, conduit degeneration as common and long-term outcome still needs to be evaluated.

Mid- and Long-Term Outcomes of Total Arterial Myocardial Revascularization in Patients Aged 70 Years and Older: A Single-Center Experience.

BACKGROUND: Patients receiving arterial grafts have superior late survival after coronary artery bypass graft (CABG) surgery. The aim of our study was to evaluate the mid- and long-term results of total arterial (TA) revascularization in the elderly. METHODS: Between January 2005 and December 2012, a retrospective study on age-, gender-, and EuroSCORE-matched patients aged 70 years and older was performed. Altogether, 356 patients who received isolated CABG were assigned to either TA group or control (CON) group. RESULTS: No significant differences were noted in regard to preoperative risk factors. The number of distal anastomoses was significantly higher in the CON group (3.6 ± 0.6 vs. 2.9 ± 0.8; p < 0.001). Postoperatively, no significant differences were noted in regard to morbidity or mortality. There were no significant differences in mortality rate at 1 year (5.6 vs. 5.2%; p = 0.98), or 5 years (9.0 vs. 12.1%; p = 0.39) between both groups. However, the TA group was associated with significantly higher rate of event-free survival (p = 0.017). CONCLUSION: This study suggests that TA revascularization is an effective procedure. Lower rates of late cardiac events encourage the use of this concept for the elderly.

[Maturity Levels of Quality and Risk Management at the University Hospital Schleswig-Holstein]. / Reifegrade des Qualitäts- und Risikomanagementsystems am Universitätsklinikum Schleswig-Holstein.

INTRODUCTION: Quality and risk management in hospitals are not only required by law but also for an optimal patient-centered and process-optimized patient care. To evaluate the maturity levels of quality and risk management at the University Hospital Schleswig-Holstein (UKSH), a structured analytical tool was developed for easy and efficient application. METHODS: Four criteria concerning quality management - quality assurance (QS), critical incident reporting system (CIRS), complaint management (BM) and process management (PM) - were evaluated with a structured questionnaire. Self-assessment and external assessment were performed to classify the maturity levels at the UKSH (location Kiel and Lübeck). Every quality item was graded into four categories from "A" (fully implemented) to "D" (not implemented at all). First of all, an external assessment was initiated by the head of the department of quality and risk management. Thereafter, a self-assessment was performed by 46 clinical units of the UKSH. Discrepancies were resolved in a collegial dialogue. Based on these data, overall maturity levels were obtained for every clinical unit. RESULTS: The overall maturity level "A" was reached by three out of 46 (6.5%) clinical units. No unit was graded with maturity level "D". 50% out of all units reached level "B" and 43.5% level "C". The distribution of the four different quality criteria revealed a good implementation of complaint management (maturity levels "A" and "B" in 78.3%), whereas the levels for CIRS were "C" and "D" in 73.9%. Quality assurance and process management showed quite similar distributions for the levels of maturity "B" and "C" (87% QS; 91% PM). DISCUSSION: The structured analytical tool revealed maturity levels of 46 clinical units of the UKSH and defined the maturity levels of four relevant quality criteria (QS, CIRS, BM, PM). As a consequence, extensive procedures were implemented to raise the standard of quality and risk management. In future, maturity levels will be reevaluated every two years. This qualitative maturity level model enables in a simple and efficient way precise statements concerning presence, manifestation and development of quality and risk management.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults.

Objectives: Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients. Methods: We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery. Results: The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P = 0.12). Conclusions: Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Impact of Gender on Outcome in Octogenarians after Coronary Artery Bypass Grafting.

Background Increasing life expectancy makes cardiac surgery in octogenarians not very uncommon. In this study, the impact of gender on outcome of octogenarians after coronary artery bypass grafting (CABG) was assessed. Materials and Methods We retrospectively studied 485 octogenarians (176 females: mean age 82.4 ± 2.2 years vs. 306 males: mean age 82.2 ± 2.4 years) who underwent isolated CABG using extracorporeal circulation between January 2005 and December 2012. Results No significant differences were noted between both gender groups with regard to preoperative risk factors. At baseline, the groups differed significantly with respect to mean logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) (women: 22.3 ± 17.4% vs. men: 17.5 ± 13.3%; p < 0.001). Likewise, EuroSCORE II differs significantly between women and men in our cohort (women: 16.7 ± 11.9% vs. men: 13.9 ± 10.7%; p = 0.008). Intraoperatively, the number of distal anastomoses (3.1 ± 0.9 vs. 3.2 ± 0.8), the mean extracorporeal circulation time (99 ± 31 vs. 102 ± 29 minutes), and the mean aortic cross-clamp time (63 ± 31 vs. 60 ± 19 minutes) were similar in both groups. Postoperatively, no significant differences in complications and major morbidity were observed between the groups. The 30-day mortality (women 8.0 vs. men 9.7%; p = 0.62) were without statistical significance between the groups. Conclusion Outcome of octogenarians after CABG resulted in acceptable mortality. Female gender was not associated with increased risks for morbidity and mortality after surgery. Satisfactory outcomes encourage the offering of surgery in octogenarians.

Outcome after surgery for acute aortic dissection type A in the elderly: a single-center experience.

OBJECTIVES: Despite improvements in surgical and perfusion techniques, surgery for acute aortic dissection type A (AADA) remains associated with high mortality rates. The aim of this study was to evaluate outcome after surgery for AADA in elderly in comparison with the outcome in younger patients. METHODS: Between January 2004 and December 2012, 204 patients underwent operation for AADA. Of these, 65 patients were aged 70 years and older (elderly group; range, 70-85 years) and 139 were younger than 70 years (younger group; range, 18-69 years). RESULTS: No significant differences were detected between the groups with regard to preoperative risk factors on admission. Significantly more number of elderly patients than younger underwent supracoronary replacement of the ascending aorta (93.8% versus 80.6%, p = 0.013). In comparison to the elderly patients, younger patients more frequently received complex surgery (Bentall and David operation). The mean extracorporeal circulation time (183 ± 62 minutes versus 158 ± 3 minutes; p = 0.003) and the mean aortic cross-clamp time (100 ± 45 minute versus 82 ± 30 minute; p = 0.006) were significantly higher for younger patients. No significant differences in postoperative complications and major morbidity were observed. The operative mortality (elderly group 4.6% versus younger group 1.4%; p = 0.33) and 30-day mortality (elderly group 18.5% versus younger group 8.6%; p = 0.06) were without statistical significance between the groups. CONCLUSION: Surgery for AADA in the elderly resulted in acceptable mortality. Satisfactory outcomes should encourage the offering of surgery in these patients.

Minimally invasive direct coronary artery bypass in a child with an occlusion of left main coronary artery after arterial switch operation.

We present a case of a 13-year old girl experiencing recurring angina pectoris due to an occlusion of the left main coronary artery after arterial switch operation in infancy. To avoid a repeat sternotomy and the use of cardiopulmonary bypass, the patient underwent uncomplicated operative myocardial revascularization in the minimally invasive direct coronary artery bypass (MIDCAB) technique.

Highly flexible nitinol mesh to encase aortocoronary saphenous vein grafts: first clinical experiences and angiographic results nine months postoperatively.

Saphenous vein graft patency is frequently limited by degeneration. Experimental studies have indicated that rigid external support of venous grafts by a flexible, tubular nitinol mesh may improve graft patency. The study presented was part of a prospective, randomized, multicenter first-in-man trial investigating the safety and effectiveness of nitinol-supported venous grafts in coronary artery bypass graft (CABG) surgery. From our clinic, 25 subjects with multivessel coronary artery disease requiring saphenous vein graft CABG of the right coronary artery (RCA) and the circumflex artery were entered into the trial. Subjects were randomized to receive a mesh-supported graft on one of these arteries; the other vessel received an untreated vein graft. Graft patency was assessed by coronary angiography nine months after surgery. The implantation of mesh grafts was simple and safe. In 10 cases, a nitinol mesh-supported venous graft was anastomosed to the circumflex artery and in 15 cases to the RCA. All patients survived the observation period. A total of 72% of the patients underwent control coronary angiography. The patency rate of mesh-supported grafts was 27.8% nine months postoperatively. Conventional vein grafts showed an 85.7% patency, and arterial grafts had a 100% patency. No complications directly related to the implantation of mesh-supported grafts were observed. The promising experimental results of mesh-supported venous grafts could not be reproduced in the study presented. A critical item seems to be correct selection of nitinol mesh diameter, the anastomotic method and fixation of the mesh tube to the venous graft.