Factors of mortality in patients with cardiac implantable electronic device: 5-year experience.

OBJECTIVE: The use of cardiac implantable electronic devices has increased in recent years. It has also brought some issues. Among these, the complications of cardiac implantable electronic devices infection and pocket hematoma are difficult to manage. It can be fatal with the contribution of patient-related risk factors. In this study, we aimed to find mortality rates in patients who developed cardiac implantable electronic devices infection and pocket hematoma over 5 years. We also investigated the risk factors affecting mortality in patients with cardiac implantable electronic devices. METHODS: A total of 288 cardiac implantable electronic devices patients were evaluated. Demographic details, history, and clinical data of all patients were recorded. Cardiac implantable electronic devices infection was defined according to the modified Duke criteria. The national registry was used to ascertain the mortality status of the patients. The patients were divided into two groups (exitus and survival groups). In addition, the pocket hematoma was defined as significant bleeding at the pocket site after cardiac implantable electronic devices placement. RESULTS: The cardiac implantable electronic devices infection was similar in both groups (p=0.919), and the pocket hematoma was higher in the exitus group (p=0.019). The exitus group had higher usage of P2Y12 inhibitors (p≤0.001) and novel oral anticoagulants (p=0.031). The Cox regression analysis, including mortality-related factors, revealed that renal failure is the most significant risk factor for mortality. Renal failure was linked to a 2.78-fold higher risk of death. CONCLUSION: No correlation was observed between cardiac implantable electronic devices infection and mortality, whereas pocket hematoma was associated with mortality. Furthermore, renal failure was the cause of the highest mortality rate in patients with cardiac implantable electronic devices.

Minimally invasive procedures for right side infective endocarditis: A targeted literature review.

INTRODUCTION: Right-side infective endocarditis (RSIE) is caused by microorganisms and develops into intracardiac and extracardiac complications with high in-hospital and 1-year mortality. Treatments involve antibiotic and surgical intervention. However, those presenting with extremes e.g. heart failure, or septic shock who are not ideal candidates for conventional medical therapy might benefit from minimally invasive procedures. OBJECTIVE: This review summarizes existing observational studies that reported minimally invasive procedures to debulk vegetation due to infective endocarditis either on valve or cardiac implantable electronic devices. METHODS: A targeted literature review was conducted to identify studies published in PubMed/MEDLINE, EMBASE, and Cochrane Central Database from January 1, 2015 to June 5, 2023. The efficacy and/or effectiveness of minimally invasive procedural interventions to debulk vegetation due to RSIE were summarized following PRISMA guidelines. RESULTS: A total of 11 studies with 208 RSIE patients were included. There were 9 studies that assessed the effectiveness of the AngioVac system and 2 assessed the Penumbra system. Overall procedure success rate was 87.9%. Among 8 studies that reported index hospitalization, 4 studies reported no death, while the other 4 studies reported 10 deaths. CONCLUSIONS: This study demonstrates that multiple systems can provide minimally invasive procedure options for patients with RSIE with high procedural success. However, there are mixed results regarding complications and mortality rates. Further large cohort studies or randomized clinical trials are warranted to assess and/or compare the efficacy and safety of these systems.

Device-related infection associated with increased mortality risk in de novo transvenous implantable cardioverter-defibrillator medicare patients.

INTRODUCTION: Transvenous implantable cardioverter-defibrillators (TV-ICD) infection is a serious complication that frequently requires complete device removal for attempted cure, which can be associated with patient morbidity and mortality. The objective of this study is to assess mortality risk associated with TV-ICD infection in a large Medicare population with de novo TV-ICD implants. METHODS: A survival analysis was conducted using 100% fee-for-service Medicare facility-level claims data to identify patients who underwent de novo TV-ICD implantation between 7/2016 and 1/2018. TV-ICD infection within 2 years of implantation was identified using International Classification of Disease, 10th Edition and current procedural terminology codes. Baseline patient risk factors associated with mortality were identified using the Charlson Comorbidity Index categories. Infection was treated as a time-dependent variable in a multivariate Cox proportional hazards model to account for immortal time bias. RESULTS: Among 26,742 Medicare patients with de novo TV-ICD, 518 (1.9%) had a device-related infection. The overall number of decedents was 4721 (17.7%) over 2 years, with 4555 (17%) in the noninfection group and 166 (32%) in the infection group. After adjusting for baseline patient demographic characteristics and various comorbidities, the presence of TV-ICD infection was associated with an increase of 2.4 (95% CI: 2.08-2.85) times in the mortality hazard ratio. CONCLUSION: The rate of TV-ICD infection and associated mortality in a large, real-world Medicare population is noteworthy. The positive association between device-related infection and risk of mortality further highlights the need to reduce infections.

Risk factors for mortality following one-stage septic hip arthroplasty - a case-control study.

PURPOSE: Despite good clinical outcomes and a high success rate, there is a comparatively high mortality after one stage septic exchange of total hip arthroplasty. The aim of this study was to identify risk factors for mortality in the hospitalization period after one-stage septic exchange of THA. METHODS: We retrospectively analyzed in our database all patients who had a one-stage septic exchange for periprosthetic infection of THA and died during hospitalization (n = 33). The control group was matched semi-randomly by surgical procedure (n = 121) who did not die during hospitalization. The two groups were analyzed for risk factors such as age, Charlson Comorbidity Index (CCI), and high-/low-virulence bacteria. RESULTS: In the deceased group, 16 patients were female and 17 were male with a mean age at surgery of 73.2 years. In the control group, there were 55 females and 66 males with an average age at surgery of 68.2 years. Comparing the two groups, the deceased group had a significantly higher proportion of liver disease as well as higher rate of pulmonary embolism, apoplexy, and/or myocardial infarction, an increased CCI with an average of 6.5 and advanced age. Further demographic and surgery-related parameters especially high- or low-virulent germs were not identified as risk factors for mortality during the hospitalization period. The binominal logistic regression analysis showed that the probability of an inpatient death following one-stage septic exchange of THA increases by a factor of 3.079, with each additional point of the CCI. CONCLUSION: In conclusion, advanced age and high CCI are the main risk factors for mortality after single-stage septic change of THA. However, high-virulence bacteria have no influence on the mortality during the hospitalization period after one-stage septic exchange of THA.

Surgical treatment of valve endocarditis in high-risk patients and predictors of long-term outcomes.

Infective endocarditis represents a surgical challenge associated with perioperative mortality. The aim of this study is to evaluate the predictors of operative mortality and long-term outcomes in high-risk patients. We retrospectively analyzed 123 patients operated on for infective endocarditis from January 2011 to December 2020. Logistic regression model was used to identify prognostic factors of in-hospital mortality. Long term follow-up was made to asses late prognosis. Preoperative renal failure, an elevation EuroSCORE II and prior aortic valve re-replacement were found to be preoperative risk factors significantly associated with mortality. In-hospital mortality was 27% in patients who had previously undergone aortic valve replacement (n = 4 out of 15 operated, p = 0.01). Patients who were operated on during the active phase of infective endocarditis showed a higher mortality rate than those operated on after the acute phase (16% vs. 0%; p = 0.02). The type of prosthesis used (biological or mechanical) was not associated with mortality, whereas cross-clamp time significantly correlated with mortality (mean cross-clamp time 135 ± 65 min in dead patients vs. 76 ± 32 min in surviving patients; p = 0.0005). Mean follow up was 57.94 ± 30.9 months. Twelve patients died (11.65%). Among the twelve mortalities, five were adjudicated to cardiac causes and seven were non-cardiac (two cancers, one traumatic accident, one cerebral hemorrhage, two bronchopneumonia, one peritonitis). Overall survival probability (freedom from death, all causes) at 3, 5, 7 and 8 years was 98.9% (95% CI 97-100%), 96% (95% CI 92-100%), 85.9% (95% CI 76-97%), and 74% (95% CI 60-91%) respectively. Our study demonstrates that an early surgical approach may represent a valuable treatment option for high-risk patients with infective endocarditis, also in case of prosthetic valve endocarditis. Although several risk factors are associated with higher mortality, no patient subset is inoperable. These findings can be helpful to inform decision-making in heart team discussion.

Editor's Choice - Outcome of Radical Surgical Treatment of Abdominal Aortic Graft and Endograft Infections Comparing Extra-anatomic Bypass with In Situ Reconstruction: A Nationwide Multicentre Study.

OBJECTIVE: Abdominal aortic graft and endograft infection (AGI) is primarily treated by resection of the infected graft and restoration of distal perfusion through extra-anatomic bypass (EAB) or in situ reconstruction/repair (ISR). The aim of this study was to compare these surgical strategies in a nationwide multicentre retrospective cohort study. METHODS: The Swedish Vascular Registry (Swedvasc) was used to identify surgically treated abdominal AGIs in Sweden between January 1995 and May 2017. The primary aim was to compare short and long term survival, as well as complications for EAB and ISR. RESULTS: Some 126 radically surgically treated AGI patients were identified - 102 graft infections and 24 endograft infections - treated by EAB: 71 and ISR: 55 (23 neo-aorto-iliac systems, NAISs). No differences in early 30 day (EAB 81.7% vs. ISR 76.4%, p = .46), or long term five year survival (48.2% vs. 49.9%, p = .87) were identified. There was no survival difference comparing NAIS to other ISR strategies. The frequency of recurrent graft infection during follow up was similar: EAB 20.3% vs. ISR 17.0% (p = .56). Survival and re-infection rates of the new conduit did not differ between NAIS and other ISR strategies. Age ≥ 75 years (odds ratio [OR] 4.0, confidence interval [CI] 1.1 - 14.8), coronary artery disease (OR 4.2, CI 1.2 - 15.1) and post-operative circulatory complications (OR 5.2, CI 1.2 - 22.5) were associated with early death. Prolonged antimicrobial therapy (> 3 months) was associated with reduced long term mortality (HR 0.3, CI 0.1 - 0.9). CONCLUSION: In this nationwide multicentre study comparing outcomes of radically treated AGI, no differences in survival or re-infection rate could be identified comparing EAB and ISR.

Deep Femoral Vein Reconstruction for Abdominal Aortic Graft Infections is Associated with Low Aneurysm Related Mortality and a High Rate of Permanent Discontinuation of Antimicrobial Treatment.

OBJECTIVE: Aortic prosthesis infection is a devastating complication of aortic surgery. In situ reconstruction with the neo-aorto-iliac system (NAIS) bypass technique has become increasingly used and is recommended in recent treatment guidelines. The main aim was to evaluate NAIS procedural outcomes when undertaken after previous open or endovascular aortic repair in Sweden. METHODS: In this retrospective study, The National Quality Registry for Vascular Surgery (Swedvasc) was used to identify Swedish centres that offered the NAIS bypass procedure for aortic prosthesis infection between 2008 and 2018. Variables of special interest were procedural details, short and long term survival, renal and other complications, and the durtion of antimicrobial treatment. RESULTS: Forty patients (36 males, four females [mean age 69 years], 32 open repairs, seven endovascular aortic repairs [EVAR] and one fenestrated EVAR; 21 presented with aorto-enteric fistula) operated on with NAIS bypass were reviewed. The median time from the primary aortic intervention to the NAIS bypass procedure was 32 months (range 0 - 252 months). Mean ± standard deviation operating time was 645 ± 160 minutes, mean blood loss was 6 277 ± 6 525 mL, mean length of intensive care unit stay was 5.3 ± 3.7 days, and mean length of overall hospital stay was 21.2 ± 11.4 days. Thirty-five patients (88%) had a positive microbial culture; the most commonly isolated pathogen was Candida spp. The majority of patients survived for 30 days (n = 35 [88%]), and 33 (83%) and 32 (80%) patients survived for 90 days and one year, respectively. The number of surviving patients free from antimicrobial treatment at 90 days, six months, and one year was 19 (58%), 29 (88%), and 30 (94%). After a mean long term follow up of 69.9 ± 44.7 months, 20 patients were still alive. CONCLUSION: The NAIS bypass procedure offered reasonable survival and functional outcomes, and was associated with a high cure rate, defined as freedom from any antimicrobial treatment.

Contemporary Outcomes After Partial Resection of Infected Aortic Grafts.

INTRODUCTION: Aortic graft infection remains a considerable clinical challenge, and it is unclear which variables are associated with adverse outcomes among patients undergoing partial resection. METHODS: A retrospective, multi-institutional study of patients who underwent partial resection of infected aortic grafts from 2002 to 2014 was performed using a standard database. Baseline demographics, comorbidities, operative, and postoperative variables were recorded. The primary outcome was mortality. Descriptive statistics, Kaplan-Meier (KM) survival analysis, and Cox regression analysis were performed. RESULTS: One hundred fourteen patients at 22 medical centers in 6 countries underwent partial resection of an infected aortic graft. Seventy percent were men with median age 70 years. Ninety-seven percent had a history of open aortic bypass graft: 88 (77%) patients had infected aortobifemoral bypass, 18 (16%) had infected aortobiiliac bypass, and 1 (0.8%) had an infected thoracic graft. Infection was diagnosed at a median 4.3 years post-implant. All patients underwent partial resection followed by either extra-anatomic (47%) or in situ (53%) vascular reconstruction. Median follow-up period was 17 months (IQR 1, 50 months). Thirty-day mortality was 17.5%. The KM-estimated median survival from time of partial resection was 3.6 years. There was no significant survival difference between those undergoing in situ reconstruction or extra-anatomic bypass (P = 0.6). During follow up, 72% of repairs remained patent and 11% of patients underwent major amputation. On univariate Cox regression analysis, Candida infection was associated with increased risk of mortality (HR 2.4; P = 0.01) as well as aortoenteric fistula (HR 1.9, P = 0.03). Resection of a single graft limb only to resection of abdominal (graft main body) infection was associated with decreased risk of mortality (HR 0.57, P = 0.04), as well as those with American Society of Anesthesiologists classification less than 3 (HR 0.35, P = 0.04). Multivariate analysis did not reveal any factors significantly associated with mortality. Persistent early infection was noted in 26% of patients within 30 days postoperatively, and 39% of patients were found to have any post-repair infection during the follow-up period. Two patients (1.8%) were found to have a late reinfection without early persistent postoperative infection. Patients with any post-repair infection were older (67 vs. 60 years, P = 0.01) and less likely to have patent repairs during follow up (59% vs. 32%, P = 0.01). Patients with aortoenteric fistula had a higher rate of any post-repair infection (63% vs. 29%, P < 0.01) CONCLUSION: This large multi-center study suggests that patients who have undergone partial resection of infected aortic grafts may be at high risk of death or post-repair infection, especially older patients with abdominal infection not isolated to a single graft limb, or with Candida infection or aortoenteric fistula. Late reinfection correlated strongly with early persistent postoperative infection, raising concern for occult retained infected graft material.

What Are the Long-term Outcomes of Mortality, Quality of Life, and Hip Function after Prosthetic Joint Infection of the Hip? A 10-year Follow-up from Sweden.

BACKGROUND: Prosthetic joint infection (PJI) is a complication after arthroplasty that negatively affects patient health. However, prior reports have not addressed the long-term consequences of hip PJI in terms of patient mortality, quality of life, and hip function. QUESTIONS/PURPOSES: At a minimum of 10 years after PJI in patients undergoing primary THA, in the context of several large, national databases in Sweden, we asked: (1) Is mortality increased for patients with PJI after THA compared with patients with a noninfected THA? (2) Does PJI of the hip have a negative influence on quality of life as measured by the Euro-QoL-5D-5L (EQ-5D-5L), ambulatory aids, residential status, and hip function as measured by the Oxford Hip Score (OHS)? (3) Which factors are associated with poor patient-reported outcome measures (PROMs) for patients with PJI after primary THA? METHODS: This study included 442 patients with a PJI after primary THA, from a previously published national study, including all patients with a THA performed from 2005 to 2008 in Sweden (n = 45,570) recruited from the Swedish Hip Arthroplasty Registry (SHAR). Possible deep PJIs were identified in the Swedish Dispensed Drug Registry and verified by review of medical records. Mortality in patients with PJI was compared with the remaining cohort of 45,128 patients undergoing primary THA who did not have PJI. Mortality data were retrieved from the SHAR, which in turn is updated daily from the population registry. A subgroup analysis of patients who underwent primary THA in 2008 was performed to adjust for the effect of comorbidities on mortality, as American Society of Anesthesiologists (ASA) scores became available in the SHAR at that time. For the PROM analysis, we identified three controls matched by age, gender, indication for surgery, and year of operation to each living PJI patient. A questionnaire including EQ-5D-5L, ambulatory aids, residential status, and OHS was collected from patients with PJI and controls at a mean of 11 years from the primary procedure. Apart from age and gender, we analyzed reoperation data (such as number of reoperations and surgical approach) and final prosthesis in situ to explore possible factors associated with poor PROM results. RESULTS: After controlling for differences in sex, age, and indication for surgery, we found the all-cause 10-year mortality higher for patients with PJI (45%) compared with patients undergoing THA without PJI (29%) (odds ratio 1.4 [95% CI 1.2 to 1.6]; p < 0.001). The questionnaire, with a minimum of 10 years of follow-up, revealed a lower EQ-5D-5L index score (0.83 versus 0.94, -0.13 [95% CI -0.18 to -0.08; p < 0.001]), greater proportion of assisted living (21% versus 12%, OR 2.0 [95% CI 1.2 to 3.3]; p = 0.01), greater need of ambulatory aids (65% versus 42%, OR 3.1 [95% 2.1 to 4.8]; p < 0.001), and a lower OHS score (36 versus 44, -5.9 [-7.7 to -4.0]; p < 0.001) for patients with PJI than for matched controls. Factors associated with lower OHS score for patients with PJI were three or more reoperations (-8.0 [95% CI -13.0 to -3.2]; p = 0.01) and a direct lateral approach used at revision surgery compared with a posterior approach (-4.3 [95% CI -7.7 to -0.9]; p = 0.01). CONCLUSION: In this study, we found that PJI after THA has a negative impact on mortality, long-term health-related quality of life, and hip function. Furthermore, the subgroup analysis showed that modifiable factors such as the number of reoperations and surgical approach are associated with poorer hip function. This emphasizes the importance of prompt, proper initial treatment to reduce repeated surgery to minimize the negative long-term effects of hip PJI. LEVEL OF EVIDENCE: Level III, therapeutic study.

Treatment and Outcomes of Aortic Graft Infections Using a Decision Algorithm.

BACKGROUND: Aortic graft infection (AGI) is a rare but devastating complication requiring both explant of the infected prosthesis and lower extremity revascularization. Despite a variety of methods to treat AGI, there is a paucity of evidence that describes comparative outcomes. Moreover, controversy exists surrounding what the optimal repair strategy is with limited descriptions of how these techniques should be employed in this complex group of patients. Therefore, the purpose of this analysis was to review our experience with AGI management while highlighting a practice philosophy that can achieve acceptable outcomes. METHODS: All AGI patients between 2002-2019 were reviewed. The primary end-point was 30-day mortality. Secondary end-points included complications, re-infection, unplanned re-operation and all-cause mortality. Kaplan-Meier methodology was used to estimate time to events. Cox regression models were employed to identify association between patient factors and operative strategy with survival. Subgroup analysis included outcome comparison among four different operative approaches(extra-anatomic bypass with aortic ligation [EAB] and in-situ reconstruction [ISR] using either NAIS, cryopreserved allograft [Cryo], or antibiotic-soaked prosthetic grafts [Other]). RESULTS: 142 patients (male-69%, mean age 67 ± 11 years) were reviewed. Median time to AGI presentation was 52 (IQR 16-128) months. ISR was performed in 70% (n = 99)[ISR: NAIS-49% (n = 49), Cryo, 33% (n = 33) and Other-23% (n = 23)]. EAB was used in 26% (n = 37), of which 57% (n = 21) were staged repairs[no reconstruction, 4%: intraoperative death-2, AGI removal without reconstruction-2]. A graft enteric erosion/fistula was identified in 39% (n = 55). Mean follow-up time was 14 ± 27 (median 2.2[IQR 0.1-16]) months. Overall, 30-day mortality was 21% and 69% (n = 98) experienced a complication. The most common complications were pulmonary (35%;n = 50), vascular (28%;n = 39), gastrointestinal (22%;n = 31) and renal (21%;n = 30). Freedom from re-infection at one and three years was 78 ± 5% and 73 ± 6% while freedom from unplanned re-operation was 50 ± 5% and 40 ± 6%, respectively. Corresponding one- and five-year freedom from all-cause mortality was 67 ± 4% and 53 ± 4%. When stratified by the four different repair strategies, unadjusted rates of postoperative complications and mortality were not different. However, EAB patients had more renal complications. All-cause mortality predictors included age (HR 1.04, 95%CI 1.01-1.1; P = 0.003), CHF (HR 2.7, 1.3-5.7; P = 0.01), and graft enteric erosion/fistula (HR 2.2, 1.3-3.8;P = 0.005) while total graft excision was protective (HR 0.34, 0.2-0.7; P = 0.003). CONCLUSIONS: AGI repair, regardless of operative strategy, results in significant early morbidity, and mortality. The need for unplanned re-operation is common; however, long-term survival is acceptable in appropriately selected patients. Re-infection risk mandates life-long surveillance and consideration of indefinite anti-microbial suppression in certain subgroups. Due to the complexity and intensity of care, all AGI should be treated, when possible, at centers performing high-volume aortic surgery.

Contemporary Trends and Outcomes of Prosthetic Valve Infective Endocarditis in the United States: Insights from the Nationwide Inpatient Sample.

BACKGROUND: Prosthetic valve endocarditis (PVE) carries high mortality and morbidity as compared to native valve endocarditis (NVE). Contemporary data on PVE are lacking, we aimed to study contemporary trends, outcomes, and burden of PVE using nationally representative data. METHODS: We used the National Inpatient Sample from 2000 to 2017 to identify patients admitted with PVE using ICD-9-CM and ICD-10 codes. Risk-adjusted rates were calculated using an Analysis of Covariance (ANCOVA) with the Generalized Linear Model (GLM). Trends were assessed with linear regression and Pearson's Chi-square when appropriate. Binomial logistic regression was used to assess predictors of in-hospital mortality. RESULTS: We identified 43,602 hospitalizations for PVE. PVE hospitalizations increased from 1803 in 2000 to 3450 in 2017. Risk-adjusted mortality decreased from 10.7% in 2002 to 7.3% in 2017 (P<0.01). Logistic regression analysis on mortality showed increase association with age (OR, 1.021, 95%CI [1.017-1.024], p<0.01), Hispanics (OR, 1.493, 95%CI [1.296-1.719], p<0.01) and patients with drug abuse (OR, 1.233, 95%CI [1.05-1.449], p=0.01). Co-morbid conditions like congestive heart failure (OR, 1.511, 95%CI [1.366-1.673], p<0.01), renal failure (OR, 1.572, 95%CI [1.427-1.732], p<0.01) and weight loss (OR, 1.425, 95%CI [1.093-1.419], p<0.01) were also associated with higher mortality. CONCLUSIONS: Over the years the adjusted in-hospital mortality in PVE has trended down but the average cost of stay has increased despite decrease in length of stay.

Short and Mid Term Outcomes of Cryopreserved Abdominal Aortic Allografts Used as a Substitute for Infected Prosthetic Grafts in 200 Patients.

OBJECTIVE: To investigate the use of cryopreserved arterial allografts (CAA) as a substitute for infected infrarenal aortic prostheses, and its outcomes. METHODS: A single centre retrospective study of consecutive patients receiving an abdominal aortic CAA after removal of an infected graft was conducted between January 1997 and December 2013. The primary outcome was the rate of allograft related revision surgery. Secondary outcomes were the 30 day mortality rate, survival, primary patency, limb salvage, and infection recurrence. Allograft ruptures secondary to infection and risk factors for allograft failure were also investigated. RESULTS: Two hundred patients (mean age 64.2 ± 9.4 years) were included. In 56 (28%) cases, infection was related to an enteric fistula. The mean follow up duration was 4.1 years. The 30 day mortality rate was 11%. Early revision surgery was needed in 59 patients (29.5%). Among them, 15 (7.5%) were allograft related and led to the death of three patients (1.5%), corresponding to a 7.5% 30 day allograft related revision surgery rate. During the first six months, 17 (8.5%) patients experienced 21 events with complete or partial rupture (pseudo-aneurysm) of the allograft responsible for five (2.5%) deaths, corresponding to a re-infection rate of 8.5%. The multivariable analysis showed that diabetes and pseudo-aneurysm of the native aorta on presentation were predictive factors for short term allograft rupture. After six months, 25 (12.5%) patients experienced long term allograft complications (rupture, n = 2, 1%; pseudo-aneurysm, n = 6, 3%; aneurysm, n = 2, 1%; thrombosis, n = 11, 5.5%; stenosis, n = 4, 2%;) requiring revision surgery resulting in one death. The five year rates of survival, allograft related revision surgery, limb salvage, primary patency, and infection recurrence were 56%, 30%, 89%, 80%, and 12%, respectively. CONCLUSION: CAAs provide acceptable results to treat aortic graft infection with few early graft related fatal complications. Long term allograft related complications are quite common but are associated with low mortality and amputation rates.

Surgical treatment for infective endocarditis in the ageing society: a nationwide retrospective study in Japan.

OBJECTIVE: The current status of surgical treatment for infective endocarditis (IE) among very elderly people is unclear. METHODS: We extracted data on patients in Japan with community-acquired IE who were admitted and discharged between April 2010 and February 2018 using a nationwide inpatient, the Diagnosis Procedure Combination database. We divided patients into three groups: non-elderly (<65 years), elderly (65-79 years) and very elderly (≥80 years). A 1:1 propensity score matching was performed to compare proportions of surgical treatment and in-hospital mortality among the groups. RESULTS: We identified 20 667 eligible patients (median age 70 years, 61.0% men). The proportion of very elderly patients significantly increased (19.1% in 2010 to 29.7% in 2018). The proportion of surgical treatment was significantly lower, and in-hospital mortality was significantly higher in very elderly patients. This tendency was more pronounced among patients with in-hospital complications such as heart failure, stroke or embolism. Surgical treatment was significantly associated with lower in-hospital mortality even in very elderly patients, both in an unmatched (OR 0.61; 95% CI 0.47 to 0.78) and a propensity score matched cohort (OR 0.61; 95% CI 0.43 to 0.85). CONCLUSIONS: The proportion of very elderly patients with IE was increasing, and very elderly patients had higher in-hospital mortality. The proportion of surgical treatment for IE among very elderly patients was low, but it was associated with lower in-hospital mortality. Further studies are needed to establish the optimal strategy for IE among very elderly patients.

A Canadian multicenter experience describing outcomes after endovascular abdominal aortic aneurysm repair stent graft explantation.

BACKGROUND: Most studies describing the outcomes after endovascular abdominal aortic aneurysm repair (EVAR) explantation have been from single, high-volume, centers. We performed a multicenter cross-Canadian study of outcomes after EVAR stent graft explantation. Our objectives were to describe the outcomes after late open conversion and EVAR graft explantation at various Canadian centers and the techniques and outcomes stratified by the indication for explant. METHODS: The Canadian Vascular Surgery Research Group performed a retrospective multicenter study of all cases of EVAR graft explantation at participating centers from 2003 to 2018. Data were collected using a standardized, secure, online platform (RedCap [Research Electronic Data Capture]). Univariate statistical analysis was used to compare the techniques and outcomes stratified the indication for graft explantation. RESULTS: Patient data from 111 EVAR explants collected from 13 participating centers were analyzed. The mean age at explantation was 74 years, the average aneurysm size was 7.5 cm, and 28% had had at least one instructions for use violation at EVAR. The average time between EVAR and explantation was 42.5 months. The most common indication for explantation was endoleak (n = 66; type Ia, 46; type Ib, 2; type II, 9; type III, 2; type V, 7), followed by infection in 20 patients; rupture in 18 patients (due to type Ia endoleak in 10 patients, type Ib in 1, type II in 1, type III in 2, and type V in 1), and graft thrombosis in 7 patients. The overall 30-day mortality was 11%, and 45% of the patients had experienced at least one major perioperative complication. Mortality was significantly greater for patients with rupture (33.3%) and those with infection (15%) compared with patients undergoing elective explantation for endoleak (4.5%; P = .003). The average center volume during the previous 15 years was 8 cases with a wide range (2-19 cases). A trend was seen toward greater mortality for patients treated at centers with fewer than eight cases compared with those with eight or more cases (19% vs 9%). However, the difference did not reach statistical significance (P = .23). Overall, 41% of patients had undergone at least one attempt at endovascular salvage before explantation, with the highest proportion among patients who had undergone EVAR explantation for endoleak (51%). Only 22% of patients with rupture had undergone an attempt at endovascular salvage before explantation. CONCLUSIONS: The performance of EVAR graft explantation has increasing in Canada. Patients who had undergone elective explantation for endoleak had lower mortality than those treated for either infection or rupture. Thus, patients with an indication for explanation should be offered surgery before symptoms or rupture has occurred. A trend was seen toward greater mortality for patients treated at centers with lower volumes.

Results of cryopreserved arterial allograft replacement for thoracic and thoracoabdominal aortic infections.

BACKGROUND: Primary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts. METHODS: Between January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity. RESULTS: Thirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved. Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days. During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively. CONCLUSIONS: Although rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications.

Surgical results for prosthetic versus native valve endocarditis: A multicenter analysis.

OBJECTIVES: Prosthetic valve endocarditis is associated with worse outcomes compared with native valve endocarditis. Our aim was to evaluate the impact of native valve endocarditis versus prosthetic valve endocarditis on postoperative outcomes and long-term survival and to identify preoperative risk factors in a large cohort of 4300 patients with infective endocarditis. METHODS: This retrospective cohort study was conducted in 5 German Cardiac Surgery Centers: the Clinical Multicenter Project of Analysis of Infective Endocarditis in Germany. Data of 4300 patients undergoing valve surgery for native valve endocarditis and prosthetic valve endocarditis were retrospectively analyzed. Univariable and multivariable analyses were used for risk stratification, Kaplan-Meier analysis for long-term survival. In addition, we performed Cox proportional hazards regression with multivariable adjustment. RESULTS: Between 1994 and 2016, 3143 patients (73.1%) underwent surgery for native valve endocarditis and 1157 patients (26.9%) underwent surgery for prosthetic valve endocarditis. Patients with prosthetic valve endocarditis were older (69 [60-75] vs 63 [52-72] years; P < .001) and had more comorbidities, such as hypertension (55% vs 46%; P < .001), diabetes (28% vs 25%; P = .020), coronary artery disease (32% vs 23%; P < .001), and preoperative acute kidney injury (41% vs 32%; P < .001). Kaplan-Meier analysis revealed significantly decreased long-term survival of patients undergoing surgery for prosthetic valve endocarditis compared with native valve endocarditis (P < .001). However, after multivariable adjustment, there was no significant difference in long-term survival between patients undergoing cardiac surgery with prosthetic valve endocarditis compared with native valve endocarditis. CONCLUSIONS: After adjusting for preoperative comorbidities, long-term survival for prosthetic valve endocarditis and native valve endocarditis is comparable. Thus, our large cohort study provides evidence that prosthetic valve endocarditis alone should not be a contraindication for redo operations.

Resection and replacement of thoracic aortic graft infections.

OBJECTIVES: Thoracic aortic graft infection (TAGI) presents a formidable challenge with high mortality. We evaluated our 22-year experience managing TAGI with extensive debridement, graft replacement, vascularized tissue coverage, and aggressive antibiotics. METHODS: We reviewed all consecutive patients with TAGI from 1991 to 2013. We also compared infected cases versus noninfected reoperative controls using a case-control design. Standard statistical methods were used for descriptive analysis, and Kaplan-Meier for survival analysis. RESULTS: We treated 32 TAGI patients, involving 19 ascending/arch (A/A) and 13 descending/thoracoabdominal (D/TAA) grafts, including 4 endografts. In total, 19 (59.4%) presented with pseudoaneurysm and 11 (34.4%) with aortic fistula. Vascularized tissue (omentum or muscle) coverage was possible in 22 (71.0%) patients. Thirty-day mortality occurred in 3 (9.4%) patients, with no 30-day mortality among those receiving vascularized graft coverage (P = .018). During follow-up, reinfection occurred in 8 patients (25% [4 A/A and 4 D/TAA]). Five-year overall (A/A 45.4% vs D/TAA 28.9%, P = .434) and reinfection-free (A/A 19.2%, D/TAA 27%, P = .409) survival was similar between groups. Long-term mortality was greater after endograft infection (100% vs 25% at 2.5 months, P = .0007) or aortobronchial fistulization (100% vs 37.9% at 6 months, P = .026). Time to reintervention was shorter in infected versus non-infected reoperative cases (31 vs 83 months, P < .0001), but there were no significant differences in long-term mortality after reoperation. CONCLUSIONS: TAGI continues to represent a highly morbid surgical challenge. Prompt antimicrobial coverage, debridement, graft replacement, and vascularized graft coverage, yielded best long-term results. Endograft infection and aortobronchial fistula had very poor prognoses.

The safety of bovine tissue arterial repair in removal of infected prosthetic hemodialysis grafts.

BACKGROUND: More than 400,000 Americans require dialysis, and many receive it via a prosthetic arteriovenous graft. Infection of these grafts is rare, but associated with significant morbidity and mortality. The gold standard is total graft excision with arteriotomy closure. This was previously done with autologous vein, but bovine tissue offers a reasonable alternative. The objective of this article is to evaluate a community hospital experience with bovine tissue arterial repair after total graft excision of infected prosthetic arteriovenous graft. METHODS: A retrospective review was performed of all cases of infected prosthetic arteriovenous graft removal with bovine tissue arterial repair was performed. Thirteen cases were identified. Presentation, location of graft, and causative organism were reviewed; outcomes including reoperation and mortality were recorded. RESULTS: Of the 13 patients, 12 (92%) had positive cultures of the graft, bloodstream, or wound. Methicillin-resistant Staphylococcus aureus was the most commonly isolated organism (54%). There were two unplanned reoperations including hematoma drainage and wound debridement within the first year. Over the 1-year follow-up period, 1 patient died for a mortality of 8%. There were no re-infections during follow-up. DISCUSSION: Prosthetic arteriovenous graft infection remains a difficult challenge and is associated with significant morbidity and mortality. It presents in a variety of ways, including within an old thrombosed graft. Over the last several years, the causative organism has increasingly become drug resistant. Treatment with total graft excision requires arteriotomy closure, and for this bovine tissue has been demonstrated to be a viable option.

Total Resection of Infected Peripheral Hemodialysis Grafts Has a Favorable Impact on Outcomes.

BACKGROUND: Surgical resection could be an eradication treatment for patients with infected hemodialysis arteriovenous grafts (AVGs). This study aimed to investigate the outcomes of 3 surgical methods, including total resection, subtotal resection, and revision. METHODS: The patients who underwent surgical excision of infected AVGs performed at a single center from August 2012 to March 2019 were retrospectively analyzed. The following 3 surgical methods were used in our study: revision, subtotal resection, and total resection. Patients' demographics, medical history, perioperative details, reconstruction time, and follow-up data were collected. The outcomes including perioperative complications (within 30 days), mortality, reinfection rate of AVGs, with new access reconstruction or not, and the outcomes between reconstruction and nonreconstruction in the follow-up period were evaluated. RESULTS: Forty-one patients had infected AVGs in our study. Patients' mean age was 62 years, and 65.9% of the patients were female. The mean duration from the time of diagnosis to the operation was 14.4 days. Signs and symptoms at presentation included fever (51.2 %), swelling (43.9%), pain (58.5%), erythematous change (92.7%), and more severe features, such as altered consciousness (14.6%) and hypotension (12.2%). The pathological changes in the infected grafts included bleeding (29.3%), pus formation (73.2%), pseudoaneurysm (26.8%), and graft exposure (17.1%). Wound and graft cultures revealed an infectious etiology with fungi (7.3%), Pseudomonas aeruginosa (12.2%), Enterococcus spp. (2.4%), and Staphylococcus spp. (58.5%), with methicillin-resistant Staphylococcus aureus accounting for only 7.3%. Total resection, subtotal resection, and revision surgery were performed in 17.1%, 63.4%, and 19.5% of patients, respectively. Seven patients with complications required reoperation (17.1%), and adhesion ileus and hospital-acquired pneumonia occurred in only 2.4% and 7.3% of patients, respectively. During follow-up, most patients (82.9%) had reconstruction of the peripheral hemodialysis access with mean time of 64.3 (range: 21-92) days; mean time of use of new access was 90.5 days; and mean time of removal of catheter was about 106.3 days. Mortality rates in patients without and with reconstructed AV access during follow-up were 50% and 18%, respectively (P < 0.004). Eight cases (19.5%) had recurrence of AV access infections during follow-up; of these, 2 had revision surgery and 6 had subtotal resection. However, no patient with total resection had recurrent infections. CONCLUSIONS: The total resection group had no recurrent infection compared to the subtotal and revision groups. In addition, patients with reconstruction of peripheral hemodialysis access had a low mortality rate during the follow-up period.