Life expectancy after surgical aortic valve replacement for low-gradient aortic stenosis with preserved ejection fraction.

INTRODUCTION AND OBJECTIVES: Surgical aortic valve replacement (SAVR) can modify the natural history of severe aortic stenosis (SAS). However, compared with the general population, these patients have a loss of life expectancy. The life expectancy of patients who undergo SAVR due to low-gradient SAS with preserved left ventricular ejection fraction (LVEF) is unknown. METHODS: We included all patients between 50 and 65 years who underwent isolated SAVR in 27 Spanish centers during an 18-year period. We analyzed observed and expected survival at 18 years in patients with low-gradient SAS with preserved LVEF and all other types of SAS. We used propensity score matching to compare the life expectancy of patients with low-gradient SAS with preserved LVEF vs those with high-gradient SAS with preserved LVEF. RESULTS: We analyzed 5084 patients, of whom 413 had low-gradient SAS with preserved LVEF. For these patients, observed survival at 10, 15 and 18 years was 86.6% (95%CI, 85.3-87.8), 75% (95%CI, 72.7-77.2), and 63.5% (95%CI, 58.8-67.8). Expected survival at 10, 15 and 18 years was 90.2%, 82.1%, and 75.7%. In the matched sample, survival of patients with low-gradient SAS with preserved LVEF was similar to that of patients with high-gradient with preserved LVEF, log-rank test, P=.95; HR=1 (95%CI, 0.7-1.4; P=.95). CONCLUSIONS: There is a loss of life expectancy in patients with all types of SAS undergoing SAVR. This loss is higher in patients with left ventricular dysfunction and lower in patients with low-gradient or high-gradient aortic stenosis with preserved LVEF. The benefit of surgery is similar between these last 2 groups.

Life expectancy after aortic valve replacement in young patients.

INTRODUCTION AND OBJECTIVES: In young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. METHODS: We analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. RESULTS: A total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). CONCLUSIONS: Life expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Differences in life expectancy between men and women after aortic valve replacement.

OBJECTIVES: Some researchers have observed an increased number of deaths during the follow-up of young patients who undergo aortic valve replacement due to severe aortic stenosis, suggesting that this procedure does not restore their life expectancy. Our goal was to confirm these findings and explore sex-based differences. METHODS: All patients between 50 and 65 years of age who underwent isolated aortic valve replacement in 27 Spanish centres during an 18-year period were included. We compared observed and expected survival at 15 years of follow-up and estimated the cumulative incidence of death from a competing risks point of view. We stratified by sex and analysed if being a woman was an independent risk factor for death. RESULTS: For men, the observed survival at 10 and 15 years of follow-up was 85% [95% confidence interval (CI) 83.6%-86.4%] and 72.3% (95% CI 69.7%-74.7%), respectively whereas the expected survival was 88.1% and 78.8%. For women, the observed survival at 10 and 15 years was 85% (95% CI 82.8%-86.9%) and 73% (95% CI 69.1%-76.4%), whereas the expected survival was 94.6% and 89.4%. At 15 years of follow-up, the cumulative incidence of death due to the disease in men and women was 8.2% and 16.7%, respectively. In addition, being a woman was an independent risk factor for death (hazard ratio = 1.23 (95% CI 1.02-1.48; P = 0.03). CONCLUSIONS: After the aortic valve replacement, men and women do not have their life expectancy restored, but this loss is much higher in women than in men. In addition, being a woman is a risk factor for long-term death. Reasons for these findings are unknown and must be investigated.

Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital: Prospective evaluation through real-time observations of patient safety incidents.

The effectiveness of a hospital incident-reporting system (IRS) on improve patient safety is unclear. This study objective was to assess which implemented improvement actions after the analysis of the incidents reported were effective in reduce near-misses or adverse events.Patient safety incidents (PSIs), near misses and adverse events, notified to the IRS were analyzed by local clinical safety leaders (CSLs) who propose and implement improvement actions. The local CSLs received training workshops in patient safety and analysis tools. Following the notification of a PSI in the IRS, prospective real-time observations with external staff were planned to record and rated the frequency of that PSI. This methodology was repeated after the implementation of the improvement actions.Ultimately, 1983 PSIs were identified. Surgery theaters, emergency departments, intensive care units, and general adult care units comprised 82% of all PSIs. The PSI rate increased from 0.39 to 3.4 per 1000 stays in 42 months. A significant correlation was found between the reporting rate per month and the number of workshop-trained local CSLs (Spearman coefficient = 0.874; P = .003). A total of 24,836 real-time observations showed a statistically significant reduction in PSIs observed in 63.15% (categories: medication P = .044; communication P = .037; technology P = .009) of the implemented improvements actions, but not in the organization category (P = .094). In the multivariate analyses, the following factors were associated with the reduction in near misses or adverse events after the implementation of the improvement actions: "adverse event" type of PSI (odds ratio [OR], 3.67; 95% confidence interval [CI], 1.93-5.74), "disussion group" type of analysis (OR, 2.45; 95% CI, 1.52-3.76), and root cause type of analysis (OR, 2.32; 95% CI: 1.17-3.90).The implementation of a hospital IRS, together with the systematization of the method and analysis of PSIs by workshop-trained local CSLs led to an important reduction in the frequency of PSIs.

Factores predictores de mortalidad y reoperación en la cirugía de la disección aórtica aguda tipo A: 18 años de experiencia / Predictors of mortality and reoperation in acute type-A aortic dissection surgery: 18 years of experience

Introducción y objetivos. El objetivo de este estudio retrospectivo es mostrar nuestra experiencia en la cirugía de la disección aórtica aguda tipo A y analizar la influencia de la protección cerebral en nuestros resultados. Métodos. Entre marzo de 1990 y octubre de 2007, 98 pacientes consecutivos fueron intervenidos por disección aórtica aguda tipo A. En 85 pacientes se reemplazó la aorta ascendente, que en 13 se extendió al arco aórtico. La válvula aórtica fue sustituida en 34 pacientes y se preservó en el resto. La rotura intimal pudo identificarse en 83 pacientes. Resultados. La mortalidad hospitalaria fue del 15%. Los factores de riesgo de mortalidad hospitalaria fueron la edad ≥ 70 años y el shock cardiogénico preoperatorio (p < 0,05). La perfusión cerebral anterógrada se utilizó en los últimos 16 pacientes consecutivos y presentó una mortalidad hospitalaria del 6%. La ausencia de reoperación y la supervivencia fueron del 98,6% ± 1,3%, el 86,2% ± 4,6%, el 68,2% ± 8,9% y el 97,2% ± 1,9%, el 82,5% ± 4,8%, el 55,9% ± 7,9% tras 1, 5 y 10 años de seguimiento respectivamente. Resultaron factores de riesgo de reoperación la insuficiencia aórtica severa preoperatoria y la preservación de la válvula aórtica (p < 0,05). El único factor de riesgo de mortalidad tardía fue no realizar perfusión cerebral anterógrada (p < 0,05). Conclusiones. Pese a su extrema gravedad, la cirugía de la disección aórtica aguda presenta unos buenos resultados a corto y largo plazo. La perfusión cerebral ante-rógrada mejora el pronóstico de estos pacientes y está recomendada como método de protección cerebral de elección (AU)

Introduction and objectives. To describe our experience with acute type-A aortic dissection surgery, including an analysis of the effect of cerebral protection on outcome. Methods. Between March 1990 and October 2007, 98 consecutive patients underwent surgery for acute type-A aortic dissection. Of these, 85 had an ascending aorta replacement, while the entire arch was replaced in 13. The aortic valve was replaced in 34 patients but preserved in the rest. An intimal tear was observed in 83 patients. Results. The in-hospital mortality rate was 15%. Risk factors for in-hospital mortality were age ≥70 years and preoperative cardiogenic shock (P<.05). Antegrade cerebral perfusion was used in the last 16 consecutive patients, whose in-hospital mortality rate was 6%. The proportions of patients who survived and who did not require reoperation at 1, 5 and 10 years of follow-up were 98.6%(1.3%), 86.2%(4.6%) and 68.2%(8.9%), and 97.2%(1.9%), 82.5%(4.8%) and 55.9%±7.9% for the 2 outcomes, respectively. The risk factors for reoperation were found to be severe preoperative aortic regurgitation and preservation of the aortic valve (P<.05). The only risk factor for late mortality was not using antegrade cerebral perfusion (P<.05). Conclusions. Despite its seriousness, surgery for acute aortic dissection produces good early and long-term results. Antegrade cerebral perfusion improves the prognosis of these patients and should be the technique of choice for cerebral protection (AU)

Predictors of mortality and reoperation in acute type-a aortic dissection surgery: 18 years of experience.

INTRODUCTION AND OBJECTIVES: To describe our experience with acute type-A aortic dissection surgery, including an analysis of the effect of cerebral protection on outcome. METHODS: Between March 1990 and October 2007, 98 consecutive patients underwent surgery for acute type-A aortic dissection. Of these, 85 had an ascending aorta replacement, while the entire arch was replaced in 13. The aortic valve was replaced in 34 patients but preserved in the rest. An intimal tear was observed in 83 patients. RESULTS: The in-hospital mortality rate was 15%. Risk factors for in-hospital mortality were age > or = 70 years and preoperative cardiogenic shock (P< .05). Antegrade cerebral perfusion was used in the last 16 consecutive patients, whose in-hospital mortality rate was 6%. The proportions of patients who survived and who did not require reoperation at 1, 5 and 10 years of follow-up were 98.6%+/-1.3%, 86.2%+/-4.6% and 68.2%+/-8.9%, and 97.2%+/-1.9%, 82.5%+/-4.8% and 55.9%+/-7.9% for the two outcomes, respectively. The risk factors for reoperation were found to be severe preoperative aortic regurgitation and preservation of the aortic valve (P< .05). The only risk factor for late mortality was not using antegrade cerebral perfusion (P< .05). CONCLUSIONS: Despite its seriousness, surgery for acute aortic dissection produces good early and long-term results. Antegrade cerebral perfusion improves the prognosis of these patients and should be the technique of choice for cerebral protection.