[The effect of obesity on the outcome of surgical aortic valve replacement for aortic stenosis].

INTRODUCTION: Our objective was to investigate the effect of obesity on short-term complications and long-term survival after surgical aortic valve replacement (SAVR) for aortic stenosis (AS). MATERIAL AND METHODS: A retrospective study on 748 patients who underwent SAVR for AS in Iceland 2003-2020. Patients were divided into groups based on body mass index (BMI): normal (18.5-24.9 kg/m2, n=190), overweight (25-29.9 kg/m2, n=339), obese (30-34.9 kg/m2, n=165) and severely obese (≥35 kg/m2, n=54). Six patients with BMI p<18,5 kg/m2 were excluded. Clinical information regarding patient history, risk factors, together with complications and 30-day mortality were collected from patient records. The four BMI groups were compared and long-term survival estimated with Kaplan-Meier plots and risk factors for long-term survival evaluated with Cox multivariate analysis. RESULTS: Severely obese patients were on average four years younger than patients with normal BMI, more often had risk factors for cardiovascular disease, and their EuroSCORE II was higher (5.3 vs. 4.4%, p=0.03). On the other hand, severely obese patients bled less the first 24 hours post-surgery, compared to normal BMI-patients (558 vs. 1091 ml, p<0.001), stroke was less frequent (0 vs 6.4%, p=0.03), but they more often experienced sternum dehiscence (5.6 vs 2.7%, p=0.04), deep sternal wound infection (3.7 vs 0%, p=0.04) and acute kidney injury (26.4 vs 15.2%, p=0.005). Thirty-day mortality and long-term survival did not differ significantly between the groups and BMI was not an independent predictor of long-term survival in multivariate analysis. CONCLUSIONS: The outcome for obese patients undergoing SAVR for AS is good and both short-term complications and long-term survival do not differ significantly from patients with a normal BMI. Therefore, a high BMI itself should not be a contraindication for SAVR due to AS.

Improved long-term outcome of surgical AVR for AS: Results from a population-based cohort.

BACKGROUND: The aim of this retrospective study was to determine changes in outcomes after surgical aortic valve replacement (SAVR) for aortic stenosis (AS) in Iceland over a 15-year period. METHODS: We included 587 patients who underwent SAVR for AS in Iceland during the period 2002-2016, with a total follow-up of 3245 patient-years. Short-term and long-term outcomes, 30-day mortality, and long-term survival (Kaplan-Meier) were analyzed. Univariate linear regression and univariate and multinomial logistic regression analyses were performed on preoperative and perioperative variables. Poisson regression analysis was used to evaluate changes in rates of short-term outcomes. RESULTS: Mean age was 71 years, 65.1% were males, and mean EuroSCORE II was 3.9. Mean preoperative aortic valve area increased significantly (0.013 cm2 /year; P < .001) and mean aortic cross-clamp time declined (108 minutes, 2.8 min/year; P < .001). The rate of complications decreased, including new-onset atrial fibrillation (60.9% overall, decreased by 3.1%/year, P = .02), acute kidney injury (17.1%, 7.6%/year, P < .001), and reoperation for bleeding (12.5%, 6.3%/year, P = .02). Operative mortality did not change (5.4%); nor did 1- and 5-year overall survival (92.5% and 81.6%, respectively). Notable long-term events were chronic heart failure (27.7 admissions/100 patient-years), embolic event (15.9/100 patient-years), and bleeding (13.0/100 patient-years). CONCLUSIONS: Results of SAVR in this well-defined nationwide cohort of patients in Iceland have improved. This may be related to the patients having less severe AS at the time of operation and shorter operating times, as reflected by lower rates of short-term complications. However, the rate of long-term complications did not change significantly, with prosthetic valve-specific events being rare.

[Early outcome of surgical aortic valve replacement for aortic stenosis in Icelandic females].

INTRODUCTION: Aortic valve replacement (AVR) for aortic stenosis (AS) is the second most common open-heart procedure performed in Iceland. The aim of this study was to analyze the early outcome of AVR among females in Iceland. MATERIALS AND METHODS: This was a retrospective study including 428 patients who underwent surgical AVR due to AS in Iceland from 2002-2013. Information was gathered from medical records, including pre- and postoperative results of echocardiography and complications. Overall survival was estimated (Kaplan-Meier) and logistic regression used to identify predictors of operative mortality. The median follow-up time was 8.8 years (0-16.5 years). RESULTS: Of the 428 patients, 151 were female (35.3%), that were on average 2 years older than men (72.6 ± 9.4 vs. 70.4 ± 9.8 yrs., p=0.020). Preoperative symptoms were similar, but women had significantly higher EurosSCORE II than men (5.2 ± 8.8 vs. 3.2 ± 4.6, p=0.002). Maximal pressure-gradient across the aortic valve was higher for women (74.4 ± 29.3 mmHg vs. 68.0 ± 23.4 mmHg, p=0,013) but postoperative complications, operative mortality (8.6% vs. 4.0%, p=0.068) and 5-year survival (78.6% vs. 83.1%, p=0.245) were comparable for women and men. Logistic regression analysis showed that female gender was not an independent predictor of 30-day mortality (OR 1.54, 95% CI 0.63-3.77). CONCLUSIONS: Females constitute one third of patients that undergo AVR for AS in Iceland. At the time of surgery females are two years older than men and appear to have a more significant aortic stenosis at the time of surgery. However, complication rates, operative mortality and long-term survival were comparable for both genders.

[The outcomes of coronary artery bypass and aortic valve replacement in elderly patients]. / Árangur kransædahjáveituadgerda og ósædarlokuskipta hjá öldrudum.

OBJECTIVE: To study the outcome of open heart surgery in an increasing population of elderly patients in Iceland. MATERIAL AND METHODS: A retrospective study of patients (n=876) that underwent coronary artery bypass (CABG) or aortic valve replacement (AVR) for aortic stenosis in Iceland 2002-2006. Complication rates, operative mortality and long-term survival were compared between patients older (n=221, 25%) and younger (n=655, 75%) than 75 years. Long-term survival of the older group was compared to an age and sex matched reference population. RESULTS: Older patients had a higher incidence of atrial fibrillation (57% vs. 37%, p<0.001), stroke (5% vs. 1%, p=0.009) and operative mortality (9% vs. 2%, p<0.001) following CABG. Length of ICU stay was similar but total length of stay was one day longer in the older cohort. Following AVR, older patients had a higher incidence of atrial fibrillation (90% vs. 71%, p=0.006), ARDS (19% vs. 7%, p=0.04), myocardial infarction (21% vs. 8%, p=0.05) and operative mortality (11% vs. 2%, p=0.04). The ICU stay was a day longer and the total length of stay was about four days longer in the older cohort. A total of 75% of the older patients were alive five years after CABG, compared to 74% of the reference population (p=0.87). Similar numbers for AVR were 65% for the patients compared to 74% in the reference population (p=0.06). CONCLUSION: The rate of complications, operative mortality and length of hospital stay is higher in patients older than 75 years compared to younger patients. Survival of the older group of patients indicates good long-term results after open heart surgery for this patient cohort.

[Aortic valve replacement for aortic stenosis in Iceland 2002-2006: Long term complications and survival]. / Lokuskipti vegna ósædarlokuthrengsla á Islandi 2002-2006 - langtímafylgikvillar og lifun.

OBJECTIVE: To investigate long-term complications and survival following aortic valve replacement (AVR) in patients with aortic stenosis (AS) in Iceland. MATERIAL AND METHODS: Included were 156 patients (average age 71.7 yrs, 64.7% males) that underwent AVR for AS at Landspitali between 2002 and 2006. A mechanical prosthesis was used in 29 patients (18.6%) and a bioprosthesis in 127. Long-term complications and operation-related admissions were registered from hospital and outpatient records until April 1, 2010. Overall survival was estimated and compared with the Icelandic population of the same age and gender. RESULTS: The mean preop. EuroSCORE(st) was 6.9%, the max. transvalvular pressure gradient 74.1 mmHg and the left ventricular ejection fraction (LVEF) (57.2%). At six months following AVR the maximal pressure gradient was 19.8 mmHg (range; 2.5-38). Echocardiography results were not available for 23.6% of the patients 6 months postoperatively. In the follow-up period one in four patients was admitted due to valve-related problems. Re-admission rate was 6.0/100 patient-years (pt-y); most commonly due to cardiac failure (1.7/100 pt-y), emboli (1.6/100 pt-y), hemorrhage (1.6/100 pt-y), endocarditis (0.7/100 pt-y) and myocardial infarction (0.4/100 pt-y). Survival at 1 and 5 year was 89.7% and 78.2%, respectively, making survival comparable to the estimated survival of Icelanders of the same age and gender. CONCLUSIONS: The rate of long-term complications following AVR in Iceland is in line with other studies. The same applies to long-term survival, which was similar to that of the Icelandic population of the same age and gender. Key words: Aortic valve replacement, aortic stenosis, heart surgery, results, long-term complication, survival.

[Aortic valve replacement for aortic stenosis in Iceland 2002-2006: Indications and short term complications]. / Lokuskipti vegna óædarlokuprengsla á islandi 2002-2006: ábendingar og snemmkomnir fylgikvillar.

OBJECTIVE: Information on surgical outcome of aortic valve replacement (AVR) has not been available in Iceland. We therefore studied the indications, short-term complications and operative mortality in Icelandic patients that underwent AVR with aortic stenosis. MATERIAL AND METHODS: This was a retrospective study including all patients that underwent AVR for aortic stenosis at Landspitali between 2002 and 2006, a total of 156 patients (average age 71.7 years, 64.7% males). Short term complications and operative mortality (≤ 30 days) were registered and risk factors analysed with multivariate analysis. RESULTS: The most common symptoms before AVR were dyspnea (86.9%) and angina pectoris (52.6%). Preop. max aortic valve pressure gradient was on average 74 mmHg, the left ventricular ejection fraction 57.2% and EuroSCORE (st) 6.9%. The average operating time was 282 min and concomitant CABG was performed in 55% of the patients and mitral valve surgery in nine. A bioprothesis was implanted in 127 of the patients (81.4%), of which 102 were stentless valves, and a mechanical valve in 29 (18.6%) cases. The mean prosthesis size was 25.6 mm (range 21-29). Atrial fibrillation (78.0%) and acute renal injury (36.0%) were the most common complications and 20 patients (13.0%) developed multiple-organ failure. Twenty-six patients (17.0%) needed reoperation due to bleeding. Median hospital stay was 13 days and operative mortality was 6.4%. CONCLUSIONS: The rate of short term complications following AVR was relatively high, including reoperations for bleeding and atrial fibrillation. Operative mortality is twice that of CABG, which is in line with other studies.

[Impact of obesity on surgical outcomes following coronary artery bypass graft surgery]. / Tengsl offitu við árangur kransæðahjáveituaðgerða.

INTRODUCTION: Obesity has been related to increased postoperative morbidity and mortality following open-heart surgery. However, recent studies have shown no association or even a more favourable outcome in obese patients. This relationship was investigated in a well-defined cohort of patients that underwent myocardial revascularisation in Iceland. MATERIAL AND METHODS: A retrospective study including all patients that underwent isolated myocardial revascularisation in Iceland from 2002 to 2006. Altogether 720 patients were divided into two groups, an obese group, with BMI >30 kg/m2 (n=207, 29%), and a non-obese group with BMI ≤30 kg/m2 (n=513, 71%). Patient demographics, complications, operative mortality and long term survival of both groups were compared. RESULTS: Demographics were comparable between the groups. Obese patients were 2.4 years younger, more likely to use statins (83,3% vs. 71,2%, had a significantly lower EuroSCORE (4.3 vs. 5.0) but a slightly longer operation time. Pleural fluid was less often drained in obese patients (8.2 vs. 15.0%) but rates for other complications were similar in both groups, as was operative mortality ≤30 days (2.0% vs. 3.7%), 1 and 5 year survival. In a multivariate analysis obesity was not an independent risk factor for minor or major complications, operative mortality or long term survival. CONCLUSION: The rate of complications and operative mortality after myocardial revascularisation is not significantly higher in obese patients and the same applies to long term survival. This is true even after correcting for confounding factors in a multivariate analysis.