The association between vegetation size and surgical treatment on 6-month mortality in left-sided infective endocarditis.

AIMS: In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size. METHODS AND RESULTS: Patients with definite, left-sided IE (2008-2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27-1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48-2.34)] rather than surgically [HR 1.01 (0.69-1.49)]. CONCLUSION: Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.

Association between the timing of surgery for complicated, left-sided infective endocarditis and survival.

BACKGROUND: In patients with active infective endocarditis (IE), the relationship between timing of surgery and survival is uncertain. The objective was to evaluate clinical characteristics associated with timing of surgery and the association between surgical timing and 6-month survival in complicated, left-sided IE. METHODS: In a prospective, multicenter, observational registry (The International Collaboration on Endocarditis-PLUS, registry from 2008 to 2012), clinical factors associated with timing of surgery during the index hospitalization were determined among 485 adult patients with definite, complicated, left-sided IE who underwent cardiac surgery during their index hospitalization. The relationship between early surgical intervention (<7 days from admission to surgery center) and outcome after surgery was analyzed. The primary end point of the study was 6-month survival. RESULTS: The median time to surgery from admission to surgical center was 7 (interquartile range 2-15) days. Patients who underwent earlier surgery were more likely transferred to the surgical center (74.2% vs 46.4%, P < .001) and had a lower percentage of preexisting heart failure (before IE diagnosis) (6.0% vs 17.3%, P < .001) but higher rate of acute heart failure (53.2% vs 38.4%, P = .001). Variables independently associated with surgery <7 days from admission were patient transfer, acute heart failure, and nonelective surgical status (C-index = 0.84), but predicted operative risk was not. Cox proportional hazards modeling with inverse probability of treatment weighting found that earlier surgery was associated with a trend toward higher 6-month mortality compared with later surgery (hazard ratio = 1.68, 95% CI 0.97-2.96; P = .065), particularly surgery within 2 days of admission or transfer. Mortality was significantly associated with operative risk and complicated IE, including Staphylococcus aureus infection and presence of abscess. CONCLUSIONS: Earlier surgery in IE is strongly associated with acute heart failure and surgical urgency. After adjustment for operative risk and IE complications, earlier surgery <7 days from admission was associated with a trend toward higher 6-month overall mortality compared with surgery later in the index hospitalization.

Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis.

BACKGROUND: Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. METHODS AND RESULTS: The International Collaboration on Endocarditis-PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non-cardiac device-related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. CONCLUSIONS: Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.

Transaortic TAVI Is a Valid Alternative to Transapical Approach.

BACKGROUND AND AIM: Transcatheter aortic valve implantation (TAVI) can be performed via a number of different anatomical approaches based on patient characteristics and operator choice. The aim of this study was to compare procedural outcomes between transaortic (TAo) and transapical (TA) approaches in an effort to establish whether any differences exist. METHODS: A systematic review and meta-analysis of the current literature reporting outcomes for patients undergoing TAo and TA TAVI was performed to compare outcomes using each vascular approach to valve deployment. RESULTS: A total of 10 studies and 1736 patients were included. A total of 193 patients underwent TAo and 1543 TA TAVI. No significant difference in 30-day mortality was identified (TAo 9.4, TA 10.4 p = 0.7). There were no significant differences identified between TAo and TA TAVI in procedural success rate (96.3% vs. 93.7% p = 0.3), stroke and transient ischemic attack (TIA) incidence (1.8% vs. 2.3% p = 0.7), major bleed (5.8% vs. 5.5% p = 0.97) or pacemaker insertion rates (6.1% vs. 7.4% p = 0.56). In addition, the incidence of clinically significant paravalvular regurgitation (PVR) was the same between groups (6.7% vs. 11% p = 0.43). CONCLUSION: Comparison of TAo and TA approaches revealed equivalent outcomes in 30-day mortality, procedural success, major bleeding, stroke/TIA incidence, pacemaker insertion rates and paravalvular leak. Heart teams should be familiar with the use of both TA and TAo access and tailor their selection on a case-to-case basis.

Importance of strict patient selection criteria for combined carotid endarterectomy and coronary artery bypass grafting.

BACKGROUND: Management of patients with severe concomitant carotid and coronary disease remains controversial. We report our experience of combined carotid endarterectomy (CEA) and coronary artery bypass surgery (CABG) over a fifteen year period using strict patient selection criteria. METHODS: From 1st January 1995 to December 31st 2009 165 patients underwent combined CABG/CEA procedures at the Mater Hospital. Mean age was 68.2 years (range 43-88) and 127 (77%) were male. Fifty-three (32%) had symptomatic carotid disease. Indications for combined procedures were the presence of symptomatic >70% or asymptomatic >80% internal carotid artery stenosis in a patient requiring urgent CABG because of either unstable angina, recent MI, severe triple vessel disease or severe Left Anterior Descending or Left Main Stem stenosis. RESULTS: Thirty-day stroke and death rate was 3%. All neurological events were in the hemisphere contralateral to the carotid surgery and symptoms had completely resolved prior to discharge from hospital. One patient required evacuation of a cervical haematoma and there were two transient XII nerve palsies. CONCLUSION: Combined CEA/CABG can be performed safely with acceptable morbidity and mortality in patients selected in accordance with strict criteria in a centre with a large experience of both cardiac and carotid surgery.

Measurements of the leachability of potentially hazardous trace elements from solid coal gasification wastes in China.

Solid wastes from commercial coal gasification plants are a significant environmental issue in China because of the large quantities produced. In recent years, with the rapid development of coal gasification technologies in China, more and more coal gasification residues are being disposed of in landfills because of the low utilization of the residues. In the present study, the column leaching procedure M1314 developed by the U.S. Environmental Protection Agency was used to evaluate the potential for environmental pollution by potentially hazardous trace elements (Be, V, Mn, Cr, Co, Ni, Cu, Zn, As, Se, Sr, Mo, Cd, Sb, Cs, Ba, Tl, Pb, Hg, Th, and U) in the coarse and fine gasification residues from two plants using General Electric (GE) and Gaskombinat Schwarze Pumpe (GSP) coal gasification technologies in northwest China. The potentially hazardous trace elements in the residues show different release patterns with the liquid-solid ratio increasing. The cumulative leached concentrations of the potentially hazardous trace elements from the coal gasification residues were generally low, and only Mo in the leachate of GSP fine residue was moderately soluble. V in the GSP coal gasification residues showed an increasing leachability in the leaching procedure. As, Se, Mo, Sb, and Tl in some leachates exceeded their thresholds in Level III of the Chinese Quality Standard for Groundwater and/or the Maximum Contaminant Levels of the U.S. National Primary Drinking Water Regulations. According to the risk assessment code, Se in the GE fine residue and Mo in the GE and GSP fine residues had medium risk to the ecosystem. Those data indicated that the potential for environmental pollution by those elements from coal gasification plants should be given consideration.

A Meta-Analysis Examining Differences in Short-Term Outcomes Between Sutureless and Conventional Aortic Valve Prostheses.

OBJECTIVE: Sutureless aortic valve prostheses are anchored by radial force in a mechanism similar to that of transcatheter aortic valve implantation. Transcatheter aortic valve implantation is associated with an increased permanent pacemaker (PPM) requirement in a significant proportion of patients. We undertook a meta-analysis to examine the incidence of PPM insertion associated with sutureless compared with conventional surgical aortic valve replacement. METHODS: A systematic review was conducted in accordance with the Prisma guidelines. All searches were performed on August 10, 2014. Studies between 2007 and 2014 were included in the search. RESULTS: A total of 832 patients were included in the sutureless group and 3,740 in the conventional group. Aortic cross-clamp (39.8 vs 62.4 minutes; P < 0.001) and cardiopulmonary bypass (64.9 vs 86.7 minutes; P = 0.002) times were shorter in the sutureless group. Permanent pacemaker implantation rate was higher in the sutureless cohort (9.1% vs 2.4%; P = 0.025). CONCLUSIONS: Sutureless aortic valve prostheses are associated with significantly shorter cardiopulmonary bypass and aortic cross-clamp times and a higher incidence of PPM insertion than conventional. Further investigation of the prognostic significance is required.

The effect of obesity on acute kidney injury after cardiac surgery.

OBJECTIVE: Postoperative acute kidney injury is a frequent and serious consequence of cardiac surgery. We undertook to investigate the association of obesity and the risk of acute kidney injury development after cardiac surgery. METHODS: A total of 432 patients who underwent cardiac surgery with cardiopulmonary bypass between October 2009 and August 2010 were included in the final retrospective analysis. Obesity was defined as body mass index 30 kg/m(2) or greater. Acute kidney injury was defined as a creatinine increase of 25% or more from baseline at 48 hours after surgery. RESULTS: The overall incidence of acute kidney injury was 29.9% (n = 129). There was an increased incidence of postoperative renal impairment in the obese versus nonobese cohort; however, this was not statistically significant (39% vs 25.9%, P = .007). Multivariate logistic regression revealed that body mass index 30 kg/m(2) or greater was independently associated with the development of postoperative acute kidney injury (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.27-3.54; P = .004), as were age (OR, 0.98; 95% CI, 0.96-1.0; P = .04) and cardiopulmonary bypass time (OR, 0.99; 95% CI, 0.98-1.0; P = .048). CONCLUSIONS: Obesity with body mass index 30 kg/m(2) or greater is independently associated with an increased risk of acute kidney injury after cardiac surgery. Further understanding of the molecular basis of this association is critical to the design of preventative strategies.

The Combined Impact of Surgical Team Education and Chlorhexidine 2% Alcohol on the Reduction of Surgical Site Infection following Cardiac Surgery.

BACKGROUND: The use of 2% chlorhexidine in 70% alcohol (CHG) has been associated with reduction in catheter-related bloodstream infections and surgical site infection (SSI) in general surgery. Also, improved awareness of best practice from the perspective of the operative team is likely to result in reductions in SSI rates. METHODS: This is an ambispective cohort study of patients undergoing elective cardiac surgery. Between January 2010 and December 2010, patients underwent surgical preparation using Alcohol Povidone Iodine (API). Between January 2011 and December 2011, the surgical team received education and switched to CHG for surgical preparation. Univariate analysis was performed to identify the impact of known risk factors for SSI. A logistic regression model was then fit to estimate the effect of education and CHG in the reduction of SSI in 2011, controlling for known SSI risk factors. RESULTS: There was a substantial reduction in overall SSI rate in 2011 following staff education and the introduction of CHG. The overall unadjusted SSI rate was 4.67% versus 2.08% (p<0.05) for 2010 and 2011 respectively. Using a logistic regression model, the combined effect of education and CHG in 2011 was a 63% reduction in SSI in cardiothoracic surgery (OR 0.37, 95% CI: 0.17-0.83, p=0.016), controlling for age, major co-morbidities, and SSI risk factors. CONCLUSIONS: Using CHG as pre-operative antiseptic in cardiothoracic surgery in a risk-adjusted cohort with education of the surgical team is associated with significantly lower SSI infection rates when compared with API. Emphasis must be placed on the multifactorial approach required to prevent postoperative wound infections.

The 100 most cited publications in transplantation.

Bibliometric analyses are viewed as a proxy marker of a papers influence and therefore an analysis of the most influential papers published in recent decades. This study is a citation analysis of the top 100 most cited papers in transplantation. We hypothesized that the field of transplantation could serve as an exemplar model of an area in which advancement of the specialty could be heavily attributed to translational research. This paper represents the first use of this technique of bibliometric analysis in the context of transplantation as a whole and also to subdivide the top cited papers within the field according to clinical versus scientific origin. Papers ranking in the top 100 were published in 16 journals. A total of 48 of the top 100 papers were scientific with 52 clinical. The majority of the top cited papers (67) originated in the USA and were published between 2000 and 2009. The New England Journal of Medicine published the majority of the top 100 papers in transplantation (24), followed by Transplantation (21) and Nature (18). This article provides a valuable perspective on this field by outlining the key publications and highlighting the importance of translational research in advancing the progress.