Performance of administrative database frailty instruments in predicting clinical outcomes and cost for patients undergoing transcatheter aortic valve implantation: a historical cohort study.

PURPOSE: Frailty instruments may improve prognostic estimates for patients undergoing transcatheter aortic valve implantation (TAVI). Few studies have evaluated and compared the performance of administrative database frailty instruments for patients undergoing TAVI. This study aimed to examine the performance of administrative database frailty instruments in predicting clinical outcomes and costs in patients who underwent TAVI. METHODS: We conducted a historical cohort study of 3,848 patients aged 66 yr or older who underwent a TAVI procedure in Ontario, Canada from 1 April 2012 to 31 March 2018. We used the Johns Hopkins Adjusted Clinical Group (ACG) frailty indicator and the Hospital Frailty Risk Score (HFRS) to assign frailty status. Outcomes of interest were in-hospital mortality, one-year mortality, rehospitalization, and healthcare costs. We compared the performance of the two frailty instruments with that of a reference model that adjusted baseline covariates and procedural characteristics. Accuracy measures included c-statistics, Akaike information criterion (AIC), Bayesian information criterion (BIC), integrated discrimination improvement (IDI), net reclassification index (NRI), bias, and accuracy of cost estimates. RESULTS: A total of 863 patients (22.4%) were identified as frail using the Johns Hopkins ACG frailty indicator and 865 (22.5%) were identified as frail using the HFRS. Although agreement between the frailty instruments was fair (Kappa statistic = 0.322), each instrument classified different subgroups as frail. Both the Johns Hopkins ACG frailty indicator (rate ratio [RR], 1.13; 95% confidence interval [CI], 1.06 to 1.20) and the HFRS (RR, 1.14; 95% CI, 1.07 to 1.21) were significantly associated with increased one-year costs. Compared with the reference model, both the Johns Hopkins ACG frailty indicator and HFRS significantly improved NRI for one-year mortality (Johns Hopkins ACG frailty indicator: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) and rehospitalization (Johns Hopkins ACG frailty indicator: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001). These improvements in NRI largely resulted from classification improvement among those who did not experience the event. With one-year mortality, there was a significant improvement in IDI (IDI, 0.003; P < 0.001) with the Johns Hopkins ACG frailty indicator. This improvement in performance resulted from an increase in the mean probability of the event among those with the event. CONCLUSION: Preoperative frailty assessment may add some predictive value for TAVI outcomes. Use of administrative database frailty instruments may provide small but significant improvements in case-mix adjustment when profiling hospitals for certain outcomes.

RéSUMé: OBJECTIF: L'utilisation d'indicateur de fragilité pourrait améliorer l'évaluation pronostique des patients bénéficiant d'un remplacement valvulaire aortique par voie percutanée (procédure TAVI). Peu d'études ont évalué et comparé la performance des instruments d'évaluation de la fragilité développés à partir de données administratives chez les patients bénéficiant d'un TAVI. Nous avions pour objectif d'examiner la performance des instruments d'évaluation de la fragilité développés à partir de données administratives dans la prédiction des issues cliniques et des coûts chez les patients ayant bénéficié d'un TAVI. MéTHODE: Nous avons réalisé une étude de cohorte historique auprès de 3848 patients âgés de 66 ans ou plus qui ont bénéficié d'une procédure TAVI en Ontario, Canada, du 1er avril 2012 au 31 mars 2018. Nous avons utilisé l'indicateur de fragilité ACG (Adjusted Clinical Group) de Johns Hopkins et le score de risque de fragilité à l'hôpital (HFRS) pour définir la fragilité. Les critères d'évaluation étaient la mortalité hospitalière, la mortalité à un an, la réhospitalisation et les coûts des soins de santé. Nous avons comparé la performance des deux instruments d'évaluation de la fragilité à celle d'un modèle de référence qui ajustait les covariables de base et les caractéristiques procédurales. Les mesures d'exactitude comprenaient l'analyse statistique c, le critère d'information d'Akaike (AIC), le critère d'information bayésien (BIC), l'amélioration de la discrimination intégrée (IDI), l'indice NRI (net reclassification index), le biais et l'exactitude des estimations de coûts. RéSULTATS: Au total, 863 patients (22,4 %) ont été identifiés comme fragiles à l'aide de l'indicateur de fragilité ACG de Johns Hopkins, et 865 (22,5 %) ont été identifiés comme fragiles à l'aide du HFRS. Bien que l'agrément entre les instruments d'évaluation de la fragilité ait été acceptable (statistique de Kappa = 0,322), chaque instrument a classé des sous-groupes différents comme étant fragiles. L'indicateur de fragilité ACG de Johns Hopkins (rapport de taux [RR], 1,13; intervalle de confiance à 95 % [IC], 1,06 à 1,20) et le HFRS (RR, 1,14; IC 95 %, 1,07 à 1,21) étaient associés de façon significative à une augmentation des coûts sur un an. Par rapport au modèle de référence, l'indicateur de fragilité ACG de Johns Hopkins améliorent de façon significative le NRI pour la mortalité (l'indicateur de fragilité ACG de Johns Hopkins: NRI, 0.160; P < 0.001; HFRS: NRI, 0.146; P = 0.001) et la réhospitalisation (l'indicateur de fragilité ACG: NRI, 0.201; P < 0.001; HFRS: NRI, 0.141; P = 0.001) à un an. Ces améliorations du NRI résultent en grande partie de l'amélioration de la classification chez ceux qui n'ont pas bénéficié d'un TAVI. En ce qui a trait à la mortalité à un an, il y a eu une amélioration significative de l'IDI (IDI, 0,003; P < 0,001) avec l'indicateur de fragilité ACG de Johns Hopkins. Cette amélioration de la performance résultait d'une augmentation de la probabilité moyenne de TAVI chez les personnes ayant vécu l'événement. CONCLUSION: L'évaluation préopératoire de la fragilité peut ajouter une certaine valeur prédictive aux issues cliniques suivant une procédure de TAVI. L'utilisation d'instruments d'évaluation de la fragilité développés à partir de données administratives peut apporter des améliorations mineures mais significatives pour l'ajustement de risque lors de l'évaluation des hôpitaux en fonction de certaines issues cliniques.

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery.

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

Effect of lipid-lowering medications in patients with coronary artery bypass grafting surgery outcomes.

BACKGROUND: Increased life expectancy and improved medical technology allow increasing numbers of elderly patients to undergo cardiac surgery. Elderly patients may be at greater risk of postoperative morbidity and mortality. Complications can lead to worsened quality of life, shortened life expectancy and higher healthcare costs. Reducing perioperative complications, especially severe adverse events, is key to improving outcomes in patients undergoing cardiac surgery. The objective of this study is to determine whether perioperative lipid-lowering medication use is associated with a reduced risk of complications and mortality after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS: After IRB approval, we reviewed charts of 9,518 patients who underwent cardiac surgery with CPB at three medical centers between July 2001 and June 2015. The relationship between perioperative lipid-lowering treatment and postoperative outcome was investigated. 3,988 patients who underwent CABG met inclusion criteria and were analyzed. Patients were divided into lipid-lowering or non-lipid-lowering treatment groups. RESULTS: A total of 3,988 patients were included in the final analysis. Compared to the patients without lipid-lowering medications, the patients with lipid-lowering medications had lower postoperative neurologic complications and overall mortality (P < 0.05). Propensity weighted risk-adjustment showed that lipid-lowering medication reduced in-hospital total complications (odds ratio (OR) = 0.856; 95% CI 0.781-0.938; P < 0.001); all neurologic complications (OR = 0.572; 95% CI 0.441-0.739; P < 0.001) including stroke (OR = 0.481; 95% CI 0.349-0.654; P < 0.001); in-hospital mortality (OR = 0.616; 95% CI 0.432-0.869; P = 0.006; P < 0.001); and overall mortality (OR = 0.723; 95% CI 0.634-0.824; P < 0.001). In addition, the results indicated postoperative lipid-lowering medication use was associated with improved long-term survival in this patient population. CONCLUSIONS: Perioperative lipid-lowering medication use was associated with significantly reduced postoperative adverse events and improved overall outcome in elderly patients undergoing CABG surgery with CPB.

Multidisciplinary approach to coronary artery revascularization: Optimal strategy for high-risk patients.

High-risk patients that are not candidates for conventional coronary artery bypass grafting surgery can undergo coronary artery revascularization through less invasive procedures. Hybrid approaches have emerged to address coronary artery disease in this subset of patients. This case report highlights the successful application of a multidisciplinary heart team approach for hybrid coronary revascularization in a very high-risk patient with complex coronary anatomy, who would not otherwise be a candidate for conventional modalities of revascularization. The optimal workup, selection criteria based on anatomy, anticoagulation strategies, and timing of intervention of hybrid coronary revascularization are outlined in this case report.

Perioperative dexmedetomidine and 5-year survival in patients undergoing cardiac surgery.

BACKGROUND: Dexmedetomidine sedation has been associated with favourable outcomes after surgery. We aimed to assess whether perioperative dexmedetomidine use is associated with improved survival after cardiac surgery. METHODS: This retrospective cohort study included 2068 patients undergoing on-pump coronary artery bypass grafting and/or valve surgery. Among them, 1029 patients received dexmedetomidine, and 1039 patients did not. Intravenous dexmedetomidine infusion of 0.007 µg kg-1 min-1 was initiated before or immediately after cardiopulmonary bypass and lasted for < 24 h. The primary outcome was 5-year survival after cardiac surgery. The propensity scores matching (PSM), inverse probability of treatment weighting (IPTW), and overlap weighting approaches were used to minimise bias. Survival analyses were performed with Cox proportional-hazard models. RESULTS: The median age was 63 yr old and the male to female ratio was 71:29 in both groups. Baseline covariates were balanced between groups after adjustment using PSM, IPTW, or overlap weighting. Patients receiving dexmedetomidine in cardiac surgical procedures had higher survival during postoperative 5 yr in unadjusted analysis (hazard ratio [HR]=0.63; 95% confidence interval [CI], 0.51-0.78; P<0.001), and after adjustment with PSM (HR=0.63; 95% CI, 0.45-0.89; P=0.009), IPTW (HR=0.70; 95% CI, 0.51-0.95; P=0.023), or overlap weighting (HR=0.67; 95% CI, 0.51-0.89; P=0.006). The 5-yr mortality rate after cardiac surgery was 13% and 20% in the dexmedetomidine and non-dexmedetomidine groups, respectively (PSM adjusted odds ratio=0.61; 95% CI, 0.42-0.89; P=0.010). CONCLUSION: Perioperative dexmedetomidine infusion was associated with improved 5-yr survival in patients undergoing cardiac surgery.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Clinical impact of disinvestment in hydroxyethyl starch for patients undergoing coronary artery bypass surgery: a retrospective observational study.

PURPOSE: To examine the effect of discontinuing hydroxyethyl starch (HES) solutions on length of hospital stay, transfusion, risk of death, acute kidney injury (AKI), and dialysis. METHODS: We conducted a historical cohort study of linked administrative and clinical databases in patients undergoing coronary artery bypass surgery (CABG) on cardiopulmonary bypass. We used propensity scores to match patients who did not receive HES (after discontinuation) with patients exposed to HES (before discontinuation) and also controlled for albumin exposure. Hospital length of stay (the primary outcome) was analyzed using Fine-Gray proportional hazard regression, with hospital discharge as the outcome and death as a competing risk. Adverse outcomes were compared between matched patients using conditional logistic regression. RESULTS: We compared 1,085 propensity score-matched pairs (n = 2,170) from a pool of 2,757 patients. Discontinuation of HES was associated with shorter length of hospital stay, as evidenced by an increased probability of discharge (hazard ratio, 1.24; 95% confidence interval [CI], 1.14 to 1.35) and a reduced risk of red blood cell transfusion (odds ratio [OR], 0.68; 95% CI, 0.55 to 0.84), plasma transfusion (OR, 0.48; 95% CI, 0.34 to 0.66), and platelet transfusion (OR, 0.62; 95% CI, 0.44 to 0.87). Discontinuation of HES was not associated with in-hospital mortality (OR, 0.74; 95% CI, 0.36 to 1.54), AKI (OR, 0.84; 95% CI, 0.57 to 1.25), or dialysis (OR, 0.83; 95% CI, 0.25 to 2.73). CONCLUSIONS: For patients undergoing CABG on cardiopulmonary bypass, discontinuation of HES was associated with reduced hospital length of stay and reduced blood product transfusion, without measurable change in renal failure, dialysis rate, or in-hospital mortality. Our results should be interpreted with caution, though we found no evidence of harms associated with discontinuing HES. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02329158); registered 31 December, 2014.

Update on revascularization in patients with heart failure and coronary artery disease.

PURPOSE OF REVIEW: The review explores the recent findings surrounding the evaluation and the treatment of patients with heart failure and coronary artery disease. It also shed the light on the gaps in this area. RECENT FINDINGS: Surgical revascularization in patients with ischemic cardiomyopathy has the potential to offer symptomatic and survival benefits. SUMMARY: Patients with heart failure and coronary artery disease should be considered candidates for revascularization on the basis of their symptoms, extent of the disease, and comorbidities. Surgical revascularization in these patients provides a symptomatic relief, and a survival benefit.

Whole body perfusion strategy for aortic arch repair under moderate hypothermia.

INTRODUCTION: Aortic arch reconstruction under moderate hypothermia is commonly performed with antegrade cerebral perfusion (ACP) for brain protection; however, hypothermia alone is often solely relied upon for visceral and lower body protection. We investigated whether the addition of simultaneous lower body perfusion to ACP (whole body perfusion - WBP) may ameliorate the metabolic derangements of moderate hypothermic circulatory arrest (MHCA). METHODS: Between 2008 and 2014, 106 consecutive patients underwent elective or emergent aortic arch surgery with MHCA, with either ACP only (44 patients, 66±12 years, 30% female) or WBP (62 patients, 61±15 years, 31% female). Primary outcomes included 30-day/in-hospital mortality, intensive care unit (ICU) and hospital lengths of stay (LOS) and specific parameters of metabolic recovery. RESULTS: There were no significant differences between the groups in 30-day/in-hospital mortality (ACP: 3 (6.8%), WBP: 2 (3.2%); p=0.65), stroke (ACP: 1 (2.3%), WBP: 1 (1.6%); p=1.0) or renal failure (ACP: 2 (4.5%), WBP: 1 (1.5%); p=0.57). In the WBP group, we identified a significant reduction in lactate level at ICU admission (ACP 5.5 vs. WBP 3.5 mmol/L; p=0.002), time to lactate normalization (p=0.014) and median ICU length-of-stay (ACP 3 vs. WBP 1 days; p=0.049). There was no difference in post-operative creatinine (ACP: 104, WBP: 107 µmol/L; p=0.66). After multivariable regression adjustment, perfusion strategy no longer remained an independent predictor of ICU discharge time (p=0.09), however, cardiopulmonary bypass time (p=0.02), age (p=0.012) and emergent surgery (p=0.02) were. CONCLUSIONS: A WBP strategy during aortic arch reconstruction with MHCA may be associated with more rapid normalization of metabolic parameters and reduced ICU length of stay compared to using ACP alone. Further evaluation with a randomized trial is warranted.

First North American experience with the transfemoral ACURATE-neoTM self-expanding transcatheter aortic bioprosthesis.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become a therapeutic alternative for patients presenting with severe symptomatic aortic stenosis and considered at high-surgical risk. Paravalvular leak (PVL), conduction disorders, and coronary obstruction remain unresolved procedure-related complications. The aim of this manuscript was to report the first North American experience with the ACURATE-neoTM aortic bioprosthesis and its ACURATE-TFTM delivery system (Symetis S.A., Ecublens, Switzerland). METHODS: Transfemoral ACURATE-neoTM aortic valve implantation was performed in 20 patients. Clinical and echocardiographic assessment was performed at baseline, postprocedure and at least 30 days. Outcomes were assessed according to valvular academic research consortium (VARC-2) criteria. RESULTS: The mean age was 82.7 ± 7.0 years with a mean logistic-EuroSCORE-II of 5.0 ± 2.9% and Society of Thoracic Surgeons score of 4.7 ± 2.3%. Device success was achieved in all patients. The mean distance between the aortic-annulus and the left main coronary artery ostium was 14.3 ± 3.2 mm, and eight (40%) patients had <12 mm. At 30 days, there were no deaths, conversions to surgery, or major procedure-related complications. New-pacemaker implantation was required in one (5.3%) patient. ACURATE-neoTM implantation resulted in a significant reduction in mean transvalvular gradient (49.9 ± 15.8 to 9.7 ± 5.7 mm Hg, P < 0.0001) and increase in effective-orifice area (0.65 ± 0.16 to 1.83 ± 0.36 cm2 , P = 0.001) at hospital discharge. Paravalvular leak was absent in four (20%) patients, trace in nine (45%) patients, and mild in seven (35%) patients. Hospital discharge occurred at a mean of 7.0 ± 4.5 days, and all patients were in NYHA class I-II at a mean follow-up of 8.6 ± 2.3 months. CONCLUSION: The present initial North American experience shows that the ACURATE-neoTM aortic bioprosthesis was safely and successfully implanted by transfemoral approach. The special design of this newer-generation device affords a stable and predictable implantation, while providing optimal hemodynamic performance with a relatively low rate of PPI. © 2016 Wiley Periodicals, Inc.

Comparison of outcomes of root replacement procedures and supracoronary techniques for surgical repair of acute aortic dissection.

BACKGROUND: Surgical approach to type A acute aortic dissection (AADA) is usually dictated by the presenting anatomy. We compared long-term outcomes of AADA repaired with a root replacement versus a supracoronary tube graft, regardless of the proximal extent of the intimal tear. METHODS: A single-centre, retrospective cohort of consecutive patients undergoing repair of AADA between December 1999 and March 2012 were stratified based on the proximal surgical procedure performed: supracoronary tube graft or root replacement. Imaging, chart reviews and clinical follow-ups were analyzed to identify the presenting anatomy and clinical outcomes. RESULTS: We included the cases of 75 patients in our analysis: 54 received a supracoronary tube graft and 21 received a root replacement. The proximal tear was identified below the sinotubular junction in all patients in the root group and in 61% of patients in the supracoronary group. We detected no differences between the groups for in-hospital mortality, length of stay, or complications. However, the root group had significantly increased renal failure (0% v. 9.5%, p = 0.018), cardiopulmonary bypass time (198.4 ± 80.0 min v. 316.5 ± 102.5 min, p < 0.001), cross-clamp time (91.6 ± 34.9 min v. 191.3 ± 52.8 min, p < 0.001), duration of surgery (457.5 ± 129.9 min v. 611.6 ± 197.8 min, p < 0.001), and platelet transfusions (8.1 ± 7.6 v. 12.8 ± 8.7 units, p = 0.021) than the supracoronary group. Long-term follow-up demonstrated a greater incidence of 2+ aortic regurgitation among patients in the supracoronary group than the root group (29.7% v. 0.0%, p = 0.006); however, there was no difference between the groups in symptoms or reoperation. CONCLUSION: In AADA, aortic root replacement involves a longer procedure with increased risk of early renal impairment. Long-term follow-up identified significantly more aortic regurgitation and root dilation in the supracoronary group than the root group, with a trend toward worse long-term survival. However, we found no difference between the groups in mortality, reoperation or New York Heart Association class.

CONTEXTE: L'approche chirurgicale à la dissection aigüe de l'aorte de type A (DAAA) dépend habituellement de la présentation anatomique. Nous avons comparé les résultats à long terme d'une DAAA réparée par remplacement de la racine de l'aorte c. greffon supracoronarien artificiel, indépendamment de la portée proximale de la déchirure de l'intima. MÉTHODES: Une cohorte rétrospective monocentrique de patients consécutifs soumis à une réparation de DAAA entre décembre 1999 et mars 2012 a été stratifiée en fonction de l'intervention chirurgicale proximale effectuée : greffon supracoronarien artificiel ou remplacement de la racine de l'aorte. Les épreuves d'imagerie, résumés de dossiers et suivis cliniques ont été analysés pour cerner la présentation anatomique et les résultats cliniques. RÉSULTATS: Nous avons inclus 75 patients dans notre analyse : 54 ont reçu un greffon supracoronarien artificiel et 21 ont subi un remplacement de la racine de l'aorte. Une déchirure proximale a été identifiée sous la jonction sinotubulaire chez tous les patients du groupe racine de l'aorte et chez 61 % des patients du groupe greffon supracoronarien. Nous n'avons décelé aucune différence entre les groupes pour ce qui est de la mortalité en milieu hospitalier, de la durée de l'hospitalisation ou des complications. Mais, le groupe racine de l'aorte a présenté des augmentations significatives du nombre de cas d'insuffisance rénale (0 % c. 9,5 %, p = 0,018), de la durée de la circulation extracorporelle (198,4 ± 80,0 min c. 316,5 ± 102,5 min, p < 0,001), du clampage de l'aorte (91,6 ± 34,9 min c. 191,3 ± 52,8 min, p < 0,001) et de la chirurgie (457,5 ± 129,9 min c. 611,6 ± 197,8 min, p < 0,001), ainsi que du nombre de transfusions plaquettaires (8,1 ± 7,6 unités c. 12,8 ± 8,7 unités, p = 0,021) comparativement au groupe greffon supracoronarien. Le suivi à long terme a fait état d'une incidence plus élevée de régurgitation aortique 2+ chez les patients du groupe greffon supracoronarien comparativement au groupe racine de l'aorte (29,7 % c. 0,0 %, p = 0,006); toutefois, on n'a noté aucune différence entre les groupes pour ce qui est des symptômes ou du taux de réopération. CONCLUSION: Dans la DAAA, le remplacement de la racine de l'aorte suppose une intervention de plus longue durée qui s'accompagne d'un risque accru d'insuffisance rénale précoce. Un suivi à long terme a révélé un nombre significativement plus élevé de cas de régurgitation aortique et de dilatation de la racine de l'aorte dans le groupe greffon supracoronarien que dans le groupe racine de l'aorte, avec une tendance moins favorable au plan de la survie à long terme. Toutefois, nous n'avons trouvé aucune différence entre les groupes pour ce qui est de la mortalité, du taux de réopération ou de la classe de la New York Heart Association.

Comparison of isoflurane and sevoflurane in cardiac surgery: a randomized non-inferiority comparative effectiveness trial.

PURPOSE: Volatile anesthetics possess cardioprotective properties, but it is unknown if the cardioprotective effects extend equally to all members of the class. Although sevoflurane is a relatively newer anesthetic than isoflurane, its introduction into practice was not preceded by a head-to-head comparison with isoflurane in a trial focusing on clinically important outcomes. Our objective was to determine whether sevoflurane was non-inferior to isoflurane on a clinically important primary outcome in a heterogeneous group of adults undergoing cardiac surgery. METHODS: This was a pragmatic randomized non-inferiority comparative effectiveness clinical trial in 464 adults having coronary artery bypass graft and/or single valve surgery during November 2011 to March 2014. The intervention was maintenance of anesthesia with sevoflurane (n = 231) or isoflurane (n = 233) administered at a dose of 0.5-2.0 MAC throughout the entire operation. All caregivers were blinded except for the anesthesiologist and perfusionist. The primary outcome was a composite of intensive care unit (ICU) length of stay ≥ 48 hr and all-cause 30-day mortality. We hypothesized that sevoflurane would be non-inferior to isoflurane (non-inferiority margin < 10% based on an expected event rate of 25%). Secondary outcomes included prolonged ICU stay, 30- and 365-day all-cause mortality, inotrope or vasopressor usage, new-onset hemodialysis or atrial fibrillation, stroke, and readmission to the ICU. RESULTS: No losses to follow-up occurred. The primary outcome occurred in 25% of sevoflurane patients and 30% of isoflurane patients (absolute difference, -5.4%; one-sided 95% confidence interval, 1.4), thus non-inferiority was declared. Sevoflurane was not superior to isoflurane for the primary outcome (P = 0.21) or for any secondary outcomes. CONCLUSION: Sevoflurane is non-inferior to isoflurane on a composite outcome of prolonged ICU stay and all-cause 30-day mortality. Sevoflurane is not superior to isoflurane on any other of the clinically important outcomes. This trial was registered at clinicaltrials.gov; NCT01477151.

RéSUMé: OBJECTIF: Les agents anesthésiques volatils possèdent des propriétés cardioprotectrices, mais nous ne savons pas si ces effets cardioprotecteurs sont équivalents pour tous les agents de cette classe. Bien que le sévoflurane soit un anesthésique plus récent que l'isoflurane, son introduction dans notre pratique n'a pas été précédée par une comparaison directe à l'isoflurane dans une étude s'intéressant à d'importants critères d'évaluation cliniques. Notre objectif était de déterminer si le sévoflurane était non inférieur à l'isoflurane en relation à un critère d'évaluation principal important d'un point de vue clinique dans un groupe hétérogène d'adultes subissant une chirurgie cardiaque. MéTHODE: Nous avons réalisé une étude clinique randomisée et pragmatique d'efficacité comparative et de non-infériorité auprès de 464 adultes subissant des pontages coronariens et/ou une chirurgie valvulaire unique entre novembre 2011 et mars 2014. L'intervention consistait en le maintien de l'anesthésie à l'aide de sévoflurane (n = 231) ou d'isoflurane (n = 233) administré à une dose de 0,5-2,0 MAC tout au long de l'opération. Aucun intervenant ne connaissait l'agent utilisé, à l'exception de l'anesthésiologiste et du perfusionniste. Le critère d'évaluation principal était une composée de la durée de séjour à l'unité de soins intensifs (USI) ≥ 48 h et de la mortalité, toutes causes confondues, à 30 jours. Nous avons émis l'hypothèse que le sévoflurane ne serait pas inférieur à l'isoflurane (marge de non-infériorité < 10 % sur la base d'un taux de complications attendu de 25 %). Les critères d'évaluation secondaires comprenaient un séjour prolongé à l'USI, la mortalité toutes causes confondues à 30 et à 365 jours, l'utilisation d'inotropes ou de vasopresseurs, une hémodialyse ou une fibrillation auriculaire nouvelles, un accident vasculaire cérébral et une réadmission à l'USI. RéSULTATS: Nous n'avons perdu aucun patient au suivi. Le critère d'évaluation principal est survenu chez 25 % des patients ayant reçu du sévoflurane et 30 % des patients ayant reçu de l'isoflurane (différence absolue, −5,4 %; intervalle de confiance unilatéral 95 %, 1,4): la non-infériorité a donc été déclarée. Le sévoflurane n'était pas supérieur à l'isoflurane en ce qui touchait au critère d'évaluation principal (P = 0,21) ou aux critères d'évaluation secondaires. CONCLUSION: Le sévoflurane n'est pas inférieur à l'isoflurane selon un critère d'évaluation composé d'une durée de séjour prolongée à l'USI et de la mortalité toutes causes confondues à 30 jours. Le sévoflurane n'est pas supérieur à l'isoflurane en ce qui touche à n'importe quel autre critère clinique important. Cette étude a été enregistrée au ClinicalTrials.gov, numéro NCT01477151.

Higher-risk mitral valve operations after previous sternotomy: endoscopic, minimally invasive approach improves patient outcomes.

BACKGROUND: Reoperative mitral valve (MV) surgery is associated with significant morbidity and mortality; however, endoscopic minimally invasive surgical techniques may preserve the surgical benefits of conventional mitral operations while potentially reducing perioperative risk and length of stay (LOS) in hospital. METHODS: We compared the outcomes of consecutive patients who underwent reoperative MV surgery between 2000 and 2014 using a minimally invasive endoscopic approach (MINI) with those of patients who underwent a conventional sternotomy (STERN). The primary outcome was in-hospital/30-day mortality. Secondary outcomes included blood product transfusion, LOS in hospital and in the intensive care unit (ICU), and postoperative complications. RESULTS: We included 132 patients in our study: 40 (mean age 68 ± 14 yr, 70% men) underwent MINI and 92 (62 ± 13 yr, 40% men) underwent STERN. The MINI group had significantly more comorbidities than the STERN group. While there were no significant differences in complications, all point estimates suggested lower mortality and morbidity in the MINI than the STERN group (in-hospital/ 30-day mortality 5% v. 11%, p = 0.35; composite any of 10 complications 28% v. 41%, p = 0.13). Individual complication rates were similar between the MINI and STERN groups, except for intra-aortic balloon pump requirement (IABP; 0% v. 12%, p = 0.034). MINI significantly reduced the need for any blood transfusion (68% v. 84%, p = 0.036) or packed red blood cells (63% v. 79%, p = 0.042), fresh frozen plasma (35% v. 59%, p = 0.012) and platelets (20% v. 40%, p = 0.024). It also significantly reduced median hospital LOS (8 v. 12 d, p = 0.014). An exploratory propensity score analysis similarly demonstrated a significantly reduced need for IABP (p < 0.001) and a shorter mean LOS in the ICU (p = 0.046) and in hospital (p = 0.047) in the MINI group. CONCLUSION: A MINI approach for reoperative MV surgery reduces blood product utilization and hospital LOS. Possible clinically relevant differences in perioperative complications require assessment in randomized clinical trials.

CONTEXTE: Les réopérations de la valve mitrale (VM) sont associées à une morbidité et à une mortalité importantes. Cependant, il semblerait que les techniques chirurgicales endoscopiques à effraction minimale préservent les avantages des opérations traditionnelles de la VM tout en réduisant potentiellement les risques périopératoires et la durée d'hospitalisation. MÉTHODES: Nous avons comparé les résultats de patients consécutifs ayant subi une réopération de la VM entre 2000 et 2014 selon une approche endoscopique à effraction minimale (groupe MINI) à ceux de patients ayant subi une sternotomie classique (groupe STERN). Le résultat primaire à l'étude était la mortalité intrahospitalière ou dans les 30 premiers jours, et les résultats secondaires, la transfusion de produits sanguins, la durée du séjour à l'hôpital et à l'unité des soins intensifs (USI), ainsi que les complications postopératoires. RÉSULTATS: Nous avons retenu 132 patients : 40 (âge moyen de 68 ± 14 ans, 70 % d'hommes) dans le groupe MINI et 92 (âge moyen de 62 ± 13 ans, 40 % d'hommes) dans le groupe STERN. Les patients du groupe MINI présentaient un nombre significativement plus élevé de comorbidités que ceux du groupe STERN. Aucune différence significative n'a été observée quant aux complications, mais toutes les estimations ponctuelles pointaient vers une mortalité et une morbidité moindres dans le groupe MINI (mortalité intrahospitalière ou dans les 30 premiers jours : 5 % c. 11 %, p = 0,35; morbidité combinée à la présence d'au moins une complication parmi 10 possibles : 28 % c. 41 %, p = 0,13). Les taux de complications individuels étaient semblables chez les patients des 2 groupes, sauf pour l'exigence de ballon de contrepulsion intra-aortique (BCIA; 0 % c. 12 %, p = 0,034). L'approche MINI a réduit significativement le taux de transfusion de sang (68 % c. 84 %, p = 0,036) ou de concentrés de globules rouges (63 % c. 79 %, p = 0,042), de plasma frais congelé (35 % c. 59 %, p = 0,012) et de plaquettes (20 % c. 40 %, p = 0,024), en plus de diminuer significativement la durée médiane d'hospitalisation (8 jours c. 12 jours, p = 0,014). En outre, une analyse exploratoire du score de propension a révélé une réduction significative du BCIA (p < 0,001) ainsi qu'une durée moyenne de séjour à l'USI (p = 0,046) et à l'hôpital (p = 0,047) plus courte dans le groupe MINI. CONCLUSION: Le recours à l'approche endoscopique à effraction minimale pour les réopérations de la VM diminuerait le recours aux produits sanguins et la durée d'hospitalisation. En ce qui a trait aux complications périopératoires, il faudra procéder à des essais cliniques aléatoires pour évaluer les différences possiblement pertinentes sur le plan clinique.

Salvaging catastrophe in transcatheter aortic valve implantation: rehearsal, preassigned roles, and emergency preparedness.

PURPOSE: Emergency rescue plans for acute complications during transcatheter aortic valve implantation (TAVI) commonly include cardiopulmonary resuscitation, femoro-femoral cardiopulmonary bypass (CPB), and hemodynamic stabilization before definitive intervention is achieved. Nevertheless, most cases of emergency resuscitation remain chaotic and disorganized and often take longer than necessary, even in experienced centres. We sought to determine which factors and procedures may be associated with improved patient outcomes when emergencies arise during TAVI. SOURCES: MEDLINE(®) and EMBASE™ were searched with the following key words: "TAVI" or "TAVR" or "transcatheter valve implantation" or "transcatheter valve replacement" and "emergency cardiac surgery" or "conversion". Two hundred seventeen articles met the criteria and were reviewed. PRINCIPAL FINDINGS: Utilization of a formal emergency checklist by a multidisciplinary TAVI team may reduce procedural errors, smooth the transition to CPB, and ultimately speed the delivery of corrective measures including emergency cardiac surgery. CONCLUSION: A well-organized regularly-rehearsed emergency rescue plan that preassigns resuscitative roles may shorten the duration of patient instability and resuscitation and improve patient outcomes when catastrophe occurs in TAVI. The anesthesia team plays a central role in preventing, detecting, and treating intraprocedural complications during TAVI.

Percutaneous superior vena cava drainage during minimally invasive mitral valve surgery: a randomized, crossover study.

OBJECTIVE: Minimally invasive techniques commonly are applied to mitral valve surgery; however, there has been little research investigating the optimal methods of cardiopulmonary bypass for the right minithoracotomy approach. Controversy exists as to whether a percutaneous superior vena cava drainage cannula (PSVC) is necessary during these operations. The authors, therefore, sought to determine the effect of using a percutaneous superior vena cava catheter on brain near-infrared spectroscopy, blood lactate levels, hemodynamics and surgical parameters. DESIGN: Randomized, blinded, crossover trial. SETTING: Tertiary care university hospital. PARTICIPANTS: Patients undergoing minimally invasive mitral valve surgery via a right minithoracotomy. INTERVENTIONS: Twenty minutes of either clamped or unclamped percutaneous superior vena cava neck catheter drainage, during mitral valve repair. MEASUREMENT AND MAIN RESULTS: For the primary outcome of brain near-infrared spectroscopy, there were no differences between the two groups (percutaneous superior vena cava clamped 55.0%±11.6% versus unclamped 56.1%±10.2%) (p = 0.283). For the secondary outcomes pH (clamped 7.35±0.05 versus unclamped 7.37±0.05 p = 0.015), surgical score (clamped 1.96±1.14 versus unclamped 1.22±0.51 p = 0.002) and CVP (clamped 11.6 mmHg±4.8 mmHg versus unclamped 6.1 mmHg±6.1 mmHg p<0.001) were significantly different. CONCLUSIONS: The use of a percutaneous superior vena cava drainage improved surgical visualization and lowered CVP, but had no effect on brain near infrared spectroscopy during minimally invasive mitral valve surgery. (ClinicalTrials.gov Identifier: NCT01166841).

Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair.

BACKGROUND: Concerns remain that minimally invasive atrial septal defect (ASD) repair may compromise patient outcomes. We compared clinical outcomes of adult patients undergoing ASD repair via a minimally invasive endoscopic approach versus a "gold standard" sternotomy. METHODS: We retrospectively reviewed the clinical outcomes of consecutive patients who underwent ASD patch repair at our institution between 2002 and 2012. We compared in-hospital/30-day mortality, postoperative complications, length of stay in hospital and in the intensive care unit and blood product requirements between patients who underwent right mini-thoracotomy (MT) and those who underwent conventional sternotomy. RESULTS: During the study period, 73 consecutive patients underwent ASD patch repair at our institution: 51 (age 47 ± 16 yr, 66.7% women) in the MT group and 22 (age 46 ± 21 yr, 59.1% women) in the sternotomy group. In-hospital mortality was similar between the 2 groups (MT 0% v. sternotomy 4.5%, p = 0.30). There were no significant differences in any postoperative complications or blood product requirements. No patients in the MT group suffered stroke, retrograde aortic dissection or leg ischemia. Mean intensive care unit (MT 1.2 ± 1.2 d v. sternotomy 1.7 ± 2.2 d, p = 0.26) and hospital length of stays (MT 5.1 ± 2.2 d v. sternotomy 6.3 ± 3.6 d, p = 0.17) were similar between the groups; however, there was a trend toward fewer patients requiring prolonged hospital stays (> 10 d) in the MT group (3.9% v. 18.2%, p = 0.06). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via MT endoscopic approach with similar outcomes as sternotomy. Patient preference for a more cosmetically appealing incision may be considered without concern of compromised outcomes.

CONTEXTE: Des inquiétudes persistent au sujet des résultats potentiellement négatifs chez les patients soumis à une intervention de réparation de communication interauriculaire (CIA) minimalement effractive. Nous avons comparé les résultats cliniques chez des patients adultes soumis à une réparation de CIA par approche endoscopique minimalement effractive ou par sternotomie classique ­ « l'étalon-or ¼. MÉTHODES: Nous avons passé en revue de manière rétrospective les résultats cliniques chez des patients consécutifs qui ont subi un traitement d'occlusion de leur CIA dans notre établissement, entre 2002 et 2012. Nous avons comparé la mortalité en cours d'hospitalisation et à 30 jours, les complications postopératoires, la durée des séjours à l'hôpital et aux soins intensifs et le recours aux produits sanguins chez les patients selon qu'ils avaient subi une mini-thoracotomie (MT) ou une sternotomie classique. RÉSULTATS: Durant la période de l'étude, 73 patients consécutifs ont subi un traitement d'occlusion de leur CIA dans notre établissement : 51 (âge 47 ± 16 ans, 66,7 % femmes) dans le groupe MT et 22 (âge 46 ± 21 ans, 59,1 % femmes) dans le groupe sternotomie. La mortalité perhospitalière a été similaire entre les 2 groupes (MT 0 % c. sternotomie 4,5 %, p = 0,30). On n'a noté aucune différence significative quant aux complications postopératoires et aux besoins en produits sanguins. Aucun patient du groupe MT n'a subi d'AVC, de dissection aortique rétrograde ou d'ischémie à la jambe. La durée moyenne des séjours aux soins intensifs (MT 1,2 ± 1,2 j c. sternotomie 1,7 ± 2,2 j, p = 0,26) et à l'hôpital (MT 5,1 ± 2.2 j c. sternotomie 6,3 ± 3,6 j, p = 0,17) a été similaire entre les groupes; toutefois, on a noté une tendance à un nombre moindre de patients nécessitant une hospitalisation prolongée (> 10 j) dans le groupe MT (3,9 % c. 18,2 %, p = 0,06). CONCLUSION: La réparation de la CIA au niveau de l'ostium secundum et du sinus veineux peut se faire de manière sécuritaire par approche endoscopique MT, avec des résultats similaires à ceux de la sternotomie. On peut tenir compte de la préférence des patients pour une incision plus acceptable au plan esthétique sans crainte de compromettre les résultats.

A Retrospective Evaluation of Endo-Aortic Balloon Occlusion Compared to External Clamping in Minimally Invasive Mitral Valve Surgery.

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N = 60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P = 0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.

Quality of Life 5 Years Following Transfemoral TAVR or SAVR in Intermediate Risk Patients.

BACKGROUND: Symptomatic patients with severe aortic stenosis (AS) at high risk for surgical aortic valve replacement (SAVR) sustain comparable improvements in health status over 5 years after transcatheter aortic valve replacement (TAVR) or SAVR. Whether a similar long-term benefit is observed among intermediate-risk AS patients is unknown. OBJECTIVES: The purpose of this study was to assess health status outcomes through 5 years in intermediate risk patients treated with a self-expanding TAVR prosthesis or SAVR using data from the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial. METHODS: Intermediate-risk patients randomized to transfemoral TAVR or SAVR in the SURTAVI trial had disease-specific health status assessed at baseline, 30 days, and annually to 5 years using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Health status was compared between groups using fixed effects repeated measures modelling. RESULTS: Of the 1,584 patients (TAVR, n = 805; SAVR, n = 779) included in the analysis, health status improved more rapidly after TAVR compared with SAVR. However, by 1 year, both groups experienced large health status benefits (mean change in KCCQ-Overall Summary Score (KCCQ-OS) from baseline: TAVR: 20.5 ± 22.4; SAVR: 20.5 ± 22.2). This benefit was sustained, albeit modestly attenuated, at 5 years (mean change in KCCQ-OS from baseline: TAVR: 15.4 ± 25.1; SAVR: 14.3 ± 24.2). There were no significant differences in health status between the cohorts at 1 year or beyond. Similar findings were observed in the KCCQ subscales, although a substantial attenuation of benefit was noted in the physical limitation subscale over time in both groups. CONCLUSIONS: In intermediate-risk AS patients, both transfemoral TAVR and SAVR resulted in comparable and durable health status benefits to 5 years. Further research is necessary to elucidate the mechanisms for the small decline in health status noted at 5 years compared with 1 year in both groups. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Severe, Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement [SURTAVI]; NCT01586910).

Early and late outcomes after cardiac retransplantation.

BACKGROUND: Cardiac retransplantation remains the most viable option for patients with allograft heart failure; however, careful patient selection is paramount considering limited allograft resources. We analyzed clinical outcomes following retransplantation in an academic, tertiary care institution. METHODS: Between 1981 and 2011, 593 heart transplantations, including 22 retransplantations were performed at our institution. We analyzed the preoperative demographic characteristics, cause of allograft loss, short- and long-term surgical outcomes and cause of death among patients who had cardiac retransplantations. RESULTS: Twenty-two patients underwent retransplantation: 10 for graft vascular disease, 7 for acute rejection and 5 for primary graft failure. Mean age at retransplantation was 43 (standard deviation [SD] 15) years; 6 patients were women. Thirteen patients were critically ill preoperatively, requiring inotropes and/or mechanical support. The median interval between primary and retransplantation was 2.2 (range 0-16) years. Thirty-day mortality was 31.8%, and conditional (> 30 d) 1-, 5- and 10-year survival after retransplantation were 93%, 79% and 59%, respectively. A diagnosis of allograft vasculopathy (p = 0.008) and an interval between primary and retransplantation greater than 1 year (p = 0.016) had a significantly favourable impact on 30-day mortality. The median and mean survival after retransplantation were 3.3 and 5 (SD 6, range 0-18) years, respectively; graft vascular disease and multiorgan failure were the most common causes of death. CONCLUSION: Long-term outcomes for primary and retransplantation are similar if patients survive the 30-day postoperative period. Retransplantation within 1 year of the primary transplantation resulted in a high perioperative mortality and thus may be a contraindication to retransplantation.