Male-Female Differences in Acute Type B Aortic Dissection

BACKGROUND

Acute type B aortic dissection is a cardiovascular emergency with considerable mortality and morbidity risk. Male-female differences have been observed in cardiovascular disease; however, literature on type B aortic dissection is scarce.

METHODS AND RESULTS

A retrospective cohort study was conducted including all consecutive patients with acute type B aortic dissection between 2007 and 2017 in 4 tertiary hospitals using patient files and questionnaires for late morbidity. In total, 384 patients were included with a follow-up of 6.1 (range, 0.02-14.8) years, of which 41% (n=156) were female. Women presented at an older age than men (67 [interquartile range (IQR), 57-73] versus 62 [IQR, 52-71]; P=0.015). Prior abdominal aortic aneurysm (6% versus 15%; P=0.009), distally extending dissections (71 versus 85%; P=0.001), and clinical malperfusion (18% versus 32%; P=0.002) were less frequently observed in women. Absolute maximal descending aortic diameters were smaller in women (36 [IQR: 33-40] mm versus 39 [IQR, 36-43] mm; P<0.001), while indexed for body surface area diameters were larger in women (20 [IQR, 18-23] mm/m2 versus 19 [IQR, 17-21] mm/m2). No male-female differences were found in treatment choice; however, indications for invasive treatment were different (P<0.001). Early mortality rate was 9.6% in women and 11.8% in men (P=0.60). The 5-year survival was 83% (95% CI, 77-89) for women and 84% (95% CI, 79-89) for men (P=0.90). No male-female differences were observed in late (re)interventions.

CONCLUSIONS

No male-female differences were found in management, early or late death, and morbidity in patients presenting with acute type B aortic dissection, despite distinct clinical profiles at presentation. More details on the impact of age and type of intervention are warranted in future studies.

Successful aortic arch cannulation and perfusion of a heart donated after circulatory death: A case report

INTRODUCTION

We describe successful aortic arch cannulation and perfusion of a heart donated after circulatory death using the Transmedics Organ Care System™.

CASE REPORT

A 47-year old man developed advanced heart failure symptoms after prior mustard operation for transposition of the great arteries. He matched a DCD-donor and required an elongated aorta for implantation due to his altered anatomy. The donor heart was retrieved and successfully perfused via aortic arch cannulation for 4.5 h with satisfactory perfusion parameters.

DISUSSION

Although Transmedics advises against aortic arch cannulation due to concerns regarding malperfusion, satisfactory and safe perfusion can be achieved by careful positioning of the heart. Awareness and attention to the occurrence of malperfusion is mandatory, especially during transport, to achieve satisfactory outcome.

CONCLUSION

Aortic arch cannulation is feasible without compromising quality of perfusion. This is relevant for patient that require an elongated aorta after surgically corrected congenital heart disease.

Long Term Health Related Quality of Life After Acute Type B Aortic Dissection: a Cross Sectional Survey Study

OBJECTIVE

Acute type B aortic dissection (ATBD) is a rare yet serious cardiovascular event that potentially has an impact on health related quality of life (HRQoL). However, long term follow up data on this topic are scarce. This study aimed to review the long term HRQoL among patients treated for ATBD.

METHODS

In this multicentre, cross sectional survey study, consecutive treated patients with ATBD between 2007 and 2017 in four referral centres in the Netherlands were retrospectively included and baseline data were collected. Between 2019 and 2021 the 36 Item Short Form Survey (SF-36) was sent to all surviving patients (n = 263) and was compared with validated SF-36 scores in the Dutch general population stratified by age and sex.

RESULTS

In total, 144 of 263 surviving patients completed the SF-36 (response rate 55%). Median (IQR) age was 68 (61, 76) years at completion of the questionnaire, and 40% (n = 58) were female. Initial treatment was medical in 55% (n = 79), endovascular in 41% (n = 59), and surgical in 4% (n = 6) of ATBD patients. Median follow up time was 6.1 (range 1.7-13.9; IQR 4.0, 9.0) years. Compared with the general population, patients scored significantly worse on six of eight SF-36 subdomains, particularly physical domains. Apart from bodily pain, there were no substantial differences in HRQoL between male and female ATBD patients. Compared with sex matched normative data, females scored significantly worse on five of eight subdomains, whereas males scored significantly lower on six subdomains. Younger patients aged 41-60 years seemed more severely impaired in HRQoL compared with the age matched general population. Treatment strategy did not influence HRQoL outcomes. Follow up time was associated with better Physical and Mental Component Summary scores.

CONCLUSION

Long term HRQoL was impaired in ATBD patients compared with the Dutch general population, especially regarding physical status. This warrants more attention for HRQoL during clinical follow up. Rehabilitation programmes including exercise and physical support might improve HRQoL and increase patients' health understanding.

Circulating biomarkers associated with aortic diameter in male and female patients with thoracic aortic disease: a cross-sectional study

OBJECTIVE

As thoracic aortic disease (TAD) is generally asymptomatic, biomarkers are needed to provide insight into early progression. We aimed to examine the association between circulating blood biomarkers and the maximal thoracic aortic diameter (TADmax).

METHODS

In this cross-sectional study, consecutive adult patients with a thoracic aortic diameter ≥40 mm and/or genetically proven hereditary TAD (HTAD) visiting our specialised outpatient clinic between 2017 and 2020 were prospectively included. Venous blood sampling and CT angiography and/or transthoracic echocardiography of the aorta were performed. Linear regression analyses were performed and estimates were presented as mean difference in TADmax in mm per doubling of standardised biomarker level.

RESULTS

In total, 158 patients were included (median age 61 (50.3-68.8) years, 37.3% female). HTAD diagnosis was confirmed in 36 of 158 (22.7%) patients. TADmax was 43.9±5.2 mm in men vs 41.9±5.1 in women (p=0.030). In unadjusted analysis, significant associations with TADmax were found for interleukin-6 (1.15 (95% CI 0.33 to 1.96), p=0.006), growth differentiation factor-15 (1.01 (95% CI 0.18 to 1.84), p=0.018), microfibrillar-associated protein 4 (MFAP4) (-0.88 (95% CI -1.71 to 0.05), p=0.039) and triiodothyronine (T3) (-2.00 (95%CI -3.01 to 0.99), p<0.001). The association of MFAP4 with TADmax was stronger in women (p for interaction=0.020) and for homocysteine, an inverse association with TADmax was observed when compared with men (p for interaction=0.008). When adjusted for age, sex, hyperlipidaemia and HTAD, total cholesterol (1.10 (95% CI 0.27 to 1.93), p=0.010) and T3 (-1.20 (95% CI -2.14 to 0.25), p=0.014) were significantly associated with TADmax.

CONCLUSIONS

Circulating biomarkers indicative of inflammation, lipid metabolism and thyroid function might be associated with TAD severity. Possible distinct biomarker patterns for men and women warrant further investigation.

Pregnancy outcomes in women with a mitral valve prosthesis: A systematic review and meta-analysis

Objectives

To evaluate the ongoing debate concerning the choice of valve prosthesis for women requiring mitral valve replacement (MVR) and who wish to conceive. Bioprostheses are associated with risk of early structural valve deterioration. Mechanical prostheses require lifelong anticoagulation and carry maternal and fetal risks. Also, the optimal anticoagulation regimen during pregnancy after MVR remains unclear.

Methods

A systematic review and meta-analysis was conducted of studies reporting on pregnancy after MVR. Valve- and anticoagulation-related maternal and fetal risks during pregnancy and 30 days' postpartum were analyzed.

Results

Fifteen studies reporting 722 pregnancies were included. In total, 87.2% of pregnant women had a mechanical prosthesis and 12.5% a bioprosthesis. Maternal mortality risk was 1.33% (95% confidence interval [CI], 0.69-2.56), any hemorrhage risk 6.90% (95% CI, 3.70-12.88). Valve thrombosis risk was 4.71% (95% CI, 3.06-7.26) in patients with mechanical prostheses. 3.23% (95% CI, 1.34-7.75) of the patients with bioprostheses experienced early structural valve deterioration. Of these, the mortality was 40%. Pregnancy loss risk was 29.29% (95% CI, 19.74-43.47) with mechanical prostheses versus 13.50% (95% CI, 4.31-42.30) for bioprostheses. Switching to heparin during the first trimester demonstrated a bleeding risk of 7.78% (95% CI, 3.71-16.31) versus 4.08% (95% CI, 1.17-14.28) for women on oral anticoagulants throughout pregnancy and a valve thrombosis risk of 6.99% (95% CI, 2.08-23.51) versus 2.89% (95% CI, 1.40-5.94). Administration of anticoagulant dosages greater than 5 mg resulted in a risk of fetal adverse events of 74.24% (95% CI, 56.11-98.23) versus 8.85% (95% CI, 2.70-28.99) in ≤5 mg.

Conclusions

A bioprosthesis seems the best option for women of childbearing age who are interested in future pregnancy after MVR. If mechanical valve replacement is preferred, the favorable anticoagulation regimen is continuous low-dose oral anticoagulants. Shared decision-making remains priority when choosing a prosthetic valve for young women.

The clinical impact of tricuspid regurgitation in patients with a biatrial orthotopic heart transplant

In this study, we aim to elucidate the clinical impact and long-term course of tricuspid regurgitation (TR), taking into account its dynamic nature, after biatrial orthotopic heart transplant (OHT). All consecutive adult patients undergoing biatrial OHT (1984-2017) with an available follow-up echocardiogram were included. Mixed-models were used to model the evolution of TR. The mixed-model was inserted into a Cox model in order to address the association of the dynamic TR with mortality. In total, 572 patients were included (median age: 50 years, males: 74.9%). Approximately 32% of patients had moderate-to-severe TR immediately after surgery. However, this declined to 11% on 5 years and 9% on 10 years after surgery, adjusted for survival bias. Pre-implant mechanical support was associated with less TR during follow-up, whereas concurrent LV dysfunction was significantly associated with more TR during follow-up. Survival at 1, 5, 10, 20 years was 97% ± 1%, 88% ± 1%, 66% ± 2% and 23% ± 2%, respectively. The presence of moderate-to-severe TR during follow-up was associated with higher mortality (HR: 1.07, 95% CI (1.02-1.12), p = 0.006). The course of TR was positively correlated with the course of creatinine (R = 0.45). TR during follow-up is significantly associated with higher mortality and worse renal function. Nevertheless, probability of TR is the highest immediately after OHT and decreases thereafter. Therefore, it may be reasonable to refrain from surgical intervention for TR during earlier phase after OHT.

Novel biomarkers associated with thoracic aortic disease

BACKGROUND

Biomarkers might help to improve diagnosis, surveillance and risk stratification of thoracic aortic disease (TAD). We explored the association between a broad spectrum of cardiovascular biomarkers with clinical characteristics and thoracic aortic diameter in TAD patients.

METHODS

Venous blood-samples were obtained in 158 clinically stable TAD patients visiting our outpatient clinic (2017-2020). TAD was defined as a thoracic aortic diameter ≥ 40 mm, or genetic confirmation (hereditary TAD). The cardiovascular panel III of the Olink multiplex platform was used for batch analysis of 92 proteins. A comparison was made between biomarker levels in patients with and without previous aortic dissection and/or surgery, and with and without hereditary TAD. Linear regression analyses were applied to identify (relative, normalized) biomarker concentrations associated with the absolute thoracic aortic diameter (AD_max), and thoracic aortic diameter indexed for body surface area (ID_max).

RESULTS

Median age of study patients was 61.0 (IQR 50.3-68.8) years, 37.3% females. Mean AD_max and ID_max were 43.3 ± 5.4 mm and 21.3 ± 3.3 mm/m². After multivariable adjustment, Matrix Metalloproteinase-3 (MMP-3) and Insulin-like growth factor binding protein 2 (IGFBP-2) showed a significant positive association with AD_max and ID_max, respectively. Patients with previous aortic surgery/dissection had higher N-terminal-pro hormone BNP (NTproBNP) (median 3.67 [IQR 3.01-3.99] vs 2.84 [2.32-3.26], p ≤0.001). Patients with hereditary TAD had higher Trem-like transcript protein 2 (TLT-2) (median 4.64 [IQR 4.45-4.84]) than those with non-heriditary TAD (4.40 [4.17-4.64]; p = 0.00042).

CONCLUSIONS

Among a broad range of biomarkers, MMP-3 and IGFBP-2 were associated with disease severity in TAD patients. The pathophysiological pathways uncovered by these biomarkers, and their potential clinical use warrants further research.

Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years

OBJECTIVE

There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure.

METHODS

A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting).

RESULTS

There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span).

CONCLUSIONS

Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection.

Optimal temperature management in aortic arch surgery: A systematic review and network meta-analysis

OBJECTIVES

New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis.

METHODS

The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI).

RESULTS

A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval [CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, p value = .0029 and OR, 1.74, 95% CI, 1.09-2.77, p value = .019).

CONCLUSIONS

In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.

Male-female differences in acute type B aortic dissection: the DisSEXion study

Background/Introduction

Acute type B aortic dissection (ATBAD) is a cardiovascular emergency with high risk of morbidity and mortality. Elucidating male-female differences in ATBAD might help optimize patient-specific care, while data is scarce on this topic.

Purpose

The aim of this study was to identify differences between male and female ATBAD patients in presentation, management and outcomes.

Methods

A retrospective cohort study was conducted including all consecutive patients who presented with ATBAD between 2007–2017 in four tertiary centers. Non-acute, traumatic, and iatrogenic dissections were excluded. We included patients presenting with an intramural hematoma or penetrating aortic ulcer in acute setting.

Results

The study population consisted of 384 patients, of which 41% (n=156) was female. In comparison to males, females presented at an older age (67 [IQR: 57–73] vs. 62 [IQR: 52–71], p=0.015) and fewer female patients had a history of abdominal aortic aneurysm (6% vs. 15%, p=0.009). Imaging diagnostics revealed a smaller proportion of patients with distally extended dissections in females. DeBakey type IIIb was diagnosed less frequently in females (73% vs. 85%, p=0.008) as was renal artery involvement (48% vs. 66%, p=0.009). Furthermore, classical type B dissection was less often observed in female patients compared to male patients (56% vs. 78%, p&lt;0.001). Absolute maximum thoracic aortic diameters were not significantly different in females and males (44.0 [38.0–50.0] mm vs. 42.0 [39.0–49.0], p=0.870). No male-female differences were found in treatment strategy (p=0.561, Figure 1). In-hospital/30-day mortality was 9.6% in female patients and 11.8% in male patients (p=0.603). Long-term mortality did not show a significant male-female difference (p=0.90) during a median follow-up duration of 6.1 [IQR: 4.1–9.1] years (Figure 2).

Conclusion

This study showed that female patients were older at presentation, while male patients more often had distally extended dissections. Although mortality was not significantly different, we encourage male-female specific risk factor studies on late mortality. In this way ATBAD male and female patients at high risk of mortality can be identified and patient-specific care can be implemented.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMw

Longitudinal changes of thoracic aortic diameters in the general population aged 55 years or older

OBJECTIVE

Longitudinal data on age-related changes in the diameters of the thoracic aorta are scarce. To better understand normal variation and to identify factors influencing this process, we aimed to report male-female-specific and age-specific aortic growth rate in the ageing general population and identify factors associated with growth rate.

METHODS

From the prospective population-based Rotterdam Study, 943 participants (52.0% females, median age at baseline 65 years (62-68)) underwent serial non-enhanced cardiac CT. We measured the diameters of the ascending (AA) and descending aorta (DA) at two time points and expressed absolute and relative differences. Linear mixed effects analysis was performed to identify determinants associated with change in aortic diameters.

RESULTS

Mean AA diameter at baseline was 37.3±3.6 mm in male population and 34.7±3.2 mm in female population, mean DA diameter was 29.6±2.3 in male population and 26.9±2.2 mm in female population. The median absolute change in diameters during follow-up (mean scan interval 14.1±0.3 years) was 1 mm (0-2) for both the AA and DA. Absolute change per decade in AA diameter was significantly larger in males than in females (0.72 mm/decade (0.00-1.43) vs 0.70 mm/decade (0.00-1.41), p=0.006), as well as absolute change in AD diameter (0.71 mm/decade (0.00-1.42) vs 0.69 mm/decade (0.00-1.36), p=0.008). There was no significant difference between male and female population in relative change of their aortic diameters during follow-up. Age, male sex, higher body mass index (BMI) and higher diastolic blood pressure (DBP) showed a statistically significant independent association with increase in AA and DA diameters over time.

CONCLUSIONS

Some degree of increase in thoracic aortic diameters is typical in both men and women of an aging population. Factors associated with this change in thoracic aortic diameters were sex, age, BMI and DBP.

OUP accepted manuscript

Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess outcome differences between unilateral antegrade cerebral perfusion (ACP), bilateral ACP, retrograde cerebral perfusion (RCP) and deep hypothermic circulatory arrest (DHCA). A systematic literature search was performed in Embase, Medline, Web of Science, Cochrane and Google Scholar for all papers published till February 2021 reporting on early clinical outcome after aortic arch surgery utilizing either unilateral, bilateral ACP, RCP or DHCA. The primary outcome was operative mortality. Other key secondary endpoints were occurrence of postoperative disabling stroke, paraplegia, renal and respiratory failure. Pooled outcome risks were estimated using random-effects models. A total of 222 studies were included with a total of 43 720 patients. Pooled postoperative mortality in unilateral ACP group was 6.6% [95% confidence interval (CI) 5.3–8.1%], 9.1% (95% CI 7.9–10.4%), 7.8% (95% CI 5.6–10.7%), 9.2% (95% CI 6.7–12.7%) in bilateral ACP, RCP and DHCA groups, respectively. The incidence of postoperative disabling stroke was 4.8% (95% CI 3.8–6.1%) in the unilateral ACP group, 7.3% (95% CI 6.2–8.5%) in bilateral ACP, 6.4% (95% CI 4.4–9.1%) in RCP and 6.3% (95% CI 4.4–9.1%) in DHCA subgroups. The present meta-analysis summarizes the clinical outcomes of different cerebral protection techniques that have been used in clinical practice over the last decades. These outcomes may be used in advanced microsimulation model. These findings need to be placed in the context of the underlying aortic disease, the extent of the aortic disease and other comorbidities.

Prospero registration number: CRD42021246372

METC: MEC-2019-0825

Clinical impact and 'natural' course of uncorrected tricuspid regurgitation after implantation of a left ventricular assist device: an analysis of the European Registry for Patients with Mechanical Circulatory Support (EUROMACS)

OBJECTIVES

Data on the impact and course of uncorrected tricuspid regurgitation (TR) during left ventricular assist device (LVAD) implantation are scarce and inconsistent. This study explores the clinical impact and natural course of uncorrected TR in patients after LVAD implantation.

METHODS

The European Registry for Patients with Mechanical Circulatory Support was used to identify adult patients with LVAD implants without concomitant tricuspid valve surgery. A mediation model was developed to assess the association of TR with 30-day mortality via other risk factors. Generalized mixed models were used to model the course of post-LVAD TR. Joint models were used to perform sensitivity analyses.

RESULTS

A total of 2496 procedures were included (median age: 56 years; men: 83%). TR was not directly associated with higher 30-day mortality, but mediation analyses suggested an indirect association via preoperative elevated right atrial pressure and creatinine (P = 0.035) and bilirubin (P = 0.027) levels. Post-LVAD TR was also associated with increased late mortality [hazard ratio 1.16 (1.06–1.3); P = 0.001]. On average, uncorrected TR diminished after LVAD implantation. The probability of having moderate-to-severe TR immediately after an implant in patients with none-to-mild TR pre-LVAD was 10%; in patients with moderate-to-severe TR pre-LVAD, it was 35% and continued to decrease in patients with moderate-to-severe TR pre-LVAD, regardless of pre-LVAD right ventricular failure or pulmonary hypertension.

CONCLUSIONS

Uncorrected TR pre-LVAD and post-LVAD is associated with increased early and late mortality. Nevertheless, on average, TR diminishes progressively without intervention after an LVAD implant. Therefore, these data suggest that patient selection for concomitant tricuspid valve surgery should not be based solely on TR grade.

Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure

Importance

There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed.

Objective

To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure.

Design, Setting, and Participants

A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018.

Main Outcomes and Measures

Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling.

Results

During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year).

Conclusions and Relevance

Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.

Propensity score-based analysis of long-term outcome of patients on HeartWare and HeartMate 3 left ventricular assist device support

Aims

Left ventricular assist device therapy has become the cornerstone in the treatment of end‐stage heart failure and is increasingly used as destination therapy next to bridge to transplant or recovery. HeartMate 3 (HM3) and HeartWare (HVAD) are centrifugal continuous flow devices implanted intrapericardially and most commonly used worldwide. No randomized controlled trials have been performed yet. Analysis based on large registries may be considered as the best alternative but has the disadvantage of different standard of care between centres and missing data. Bias is introduced, because the decision which device to use was not random, even more so because many centres use only one type of left ventricular assist device. Therefore, we performed a propensity score (PS)‐based analysis of long‐term clinical outcome of patients that received HM3 or HVAD in a single centre.

Methods and results

Between December 2010 and December 2019, 100 patients received HVAD and 81 patients HM3 as primary implantation at the University Medical Centre Utrecht. We performed PS matching with an extensive set of covariates, resulting in 112 matched patients with a median follow‐up of 28 months. After PS matching, survival was not significantly different (P = 0.21) but was better for HM3. The cumulative incidences for haemorrhagic stroke (P = 0.01) and pump thrombosis (P = 0.02) were significantly higher for HVAD patients. The cumulative incidences for major bleeding, ischaemic stroke, right heart failure, and driveline infection were not different between the groups. We found no interaction between the surgeon who performed the implantation and survival (P = 0.59, P = 0.78, and P = 0.89). Sensitivity analysis was performed, by PS matching without patients on preoperative temporary support resulting in 74 matched patients. This also resulted in a non‐significant difference in survival (P = 0.07). The PS‐adjusted Cox regression showed a worse but non‐significant (P = 0.10) survival for HVAD patients with hazard ratio 1.71 (95% confidence interval 0.91–3.24).

Conclusions

Survival was not significantly different between both groups after PS matching, but was better for HM3, with a significantly lower incidence of haemorrhagic stroke and pump thrombosis for HM3. These results need to be interpreted carefully, because matching may have introduced greater imbalance on unmeasured covariates. A multicentre approach of carefully selected centres is recommended to enlarge the number of matched patients.

Initial clinical experience with minimally invasive surgical aortic valve replacement

BACKGROUND

The ministernotomy approach is increasingly used in aortic valve surgery. However, the advantages are still a matter of discussion. The aim of this study was to compare the postoperative outcome in patients undergoing elective aortic valve operation, either through mini-sternotomy or conventional sternotomy.

METHODS

We included 317 patients who were treated for their aortic valve, 63 patients underwent a minimally invasive aortic valve replacement (mini-AVR) and 254 patients underwent a full-sternotomy AVR. Patients with endocarditis, those who underwent previous cardiac surgery and those who required a concomitant procedure were excluded from the analysis. The method of matching weights according to propensity score was used to adjust for differences between the two treatment groups, and outcomes were compared.

RESULTS

The mediastinal drainage was significantly lower at 6, 24 hours and total after mini-AVR procedure than after full-sternotomy AVR (median: 373 vs. 499 mL, P<0.001). However, the number of patients receiving packed red blood cells transfusion was similar. Overall, the hospital mortality was lower in the full-sternotomy group, 0% vs. 3.2%, P=0.039. No difference was found in the median hospital length of stay, perioperative myocardial infarction, postoperative incidence of new pacemaker implantation, stroke, prolonged mechanical ventilation and mediastinitis. No patients in the mini-AVR group experienced paravalvular leakage. Midterm survival resulted in no difference between the treatment groups at 4-year (90.5% vs. 95.2%), P=0.75.

CONCLUSIONS

Although the minimally invasive surgery for AVR may increasingly be applied, our initial experience calls for a careful approach of adapting this procedure.

Male-female differences in characteristics and early outcomes of patients undergoing tricuspid valve surgery: a national cohort study in the Netherlands

OBJECTIVES

This study aims to explore male-female differences in baseline and procedural characteristics, and outcomes of patients undergoing isolated or concomitant tricuspid valve (TV) surgery.

METHODS

All TV procedures registered between 2007 and 2016 in the database of the Netherlands Association for Cardio-Thoracic Surgery were analysed. Logistic regression analyses with interaction terms were used to determine whether sex was associated with hospital mortality.

RESULTS

Five thousand five hundred and eighty-two patients underwent TV surgery [isolated: N = 685 (49% male), TVrepair: N = 5286 (50% male) and TVreplacement: N = 250 (46% male)]. In the TVrepair group, females were significantly older, had less prior percutaneous/surgical coronary interventions, less extracardiac arteriopathies, a lower prevalence of renal impairment, less endocarditis, a lower prevalence of preoperative critical condition, less recent myocardial infarction, less concomitant coronary artery bypass grafting (CABG) and, in case of concomitant mitral valve surgery, less concomitant mitral valve repair compared to males. In the TVreplacement group, females more often had a history of prior valve surgery and less prior CABG. Hospital mortality for males and females was 7.0% (N = 183) and 6.1% (N = 163), P = 0.241 in the TVrepair group and 2.6% (N = 3) and 8.8% (N = 12), P = 0.074 in the TVreplacement group. Sex was not associated with hospital mortality (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.88-1.48; P = 0.322). Sex demonstrated a significant interaction with the parameter 'critical preoperative condition' (OR 0.44, 95% CI 0.22-0.90; P = 0.026).

CONCLUSIONS

Substantial differences in patient and procedural characteristics existed between male and female patients undergoing TV surgery, although sex was not a derterminant for hospital mortality. Nevertheless, sex interacted with a critical preoperative condition, indicating the usefulness of separate risk factor models for males and females requiring TV surgery.

[How does a new medicine reach the patient?]

The Medicines Evaluation Board (MEB) grants market authorisation for medicinal products in the Netherlands. The European Medicines Agency (EMA) coordinates the evaluation and safeguarding of medicinal products in the European Union. The core task of the MEB is to evaluate the quality of every medicinal product for which marketing authorisation is applied for by the manufacturer, and to assess the risk - efficacy balance of the product concerned. There are three different procedures that a manufacturer can follow: (a) the national procedure; (b) the decentralised procedure or mutual recognition procedure; (c) the centralised procedure. After marketing authorisation has been granted, the MEB ensures pharmacovigilance in cooperation with partners such as the Netherlands Pharmacovigilance Centre (Lareb). The MEB determines the text of the package leaflet, the packaging and the Summary of Product Characteristics (SmPC). The MEB checks the warnings that are sent out by manufacturers if important new information about a medicinal product becomes available.

A clinician's guide for developing a prediction model: a case study using real-world data of patients with castration-resistant prostate cancer

PURPOSE

With the increasing interest in treatment decision-making based on risk prediction models, it is essential for clinicians to understand the steps in developing and interpreting such models.

METHODS

A retrospective registry of 20 Dutch hospitals with data on patients treated for castration-resistant prostate cancer was used to guide clinicians through the steps of developing a prediction model. The model of choice was the Cox proportional hazard model.

RESULTS

Using the exemplary dataset several essential steps in prediction modelling are discussed including: coding of predictors, missing values, interaction, model specification and performance. An advanced method for appropriate selection of main effects, e.g. Least Absolute Shrinkage and Selection Operator (LASSO) regression, is described. Furthermore, the assumptions of Cox proportional hazard model are discussed, and how to handle violations of the proportional hazard assumption using time-varying coefficients.

CONCLUSION

This study provides a comprehensive detailed guide to bridge the gap between the statistician and clinician, based on a large dataset of real-world patients treated for castration-resistant prostate cancer.

Outcomes of different aortic arch replacement techniques

Background

Consensus on the best treatment for aortic arch pathology is unresolved due to an emerging variety of procedures. We aimed to compare the outcomes of two major techniques for open aortic arch replacement involving the supra‐aortic branches and to identify the risk factors for specific adverse events.

Methods

Between 1974 and 2017, 172 patients were treated with either the en bloc (island, n = 59; 34.3%) or branched graft technique (n = 113, 65.7%). Most of the patients were treated in an emergent/urgent setting (52.4%).

Results

Patients who underwent the en bloc procedure had significantly shorter cardiopulmonary bypass (median: 241 vs 271 minutes, P = .041) and aortic cross clamp times (median: 124 vs 168 minutes, P = .005) than patients who underwent the separate graft technique. Overall, the hospital mortality was lower in the en bloc group, 8.5% vs 19.5%, although the difference was not significant (P = .077). No difference was found in the survival between the separate graft and en bloc groups at 1 (77.0 vs 86.3%), 5 (67.7 vs 66.3%) and 10 years (42.4 vs 51.3%), (P = .63). The postoperative stroke rate was comparable between the en bloc and separate graft cohorts (14.3 vs 19.6%, P = .52). Diabetics and those who underwent an elephant trunk procedure were at a higher risk for reintervention.

Conclusions

The separate graft technique, which is more common today, showed no difference from the en bloc technique with regard to hospital mortality and morbidity. Furthermore, the late survival and reintervention rates were similar after both procedures.

Individualized dynamic prediction of survival with the presence of intermediate events

Often, in follow-up studies, patients experience intermediate events, such as reinterventions or adverse events, which directly affect the shapes of their longitudinal profiles. Our work is motivated by two studies in which such intermediate events have been recorded during follow-up. In both studies, we are interested in the change of the longitudinal evolutions after the occurrence of the intermediate event and in utilizing this information to improve the accuracy of dynamic prediction of their risk. To achieve so, we propose a flexible joint modeling framework for longitudinal and time-to-event data, which includes features of the intermediate event as time-varying covariates in both the longitudinal and survival submodels. We consider a set of joint models that postulate different effects of the intermediate event in the longitudinal profile and the risk of the clinical endpoint, with different formulations for the association structure while allowing its functional form to change after the occurrence of the intermediate event. Based on these models, we derive dynamic predictions of conditional survival probabilities which are adaptive to different scenarios with respect to the occurrence of the intermediate event. We evaluate the predictive accuracy of these predictions with a simulation study using the time-dependent area under the receiver operating characteristic curve and the expected prediction error adjusted to our setting. The results suggest that accounting for the changes in the longitudinal profiles and the instantaneous risk for the clinical endpoint is important, and improves the accuracy of the dynamic predictions.

Outcomes after surgery for functional tricuspid regurgitation: a systematic review and meta-analysis

Aims 

This study aims to provide a contemporary overview of outcomes after tricuspid valve (TV) surgery for functional tricuspid regurgitation (TR).

Methods and results 

The literature was systematically searched for papers published between January 2005 and December 2017 reporting on clinical/echocardiographic outcomes after TV surgery for functional TR. A random effects meta-analysis was conducted for outcome variables, and late outcomes are visualized by pooled Kaplan–Meier curves. Subgroup analyses were performed for studies with a within-study comparison of suture vs. ring repair and flexible vs. rigid ring repair. Eighty-seven publications were included, encompassing 13 184 patients (mean age: 62.1 ± 11.8 years, 55% females). A mitral valve procedure was performed in 92% of patients. Pooled mean follow-up was 4.0 ± 2.8 years. Pooled early mortality was 3.9% (95% CI: 3.2–4.6), and late mortality rate was 2.7%/year (95% CI: 2.0–3.5), of which approximately half was cardiac-related 1.2%/year (95% CI: 0.8–1.9). Pooled risk of early moderate-to-severe TR at discharge was 9.4% (95% CI: 7.0–12.1). Late moderate-to-severe TR rate after discharge was 1.9%/year (95% CI: 1.0–3.5). Late reintervention rate was 0.3%/year (95% CI: 0.2–0.4). Mortality and overall (early and late) TR rate were comparable between suture vs. ring annuloplasty (14 studies), whereas overall TR rate was higher after flexible ring vs. rigid ring annuloplasty (6 studies) (7.5%/year vs. 3.9%/year, P = 0.002).

Conclusion 

This study shows that patients undergoing surgery for functional tricuspid regurgitation (FTR) have an acceptable early and late mortality. However, TR remains prevalent after surgery. The results of this study can be used to inform patients and clinicians about the expected outcome after surgery for FTR and can results serve as a benchmark for the performance of emerging transcatheter TV interventions.

Effectiveness of adherence to a preoperative antiplatelet and anticoagulation cessation protocol in cardiac surgery

OBJECTIVES

Reduction of blood loss after cardiac surgery remains challenging. The effectiveness of adherence to a protocol on cessation of anticoagulants and platelet-inhibiting medications was investigated together with the influence of protocol violations on blood loss after surgery, use of blood products, surgical re-explorations and 30-day mortality.

METHODS

Between 2009 and 2013, data were collected prospectively for all elective cardiac surgery procedures in adult patients (n = 1637). Two groups were distinguished: Group 1 adhered to the protocol for cessation or continuation of medication (n = 1287, 79%) and Group 2 violated the protocol (n = 350, 21%).

RESULTS

Median blood loss was 300 ml (interquartile range 175-500 ml). Eighty patients underwent re-exploration due to blood loss (5%). Thirty-day mortality was 2% (n = 27). Protocol violation was associated with increased blood loss [median 275 ml (175-475 ml) vs 350 ml (250-612); P ≤ 0.001] and with increased average use of fresh frozen plasma (226 ml vs 139 ml; P  << 0.00001), red blood cell transfusion (115 ml vs 87 ml; P = 0.081) and thrombocyte transfusions (52 ml vs 37 ml; P = 0.0082). The number of re-explorations (4% vs 6%; P = 0.39) and mortality risk (1% vs 2%; P = 0.72) did not differ.

CONCLUSIONS

Balancing the benefit of continuing platelet inhibitors or anticoagulants versus cessation before surgery remains challenging. Adherence to the protocol will lead to lower blood loss and in a lower consumption of blood products although the decision to go for re-exploration and 30-day mortality does not differ compared with the protocol violation. Stopping medication does not lead to thromboembolic events.

Statistical primer: performing repeated-measures analysis

Longitudinal data arise when repeated measurements are taken on the same individuals over time. Inference about between-group differences of within-subject change is usually of interest. This statistical primer for cardiothoracic and vascular surgeons aims to provide a short and practical introduction of biostatistical methods on how to analyse repeated-measures data. Several methodological approaches for analysing repeated measures will be introduced, ranging from simple approaches to advanced regression modelling. Design considerations of studies involving repeated measures are discussed, and the methods are illustrated with a data set measuring coronary sinus potassium in dogs after occlusion. Cardiothoracic and vascular surgeons should be aware of the myriad approaches available to them for analysing repeated-measures data, including the relative merits and disadvantages of each. It is important to present effective graphical displays of the data and to avoid arbitrary cross-sectional statistical comparisons.

Reconstructive surgery for Ebstein anomaly: three decades of experience

OBJECTIVES

Since 1988, our centre employs vertical plication repair with deattachment and reattachment of the tricuspid valve for Ebstein anomaly. This study describes the characteristics and long-term outcomes of our single-centre cohort.

METHODS

Data from all patients operated on between 1988 and 2016 were retrospectively collected. Kaplan-Meier analyses were done for survival data and mixed models were used to analyse longitudinally collected clinical and echocardiography data.

RESULTS

Thirty-six patients (mean age: 25.4 ± 15.9 years, 36% male) were operated on using the Carpentier-Chauvaud 21 (58%) or Cone repair 15 (42%). One patient (3%) died in hospital. Two late deaths were observed, yielding a survival of 97 ± 3% at 25 years. Reoperation was performed in 6 patients after a mean follow-up of 14.1 ± 10.3 years, resulting in a freedom of reoperation of 80 ± 8% at 25 years. During follow-up, predicted probability of being in New York Heart Association III/IV did not exceed 10%. Modelling longitudinal evolution of tricuspid regurgitation showed no major changes over time. Additionally, a rigid ring repair was associated with a higher probability of tricuspid regurgitation, especially after the first years after the operation. A full Cone repair was associated with less progression of tricuspid regurgitation over time.

CONCLUSIONS

Repair of Ebstein abnomaly is associated with low mortality and morbidity, acceptable reoperation rate and excellent valve function over time, especially in patients with completed Cone repair. Therefore, we conclude that in our centre, repair of Ebstein abnomaly is a durable technique to treat patients.

Downsized cryopreserved and standard-sized allografts for right ventricular outflow tract reconstruction in children: long-term single-institutional experience

OBJECTIVES

The objective of this study was to determine long-term results with bicuspidalized allografts compared to non-bicuspidalized allografts in children under 2 years undergoing primary correction of the right ventricular outflow tract.

METHODS

Thirty-five consecutive bicuspidalized allografts were compared to 45 consecutive non-bicuspidalized allografts implanted during the same period. Valve-related events were analysed with Kaplan-Meier and Cox-regression techniques. Mixed-effects modelling was used to analyse serial echocardiographic measurements of pulmonary gradient. In addition, a systematic review with meta-analysis of the published literature concerning implantation of bicuspidalized allografts was performed.

RESULTS

Perioperative characteristics and in-hospital mortality [bicuspidalized 5 (14.3%), non-bicuspidalized 6 (13.3%)] were comparable (P = 0.902). Bicuspidalized allografts were smaller (14.7 vs 16.5 mm, P = 0.023) and always (100%) of pulmonary origin compared to 26 (57.8%) of the standard-sized allografts. There were no differences in late mortality between the bicuspidalized and non-bicuspidalized group (6.7% vs 7.7%, P = 0.798) or freedom from allograft replacement at 10 years (82 ± 10% and 71 ± 8%, for bicuspidalized and non-bicuspidalized allografts, respectively). Evolution of peak pulmonary gradient (P = 0.273) was comparable between bicuspidalized and non-bicuspidalized allografts. Meta-analysis showed a pooled early and late mortality for bicuspidalized allograft patients of 10.72% [95% confidence interval (CI) 6.13-18.75] and 1.6% per year (95% CI 0.99-2.79), respectively. Pooled estimated late reintervention and replacement rates were 5.94% per year (95% CI 3.42-10.30) and 3.78% per year (95% CI 2.69-5.32), respectively.

CONCLUSIONS

Bicuspidalization seems to be a viable alternative to combat limited supply of small-sized allografts with acceptable survival and reintervention rates comparable to non-bicuspidalized allografts.

Atrioesophageal Fistula after Minimally Invasive Video-Assisted Epicardial Ablation for Lone Atrial Fibrillation

Minimally invasive video-assisted epicardial beating heart ablation for lone atrial fibrillation claims to be safe and effective. We, however, report on three patients with an atrioesophageal fistula after this procedure. The exact pathogenesis of this complication is unknown. All patients presented around 6 weeks after surgery with either fever or neurological deficits. Diagnosis can be made by computed tomography scan. We advocate an aggressive surgical approach with closure of the atrial defect on cardiopulmonary bypass and closure and reinforcement of the esophagus with an intercostal muscle flap in a single-stage surgery. Some caution as to the low-risk character of this procedure seems to be realistic.

Male-female differences and survival in patients undergoing isolated mitral valve surgery: a nationwide cohort study in the Netherlands

OBJECTIVES

The objective of this study was to compare male-female differences with respect to baseline characteristics and short-term outcome in a contemporary nationwide cohort of patients who underwent isolated mitral valve (MV) surgery.

METHODS

All patients [N = 3411; 58% males (N = 1977)] who underwent isolated MV surgery (replacement: N = 1048, 31%; reconstruction: N = 2364, 69%) in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics and in-hospital outcome were compared between male and female patients.

RESULTS

Female patients were generally older (mean age, 64 vs 61 years, P < 0.001), presented more often with pulmonary hypertension (P = 0.03) and had higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) I (P < 0.001). Male patients presented more often with prior coronary artery bypass graft surgery (P < 0.001) and active endocarditis (P = 0.002). Female patients underwent MV replacement more often (P < 0.001) and, in case of replacement, received stented bioprostheses more often (P < 0.001). In-hospital mortality rates after MV replacement were 7% (n = 33) and 7% (n = 40) in male and female patients, respectively (OR 1.08, 95% CI 0.67-1.75; P = 0.75). In-hospital mortality rates after MV reconstruction were 1.4% (n = 21) and 1.3% (n = 11) in male and female patients, respectively (OR 0.88, 95% CI 0.42-1.84; P = 0.74).

CONCLUSIONS

There are substantial male-female differences in patient presentation and procedural aspects in isolated MV surgery in the Netherlands. Female patients are older, have more severe disease at the time of surgery and undergo valve repair less often. Future studies are needed to identify potentially modifiable patient factors to improve the outcome of female patients with MV disease.

Prosthetic valve endocarditis due to Propionibacterium acnes

OBJECTIVES

To study the characteristics of patients with Propionibacterium acnes prosthetic valve endocarditis (PVE) who required surgery.

METHODS

A single-centre retrospective cohort study was conducted during a 7-year period. Patients with definite infective P. acnes endocarditis, according to the modified Duke criteria, were included. An extended culture protocol was applied. Information on medical health status, surgery, antibiotic treatment and mortality was obtained.

RESULTS

Thirteen patients fulfilled the criteria for P. acnes endocarditis (0.53% of 2466 patients with valve replacement in a 7-year period). All patients were male and had a previous valve replacement. The health status of patients was poor at diagnosis of P. acnes PVE. Most patients (11 of 13, 85%) were admitted with signs of heart failure due to a significant paravalvular leak; 2 of 13 (15%) patients presented with septic emboli. Twelve patients needed redo surgery, whereas one could be treated with antibiotic therapy only. The time between the index surgery and presentation with P. acnes PVE varied between 5 and 135 months (median 26.5 months). Replacement and reconstruction of the dysfunctional valve and affected anatomical structures was mainly performed with a mechanical valve (n = 5, 42%) or a (bio-) Bentall prosthesis (n = 6, 50%). Antibiotic therapy consisted of penicillin with or without rifampicin for 6 weeks after surgery. The mortality in this series was low (n = 1, 8%) and no recurrent endocarditis was found during a median follow-up of 38 months.

CONCLUSIONS

Propionibacterium acnes PVE is a rare complication after valve surgery. Redo surgery is often required. Treatment of the dysfunctional prosthetic aortic valve most often consists of root replacement, in combination with antibiotic therapy.

Contemporary outcomes after surgical aortic valve replacement with bioprostheses and allografts: a systematic review and meta-analysis

Many observational studies have reported outcomes after surgical aortic valve replacement (AVR), but there are no recent systematic reviews and meta-analyses including all available bioprostheses and allografts. The objective of this study is to provide a comprehensive and up-to-date overview of the outcomes after AVR with bioprostheses and allografts reported in the last 15 years. We conducted a systematic literature review (PROSPERO register: CRD42015017041) of studies published between 2000–15. Inclusion criteria were observational studies or randomized controlled trials reporting on outcomes of AVR with bioprostheses (stented or stentless) or allografts, with or without coronary artery bypass grafting (CABG) or valve repair procedure, with study population size n ≥ 30 and mean follow-up length ≥5 years. Fifty-four bioprosthesis studies and 14 allograft studies were included, encompassing 55 712 and 3872 patients and 349 840 and 32 419 patient-years, respectively. We pooled early mortality risk and linearized occurrence rates of valve-related events, reintervention and late mortality in a random-effects model. Sensitivity, meta-regression and subgroup analyses were performed to investigate the influence of outliers on the pooled estimates and to explore sources of heterogeneity. Funnel plots were used to investigate publication bias. Pooled early mortality risks for bioprostheses and allografts were 4.99% (95% confidence interval [CI], 4.44–5.62) and 5.03% (95% CI, 3.61–7.01), respectively. The late mortality rate was 5.70%/patient-year (95% CI, 4.99–5.62) for bioprostheses and 1.68%/patient-year (95% CI, 1.23–2.28) for allografts. Pooled reintervention rates for bioprostheses and allografts were 0.75%/patient-year (95% CI, 0.61–0.91) and 1.87%/patient-year (95% CI, 1.52–2.31), respectively. There was substantial heterogeneity in most outcomes. Meta-regression analyses identified covariates that could explain the heterogeneity: implantation period, valve type, patient age, gender, pre-intervention New York Heart Association class III/IV, concomitant CABG, study design and follow-up length. There is possible publication bias in all outcomes. This comprehensive systematic review and meta-analysis provides an overview of the outcomes after AVR with bioprostheses and allografts reported during the last 15 years. The results of this study can support patients and doctors in the prosthetic valve choice and can be used in microsimulation models to predict patient outcomes and estimate the cost-effectiveness of AVR with bioprostheses or allografts compared with current and future heart valve prostheses.

Intermittent warm blood versus cold crystalloid cardioplegia for myocardial protection: a propensity score-matched analysis of 12-year single-center experience

Objectives:

This study analyzes the efficacy in myocardial protection of two types of cardioplegia solutions, namely, blood and crystalloid cardioplegia, both given intermittently in patients undergoing coronary artery bypass grafting (CABG).

Methods:

Adult patients undergoing primary isolated coronary artery bypass grafting between January 1998 and January 2011 with cardiopulmonary bypass, using either blood or crystalloid cardioplegia, were identified in our database. Propensity score matching was performed to create comparable patient groups. Multivariate logistic regression analysis was performed to identify independent risk factors for perioperative myocardial damage. The primary endpoint of the study was the maximum creatine kinase-MB (CK-MB) value within 5 days postoperatively with a cut-off point of 100 U/L. Early mortality and perioperative low cardiac output syndrome in both groups were compared.

Results:

The study included 7138 CABG patients: 3369 patients using crystalloid cardioplegia and 3769 using blood cardioplegia. After propensity score matching, 2585 patients per study group remained for the analysis. Wilcoxon signed-rank test revealed significantly higher CK-MB levels in patients operated with the use of blood cardioplegia. Multivariate regression analysis identified blood cardioplegia as an independent risk factor for elevated CK-MB levels. However, it was associated with lower aspartate aminotransferase (AST) levels. The type of cardioplegia had no influence on early mortality, postoperative low cardiac output syndrome or intensive care unit stay.

Conclusions:

Blood cardioplegia was identified as an independent risk factor for elevated levels of CK-MB after CABG, but was associated with lower AST levels. The authors conclude that the type of cardioplegia had no significant influence on clinical outcome.

Clinical outcome of the PAS-Port® proximal anastomosis system in off-pump coronary artery bypass grafting in 201 patients

AIM

The PAS-Port® Proximal Anastomosis System (Cardica, Inc, Redwood City, CA, USA) has been used worldwide since March 2003. The objective of the present study was to evaluate the clinical outcome of the PAS-Port® Proximal Anastomosis System.

METHODS

All the patients who underwent off-pump coronary artery bypass grafting in the Catharina Hospital Eindhoven between August 2006 and April 2010 were included in a non-randomized retrospective case-control study, if they had at least one proximal vein graft anastomosis. Study end-points consisted of overall survival, coronary reintervention and postoperative stroke.

RESULTS

The study included 312 patients (201 cases, 111 controls). After 36 months of follow-up there was no difference in survival between cases and controls (92.2% vs. 93.7%, P=0.52). No significant difference could be detected between cases and controls with respect to overall coronary reintervention-free survival (93% vs. 96.4%, P=0.20) and freedom from coronary reintervention due to proximal vein graft failure (98% vs. 100% P=0.14). The use of the PAS-Port system could not be identified as an independent risk factor of coronary reintervention (p=0.21). Postoperative stroke rates of cases and controls (2% vs. 0.9%, P=0.42) were comparable.

CONCLUSION

The clinical outcomes in patients treated with the PAS-Port® Proximal Anastomosis System were satisfactory compared with those treated with the conventional hand-sewing technique. The use of the PAS-Port system was not associated with higher adverse outcome in terms of overall survival, stroke, coronary reintervention-free survival and freedom from reintervention due to proximal vein graft failure.