Repeat heart valve surgery: risk factors for operative mortality.

BACKGROUND: Patients undergoing repeat heart valve operations are a diverse population. We assessed risk factors for operative mortality in patients undergoing a first heart valve reoperation. METHODS: A retrospective review of hospital records was performed for 671 patients who underwent first repeat heart valve operations between 1969 and 1998. Univariable and multivariable analyses were performed. RESULTS: Operative mortality was 8.6%. Mortality fell each decade to 4.8% in the most recent period (adjusted chi(2) for linear trend P <.0005). Mortality increased from 3.0% for reoperation for a failed repair or reoperation at a new valve site to 10.6% for prosthetic valve dysfunction or periprosthetic leak and to 29.4% for endocarditis or valve thrombosis. Concomitant coronary artery bypass grafting was associated with a mortality of 15.4% compared with 8.2% when it was not required. Mortality for aortic valve replacement was 6.4%, mitral valve replacement 7.4%, aortic and mitral valve replacement 11.5%, tricuspid valve replacement 25.6%, periprosthetic leak repair 9.1%, and isolated valve repair 2.2%. Among 336 patients requiring replacement of prosthetic valves, mortality was 26.1% for replacement of a mechanical valve compared with 8.6% for replacement of a tissue valve (P <.0005). Multivariable analyses identified year of reoperation, age, coronary artery bypass grafting, indication, and replacement of a mechanical valve rather than a tissue valve as significant explanatory variables for operative mortality. CONCLUSIONS: Heart valve reoperations can be performed with an acceptable operative mortality. However, we have identified several categories of patients in whom reoperation carries an increased risk.     

Aortic valve replacement in geriatric patients: determinants of in-hospital mortality

BACKGROUND: Aortic valve replacement is a common procedure in elderly patients. There has been a great deal of controversy about the risks associated with early mortality. Uncertainty of the risk associated with a small valve continues to remain controversial. This study was designed to identify the risk factors influencing early mortality and establish an accurate model for the prediction of in-hospital mortality. METHODS: One hundred eighty septuagenarians and octogenarians (58% women; mean age, 76 +/- 4.7 years) underwent primary isolated aortic valve replacement between 1986 and 1997. There was an overall mortality of 16.7% (n = 180). Patients with a body surface area less than 1.8 m2 had an in-hospital mortality of 23.2% (n = 95) compared with 8.1% (n = 74; p = 0.009) for patients with a body surface area of 1.8 m2 or more. Patients with a cardiopulmonary bypass time of less than 100 minutes experienced an early mortality of 8.9% (n = 56) compared with a 10.2% (n = 59) early mortality for patients on bypass time between 100 and 124 minutes and a 29.6% (n = 64) early mortality in patients with a pump time longer than 124 minutes (p = 0.040). RESULTS: Multivariate logistic regression analysis identified small body surface area and long cardiopulmonary bypass time as independent risk factors. A higher mortality was seen in female patients and patients receiving smaller valves. However, there was a strong correlation between small body surface area, small valve size, and female gender. CONCLUSIONS: Small body surface area and long cardiopulmonary bypass time are two independent risk factors in early mortality for elderly patients undergoing primary isolated aortic valve replacement. The use of small valves does not influence early mortality.     

Validation of two risk models for perioperative mortality in patients undergoing elective abdominal aortic aneurysm surgery

The authors validated 2 clinical risk models for perioperative mortality in patients scheduled for elective open abdominal aortic aneurysm surgery (AAA surgery). They studied 361 patients who underwent elective AAA surgery between 1991 and 1999 (validation population). Two clinical risk models were validated. The first was developed in 238 patients from Leiden University Hospital (Leiden risk model). The Leiden risk model was modified to provide predictions for the validation population based on 6 predictors including age, gender, a history of previous myocardial infarction, congestive heart failure, renal disease, and pulmonary disease. The second was a recently published simpler risk model developed in 820 patients in the UK Small Aneurysm Trial (UK risk model) and included 3 predictors (age and renal and pulmonary comorbidity). Logistic regression was used to quantify the relationship between predictors and outcome (mortality within 30 days of surgery). Validation further included the concordance statistic (c-statistic) for discriminative ability and the Hosmer-Lemeshow test for model reliability. The perioperative mortality in the validation population was 6.6% (24/361). Predictors had similar odds ratios, with particularly strong effects of congestive heart failure, pulmonary disease, and renal impairment. The Leiden risk model had reasonable good ability (c-statistic 0.72) and showed adequate calibration (chi(2)=3.3, p=0.97). It could particularly identify a low-risk group. The UK risk model did not perform well (c-statistic 0.60), showing statistically significant lack of fit (chi(2)=64.9, p<0.001). This study showed similar predictive ability of previously identified predictors for perioperative mortality. The Leiden risk model could identify a low-risk group, while the UK risk model showed a relatively poor performance. The current study supports the use of the Leiden model for preoperative risk assessment.     

Dialysis is an independent risk factor for perioperative adverse events,readmission, reoperation,and mortality for patients undergoing elective spine surgery

Background Context

The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data.

A systematic review of risk prediction models for perioperative mortality after thoracic surgery

OBJECTIVESGuidelines advocate that patients being considered for thoracic surgery should undergo a comprehensive preoperative risk assessment. Multiple risk prediction models to estimate the risk of mortality after thoracic surgery have been developed, but their quality and performance has not been reviewed in a systematic way. The objective was to systematically review these models and critically appraise their performance.Open in a separate windowMETHODSThe Cochrane Library and the MEDLINE database were searched for articles published between 1990 and 2019. Studies that developed or validated a model predicting perioperative mortality after thoracic surgery were included. Data were extracted based on the checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies.RESULTSA total of 31 studies describing 22 different risk prediction models were identified. There were 20 models developed specifically for thoracic surgery with two developed in other surgical specialties. A total of 57 different predictors were included across the identified models. Age, sex and pneumonectomy were the most frequently included predictors in 19, 13 and 11 models, respectively. Model performance based on either discrimination or calibration was inadequate for all externally validated models. The most recent data included in validation studies were from 2018. Risk of bias (assessed using Prediction model Risk Of Bias ASsessment Tool) was high for all except two models.CONCLUSIONSDespite multiple risk prediction models being developed to predict perioperative mortality after thoracic surgery, none could be described as appropriate for contemporary thoracic surgery. Contemporary validation of available models or new model development is required to ensure that appropriate estimates of operative risk are available for contemporary thoracic surgical practice.     

Current determinants of operative mortality in 1400 patients requiring aortic valve replacement

BACKGROUND: Determinants of operative mortality after aortic valve replacement vary with a changing patient population due to advances in operative management and increasing life expectancy. In order to predict current groups of high risk patients, a statistically valid large study population base recruited over a short period of time is required. METHODS: Between January 1996 and June 2001, 1408 aortic valves were replaced in 1400 patients (572 of them with simultaneous coronary artery bypass grafting). The data were analyzed by multivariate logistic regression to evaluate the operative risk. Mean age of the study population was 68 +/- 11 years (range 19 to 90 years old, 44% female). RESULTS: Overall operative mortality (within 30 days) was 3.8%. Independent predictive factors for operative mortality were previous bypass surgery, emergency operation, simultaneous mitral valve replacement, renal dysfunction, more than 80 years old, simultaneous bypass surgery in female patients with a body mass index greater than 29 kg/m(2), and height smaller than 1.57 m for patients more than 71 years old. Simultaneous coronary artery bypass grafting in general (p = 0.6), previous aortic valve replacement (p = 0.59), and implantation of stented bioprostheses (p = 0.39) or stentless bioprostheses (p = 0.7) were not identified as independent risk factors. CONCLUSIONS: Certain groups of patients with a high operative risk were identified: patients more than 80 years old, women with a body mass index greater 29 kg/m(2) undergoing simultaneous coronary artery bypass surgery, and "small" patients more than 71 years old.     

Analysis of risk factors for perioperative mortality in elderly patients with intertrochanteric fracture

European Journal of Orthopaedic Surgery & Traumatology - To investigate risk factors for perioperative death in elderly patients with intertrochanteric fracture. Clinical data from 1051 cases...     

Results of triple valve replacement: perioperative mortality and long term results

Between 1970 and 1984, 37 patients underwent simultaneous triple valve replacement by the same surgeon, all for rheumatic valve disease. Bj?rk-prosthesis were used for aortic, Starr, Bj?rk or St. Jude for mitral and bioprosthesis for tricuspid replacements. The median follow-up was 68 months (range, 2 months to 9.6 years). Two patients died in the first postoperative month (5.4%). Most late deaths were of cardiac origin. 85% of all deaths were in Functional Class IV. Five and ten year actuarial survival rate was 75% and 58% for the entire group. Twenty three long-term survivors were followed; all were improved for at least one Functional Class (p = 0.001). Moderate but significant (p = 0.05) cardiothoracic ratio regression was observed. Seven patients had postoperative non lethal complications. In summary, when necessary, triple valve replacement carried an excellent symptomatic improvement. Surgical intervention before patients reach Functional Class IV is preferable. The use of bioprosthesis in tricuspid position is suggested.     

Cardiac risk in patients undergoing carotid endarterectomy: impact on perioperative and long-term mortality

To identify patients undergoing carotid endarterectomy who are at high risk for cardiac events and death, we studied the course of 614 patients with known risk factors who were entered into our carotid follow-up registry. Patients were divided into two groups, group I with overt coronary disease (prior myocardial infarction, angina, significant electrocardiographic abnormalities) (N = 324) and group II without overt coronary disease (N = 290). Group II patients were subdivided into groups with (IIA) (N = 206) and without (IIB) (N = 84) coronary risk factors (cigarettes, diabetes, or hyperlipidemias). Thirty-day, 5-, 10-, and 15-year life-table survival for the groups was: I = 98.5%, 68.6%, 44.9%, 36.4%, respectively; II = 100%, 86.4%, 72.3%, 54.3%, respectively; IIA = 100%, 84.8%, 66.9%, 41.5%, respectively; IIB = 100%, 90.5%, 87.9%, 87.9%, respectively. Overt coronary disease was associated with diminished 30-day (p = 0.03) and late (p less than 0.0001) survival. Risk factors in the absence of overt disease were not associated with diminished 30-day survival. Late survival up to 3 years from endarterectomy was similar in groups IIA and IIB, but later survival was diminished in group IIA. Myocardial infarction was the most frequent cause of death in all groups. Patients with overt coronary disease are at high risk for late cardiac events and death. Patients without overt disease are at less risk than those with overt disease, and in the absence of overt disease, those without are at less risk than those with risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)     

Limitations of additive EuroSCORE for measuring risk stratified mortality in combined coronary and valve surgery.

OBJECTIVE: To study the use of the additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality following adult combined coronary artery bypass grafting (CABG) and valve surgery. METHODS: Data were collected prospectively, from all four centres providing adult cardiac surgery in the north west of England, on 1769 consecutive patients undergoing combined CABG and valve surgery between April 1997 and March 2002. Observed in-hospital mortality was compared to predicted mortality as determined by both additive and logistic EuroSCORE. RESULTS: Observed mortality for simultaneous CABG and valve surgery was 8.7%, compared to 6.7% (additive) and 9.4% (logistic). Sixty-five percent of patients were classified as high-risk (additive EuroSCORE >5); the observed mortality was 11.5%, compared to 8.1% (additive) and 12.8% (logistic). Discrimination was similar in both systems as measured by the C statistic (additive 0.73, logistic 0.73). CONCLUSIONS: The logistic EuroSCORE is more accurate at predicting mortality in simultaneous CABG and valve surgery, as the additive EuroSCORE significantly under-predicts in this high-risk group.     

Comparison of short-term mortality risk factors for valve replacement versus coronary artery bypass graft surgery

BACKGROUND: Risk factors for 30-day operative (short-term) mortality following coronary artery bypass graft (CABG only) procedures are well established. However, little is known about how the risk factors for short-term mortality following valve replacement procedures (with or without a CABG procedure performed) compare with CABG only risk factors. METHODS: Department of Veterans Affairs (VA) records (65,585 records) were collected from October 1991 through March 2001 and analyzed. Risk factors for short-term mortality were compared across three subgroups of patients: CABG only surgery (n = 56,318), aortic valve replacement (AVR) with or without CABG (n = 7450), and mitral valve replacement (MVR) with or without CABG (n = 1817). Multivariable logistic regression analyses were used to compare the relative magnitude of risk for 19 candidate predictor variables across subgroups. RESULTS: Only three patient baseline characteristics differed significantly in magnitude of risk between the procedure groups. Partially or totally dependent functional status significantly increased the risk of short-term mortality for AVR patients (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.29-2.09) and MVR patients (OR 2.21, 95% CI 1.48-3.30), but not for CABG only patients (OR 1.04, 95% CI 0.93-1.16). Conversely, previous heart surgery and New York Heart Association functional class III or IV symptoms conferred greater magnitude of risk for CABG only patients compared with the valve subgroups. CONCLUSIONS: Overall, the risk factors for short-term mortality following valve replacement and CABG surgery appear to be relatively consistent. However, clinicians should be aware of the importance of preoperative functional status as a unique predictor of mortality following valve surgery.     

Peripheral vascular surgery: update on the perioperative non-surgical management for high cardiac risk patients

This review of the recent literature regarding perioperative management in peripheral vascular surgery emphasizes some of the important features for the 2003 state-of-the-art on non surgical perioperative care for these high cardiac risk patients. The most adapted preoperative cardiac evaluation for each patient is guided by its individual risk factors and clinical history. Perioperative medication should nowadays consist of pre- and postoperative beta-blockers and acetyl salicylic acid, both reducing cardiac morbidity and mortality. Neuraxial locoregional anaesthesia techniques are reasonable alternatives to general anaesthesia because of their potential advantages, by reducing postoperative inflammatory response and reducing procoagulating activity, and increasing peripheral vascular graft patency, but the individual benefit/risk balance has always to be evaluated for patients submitted to aggressive antithrombotic therapy. During the postoperative course, early detection and treatment of postoperative myocardial ischemia or infarction by ST wave changes and/or cardiac enzyme control has to be considered.