Mid-term outcomes of coronary artery bypass grafting in patients with mild left ventricular systolic dysfunction: a multicentre retrospective cohort study

 Open in a separate windowOBJECTIVESLeft ventricular systolic dysfunction (LVSD) is common and associated with adverse events in patients receiving coronary artery bypass grafting (CABG). However, the prognosis of mild LVSD has not been clearly described. We aimed to evaluate the mid-term outcomes of patients with mild LVSD following CABG.METHODSThis multicentre cohort study using propensity score matching took place from December 2012 to October 2019 in Jiangsu Province, China, with a mean and maximum follow-up of 3.2 and 7.2 years, respectively. Patients were classified to normal left ventricular systolic function (left ventricular ejection fraction ≥53%) and mild LVSD (left ventricular ejection fraction >40%/<53%). The primary outcomes were death from all causes and death from cardiovascular causes. The secondary outcomes were heart failure, myocardial infarction, repeat revascularization and a composite of all mentioned outcomes, including death from all causes (major adverse events).RESULTSA total of 581 pairs were formed after matching. In-hospital death (1.5% vs 2.1%, P = 0.51) did not differ between 2 cohorts. Throughout 7 years, mild LVSD was associated with higher rates of death from all causes [hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.39–0.89; P = 0.012], death from cardiovascular causes (HR 0.55, 95% CI 0.36–0.90; P = 0.017), heart failure (HR 0.60, 95% CI 0.37–0.93; P = 0.023) and major adverse events (HR 0.66, 95% CI 0.49–0.91; P = 0.009). There was no difference in the rates of myocardial infarction and repeat revascularization.CONCLUSIONSMild LVSD was associated with a worse mid-term prognosis in patients following CABG.     

Tracheobronchial stents in patients with malignant airway disease: Finnish tertiary care experience

Open in a separate window OBJECTIVESTracheobronchial stenting has an established role in the palliation of malignant central airway obstruction (CAO). The purpose of this study is to describe the experience with self-expanding metal airway stents in 2 tertiary referral centres, covering a third of the population of Finland.METHODSPatients referred to and treated with airway stenting for malignant CAO using self-expanding metal-stents were identified from electronic patient records, and data were collected using a structured Endoscopic Lower Airway Management instrument. Statistical analysis to reveal factors affecting patient benefit and survival was carried out.RESULTSA total of 101 patients (mean age 65.8) and 116 procedures were identified. Procedure-related mortality was rare (3/101 patients) and complications infrequent. The median survival was 2.3 months [95% confidence interval (CI): 1.4–3.1). Stent benefit was not significantly affected by clinical characteristics. Survival was impacted by the use of adjunct procedures [hazard ratio (HR) 0.36, 95% CI: 0.23–0.58, P < 0.001), procedural urgency (HR 0.40; 95% CI: 0.23–0.71, P = 0.002) and post-treatment chemoradiotherapy (HR 0.29, 95% CI: 0.15–0.56, P < 0.001).CONCLUSIONSThe beneficial impact observed supports the further use of tracheobronchial stenting in malignant CAO. The use of self-expanding metal stents is encouraged.     

Sex differences in outcomes following coronary artery bypass grafting: a meta-analysis

 Open in a separate windowOBJECTIVESPrevious reports have found females are a higher risk of morbidity and mortality following isolated coronary artery bypass grafting (CABG). Here, we describe the differences in outcomes following isolated CABG between males and females.METHODSFollowing a systematic literature search, studies reporting sex-related outcomes following isolated CABG were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was operative mortality. Secondary outcomes included rates of stroke, repeat revascularization, myocardial infarction, major adverse cardiac events, and late mortality. Subgroup analyses were performed for studies published before and after the year 2000 and for the type of risk adjustment.RESULTSEighty-four studies were included with a total of 903 346 patients. Females were at higher risk for operative mortality (odds ratio: 1.77, 95% confidence interval [CI]: 1.64–1.92, P < 0.001). At subgroup analysis, there was no difference in operative or late mortality between studies published prior and after 2000 or between studies using risk adjustment. Females were at a higher risk of late mortality (incidence rate ratio [IRR]: 1.16, 95% CI: 1.06–1.26, P < 0.001), major adverse cardiac events (IRR: 1.40, 95% CI: 1.19–1.66, P < 0.001), myocardial infarction (IRR: 1.28, 95% CI: 1.13–1.45, P < 0.001) and stroke (IRR: 1.31, 95% CI: 1.15–1.51, P > 0.001) but not repeat revascularization (IRR: 0.99, 95% CI: 0.76–1.29, P = 0.95). The use of the off-pump technique or multiple arterial grafts was not associated with the primary outcome.CONCLUSIONSFemales undergoing CABG are at higher risk for operative and late mortality as well as postoperative events including major adverse cardiac events, myocardial infarction and stroke. PROSPERO registrationCRD42020187556     

Risk-adjusted analysis of long-term outcomes after on- versus off-pump coronary artery bypass grafting

 Open in a separate windowOBJECTIVESRecent data suggested that off-pump coronary artery bypass (OPCAB) may carry a higher risk for mortality in the long term when compared to on-pump coronary artery bypass (ONCAB). We, therefore, compared long-term survival and morbidity in patients undergoing ONCAB versus OPCAB in a large single-centre cohort.METHODSA total of 8981 patients undergoing isolated elective/urgent coronary artery bypass grafting between January 2009 and December 2019 were analysed. Patients were stratified into 2 groups (OPCAB n = 6649/ONCAB n = 2332). The primary end point was all-cause mortality. Secondary endpoints included repeat revascularization, stroke and myocardial infarction. To adjust for potential selection bias, 1:1 nearest neighbour propensity score (PS) matching was performed resulting in 1857 matched pairs. Moreover, sensitivity analysis was applied in the entire study cohort using multivariable- and PS-adjusted Cox regression analysis.RESULTSIn the PS-matched cohort, 10-year mortality was similar between study groups [OPCAB 36.4% vs ONCAB 35.8%: hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.87–1.12; P = 0.84]. While 10-year outcomes of secondary endpoints did not differ significantly, risk of stroke (OPCAB 1.50% vs ONCAB 2.8%: HR 0.51, 95% CI 0.32–0.83; P = 0.006) and mortality (OPCAB 3.1% vs ONCAB 4.8%: HR 0.65, 95% CI 0.47–0.91; P = 0.011) at 1 year was lower in the OPCAB group. In the multivariable- and the PS-adjusted model, mortality at 10 years was not significantly different (OPCAB 34.1% vs ONCAB 35.7%: HR 0.97, 95% CI 0.87–1.08; P = 0.59 and HR 1.01, 95% CI 0.90–1.13; P = 0.91, respectively).CONCLUSIONSData do not provide evidence that elective/urgent OPCAB is associated with significantly higher risks of mortality, repeat revascularization, or myocardial infarction during late follow-up when compared to ONCAB. Patients undergoing OPCAB may benefit from reduced risks of stroke and mortality within the first year postoperatively.     

Risk factors for acute exacerbation of interstitial lung disease following lung cancer resection: a systematic review and meta-analysis

Open in a separate window OBJECTIVESThe aim of this study was to investigate the risk factors for acute exacerbation (AE) of interstitial lung disease (ILD) following lung cancer resection. METHODSWe performed a literature screening on the databases including PubMed, Embase, Ovid MEDLINE^® and the Web of Science for related studies published up to January 2021. Eligible studies were included and data on risk factors related to postoperative AE were extracted. All analyses were performed with random-effect model.RESULTSA total of 12 studies of 2655 lung cancer patients with ILD were included in this article. The meta-analysis indicated that male [odds ratios (ORs) = 1.78, 95% confidence interval (CI): 1.02–3.11, P = 0.041], usually interstitial pneumonia pattern on CT (OR = 1.52, 95% CI: 1.06–2.17, P = 0.021), Krebs von den Lungen-6 [standardized mean difference (SMD) = 0.50, 95% CI: 0.06–0.94, P = 0.027], white blood cell (SMD = 0.53, 95% CI: 0.12–0.93, P = 0.010), lactate dehydrogenase (SMD = 0.47, 95% CI: 0.04–0.90, P = 0.032), partial pressure of oxygen (weighted mean difference = −3.09, 95% CI: −5.99 to −0.19, P = 0.037), surgery procedure (OR = 2.31, 95% CI: 1.42–3.77, P < 0.001) and operation time (weighted mean difference = 28.26, 95% CI: 1.13–55.39, P = 0.041) were risk factors for AE of ILD following lung cancer resection.CONCLUSIONSWe found that males, usually interstitial pneumonia pattern on CT, higher levels of Krebs von den Lungen-6, lactate dehydrogenase, white blood cell, lower partial pressure of oxygen, greater scope of operation and longer operation time were risk factors for AE of ILD following lung cancer resection. Patients with these risk factors should be more prudently selected for surgical treatment and be monitored more carefully after surgery.     

Myasthenia gravis affects overall survival in patients with thymoma: an analysis of multicentre database using propensity score matching

Open in a separate window OBJECTIVESAbout one-third of patients with thymoma have myasthenia gravis (MG). It remains controversial whether MG affects the prognosis of patients with thymoma. The aim of this study was to evaluate the effect of MG on the prognosis of patients with thymoma in a multicentre database.METHODSPatients with thymoma who underwent thymectomy were identified from 2 prospectively collected databases in 2 medical centres from 2010 to 2018. Kaplan–Meier curves and the log-rank test were used to assess overall survival and recurrence-free survival, and a Cox proportional hazards model was used to determine significant contributors to survival. Propensity score matching was performed to eliminate selection bias.RESULTSA total of 514 patients with thymoma were included in this study, of whom 320 patients were MG-free and 194 had MG. Patients with MG were younger (median age 50 vs 54 years, P = 0.001) and had smaller tumours (4.4 ± 2.0 vs 4.9 ± 2.3 cm, P = 0.020). Pathological analysis showed that type B tumours especially B2−B3 (B2 + B3 + mix B tumours, 55.2%) are more common in patients with MG, while type AB (37.2%) was the most common in patients without MG. A larger proportion of Masaoka III–IV stage tumour (25.7% vs 11.0%, P < 0.001) was seen in patients with thymoma and MG. Multivariable Cox regression analysis demonstrated that MG (hazard ratio [HR] = 3.729, 95% confidence interval [CI]: 1.398–9.947, P = 0.009), incomplete resection (HR = 5.441, 95% CI: 1.500–19.731, P = 0.010) and Masaoka stage III + IV (HR = 3.390, 95% CI: 1.196–9.612, P = 0.022) were negative prognostic factors of overall survival. Meanwhile, MG (HR =3.489, 95% CI: 1.403–8.680, P = 0.007) and Masaoka stage III + IV (HR = 6.582, 95% CI: 2.575–16.828, P < 0.001) were negative prognostic factors of recurrence-free survival. Propensity-matched analysis compared 148 patient pairs. K-M survival analysis demonstrated that MG was associated with worse overall survival and recurrence-free survival in propensity score-matched patients (log-rank, P = 0.034 and 0.017, respectively).CONCLUSIONSThymoma patients with MG have smaller tumours and a higher percentage of late-stage tumours, which are mainly of WHO B types, especially B2−B3 types. In addition, MG is significantly associated with worse overall survival and recurrence-free survival in thymoma.     

Epidermal growth factor receptor (EGFR)—tyrosine kinase inhibitors as a first-line treatment for postoperative recurrent and EGFR-mutated non-small-cell lung cancer

 Open in a separate windowOBJECTIVESTo clarify survival outcomes and prognostic factors of patients receiving epidermal growth factor receptor (EGFR) - tyrosine kinase inhibitors (TKIs) as first-line treatment for postoperative recurrence.METHODSA retrospective chart review was performed to identify consecutive patients who received EGFR-TKIs as first-line treatment for postoperative recurrence of non-small-cell lung cancer (NSCLC) harbouring EGFR gene mutations at our institution between August 2002 and October 2020. Therapeutic response, adverse events, progression-free survival (PFS) and overall survival (OS) were investigated. Survival outcomes were assessed using the Kaplan–Meier analysis. The Cox proportional hazards model was used for univariable and multivariable analyses.RESULTSSixty-four patients were included in the study. The objective response and disease control rates were 53% and 92%, respectively. Grade 3 or greater adverse events were noted in 4 (6.3%) patients, including 1 patient (1.6%) of interstitial pneumonia. The median follow-up period was 28.5 months (range 3–202 months). The total number of events was 43 for PFS and 23 for OS, respectively. The median PFS was 18 months, and the median OS was 61 months after EGFR-TKI treatment. In multivariable analysis, osimertinib showed a tendency to prolong PFS [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.12–1.1; P = 0.071], whereas the micropapillary component was significantly associated with shorter OS (HR 2.1, 95% CI 1.02–6.9; P = 0.045).CONCLUSIONSEGFR-TKIs as first-line treatment appeared to be a reasonable treatment option in selected patients with postoperative recurrent EGFR-mutated NSCLC. Osimertinib and the micropapillary component may be prognostic factors.     

Factors influencing length of intensive care unit stay following a bidirectional cavopulmonary shunt

 Open in a separate windowOBJECTIVESThe goal of this study was to identify the risk factors for prolonged length of stay (LOS) in the intensive care unit (ICU) after a bidirectional cavopulmonary shunt (BCPS) procedure and its impact on the number of deaths.METHODSIn total, 556 patients who underwent BCPS between January 1998 and December 2019 were included in the study.RESULTSEighteen patients died while in the ICU, and 35 died after discharge from the ICU. Reduced ventricular function was significantly associated with death during the ICU stay (P = 0.002). In patients who were discharged alive from the ICU, LOS in the ICU [hazard ratio (HR) 1.04, 95% confidence interval (CI) 1.02–1.06; P < 0.001] and a dominant right ventricle (HR 2.41, 95% CI 1.03–6.63; P = 0.04) were independent risk factors for death. Receiver operating characteristic analysis identified a cut-off value for length of ICU stay of 19 days. Mean pulmonary artery pressure (HR 1.03, 95% CI 1.01–1.05; P = 0.04) was a significant risk factor for a prolonged ICU stay.CONCLUSIONSProlonged LOS in the ICU with a cut-off value of 19 days after BCPS was a significant risk factor for mortality. High pulmonary artery pressure at BCPS was a significant risk factor for a prolonged ICU stay.     

Do in-hospital outcomes of isolated coronary artery bypass grafting vary between male and female octogenarians?

Open in a separate window OBJECTIVESFemale gender and advanced age are regarded as independent risk factors for adverse outcomes after isolated coronary artery bypass grafting (CABG). There is paucity of evidence comparing outcomes of CABG between male and female octogenarians. We aimed to analyse in-hospital outcomes of isolated CABG in this cohort.METHODSAll octogenarians that underwent isolated CABG, from January 2000 to October 2017, were included. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. A propensity score was generated for each patient from a multivariable logistic regression model based on 25 pre-treatment covariates. A total of 156 matching pairs were derived.RESULTSFive hundred and sixty-seven octogenarians underwent isolated CABG. This included 156 females (mean age 82.1 [SD: 0.9]) and 411 males (mean age 82.4 [SD: 2.1 years]). More males were current smokers (P = 0.002) with renal impairment (P = 0.041), chronic obstructive pulmonary disease (P = 0.048), history of cerebrovascular accident (P = 0.039) and peripheral vascular disease (P = 0.027) while more females had New York Heart Association class 4 (P = 0.02), left ventricular ejection fraction 30–49% (P = 0.038) and left ventricular ejection fraction <30% (P = 0.049). On-pump, CABG was performed in 140 males and 52 females (P = 0.921). There was no difference in in-hospital mortality (5.4% vs 6.4%; P = 0.840), stroke (0.9% vs 1.3%; P = 0.689), need for renal replacement therapy (17.0% vs 13.5%; P = 0.732), pulmonary complications (9.5% vs 8.3%; P = 0.746) and sternal wound infection (2.7% vs 2.6%; P = 0.882). The outcomes were comparable for the propensity-matched cohorts.CONCLUSIONSNo gender difference in outcomes was seen in octogenarians undergoing isolated CABG.     

Outcome of the frozen elephant trunk procedure as a redo operation

 Open in a separate windowOBJECTIVESThe goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery.METHODSOne hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis.RESULTSA total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19–35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23–3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091].CONCLUSIONSElective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.     

Mid-term outcomes of coronary endarterectomy combined with coronary artery bypass grafting

Open in a separate window OBJECTIVESThe aim of this study was to evaluate the mid-term outcome of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) and explore the potential risk factors for adverse events.METHODSA total of 208 consecutive patients underwent CE between 2008 and 2018 in our centre, of which 198 were included in this retrospective cohort study. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs). Kaplan–Meier analysis was performed to evaluate event-free survival, whereas subgroup analysis and Cox regression were used to explore risk factors for the outcomes.RESULTSThe median follow-up time was 34.7 months. CE + CABG was performed mainly on the left anterior descending artery (42.3%) or right coronary artery (42.3%). Both operative mortality and incidence of perioperative myocardial infarction were 1.5%. The overall survival at 3 and 5 years was 98.0% and 95.9%, whereas the MACCE-free survival was 93.7% and 89.4%, respectively. No significant difference in the incidence of MACCE was observed between on-pump and off-pump CE (P = 0.256) or between left anterior descending artery and non-left anterior descending artery endarterectomy (P = 0.540). Advanced age (>65 years) was associated with a higher risk of MACCE both in univariate [hazard ratio (HR) 3.62, 95% confidence interval (CI) 1.37–9.62; P = 0.010] and multivariate analysis (HR 3.59, 95% CI 1.32–9.77; P = 0.013).CONCLUSIONSWhen performed by experienced surgeons, CE + CABG could be an acceptable approach to achieve complete revascularization of diffusely diseased coronary arteries with satisfactory outcomes, although advanced age might increase the risk of MACCE.     

Paediatric subaortic stenosis: long-term outcome and risk factors for reoperation

Open in a separate window OBJECTIVESSurgical repair of subaortic stenosis (SAS) is associated with a substantial reoperation risk. We aimed to identify risk factors for reintervention in relation to discrete and tunnel-type SAS morphology.METHODSSingle-centre retrospective study of paediatric SAS diagnosed between 1992 and 2017. Multivariable Cox regression analysis was performed to identify reintervention risk factors.RESULTSEighty-five children [median age 2.5 (0.7–6.5) years at diagnosis] with a median follow-up of 10.1 (5.5–16.4) years were included. Surgery was executed in 83% (n = 71). Freedom from reoperation was 88 ± 5% at 5 years and 82 ± 6% at 10 years for discrete SAS, compared to, respectively, 33 ± 16% and 17 ± 14% for tunnel-type SAS (log-rank P < 0.001). Independent risk factors for reintervention were a postoperative gradient >20 mmHg [hazard ratio (HR) 6.56, 95% confidence interval (CI) 1.41–24.1; P = 0.005], tunnel-type SAS (HR 7.46, 95% CI 2.48–22.49; P < 0.001), aortic annulus z-score <−2 (HR 11.07, 95% CI 3.03–40.47; P < 0.001) and age at intervention <2 years (HR 3.24, 95% CI 1.09–9.86; P = 0.035). Addition of septal myectomy at initial intervention was not associated with lesser reintervention. Fourteen children with a lower left ventricular outflow tract (LVOT) gradient (P < 0.001) and older age at diagnosis (P = 0.024) were followed expectatively.CONCLUSIONSChildren with SAS remain at risk for reintervention, despite initially effective LVOT relief. Regardless of SAS morphology, age <2 years at first intervention, a postoperative gradient >20 mmHg and presence of a hypoplastic aortic annulus are independent risk factors for reintervention. More extensive LVOT surgery might be considered at an earlier stage in these children. SAS presenting in older children with a low LVOT gradient at diagnosis shows little progression, justifying an expectative approach.     

Pneumonectomy for primary lung cancer: contemporary outcomes,risk factors and model validation

Open in a separate window OBJECTIVESDespite the increased rate of adverse outcomes compared to lobectomy, for selected patients with lung cancer, pneumonectomy is considered the optimal treatment option. The objective of this study was to identify risk factors for mortality in patients undergoing pneumonectomy for primary lung cancer.METHODSData from all patients undergoing pneumonectomy for primary lung cancer at 2 large thoracic surgical centres between 2012 and 2018 were analysed. Multivariable logistic and Cox regression analyses were used to identify risk factors associated with 90-day and 1-year mortality and reduced long-term survival, respectively.RESULTSThe study included 256 patients. The mean age was 65.2 (standard deviation 9.4) years. In-hospital, 90-day and 1-year mortality were 6.3% (n = 16), 9.8% (n = 25) and 28.1% (n = 72), respectively. The median follow-up time was 31.5 months (interquartile range 9–58 months). Patients who underwent neoadjuvant therapy had a significantly increased risk of 90-day [odds ratio 6.451, 95% confidence interval (CI) 1.867–22.291, P = 0.003] and 1-year mortality (odds ratio 2.454, 95% CI 1.079–7.185, P = 0.044). Higher Performance Status score was associated with higher 1-year mortality (odds ratio 2.055, 95% CI 1.248–3.386, P = 0.005) and reduced overall survival (hazard ratio 1.449, 95% CI 1.086–1.934, P = 0.012). Advanced (stage III/IV) disease was associated with reduced overall survival (hazard ratio 1.433, 95% CI 1.019–2.016, P = 0.039). Validation of a pneumonectomy-specific risk model demonstrated inadequate model performance (area under the curve 0.54).CONCLUSIONSPneumonectomy remains associated with a high rate of perioperative mortality. Neoadjuvant chemoradiotherapy, Performance Status score and advanced disease emerged as the key variables associated with adverse outcomes after pneumonectomy in our cohort.     

Women have a higher resection rate for lung cancer and improved survival after surgery

 Open in a separate windowOBJECTIVESSurgery is the standard treatment in early-stage non-small-cell lung cancer and select cases of small-cell lung cancer, but gender differences in its use and outcome are poorly known. Gender differences in surgical resection rates and long-term survival after lung cancer surgery were therefore investigated. METHODSIn Finland, 3524 patients underwent resection for primary lung cancer during 2004–2014. Surgical rate and mortality data were retrospectively retrieved from 3 nationwide compulsory registries. Survival was studied by comparing propensity-matched cohorts. Median follow-up was 8.6 years.RESULTSSurgery rate was higher in women (15.9% vs 12.3% in men, P < 0.0001). Overall survival was 85.3% 1 year, 51.4% 5 years, 33.4% 10 years and 24.2% at 14 years from surgery. In matched groups, survival after resection was better in women after 1 year (91.3% vs 83.3%), 5 years (60.2% vs 48.6%), 10 years (43.7% vs 27.9%) and 14 years (29.0% vs 21.1%) after surgery [hazard ratio (HR) 0.66; confidence interval (CI) 0.58–0.75; P < 0.0001]. Of all first-year survivors, 39.1% were alive 10 years and 28.3% 14 years after surgery. Among these matched first-year survivors, women had higher 14-year survival (36.9% vs 25.3%; HR 0.75; CI 0.65–0.87; P = 0.0002).CONCLUSIONSSurgery is performed for lung cancer more often in women. Women have more favourable short- and long-term outcome after lung cancer surgery. Gender discrepancy in survival continues to increase beyond the first year after surgery.     

Mid-term clinical and haemodynamic results after aortic valve replacement with the Trifecta bioprosthesis

 Open in a separate windowOBJECTIVESThe aim of this study was to evaluate the clinical and haemodynamic results after implantation of the Trifecta bioprosthesis.METHODSThis study is a retrospective analysis of all patients undergoing Trifecta aortic valve replacement between 01 January 2012 and 31 December 2017 at the Ghent University Hospital. Univariable and multivariable analyses were performed to identify predictors of valve- and procedure-related complications and mortality. The haemodynamic performance was analysed by longitudinal Doppler echocardiography.RESULTSThe mean age of the 182 patients was 77 [standard deviation (SD): 5.5] years; 54.9% were women. The mean follow-up was 39.8 (SD: 24.3) months. Overall survival at 1 and 5 years was 86% (SD: 3%) and 68% (SD: 4%), respectively, and overall freedom from structural valve deterioration was 100% and 98% at 1 and 5 years, respectively. There was no valve thrombosis nor early endocarditis. Urgent surgery was the only risk factor for early mortality in the multivariable analysis [P = 0.009, odds ratio 0.06, 95% confidence interval (CI) 0.01–0.5]. Preoperative atrial fibrillation was the most important predictor of late mortality (P = 0.001, hazard ratio 3.68, 95% CI 1.65–8.21). The average peak gradients were stable from discharge up to 1 and 5 years postoperatively [15 (SD: 6) and 17 (SD: 8) mmHg].CONCLUSIONSThese results confirm the excellent clinical performance of the Trifecta valve, particularly in an elderly age group. Through the 7-year follow-up period, low transvalvular gradients persisted, and only a few patients needed reoperation. Although structural valve degeneration occurred rarely, it was unrelated to valve size or age at implantation; therefore, further long-term follow-up remains mandatory.     

Incidence and management of the left ventricular outflow obstruction in patients with atrioventricular septal defects

Open in a separate window OBJECTIVESLeft ventricular outflow tract obstruction (LVOTO) is a recognized complication after complete repair of atrioventricular septal defect (AVSD). This study reviewed the incidence and management of LVOTO following AVSD repair at a single institution.METHODSFrom 1975 to 2019, 24 patients (3.3%, 24/730) underwent reoperation due to LVOTO following partial AVSD (pAVSD) and complete AVSD (cAVSD) repair. The data were retrospectively reviewed.RESULTSThe incidence of LVOTO following pAVSD and cAVSD repair was 4.4% (12/275) and 2.6% (12/455). Freedom from LVOTO reoperation following pAVSD and cAVSD repair at 25 years was 94.3% [95% confidence interval (CI); 89.7–96.7] and 95% (95% CI; 91.1–97.3). The median time from complete repair of pAVSD and cAVSD to LVOTO reoperation was 4.4 years [interquartile range (IQR): 3.4–6.7] and 2.6 years (IQR: 2.2–4.7). Freedom from second LVOTO reoperation at 5, 10 and 15 years was 83.7% (95% CI; 57.2–98.2), 59.2% (95% CI; 28.7, 80.3) and 39.5% (95% CI; 13.2–65.3). The median time between the first and the second LVOTO reoperation in the groups of pAVSD and cAVSD was 6.1 years (IQR: 3.4–8.9) and 8.6 years (IQR: 5.7–9.8). There was no significant difference regarding the first (P = 0.7406) and subsequent LVOTO (P = 0.7153) following complete repair of pAVSD and cAVSD. Combined access to the left ventricular outflow tract was not protective regarding LVOTO reoccurrence. Survival for both groups after LVOTO reoperation at 15 years was 95.6% (95% CI 99.4–72.9).CONCLUSIONSIncidence of LVOTO after AVSD repair is low but the reoccurrence rate is high. Standard subaortic resection does not always provide definitive LVOTO relief. The survival after LVOTO reoperation is excellent.     

Male–female differences in acute thoracic aortic dissection: a systematic review and meta-analysis

Open in a separate window OBJECTIVESThis study aims to systematically review published literature on male–female differences in presentation, management and outcomes in patients diagnosed with acute thoracic aortic dissection (AD).METHODSA systematic literature search was conducted for studies published between 1 January 1999 and 19 October 2020 investigating mortality and morbidity in adult patients diagnosed with AD. Patient and treatment characteristics were compared with odds ratios (ORs) and standardized mean differences and a meta-analysis using a random-effects model was performed for early mortality. Overall survival and reoperation were visualized by pooled Kaplan–Meier curves.RESULTSNine studies investigating type A dissections (AD-A), 1 investigating type B dissections (AD-B) and 3 investigating both AD-A and AD-B were included encompassing 18 659 patients. Males were younger in both AD-A (P < 0.001) and AD-B (P < 0.001), and in AD-A patients males had more distally extended dissections [OR 0.57, 95% confidence interval (CI) 0.46–0.70; P < 0.001]. Longer operation times were observed for males in AD-A (standardized mean difference 0.29, 95% CI 0.17–0.41; P < 0.001) while male patients were less often treated conservatively in AD-B (OR 0.65, 95% CI 0.58–0.72; P < 0.001). The pooled early mortality risk ratio for males versus females was 0.94 (95% CI 0.84–1.06, P = 0.308) in AD-A and 0.92 (95% CI 0.83–1.03, P = 0.143) in AD-B. Pooled overall mortality in AD-A showed no male–female difference, whereas male patients had more reinterventions during follow-up.CONCLUSIONSThis systematic review shows male–female differences in AD patient and treatment characteristics, comparable early and overall mortality and inconsistent outcome reporting. As published literature is scarce and heterogeneous, large prospective studies with standardized reporting of male–female characteristics and outcomes are clearly warranted. Improved knowledge of male–female differences in AD will help shape optimal individualized care for both males and females.Clinical registration numberPROSPERO, ID number: CRD42020155926.     

Fragmented QRS complex may predict long-term mortality after isolated surgical aortic valve replacement in patients with severe aortic stenosis

 Open in a separate windowOBJECTIVESFragmented QRS (fQRS), related to myocardial fibrosis, is an important prognostic marker of cardiovascular events and mortality. Aortic stenosis (AS), the most frequent valvular heart disease in developed countries, causes myocardial fibrosis due to ventricular pressure overload. The current study aimed to investigate whether fQRS is associated with long-term mortality after isolated surgical aortic valve replacement (SAVR) in patients with severe AS.METHODSA total of 289 patients who underwent SAVR for severe AS between May 2009 and January 2020 with interpretable electrocardiogram were included. Patients were divided into 2 groups according to the presence of fQRS. Kaplan–Meier survival analyses were used to detect cumulative survival rates. Univariable and multivariable Cox proportional hazards models were used to determine the predictors of all-cause mortality.RESULTSfQRS occurred in 126 (43.5%) patients. A total of 59 (20.4%) patients died over a follow-up period of 54 ± 32 months. All-cause mortality was higher in the fQRS group (23 [14.1%] vs 36 [28.6], log-rank test P = 0.002) in the long term. The presence of fQRS [hazard ratio (HR): 1.802, confidence interval (CI): 1.035–3.135, P = 0.037], electrocardiographic left ventricular strain (HR: 1.836, CI: 1.036–3.254, P = 0.038) and history of stroke or transient ischaemic attack (HR: 3.130, CI: 1.528–6.412, P = 0.002) were independent predictors of all-cause mortality in the multivariable Cox regression model.CONCLUSIONSfQRS is associated with a 1.8-fold increase in long-term mortality in patients undergoing isolated SAVR for severe AS. Detecting fQRS in electrocardiograms may provide prognostic information about the long-term outcomes.     

Extensive calcification of the mitral valve annulus in transcatheter aortic valve implants

 Open in a separate windowOBJECTIVESThis study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation.METHODSBetween November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated.RESULTSThe prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm.CONCLUSIONSExtensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks.Subj collection122, 125