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     

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.     

Assessment of postoperative risk factors for EEG abnormalities in routine clinical management after paediatric cardiopulmonary bypass

Open in a separate window OBJECTIVESThe postoperative risk factors for electroencephalogram(EEG) abnormalities after paediatric cardiopulmonary bypass (CPB) remain to be identified. We investigated the characteristics of EEG abnormalities and risk factors in routine clinical management post-CPB.METHODSEEG and cerebral oxygen saturation (ScO₂) were monitored in 96 patients (aged 3 days, 37 months, median 5 months) for 72 h post-CPB. Clinical measurements included 4-hourly arterial and central venous pressure, arterial blood gases, doses of inotropic and vasoactive drugs, daily C-reactive protein (CRP) and NT-proB-type Natriuretic Peptide (NT-proBNP). Demographics, STAT categories and outcomes (duration of mechanical ventilation,CICU stay) were recorded. UnRESULTSSeizures occurred in 20 patients (20.8%) beginning at 0–48 hand lasting 10 min–31 h; background abnormalities occurred in 67 (69.8%) beginning at 0–8 h and lasting 4–48 h. Patients with EEG abnormalities had worse outcomes. In univariable regression, seizures positively correlated with STAT categories, CPB time, temperature, blood pressure, central venous pressure, NT-proBNP, CRP, lactate and epinephrine, negatively with ScO₂ and PaCO₂ (P < 0.001 for lactate and epinephrine, P < 0.1 for the remaining). The degree of background abnormalities positively correlated with STAT categories, CPB time, operative time, central venous pressure, milrinone, negatively with blood pressure (P = 0.0003–0.087); it negatively correlated with lower dose of epinephrine (P < 0.001) and positively with higher dose (P = 0.03l). In multivariable regression, seizures positively correlated with epinephrine, lactate and temperature; the background abnormality correlations remain significant except for milrinone and operative time (P < 0.001 for epinephrine, P < 0.05 for the remaining).CONCLUSIONSNumerous perioperative risk factors are associated with EEG abnormalities post-CPB. The most significant and consistent risk factor is epinephrine.     

Reverse left ventricular remodelling after aortic valve replacement for severe aortic insufficiency

 Open in a separate windowOBJECTIVESThe goal of this study was to investigate the long-term outcome of aortic valve replacement (AVR) for severe aortic insufficiency with a focus on pre- and postoperative left ventricular (LV) function to explore predictive factors that influence the recovery of LV function and clinical outcome.METHODSA total of 478 patients who underwent AVR for pure severe aortic insufficiency were grouped according to the preoperative echocardiographical LV ejection fraction (EF): low (LO) EF <35% (n = 43), moderate EF 35–50% (n = 150) or normal EF >50% (n = 285).RESULTSActuarial survival at 10 years post-AVR was 64% with a LO EF, 92% with a moderate EF and 93% with a normal EF (P = 0.016), whereas 10-year rates of freedom from major adverse cerebral and cardiovascular events were 47%, 79% and 84%, respectively (P < 0.0001). Echocardiography at 1 year post-AVR demonstrated that EF substantially improved in all groups. We noted a significant difference in survival (P = 0.0086) and in freedom from major adverse cerebral and cardiovascular events (P = 0.024) between patients with an EF ≥35% and those with an EF <35% in the LO EF group. The multivariable logistic regression model showed that predictive factors for lack of improvement in EF 1 year post-AVR in the LO EF group included plasma brain natriuretic peptide >365 pg/mL (P = 0.0022) and echocardiographic LV mass index) >193 g/m² (P = 0.0018).CONCLUSIONSLong-term outcome post-AVR for severe aortic insufficiency was largely influenced by preoperative LV function. Predictive factors of failure to recover ventricular function post-AVR included EF <25%, pre-brain natriuretic peptide >365 pg/mL or LV mass index >193 g/m².     

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.     

Actual incidence of cerebral infarction after thoracic endovascular aortic repair: a magnetic resonance imaging study

 Open in a separate windowOBJECTIVESThe actual incidence of cerebral infarction (CI), including asymptomatic infarction, owing to thoracic endovascular aortic repair (TEVAR) has not been reported in detail. This study was performed to investigate the incidence of post-TEVAR CI by using diffusion-weighted magnetic resonance imaging (DW-MRI) and to determine the risk factors for both symptomatic and asymptomatic CI.METHODSWe examined 64 patients undergoing TEVAR at our institute between April 2017 and November 2020. Aortic atheroma was graded from 1 to 5 by preoperative computed tomography. Cerebral DW-MRIs were conducted 2 days after the procedure to diagnose postoperative CI.RESULTSA total of 44 new foci were detected by post-interventional cerebral DW-MRI in 22 patients (34.4%). Only one patient developed a symptomatic stroke (1.6%), and TEVAR was successfully completed in all cases. Debranching of the aortic arch and left subclavian artery occlusion with a vascular plug was performed in 19 (29.7%) and 12 (18.8%) patients, respectively. The number of patients with proximal landing zones 0–2 was significantly higher in the CI group than in the non-CI group (68.2% vs 11.9%; P < 0.001). The following risk factors were identified for asymptomatic CI: aortic arch debranching (P < 0.001), left subclavian artery occlusion (P = 0.001) and grade 4/5 aortic arch atheroma (P = 0.048).CONCLUSIONSOver one-third of the patients examined by cerebral DW-MRI after TEVAR were diagnosed with CI. High-grade atheroma and TEVAR landing in zone 0–2 were found to be positively associated with asymptomatic CI.Clinical trial registration02-014.     

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.     

Mid-term outcomes of Contegra implantation for the reconstruction of the right ventricular outflow tract to proximal branch pulmonary arteries: Japan multicentre study

Open in a separate window OBJECTIVESTo reveal the mid-term outcomes of Contegra implantation for the reconstruction of the right ventricular outflow tract to proximal branch pulmonary arteries in a multicentre study. METHODSBetween April 2013 and December 2019, 178 Contegra conduits were implanted at 5 Japanese institutes. The median age and body weight at operation were 16 months (25th–75th percentile: 8–32) and 8.3 kg (6.4–10.6). Sixteen patients were neonates (9.0%). Selected conduit sizes were 12 mm in 28 patients (15.7%), 14 mm in 67 patients (37.6%), 16 mm in 66 patients (37.1%), 18 mm in 5 patients (2.8%) and <12 mm in 12 patients (6.7%). Fifty-six grafts (31.4%) were ring supported. Proximal branch pulmonary arteries were concomitantly augmented in 85 patients (47.5%). Follow-up was completed in all patients and the median follow-up period was 3.1 years (1.3–5.1).RESULTSThe overall, conduit explantation-free and conduit infection-free survival rates at 5 years were 91.3%, 71.0% and 83.7%, respectively. Infection (P = 0.009) and common arterial trunk (P = 0.024) were risk factors for explantation. Conduit durability was shorter in smaller one (P < 0.001). Catheter interventions (for conduit to proximal branch pulmonary artery)-free survival rates at 5 years was 52.9%; however, need for catheter interventions was not a risk factor for conduit explantation.CONCLUSIONSMid-term outcomes of reconstruction of the right ventricular outflow tract to the proximal branch pulmonary arteries with Contegra were acceptable. The need for explantation over time was higher in smaller conduits. Conduit infection was a strong risk factor for conduit explantation. Frequently and repeated catheter interventions effectively extended the conduit durability.     

Failure to rescue: variation in mortality after cardiac surgery

 Open in a separate windowOBJECTIVESMeasures to prevent surgical complications are critical components of optimal patient care, and adequate management when complications occur is equally crucial in efforts to reduce mortality. This study aims to elucidate clinical realities underlying in-hospital variations in failure to rescue (FTR) after cardiac surgery.METHODSUsing a statewide database for a quality improvement program, we identified 62 450 patients who had undergone adult cardiac surgery between 2011 and 2018 in 1 of the 33 Michigan hospitals performing adult cardiac surgery. The hospitals were first divided into tertiles according to their observed to expected (O/E) ratios of 30-day mortality: low-mortality tertile (O/E 0.46–0.78), intermediate-mortality tertile (O/E 0.79–0.90) and high-mortality tertile (O/E 0.98–2.00). We then examined the incidence of 15 significant complications and the rates of death following complications among the 3 groups.RESULTSA total of 1418 operative deaths occurred in the entire cohort, a crude mortality rate of 2.3% and varied from 1.3% to 5.9% at the hospital level. The death rates also diverged significantly according to mortality score tertiles, from 1.6% in the low-mortality group to 3.2% in the high-mortality group (P < 0.001). Hospitals ranked in a high- or intermediate-mortality tertile had similar rates of overall complications (21.3% and 20.7%, P = 0.17), while low-mortality hospitals had significantly fewer complications (16.3%) than the other 2 tertiles (P < 0.001). FTR increased in a stepwise manner from low- to high-mortality hospitals (8.3% vs 10.0% vs 12.7%, P < 0.001, respectively). Differences in FTR were related to survival after cardiac arrest, multi-system organ failure, prolonged ventilation, reoperation for bleeding and severe acute kidney disease that requires dialysis.CONCLUSIONSThis study demonstrates that timely recognition and appropriate treatment of complications are as important as preventing complications to further reduce operative mortality in cardiac surgery. FTR tools may provide vital information for quality improvement initiatives.     

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.     

Impact of preoperative antithrombotic therapy in patients undergoing elective isolated coronary artery bypass grafting

 Open in a separate windowOBJECTIVESThe objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG).METHODSPatients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence).RESULTSA total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29–9.83)] and increased use of blood products [37.5% vs 20.3%, P < 0.001; OR 2.35 (1.58–3.49)]. In 122 matched subgroup patients, non-adherence was associated with an increased risk of re-exploration [10.7% vs 3.3%, P = 0.044; OR 3.52 (1.11–11.12)] and increased blood product use [51.6% vs 25.4%, P < 0.001; OR 3.13 (1.83–5.38)]. Secondary end points were not significantly different among the main study groups and subgroups.CONCLUSIONSPreoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.     

European Society of Thoracic Surgeons electronic quality of life application after lung resection: field testing in a clinical setting

 Open in a separate windowOBJECTIVESTechnology has the potential to assist healthcare professionals in improving patient–doctor communication during the surgical journey. Our aims were to assess the acceptability of a quality of life (QoL) application (App) in a cohort of cancer patients undergoing lung resections and to depict the early perioperative trajectory of QoL.METHODSThis multicentre (Italy, UK, Spain, Canada and Switzerland) prospective longitudinal study with repeated measures used 12 lung surgery-related validated questions from the European Organisation for Research and Treatment of Cancer Item Bank. Patients filled out the questionnaire preoperatively and 1, 7, 14, 21 and 28 days after surgery using an App preinstalled in a tablet. A one-way repeated measures analysis of variance was run to determine if there were differences in QoL over time.RESULTSA total of 103 patients consented to participate in the study (83 who had lobectomies, 17 who had segmentectomies and 3 who had pneumonectomies). Eighty-three operations were performed by video-assisted thoracoscopic surgery (VATS). Compliance rates were 88%, 90%, 88%, 82%, 71% and 56% at each time point, respectively. The results showed that the operation elicited statistically significant worsening in the following symptoms: shortness of breath (SOB) rest (P = 0.018), SOB walk (P < 0.001), SOB stairs (P = 0.015), worry (P = 0.003), wound sensitivity (P < 0.001), use of arm and shoulder (P < 0.001), pain in the chest (P < 0.001), decrease in physical capability (P < 0.001) and scar interference on daily activity (P < 0.001) during the first postoperative month. SOB worsened immediately after the operation and remained low at the different time points. Worry improved following surgery. Surgical access and forced expiratory volume in 1 s (FEV1) are the factors that most strongly affected the evolution of the symptoms in the perioperative period.CONCLUSIONSWe observed good early compliance of patients operated on for lung cancer with the European Society of Thoracic Surgeons QoL App. We determined the evolution of surgery-related QoL in the immediate postoperative period. Monitoring these symptoms remotely may reduce hospital appointments and help to establish early patient-support programmes.     

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.     

Is the Yedikule-solitary pulmonary nodule malignancy risk score sufficient to predict malignancy? An internal validation study

Open in a separate window OBJECTIVESWe aimed to develop a malignancy risk score model for solitary pulmonary nodules (SPNs) using the demographic, radiological and clinical characteristics of patients in our centre. The model was then internally validated for malignancy risk estimation. METHODSA total of 270 consecutive patients who underwent surgery for SPN between June 2017 and May 2019 were retrospectively analysed. Using the receiver operating characteristic curve analysis, cut-off values were determined for radiological tumour diameter, maximum standardized uptake value and the Brock University probability of malignancy (BU-PM) model. The Yedikule-SPN malignancy risk model was developed using these cut-off values and demographic, radiological and clinical criteria in the first 180 patients (study cohort) and internally validated with the next 90 patients (validation cohort). The Yedikule-SPN model was then compared with the BU-PM model in terms of malignancy prediction.RESULTSMalignancy was reported in 171 patients (63.3%). Maximum standardized uptake value and BU-PM scores were sufficient to predict malignancy (P < 0.001 for both), while the effectiveness of nodule size determined on thoracic computed tomography did not reach statistical significance (P = 0.09). When the Yedikule-SPN model developed with the study cohort was applied to the validation cohort, it significantly predicted malignancy (area under the receiver operating characteristic curve: 0.883, 95% confidence interval: 0.827–0.957, P < 0.001). Comparison of patients in the validation group with Yedikule-SPN scores above (n = 53) and below (n = 37) the cut-off value of 65.75 showed that the malignancy rate was significantly higher among patients with Yedikule-SPN score over 65.75 (86.8% vs 21.6%, P < 0.001, odds ratio = 23.821, 95% confidence interval: 7.805–72.701). When compared with the BU-PM model in all patients, the Yedikule-SPN model tended to be a better predictor of malignancy (P = 0.06).CONCLUSIONSThe internally validated Yedikule-SPN model is also a good predictor of the malignancy of SPN(s). Prospective and multicentre external validation studies with large patients’ cohorts are needed.     

Risk factors for prolonged air leak and need for intervention following lung resection

 Open in a separate windowOBJECTIVESProlonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention.METHODSRetrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated.RESULTSIn total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050).Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050).On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050).CONCLUSIONSAge, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.     

Impact of gender on 10-year outcome after coronary artery bypass grafting

Open in a separate window OBJECTIVESOur goal was to evaluate the impact of gender on the 10-year outcome of patients after isolated coronary artery bypass grafting (CABG) included in the Italian nationwide PRedictIng long-term Outcomes afteR Isolated coronary arTery bypass surgery (PRIORITY) study.METHODSThe PRIORITY project was designed to evaluate the long-term outcomes of patients who underwent CABG and were included in 2 prospective multicentre cohort studies. The primary end point of this analysis was major adverse cardiac and cerebrovascular events. Baseline differences between the study groups were balanced with propensity score matching and inverse probability of treatment. Time to events was analysed using Cox regression and competing risk analysis.RESULTSThe study population comprised 10 989 patients who underwent isolated CABG (women 19.6%). Propensity score matching produced 1898 well-balanced pairs. The hazard of major adverse cardiac and cerebrovascular event was higher in women compared to men [adjusted hazard ratio (HR) 1.13, 95% confidence interval (CI) 1.03–1.23; P = 0.009]. The incidence of major adverse cardiac and cerebrovascular event in women was significantly higher at 1 year (HR 1.31, 95% CI 1.11–1.55; P < 0.001) and after 1 year (HR 1.11, 95% CI 1.00–1.24; P = 0.05). Mortality at 10 years in the matched groups was comparable (HR 1.04, 95% CI 0.93–1.16; P = 0.531). Women have significantly a higher 10-year risk of myocardial infarction (adjusted HR 1.40, 95% CI 1.17–1.68; P = 0.002) and percutaneous coronary intervention (adjusted HR 1.32, 95% CI 1.10–1.59; P = 0.003).CONCLUSIONSThe present study documented an excess of non-fatal cardiac events after CABG among women despite comparable 10-year survival with men. These findings suggest that studies investigating measures of tertiary prevention are needed to decrease the risk of adverse cardiovascular events among women.     

Density of aortopulmonary collaterals predicts in-hospital outcome in tetralogy of Fallot with pulmonary stenosis

 Open in a separate windowOBJECTIVESThe aim of this study was to characterize the anatomy of aortopulmonary collateral (APC) arteries in tetralogy of Fallot and pulmonary stenosis and to determine whether APC density identified on preoperative multidetector cardiac computed tomography predicts in-hospital outcome.METHODSThe retrospective single-centre study includes consecutive 135 (2015–2019) patients who underwent one-stage repair. Preoperative multidetector cardiac computed tomography, echocardiography and clinical outcomes were reviewed. The cut-off value of indexed total distal APC cross-sectional area (APC-CSA) was identified by receiver operating characteristic curve. Logistic regression was used for predictors analysis.RESULTSThe median age and body weight were 19.7 (10.1–89.7) months and 10 (8.3–18) kg. A total of 337 APCs were detected with only one demonstrating severe stenosis. There was a strong and significant correlation between mean APC diameter per patient and age (r = 0.70, P < 0.001). APCs were imaged but mainly received no interventions. In-hospital mortality was similar between patients with high (indexed APC-CSA ≥3.0 mm²/m²) and low (<3.0 mm²/m²) APC density (P = 0.642). Significantly greater patients with high indexed APC-CSA experienced the in-hospital composite outcome of death, arrest, renal/hepatic injury, lactic acidosis or extracorporeal membrane oxygenation (P = 0.007). High APC density was associated with greater dosing (P = 0.008) and longer (P = 0.01) use of inotropic support, prolonged pleural drainage (P = 0.013), longer ventilation (P = 0.042), intensive care unit (P = 0.014) and hospital (P = 0.027) duration. No reintervention and death occurred in the follow-up with the median duration of 24.4 (11–36.6) months. Multivariable analysis showed the Nakata index (P = 0.05) and high APC density (P = 0.02) independently predicted the composite outcome.CONCLUSIONSIn tetralogy of Fallot and pulmonary stenosis, APCs are likely to be dilated bronchial arteries. Preoperative multidetector cardiac computed tomography-derived APC density was as important as Nakata index in predicting the occurrence of in-hospital composite outcome. The APC-CSA of 3.0 mm²/m² maybe considered as a threshold for risk stratification.     

Preoperative risk factors influencing inter-stage mortality after the Norwood procedure

Open in a separate window OBJECTIVESWith improvements in early survival after the stage I palliation (S1P) Norwood procedure for hypoplastic left heart syndrome (HLHS) and its variants, inter-stage death accounts for an increasing proportion of mortality. Our aim was to identify the risk factors for inter-stage mortality.METHODSThe records of 322 neonates with HLHS or a variant who underwent the Norwood procedure at our centre between 2001 and 2019 were retrospectively analysed.RESULTSThe diagnoses included 271 neonates with HLHS (84%) and 51 with variants (16%). Aortic atresia was observed in 138 (43%) patients, mitral atresia in 91 (28%), extracardiac anomalies in 42 (13%) and genetic disorder in 14 (4%). The median age and weight of the patients at the S1P Norwood procedure were 9 (interquartile range: 7–12) days and 3.2 (2.9–3.5) kg, respectively. The median cardiopulmonary bypass time was 137 (107–163) min. Modified Blalock–Taussig shunts were used in 159 (49%) and unvalved right ventricle-to-pulmonary artery shunts in 163 (51%) patients. The number of inter-stage deaths was as follows: between S1P and stage II palliation (S2P), 61 including 38 early (<30 days) and 23 late (>30 days) deaths, and between S2P and stage III palliation, 32 deaths. Low birth weight (<2.5 kg) (odds ratio 4.37, P = 0.020) and restrictive atrial septum (odds ratio 2.97, P = 0.013) were identified as risks for early mortality. Low birth weight [hazard ratio (HR) 0.99/g, P = 0.002] was a risk for inter-stage mortality between S1P and S2P. Extracardiac anomalies (HR 4.75, P = 0.049) and significant pre-S1P atrioventricular valve regurgitation (HR: 7.72, P = 0.016) were risks for inter-stage mortality between S2P and stage III palliation. Other anatomical variables including aortic atresia, anatomical subtypes and the diameter of the ascending aorta nor shunt type were not identified as risk factors for mortality during any inter-stage period.CONCLUSIONSThe risk factors for inter-stage attrition after the Norwood procedure were different between each stage. Preoperative factors, including birth weight, restrictive atrial septum and extracardiac anomalies, adversely affected the inter-stage mortality.     

Long-term outcomes after the paediatric Ross and Ross-Konno procedures

 Open in a separate windowOBJECTIVESThe Ross procedure is an attractive option for the management of aortic valve disease in paediatric patients. We reviewed our experience with the paediatric Ross procedure to determine survival and freedom from reoperation in the third decade after surgery.METHODSWe reviewed the data of 124 paediatric patients [71% male, median age at time of surgery 11.1 years (interquartile range 6–14.8 years); 63.7% bicuspid aortic valve], who underwent the Ross procedure at 2 tertiary centres from April 1991 to April 2020. The Ross-Konno procedures were performed on 14 (11.3%) patients. Deaths were cross-checked with the national health insurance database, and survival status was available for 96.8% of the patients. The median follow-up time was 12.1 years (interquartile range 3–18 years).RESULTSThere were 3 early and 6 late deaths. All early deaths occurred in patients aged <1 year at the time of surgery. The 25-year survival was 90.3%. Actuarial freedom from reoperation (linearized rates in parentheses) was as follows: Autograft reoperation was 90.8% (0.48%/patient-year) and right ventricular outflow tract (RVOT) reoperation was 67% (2.07%/patient year) at 25 years. The univariable Cox-proportional hazard analysis revealed younger age at time of surgery (P < 0.001), smaller implanted valve size (P < 0.001) and the use of a xenograft rather than a homograft (P < 0.001) as predictors of RVOT reoperation. At multivariable Cox-proportional hazard analysis, only age was an independent risk factor for RVOT reoperation (P = 0.041).CONCLUSIONSThe Ross and the Ross-Konno procedures are associated with good outcomes in paediatric patients. Reoperation of the RVOT is frequent and associated with younger age.     

Cardiac surgery in older patients: hospital outcomes during a 15-year period from a complete national series

Open in a separate window OBJECTIVESThe objective was to review national trends in activity and hospital outcomes in older patients having cardiac surgery over a 15-year time period.METHODSData were collected prospectively and uploaded to the National Institute for Cardiovascular Outcomes Research electronically. Data were validated, cleaned and processed using reproducible algorithms. Mortality was death in hospital after index operation.RESULTSA total of 227 442 cardiac procedures were recorded in patients aged ≥70 years of which 46 354 were in those aged ≥80 years. Overall patients aged ≥70 years represented 43% of all adult cardiac surgery in the most recent study year. The annual proportion of surgery in patients ≥80 years increased from 4.1% to 10.8% between the first and last study years. There has been a significant linear increase in octogenarian valve [β 67.44, 95% confidence interval (CI) 55.04 to 79.83, P < 0.001] and coronary artery bypass graft surgery (β 32.53, 95% CI 6.16 to 58.90, P = 0.020) patients. In-hospital mortality reduced significantly for patients aged 70–79 years (β −0.17, 95% CI −0.20 to −0.13, P < 0.001) and all patients aged ≥80 (β −0.37, 95% CI −0.45 to −0.30, P < 0.001). The median length of hospital stay was 7 days for 70–79 and 9 days for ≥80 group, compared with 7 days for the whole cohort <70 years.CONCLUSIONSThis study represents the largest complete validated national dataset of cardiac surgery in the entire population of older patients. Octogenarians represent 11% of adult patients having cardiac surgery by the end of the study period, a three-fold increase from the start. In-hospital mortality in patients aged ≥80 years halved during study period to only 4% despite high logistic EuroSCORE of 15%. Cardiac surgery in octogenarians places a higher demand on resources, however, with an increased postoperative length of stay.