Long-term Outcome after Pulmonary Endarterectomy Corsico, Angelo G; D'Armini, Andrea M; Cerveri, Isa ...
American journal of respiratory and critical care medicine,
08/2008, Volume:
178, Issue:
4
Journal Article
Peer reviewed
There are few follow-up studies on long-term cardiopulmonary function after pulmonary endarterectomy (PEA), the operation of choice for chronic thromboembolic pulmonary hypertension (CTEPH).
To ...prospectively evaluate long-term outcome of patients with CTEPH treated with PEA.
Between 1994 and 2006, 157 patients (mean age 55 yr) were treated with PEA at Pavia University Hospital. The patients were evaluated before PEA and at 3 months (n = 132), 1 year (n = 110), 2 years (n = 86), 3 years (n = 69), and 4 years (n = 49) afterward by NYHA class, right heart hemodynamic, spirometry, carbon monoxide transfer factor (Tl(CO)), arterial blood gas, and treadmill incremental exercise test.
Cumulative survival was 84%. Within 3 months, 18 patients died in-hospital and 2 had lung transplantation; during long-term follow-up, 6 died, 1 had lung transplantation, and 3 had a second PEA (2.5 events per 100 person-years). NYHA class III-IV was the most important predictor of late death, lung transplant, or PEA redo (hazard ratio, 3.94). Extraordinary improvement in NYHA class, hemodynamic, and Pa(O(2)) were achieved in the first 3 months (P < 0.001) and persisted during follow-up; exercise tolerance progressively increased over time (P < 0.001). At 4 years, although 74% of the patients were in NYHA class I and none was in class IV, 24% had pulmonary vascular resistance greater than 500 dyne.s/cm(5) or Pa(O(2)) less than 60 mm Hg; they were significantly older and were more frequently in NYHA class III-IV 3 months after surgery than the others.
After PEA, long-term survival and cardiopulmonary function recovery is excellent in most patients.
Background: Use of a minimally invasive approach for isolated aortic valve surgery is increasing. However, management of the root and/or ascending aorta through a mini-invasive incision is not so ...frequent. The aim of this study is to report our initial experience with surgery of the ascending aorta through a ministernotomy approach.Methods: We retrospectively analyzed 102 patients treated for ascending aorta disease through a ministernotomy. Several types of surgeries were performed, including isolated or combined surgical procedures. Pre-operative and operative parameters and in-hospital clinical outcomes were retrospectively analyzed.Results: Patient mean age was 63.9 ± 13.6 years (range 29–85). There were 33 (32.4%) female and 69 (67.6%) male patients. Preoperative logistic EuroSCORE I was 7.4% ± 2.1%. Mean cardiopulmonary bypass and aortic cross-clamp time were 123.7 ± 36.9 and 100.8 ± 27.5 min, respectively. In-hospital mortality was 0%.Conclusions: Our experience shows that surgery of the ascending aorta with or without combined procedures can be safely performed through an upper ministernotomy, without compromising surgical results. Although our series is not large, we believe that the experience gained on the isolated aortic valve through a ministernotomy can be safely reproduced in ascending aorta surgery as a routine practice.
Objective An increasing number of elderly patients are referred for pulmonary endarterectomy. The distinction between operable and inoperable lesions has been challenged over time. Hence, we ...developed alternative cardiopulmonary bypass management and cerebral protection strategies to obtain satisfactory surgical results according to the changing patient features. Methods From April 1994 to March 2011, 347 pulmonary endarterectomies were performed at our center. We began with the technique championed by the San Diego Group, adopting a single period of deep hypothermic circulatory arrest for each side (group A). Since 2003, we began to perform short periods of intermittent deep hypothermic circulatory arrest followed by periods of reperfusion (group B). We then adopted moderate, instead of deep, hypothermia (group C). Finally, we modified our technique further performing shorter (5–7-minute) periods of circulatory arrest (group D). Results The hemodynamic results after surgery were excellent in all 4 groups. The patients' age increased significantly. A trend toward an increase in the number of Jamieson type 3 lesions was observed. Associated with our protocol changes, we observed better postoperative respiratory function, a reduction in the length of mechanical ventilation and postoperative infections, and a remarkable improvement in uneventful postoperative courses. Despite the increased total circulatory arrest time, a trend toward a reduction in the incidence of transient neurologic events was observed, and operative mortality was not affected. Conclusions In our experience, our alternative strategy resulted in a better combination of surgical accuracy and cerebral protection and improved outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Infective endocarditis (IE) is a serious disease, and in many cases, surgery is necessary. Whether the type of prosthesis implanted for aortic valve replacement (AVR) for IE impacts patient survival ...is a matter of debate. The aim of the present study is to quantify differences in long-term survival and recurrence of endocarditis AVR for IE according to prosthesis type among patients aged 40 to 65 years.
This was an analysis of the INFECT-REGISTRY. Trends in proportion to the use of mechanical prostheses versus biological ones over time were tested by applying the sieve bootstrapped t-test. Confounders were adjusted using the optimal full-matching propensity score. The difference in overall survival was compared using the Cox model, whereas the differences in recurrence of endocarditis were evaluated using the Gray test.
Overall, 4365 patients were diagnosed and operated on for IE from 2000 to 2021. Of these, 549, aged between 40 and 65 years, underwent AVR. A total of 268 (48.8%) received mechanical prostheses, and 281 (51.2%) received biological ones. A significant trend in the reduction of implantation of mechanical vs. biological prostheses was observed during the study period (
< 0.0001). Long-term survival was significantly higher among patients receiving a mechanical prosthesis than those receiving a biological prosthesis (hazard ratio HR 0.546, 95% CI: 0.322-0.926,
= 0.025). Mechanical prostheses were associated with significantly less recurrent endocarditis after AVR than biological prostheses (HR 0.268, 95%CI: 0.077-0.933,
= 0.039).
The present analysis of the INFECT-REGISTRY shows increased survival and reduced recurrence of endocarditis after a mechanical aortic valve prosthesis implant for IE in middle-aged patients.
a Division of Cardiac Surgery, IRCCS Foundation S. Matteo, Pavia, Italy
b Department of Surgical Sciences, University of Pavia, School of Medicine, Pavia, Italy
c Cardiac Surgery La Sapienza First ...University School of Medicine, Rome, Italy
*Corresponding author. Tel.: +39 349 8465085; fax: +39 038 2503523. E-mail address : ptotaro{at}yahoo.com (P. Totaro).
Objective: Antiphospholipid (a-PL) antibodies, especially IgG isotype, have been associated with a variety of neurological manifestations related to thrombotic mechanism and reactivity against nervous tissues. Furthermore, high titre of a-PL antibodies has been also correlated to chronic thromboembolic pulmonary hypertension (CTEPH) and, therefore, is frequently reported in patients undergoing pulmonary endarterectomy (PEA). The impact of a-PL antibodies in postoperative outcome following PEA, however, has not been clearly evaluated yet. In this paper, we investigated the impact of a high a-PL IgG titre (HAPT) on postoperative outcome following PEA. Methods: From April 1994 to October 2008, out of 204 patients undergoing PEA at our centre, 184 were prospectively screened for a-PL antibodies. According to the preoperative IgG titre, patients were divided into two groups: Group A (high a-PL antibodies titre – HAPT) with a-PL IgG titre >10 U/ml and Group B (low a-PL antibodies titre – LAPT) with a-PL IgG titre 10 U/ml. Early outcomes were compared between the two groups. Results: Twenty-eight patients (15%) were included in Group A, whereas 156 (85%) patients were included in Group B. HAPT influenced preoperative parameters as patients of Group A were younger compared to those of Group B (42±16 and 52±16 for Group A and B, respectively, P =0.001) and presented more frequently a previous history of deep venous thrombosis (DVT) (96% and 62% for Group A and B, respectively, P =0.001). The two groups were homogeneous for all other operative parameters. As far as postoperative outcome, in terms of mortality and major complications, there were no differences between the two groups. Incidence of transient neurological complications, however, was significantly different (32% and 10% for Group A and B, respectively, P =0.023). Conclusions: The presence of high titre of IgG isotype a-PL antibodies significantly influences preoperative characteristics of patients undergoing PEA. Furthermore, despite that no significant differences were shown in major end points, the presence of high titre of a-PL did interfere with postoperative course as caused by an increased rate of minor and transient neurological impairment (TNI). An accurate monitoring especially during hypothermic circulatory arrest (CA) period seems, therefore, mandatory in this subgroup of patients undergoing PEA.
Key Words: Pulmonary endarterectomy; Cerebral protection; Antiphospholipid syndrome
In the last decades, 4 different scores for the prediction of mortality following surgery for type A acute aortic dissection (TAAD) were proposed. We aimed to validate these scores in a large ...external multicentre cohort.
We retrospectively analysed patients who underwent surgery for TAAD between 2000 and 2020. Patients were enrolled from 10 centres from 2 European countries. Outcomes were the early (30-day and/or in-hospital) and 1-year mortality. Discrimination, calibration and observed/expected (O/E) ratio were evaluated.
A total of 1895 patients (31.7% females, mean age 63.72 ± 12.8 years) were included in the study. Thirty-day mortality and in-hospital mortality were 21.7% (n = 412) and 22.5% (n = 427) respectively. The German Registry of Acute Aortic Dissection Type A (GERAADA) score shows to have the best discrimination area under the curve (AUC) 0.671 and 0.672 in predicting as well the early and the 1-year mortality, followed by the International Registry of Acute Aortic Dissection (IRAD) model 1 (AUC 0.658 and 0.672), the Centofanti (AUC 0.645 and 0.66) and the UK aortic score (AUC 0.549 and 0.563). According to Hosmer-Lemeshow and Brier tests, the IRAD model I and GERAADA, respectively, were well calibrated for the early mortality, while the GERAADA and Centofanti for the 1-year mortality. The O/E analysis showed a marked underestimation for patients labelled as low-risk for UK aortic score and IRAD model I for both outcomes.
The GERAADA score showed the best performance in comparison with other scores. However, none of them achieved together a fair discrimination and a good calibration for predicting either the early or the 1-year mortality.
We describe an 11-year-old girl with severe obstruction of the main pulmonary arteries caused by invasive aspergillosis and managed with combined pulmonary endarterectomy and antimycotic treatment.
Background
Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (antegrade cerebral ...perfusion ACP), or retrograde. In recent years nadir temperature progressively increased to 26°C–28°C (moderately hypothermic circulatory arrest MHCA), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10 min of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming DR) can provide a neuroprotection and a lower body protection similar to that provided by MHCA + ACP.
Methods
A total of 210 patients were included in the study. DHCA + DR was used in 59 patients and MHCA + ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE), or permanent (permanent neurologic deficit PND), and need of renal replacement therapy (RRT).
Results
Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%), and PNDs in 10 (4.8%). A total of 23 patients (10.9%) needed RRT. Death + PND occurred in 21 patients (10%) and composite endpoint in 35 (19.2%). Intergroup weighed logistic regression analysis showed similar prevalence of deaths, NDs, and death + PND, but need of RRT (odds ratio OR: 7.39, confidence interval CI: 1.37–79.1) and composite endpoint (OR: 8.97, CI: 1.95–35.3) were significantly lower in DHCA + DR group compared with MHCA + ACP group.
Conclusions
The results of our study demonstrate that DHCA + DR has the same prevalence of operative mortality, NE and association of death+PND than MHCA + ACP. However, the data suggests that DHCA + DR when compared with MHCA + ACP provides better renal protection and reduced prevalence of composite endpoint.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
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