To examine whether there is an association between prehospital transfer distance and surgical mortality in emergency thoracic aortic surgery.
A retrospective cohort study using a national clinical ...database in Japan was conducted. Patients who underwent emergency thoracic aortic surgery from January 1, 2014, to December 31, 2016, were included. Patients with type B dissection were excluded. A multilevel logistic regression analysis was performed to examine the association between prehospital transfer distance and surgical mortality. In addition, an instrumental variable analysis was performed to address unmeasured confounding.
A total of 12,004 patients underwent emergency thoracic aortic surgeries at 495 hospitals. Surgical mortality was 13.8%. The risk-adjusted mortality odds ratio for standardized distance (mean 12.8 km, standard deviation 15.2 km) was 0.94 (95% confidence interval, 0.87-1.01; P = .09). Instrumental variable analysis did not reveal a significant association between transfer distance and surgical mortality as well.
No significant association was found between surgical mortality and prehospital transfer distance in emergency thoracic aortic surgery cases. Suspected cases of acute thoracic aortic syndrome may be transferred safely to distant high-volume hospitals.
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Abstract
OBJECTIVES
There have been limited data available regarding aortic arch replacement in dialysis patients. The purpose of this study was to examine real-world data and to determine the ...impact of preoperative dialysis status and other risks on surgical aortic arch replacement using the Japan Cardiovascular Surgery Database.
METHODS
A total of 5044 patients who underwent elective, isolated aortic arch replacement using antegrade cerebral perfusion during 2014–2017 were eligible for the study. Of these, 89 patients received haemodialysis preoperatively. The patients were divided into 6 groups according to their preoperative estimated glomerular filtration rate and dialysis status for comparison. Preoperative and postoperative data were examined using a multivariable regression model.
RESULTS
The overall surgical mortality rates of non-Chronic Kidney Disease (CKD) (estimated glomerular filtration rate >60 ml/min/1.73 m2), stage 3A, stage 3B, stage 4, stage 5 CKD and dialysis patients were 2.6%, 3.1%, 6.8%, 11.6%, 16.7% and 13.5%, respectively. After risk adjustment, dialysis was shown to be strongly associated with surgical mortality (odds ratio 4.39 and 95% confidence interval 2.22–8.72) and have a trend to be associated with postoperative stroke (odds ratio 2.02, 95% confidence interval 1.00–4.10, P = 0.051) when compared to the non-CKD group. As predictors of mortality, male sex, peripheral arterial disease, preoperative liver dysfunction and impaired left ventricular function were identified.
CONCLUSIONS
The Japanese nationwide database revealed the outcomes of aortic arch replacement in dialysis patients. Appropriate counselling and an alternative strategy should be considered for such patients with multiple risks for mortality.
Over 2 million people worldwide currently receive treatment with dialysis or a kidney transplant, and this population has been increasing at an annual rate of 4.5% 1.
Background:The present study aimed to clarify the current use and outcomes of coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) based on the Japan Adult Cardiovascular Surgery ...Database (JACVSD) in stratified risk categories, and also to provide guidance on selection of optimal surgical strategies for ACS.Methods and Results:From January 2008 through December 2012, 7,867 isolated CABG procedures for ACS were identifiedfrom the JACVSD. Patients were stratified into 3 subgroups (<2%, 2–9.9%, ≥10%) according to preoperative risk estimations based on this database. Off- and on-pump CABG surgical outcomes were evaluated in each subgroup. Off-pump CABG (OPCAB) was the predominant surgical strategy in all subgroups. The proportion of on-pump beating CABG increased in the higher-risk groups. Although average observed mortality rates were compatible with preoperative estimated risk in all subgroups, those after OPCAB were significantly lower in the medium (2–9.9%) risk group with lower incidence of major complications. In the low (<2%) and high (≥10%) risk groups, observed mortality rates did not show statistically significant differences between off- and on-pump CABG.Conclusions:In this study in Japan, OPCAB was mainly performed in patients with ACS, particularly those with estimated risk <10%, with lower mortality rates, whereas on-pump beating CABG was selected for higher-risk patients with ACS, with reasonable mortality rates.
Background:Perioperative risk during surgical aortic valve replacement (SAVR) is reportedly high in dialysis patients. We aimed to determine the postoperative mortality and morbidity and identify the ...perioperative risk factors of mortality during SAVR in dialysis-dependent patients.Methods and Results:From the Japan Adult Cardiovascular Surgery Database, we compared 2,875 dialysis-dependent patients with 18,839 non-dialysis patients who all underwent SAVR between January 2013 and December 2016. The operative mortality was 8.7% vs. 2.0% in the dialysis and non-dialysis groups, respectively. Multivariate stepwise logistic regression analysis for operative mortality revealed 8 independent risk factors including age (odds ratio OR=1.2), concomitant coronary artery bypass grafting (OR=1.5), peripheral arterial disease (OR=1.9), atrial fibrillation (OR=2.5), New York Heart Association class IV (OR=2.5), liver dysfunction (OR=5.8), reduced left ventricular function (OR=1.4), and history of previous cardiac surgery (OR=2.1). In addition, 8 postoperative predictors of operative mortality were identified including bleeding deep sternal infection (OR=3.4), prolonged ventilation (OR=5.4) and gastrointestinal complications (OR=10.3).Conclusions:Compared with non-dialysis patients, SAVR in dialysis patients was associated with high rates of mortality and morbidity. An appropriate surgical strategy and careful perioperative assessment and management for prevention of infection, and respiratory and gastrointestinal complications might contribute to improved clinical outcomes after SAVR in these patients.
Purpose: Continuous annual reporting on coronary artery bypass grafting (CABG) surgical practice is key for quality control and improvement of clinical results. In this report, Japanese nationwide ...features and trends in the extent of coronary artery disease and the characteristics of those undergoing CABG procedures in 2019 are presented. Clinical results of related ischemic heart disease are also presented.Methods and Results: The Japanese Cardiovascular Surgery Database (JCVSD) is a nationwide surgical case registry system. Data regarding CABG cases in the year 2019 (1 January–31 December) were captured with questionnaires regularly administered by the Japanese Association for Coronary Artery Surgery (JACAS). We analyzed trends in the number and types of grafts selected according to the number of diseased vessels in patients undergoing CABG. We also analyzed descriptive clinical results of those undergoing surgery for acute myocardial infarction or ischemic mitral regurgitation.Conclusions: This is the second publication summarizing the results following the JACAS annual report based on JCVSD Registry data from the year 2019. Clinical outcomes and surgical strategy trends were relatively stable. Further accumulation of information with a similar data collection system is expected.
Background
Cardiovascular surgery for patients with a history of heparin-induced thrombocytopenia (HIT) with thrombosis requires careful perioperative anticoagulation therapy. When cardiovascular ...surgery is required for patients having ‘remote’ HIT, such as those who had a history of HIT and platelet factor-4/heparin antibodies turned out to be negative, it is recommended that re-exposure to heparin should be limited only to the intraoperative phase. However, few case reports have described detailed strategies for perioperative anticoagulation regimens.
Case presentation
We present the case of a 76-year-old woman, presenting with unstable angina pectoris and requiring coronary artery bypass grafting. She had a history of cardiac resuscitation and percutaneous coronary intervention for unstable angina pectoris with ventricular tachycardia 7 years prior, which caused HIT with thrombosis resulting in amputation of four fingers. On admission, platelet factor-4/heparin antibodies, biomarkers for HIT were not detected; the platelet count was 18.0 × 10
4
/µl. Off-pump coronary artery bypass grafting was performed using heparin; argatroban infusion was continued until 9 h prior to the operation and restarted 3 h postoperatively, bridged with regular warfarin from 4 days to 3 months postoperatively. Platelet factor-4 /heparin antibodies were detected on postoperative day 8 without any clinical symptoms and became negative by day 91.
Conclusion
We consider this anticoagulation strategy is effective especially in countries, where bivalirudin is not available. Re-exposure to heparin in cardiovascular surgery for patients with a history of ‘remote HIT’ is reasonable, and appropriate anticoagulation is important for an uneventful postoperative course.
The use of an anastomosis assist device during coronary artery bypass grafting (CABG) is considered less invasive for the ascending aorta than the use of a side-biting clamp (Side-clamp) and to ...possibly be associated with a lower incidence of postoperative stroke. However, this benefit has not yet been clearly demonstrated. This study was to evaluate whether the use of an anastomosis assist device will minimize the postoperative stroke and other complications in patients undergoing off-pump CABG in comparison with the use of the Side-clamp.
Patients undergoing isolated off-pump CABG were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database (2013-2016). We performed a one-to-one matched analysis based on the estimated propensity scores of those who underwent off-pump CABG with an anastomosis assist device (Device group, n = 14 213) or a side-biting clamp (Side-clamp group, n = 7374) and obtained 2 cohorts (n = 7348 each). We compared the early outcomes and the details of postoperative complications using the Pearson's χ2 test. P-values of <0.05 were considered to indicate statistical significance.
No significant differences were observed in the rates of 30-day mortality (Side-clamp versus Device: 0.8% vs 0.8%, P = 0.93) or stroke (1.4% vs 1.4%, P = 0.46). Transient ischaemic attack/reversible ischaemic neurological deficit/delirium occurred more frequently in the Side-clamp group (1.3% vs 0.9%, P = 0.020), whereas new-onset atrial fibrillation (11.0% vs 12.8%, P < 0.001) and prolonged ventilation (2.0% vs 2.9%, P < 0.001) occurred more frequently in the Device group. There was no difference in the length of intensive care unit stay.
The use of an anastomosis assist device partially provided better results with regard to the transient neurological complications; however, no overall benefit was observed in this study.
Objectives
In Japan, off-pump coronary artery bypass (OPCAB) is more common than on-pump coronary artery bypass. Superior early results of OPCAB have been reported; however, long-term results were ...still unclear. Purpose of this study is to evaluate the clinical outcomes of OPCAB in Japan using Japan Adult Cardiovascular Surgery Database.
Methods
Between 2008 and 2010, 23,633 patients who underwent isolated coronary artery bypass were reported in database. We selected the cases from the hospital with mean annual coronary surgery volume of more than 50. Among the total of 7724 cases at 41 institutions, 2150 (31.2%) on-pump coronary artery bypass (ONCAB) and 5574 (68.8%) OPCAB cases were included. Propensity score (PS) matching was performed using PS developed from patient characteristics and preoperative factors resulting in 2007 cases matched pairs. Long-term follow-up data on patients’ mortality and stroke were collected.
Results
In-hospital mortality was significantly lower in OPCAB (ONCAB 1.1%, OPCAB 0.4%
p
= 0.01). Stroke was low in OPCAB group (ONCAB 1.7%, OPCAB 0.8%,
p
= 0.01). There was no statistically significant difference between OPCAB and ONCAB regarding 7-year overall survival (86.1% vs 88.1% respectively), composite outcomes (72.0% vs 73.9% respectively), or cardiac deaths (97.3% vs 97.1% respectively). Subgroup analysis (more than 75 years old) showed a worse trend in OPCAB group. Only in OPCAB group, incomplete revascularization significantly influenced 7-year survival.
Conclusions
OPCAB is associated with early prognostic benefits; however, it might be less favorable outcomes in the long term when patients are older or with incomplete revascularization.
Background
Thoracic and thoracoabdominal aortic diseases are treated using operative procedures like open aortic repair (OAR), thoracic endovascular aortic repair (TEVAR), or hybrid aortic repair ...(HAR), or a combination of OAR and TEVAR. The surgical approach to aortic repair has evolved over the decades. The purpose of this study was to examine the current trends in treatment.
Methods
We extracted nationwide data of aortic repair procedures performed in 2015 and 2016 from the Japan Cardiovascular Surgery Database (JCVSD). In addition to estimating the number of cases, we also reviewed the respective operative mortalities and associated major morbidities (e.g., stroke, spinal cord insufficiency, and renal failure) according to disease pathology (e.g., acute dissection, chronic dissection, ruptured aneurysm, and unruptured aneurysm), site of operative repair (i.e., aortic root, ascending aorta, aortic root to arch, aortic arch, descending aorta, and thoracoabdominal aorta), and the preferred surgical approach (i.e., OAR, HAR, or TEVAR).
Results
The total number of cases studied was 35,427, with an overall operative mortality rate of 7.3%. Among the 3 procedures, 64% of patients were treated with OAR. Compared to the data from our previous report (also derived from the JCVSD in 2013 and 2014), the total number of cases and number of OAR, HAR, and TEVAR procedures have increased by 17.0%, 2.4%, 126.1%, and 34.9%, respectively. While the overall stroke rates following aortic arch surgical repair with HAR, OAR, and TEVAR were 10.1%, 8.4%, and 7.3%, respectively, OAR was found to have the lowest stroke rate when limited to cases presenting with a non-dissected/unruptured aorta. The incidence rates of paraplegia following descending/thoracoabdominal aortic surgical repair using HAR, OAR, and TEVAR were 6.3%/10.4%, 4.3%/8.9%, and 3.4%/4.6%, respectively. TEVAR was found to be associated with the lowest incidence of postoperative renal failure.
Conclusions
The number of operations for thoracic and thoracoabdominal aortic diseases has increased, though the rate of operations using an OAR approach has decreased. While TEVAR showed the lowest mortality and morbidity rates, OAR demonstrated the lowest postoperative stroke rate for non-dissecting aortic arch aneurysms.
Background
Ischemic papillary muscle rupture (PMR) is a catastrophic complication following acute myocardial infarction (AMI). We evaluated early outcomes of PMR by using data from the Japan ...Cardiovascular Surgery Database, a nationwide Japanese registry.
Methods
We retrospectively analyzed data from 196 patients diagnosed with PMR following AMI in Japan between January 2014 and December 2017. Risk factors for operative mortality and severe complications following mitral valve surgery were analyzed.
Results
The 30-day and hospital mortality rates were 20% and 26%, respectively. Chronic hemodialysis, abrupt rupture after AMI, resuscitation before surgery, and preoperative venoarterial extracorporeal membrane oxygenation were associated with mortality. Mitral valve replacement was chosen mainly (90%) for surgical correction of mitral regurgitation in these patients. There was no significant difference in short-term outcomes between mitral valve replacement versus mitral valve repair, despite non-matched characteristics in background between the treatment groups. Concomitant coronary artery bypass grafting had no impact on short-term outcomes.
Conclusions
Information derived from the nationwide database of patients with AMI-associated PMR show that PMR is a rare condition in the modern era. However, PMR is a severe disease with a mortality rate as high as 26%. The severity of the condition is associated with the risk for poor outcomes.
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