Background Established endovascular treatments for aortic dissection often result in incomplete aortic repair, potentially leading to late complications involving the distal aorta. To address the ...problems of incomplete true lumen reconstitution and late aneurysmal change, we report the midterm results of combined proximal endografting with distal true lumen bare-metal stenting (STABLE: Staged Total Aortic and Branch vesseL Endovascular reconstruction) in Stanford type A and B aortic dissection. Methods Between January 2003 and January 2010, 31 patients underwent staged total aortic and branch vessel endovascular reconstruction for management of acute (type A, 13; type B, 11) and chronic (type B, 7) aortic dissection. Proximal endografting was combined with bare-metal Z stent implantation in the distal true lumen. Patients with type A dissection underwent adjunctive treatment at operation. Computed tomography angiography was performed at baseline, 1 year, and annually thereafter to assess aortic remodelling. Results Primary technical success was 97%. Thirty-day rates of death, stroke, and permanent paraplegia/paresis were 3% (n = 1), 0%, and 0%, respectively. Mean follow-up was 57.3 months (range, 5 to 100 months). Overall survival was 60% at 100 months. Aortic-specific survival was 93%. Four patients (13%) underwent device-related reintervention. One (3%) late aortic-related death occurred. Thoracic ( p = 0.64) and abdominal ( p = 0.14) aortic dimensions were stable. The true lumen index increased significantly at follow-up. Conclusions Staged total aortic and branch vessel endovascular reconstruction is a feasible ancillary endovascular technique to address the problems of distal true lumen collapse, incomplete aortic remodelling, and late aneurysm formation in aortic dissection.
The choice of a bioprosthetic valve (BV) or mechanical valve (MV) in middle-aged adults undergoing aortic valve replacement is a complex decision that must account for numerous prosthesis and patient ...factors. A systematic review and meta-analysis was performed to compare long-term survival, major adverse prosthesis-related events, anticoagulant-related events, major bleeding, reoperation, and structural valve degeneration in middle-aged patients receiving a BV or MV. A comprehensive search from six electronic databases was performed from their inception to February 2016. Results from patients aged less than 70 years undergoing aortic valve replacement with a BV or MV were included. There were 12 studies involving 8,661 patients. Baseline characteristics were similar. There was no significant difference in long-term survival among patients aged 50 to 70 or 60 to 70 years. Compared with MVs, BVs had significantly fewer long-term anticoagulant-related events (hazard ratio HR 0.54, p = 0.006) and bleeding (HR 0.48, p < 0.00001) but significantly greater major adverse prosthesis-related events (HR 1.82, p = 0.02), including reoperation (HR 2.19, p < 0.00001). The present meta-analysis found no significant difference in survival between BVs and MVs in patients aged 50 to 70 or 60 to 70 years. Compared with MVs, BVs have reduced risk of major bleeding and anticoagulant-related events but increased risk of structural valve degeneration and reoperation. However, the mortality consequences of reoperation appear lower than that of major bleeding, and recent advances may further lower the reoperation rate for BV. Therefore, this review supports the current trend of using BVs in patients more than 60 years of age.
Objectives This study sought to investigate a novel method to calculate the index of microcirculatory resistance (IMR) in the presence of significant epicardial stenosis without the need for balloon ...dilation to measure the coronary wedge pressure (Pw ). Background The IMR provides a quantitative measure of coronary microvasculature status. However, in the presence of significant epicardial stenosis, IMR calculation requires incorporation of the coronary fractional flow reserve (FFRcor ), which requires balloon dilation within the coronary artery for Pw measurement. Methods A method to calculate IMR by estimating FFRcor from myocardial FFR (FFRmyo ), which does not require Pw measurement, was developed from a derivation cohort of 50 patients from a single institution. This method to calculate IMR was then validated in a cohort of 72 patients from 2 other different institutions. Physiology measurements were obtained with a pressure-temperature sensor wire before coronary intervention in both cohorts. Results From the derivation cohort, a strong linear relationship was found between FFRcor and FFRmyo (FFRcor = 1.34 × FFRmyo − 0.32, r2 = 0.87, p < 0.001) by regression analysis. With this equation to estimate FFRcor in the validation cohort, there was no significant difference between IMR calculated from estimated FFRcor and measured FFRcor (21.2 ± 12.9 U vs. 20.4 ± 13.6 U, p = 0.161). There was good correlation (r = 0.93, p < 0.001) and agreement by Bland-Altman analysis between calculated and measured IMR. Conclusions The FFRcor , and, by extension, microcirculatory resistance can be derived without the need for Pw . This method enables assessment of coronary microcirculatory status before or without balloon inflation, in the presence of epicardial stenosis.
Background We performed the present systematic review and meta-analysis of randomized and nonrandomized comparative studies in an attempt to compare the safety and efficacy of drug-eluting stents ...with coronary artery bypass grafting for patients with coronary artery disease. Methods Twenty-five eligible comparative studies (1 randomized and 24 nonrandomized) were assessed. Two reviewers independently appraised each study. Meta-analysis was performed by combining the results of reported incidence of morbidity, mortality, and repeat revascularization. The relative risk was used as a summary statistic. Results In these 25 studies 34,278 patients were compared, of whom 18,538 received drug-eluting stents and 15,740 underwent coronary artery bypass grafting. It must be acknowledged that this comparison represented a selected group of patients who received drug-eluting stents or underwent coronary artery bypass grafting. The accumulative incidences of all-cause mortality at 12 months (4.5% vs 4.0%, P = .92) and 24 months (6.2% vs 8.4%, P = .27) and 30-day myocardial infarction (1.4% vs 2.0%, P = .60) were similar, respectively, between the drug-eluting stent and coronary artery bypass grafting groups. Drug-eluting stents were associated with lower rates of all-cause mortality at 30 days (0.9% vs 2.3%, P < .001), stroke (0.4% vs 1.7%, P < .001), and 30-day major adverse cardiac and cerebrovascular events (3.6% vs 5.5%, P < .04). However, the coronary artery bypass grafting group had a lower incidence of postprocedural myocardial infarction (5.5% vs 4.7%, P = .03), repeat revascularization (22.2% vs 4.1%, P < .001), and 12-month major adverse cardiac and cerebrovascular events (16.7% vs 10.5%, P < .001). Subgroup analysis of patients with multivessel coronary artery disease showed similar results. Conclusions Drug-eluting stents are associated with less periprocedural risks but a higher incidence of postprocedural myocardial infarction, repeat revascularization, and 12-month major adverse cardiac and cerebrovascular events compared with coronary artery bypass grafting.
Background Transcatheter aortic valve implantation (TAVI) can cause profound haemodynamic perturbation in the peri-operative period. Veno-arterial extracorporeal membrane oxygenation (ECMO) can be ...used to provide cardiorespiratory support during this time, either prophylactically or emergently. Method 100 TAVI procedures were performed between 2009 and 2013 in our institution. ECMO was used in 11 patients, including eight prophylactic and three rescue cases. Rescue ECMO was required for ventricular fibrillation after valvuloplasty, and aortic annulus rupture. The criteria for prophylactic ECMO included heart failure requiring stabilisation pre-TAVI, haemodynamic instability with balloon aortic valvuloplasty performed to improve heart function pre-TAVI, moderate or severe left and/or right ventricular failure, or borderline haemodynamics at procedure. Differences in preoperative characteristics and postoperative outcomes between ECMO and non-ECMO TAVI patients were compared, and significant results were further assessed controlling for EuroSCORE. Results Compared to TAVI patients who did not require ECMO, ECMO patients had significantly higher mean EuroSCORE (51 vs. 30%, p < .05). Postoperative outcomes, however, were largely comparable between the two groups. All-cause mortality occurred in nil prophylactic ECMO patients, one rescue ECMO patient, and two non-ECMO patients. The difference in mortality between ECMO and non-ECMO patients was not significantly different (9 vs. 2%; p > .05). ECMO patients were more likely to develop acute renal failure than non-ECMO patients (36 vs. 8%, p < .05), which was most likely due to haemodynamic collapse and end-organ dysfunction in patients that required ECMO rescue. Conclusions Instituting prophylactic ECMO in selected very high-risk patients may help avoid consequences of intra-operative complications and the need for emergent rescue ECMO.
Background The elderly population (age >70 years) incurs greater mortality and morbidity following CABG. Off-pump coronary artery bypass (OPCAB) may mitigate these otucomes. A retrospective analysis ...of the results of OPCAB in this population was performed. Methods We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons’ (ANZSCTS) database for elderly patients (n=12697) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=11676) with OPCAB (n=1021) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analyses was performed after cross-matching the database with the national death registry to identify long-term mortality. Results High-risk patients were more prevalent in the ONCAB group (p<0.05). OPCAB patients received fewer distal anastomoses than ONCAB patients (2.4±1.1 vs 3.3±1.0, p<0.001). Thirty-day mortality and stroke rates between OPCAB and ONCAB were not significantly different (2% vs 2.5% and 1.1% vs 1.8%, respectively). There was a non-significant trend towards improved 10-year survival in OPCAB patients using multivariate analysis (78.8% vs. 73.3%, p=0.076, HR 0.83; 95% CI 0.67-1.02). Conclusions Mortality and stroke rates following CABG surgery are extremely low in the elderly suggesting that surgery is a safe management option for coronary artery disease in this population. OPCAB did not offer a significant advantage over ONCAB with regards to 30-day mortality, stroke and long-term survival. Further prospective randomised trials will be necessary to clarify risks or benefits in the elderly.
Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes ...in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their “chronological age”, without considering the patient's true “biological age”.
Background Coronary artery bypass graft surgery (CABG) has been established as the preferred intervention for coronary revascularisation in the high-risk population. Off-pump coronary artery bypass ...(OPCAB) may further reduce mortality and morbidity in this population subgroup. This study presents the largest series of high-risk (AusSCORE > 5) OPCAB patients in Australia and New Zealand. Methods We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons’ (ANZSCTS) database for high-risk patients (n=7822) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=7277) with the OPCAB (n=545) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analysis was performed after cross-matching the database with the national death registry to identify long-term mortality. Results The ONCAB and OPCAB groups had similar risk profiles based on the AusSCORE. Thirty-day mortality (ONCAB vs OPCAB 3.9% vs 2.4%, p=0.067) and stroke (ONCAB vs OPCAB 2.4% vs 1.3%, p=0.104) were similar between the two groups. OPCAB patients received fewer distal anastomoses than ONCAB patients (2.5±1.2 vs 3.3±1.0, p<0.001). The rates of new postoperative atrial arrhythmia (28.3% vs 33.3%, p=0.017) and blood transfusion requirements (52.1% vs 59.5%, p=0.001) were lower in the OPCAB group, while duration of ICU stay in hours (97.4±187.8 vs 70.2±152.8, p<0.001) was longer. There was a non-significant trend towards improved 10-year survival in OPCAB patients (74.7% vs. 71.7%, p=0.133). Conclusions In the high-risk population, CABG surgery has a low rate of mortality and morbidity suggesting that surgery is a safe option for coronary revascularisation. OPCAB reduces postoperative morbidity and is a safe procedure for 30-day mortality, stroke and long-term survival in high-risk patients.
Background Valve sparing aortic root reconstruction (VSARR) has become an alternative to traditional aortic root replacement with a valved conduit. There have been various modifications but the two ...broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia. Methods We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained five- and 10-year survival estimates by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index. Results Between January 2001 and January 2012, 169 consecutive patients underwent VSARR procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, nine patients (5.9%) died within 30 days post procedure and five patients (3%) had permanent strokes. However, out of 132 elective cases, only five patients died (3.8%). Independent predictors of 30-day mortality were female gender OR 5.65(1.24-25.80), p=0.025, preoperative atrial arrhythmia OR 6.07(1.14-32.35), p=0.035 and acute type A aortic dissection OR 7.71(1.63-36.54), p=0.01. Long-term survival was estimated as 85.3% and 72.7% at five- and 10-years, respectively. Conclusions Along with an acceptable rate of early mortality and stroke, VSARR procedures provide good long-term survival according to the ANZSCTS database. As promising procedure for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery.
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