Prior reports of mitral valve surgery (MVS) for ischemic papillary muscle rupture (PMR) have been limited in patient numbers. This study evaluated national outcomes of MVS for PMR using The Society ...of Thoracic Surgeons (STS) National Database.
The study cohort was composed of patients undergoing MVS for ischemic PMR between 2011 and 2018 in the STS registry. Concomitant procedures were included. The primary outcome was operative mortality. Secondary outcomes included STS major morbidities. Multivariable logistic regression was employed for risk adjustment using clinically important variables as well as those predictive in univariate analysis.
A total of 1342 patients underwent MVS for PMR during the study period. Most of these were mitral valve replacements (79.8%; n = 1071) and were performed emergently (52.0%; n = 698). Concomitant coronary artery bypass grafting was performed in 59.3% (n = 796). Mechanical circulatory assistance before MVS included intraaortic balloon pump (56.9%; n = 764), Impella pump (4.1%; n = 55), and extracorporeal membrane oxygenation (3.1%; n = 41). The STS predicted risk for mortality was 16.9% ± 15.4%. Operative mortality was 20.0%. Blood products were transfused in 70.7% (n = 949). Major morbidity rates included prolonged ventilation (61.8%; n = 829), acute renal failure (15.4%; n = 206), reoperation (10.2%; n = 137), and stroke (5.2%; n = 70). Multivariable predictors of operative mortality included mitral valve replacement, older age, lower albumin, cardiogenic shock, ejection fraction less than 25%, and emergent salvage status.
These data provide a national overview of outcomes after MVS for PMR. Rates of mortality and morbidity are high, but most patients survive operative intervention in this high-risk and otherwise lethal condition.
Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry.
A total of 7830 adults (mean age, 63.1 ...years, SD 13.1 years) who underwent hemiarch (n = 6891; 88.0%) or total arch (n = 939; 12.0%) replacement with hypothermic circulatory arrest between 2014 and 2016 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (version 2.81). Aortic dissections were excluded from the analysis. Multivariable logistic regression was used to adjust for 29 baseline and operative variables, including demographics, comorbidity, surgery, and nadir temperature, comparing outcomes according to protection strategy. The primary end point was a composite of 30-day and in-hospital mortality or major permanent neurologic complications.
The rate of death or permanent neurologic complication was 10.9% (n = 850). Antegrade cerebral perfusion was most commonly used (n = 3369; 43%; median nadir temperature 23°C; median arrest time 30 minutes) compared with retrograde cerebral perfusion (n = 1898; 24%; 20°C; 24 minutes) and no cerebral perfusion (n = 2563; 33%; 20°C, 22 minutes). In multivariable analysis, deep hypothermia with antegrade (odds ratio OR, 0.65; 95% confidence interval CI, 0.52 to 0.81) or retrograde (OR, 0.57; 95% CI, 0.45 to 0.71) perfusion and moderate hypothermia with antegrade perfusion (OR, 0.61; 95% CI, 0.46 to 0.79) were associated with significant reductions in death and stroke compared with deep hypothermia without cerebral perfusion. Risk reduction was greatest in circulatory arrest lasting longer than 30 minutes.
For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion.
The St. Jude Medical Trifecta bioprosthesis (St. Jude Medical, St. Paul, MN) is a bovine pericardial valve mounted on a titanium stent. The objective of this study was to report a single-center ...experience with the Trifecta aortic valve.
Patients undergoing aortic valve replacement (AVR) with the Trifecta valve between 2011 and 2017 at a single center were included. The primary outcome was overall survival. Secondary outcomes included operative mortality and morbidity, aortic valve reoperations, and reoperation for structural valve deterioration. Echocardiographic outcomes were evaluated. Multivariable logistic regression models were created to identify predictors of death.
The study included 1,953 Trifecta valve implants. Operations included isolated AVR (45% n = 869), AVR plus coronary artery bypass grafting (40% n = 771), and AVR plus mitral valve operation (13% n = 254). Overall survival at 30 days, 1 year, and 5 years was 94.9%, 89.7%, and 69.8%, respectively. Overall freedom from aortic valve reintervention was 96.4% at 5 years, with an overall freedom from reoperation for structural valve deterioration of 98.7% at 5 years. For elective isolated AVRs, survival was 98.6%, 94.1%, and 77.5% at 30 days, 1 year, and 5 years, respectively. The 5-year freedom from aortic valve reintervention and reoperation for structural valve deterioration for elective isolated AVRs was 97.6% and 99.1%, respectively. Overall mean gradients were 6.8 ± 5.3 mm Hg postoperatively and remained low at 10.1 ± 6.2 mm Hg at 1 year.
This is the largest series reporting on outcomes of the Trifecta valve. Our results demonstrate that this valve can be safely implanted in the aortic position with excellent midterm durability and hemodynamics.
Video-assisted thoracoscopic surgery (VATS) is becoming increasingly popular for lung resection in some centers. However, the issue of whether VATS or open thoracotomy is better remains ...controversial. We compared outcomes of open and VATS lobectomy in a national database.
Using the 2004 and 2006 Nationwide Inpatient Sample database, we identified 13,619 discharge records of patients who underwent pulmonary lobectomy by means of thoracotomy (n = 12,860) or VATS (n = 759). Student's t and chi(2) tests were used to compare the two groups. Multivariable analysis was used to identify independent predictors of outcome measures.
The two groups of patients had similar demographics and preoperative comorbidities. They also had similar in-hospital mortality rates (3.1% versus 3.4%; p = 0.67); lengths of stay (9.3 +/- 0.1 versus 9.2 +/- 0.4 days; p = 0.84); hospitalization costs ($23,862 +/- $206 versus $25,125 +/- $1,093; p = 0.16); and rates of wound infection (0.8% versus 1.3%; p = 0.15), pulmonary complications (32.2% versus 31.2%; p = 0.55), and cardiovascular complications (3.4% versus 3.9%; p = 0.43). However, multivariable analysis showed that the VATS group had a significantly higher incidence of intraoperative complications than the thoracotomy group (odds ratio, 1.6; 95% confidence interval, 1.0 to 2.4; p = 0.04). A higher percentage of patients with annual income greater than $59,000 underwent VATS lobectomy than patients with income less than $59,000 (35.7% versus 25.4%; p < 0.0001).
Patients who underwent VATS lobectomy were 1.6 times more likely to have intraoperative complications than patients who underwent open lobectomy. However, short-term mortality, lengths of stay, and hospitalization costs were similar between the two groups of patients. There seems to be a socioeconomic disparity between VATS and open thoracotomy patients.
Objectives Thoracic endovascular aneurysm repair (TEVAR) was introduced in 2005 to treat descending thoracic aortic aneurysms. Little is known about TEVAR's nationwide effect on patient outcomes. We ...evaluated nationwide data regarding the short-term outcomes of TEVAR and open aortic repair (OAR) procedures performed in the United States during a 2-year period. Methods From the Nationwide Inpatient Sample data, we identified patients who had undergone surgery for an isolated descending thoracic aortic aneurysm from 2006 to 2007. Patients with aneurysm rupture, aortic dissection, vasculitis, connective tissue disorders, or concomitant aneurysms in other aortic segments were excluded. Of the remaining 11,669 patients, 9106 had undergone conventional OAR and 2563 had undergone TEVAR. Hierarchic regression analysis was used to assess the effect of TEVAR versus OAR after adjusting for confounding factors. The primary outcomes were mortality and the hospital length of stay (LOS). The secondary outcomes were the discharge status, morbidity, and hospital charges. Results The patients who had undergone TEVAR were older (69.5 ± 12.7 vs 60.2 ± 14.2 years; P < .001) and had higher Deyo comorbidity scores (4.6 ± 1.8 vs 3.3 ± 1.8; P < .001). The unadjusted LOS was shorter for the TEVAR patients (7.7 ± 11 vs 8.8 ± 7.9 days), but the unadjusted mortality was similar (TEVAR 2.3% vs OAR 2.3%; P = 1.0). The proportion of nonelective interventions was similar between the 2 groups (TEVAR 15.9% vs OAR 15.8%; P = .9). The TEVAR and OAR techniques produced similar risk-adjusted mortality rates; however, the TEVAR patients had 60% fewer complications overall (odds ratio, 0.39; P < .001) and a shorter LOS (by 1.3 days). The TEVAR patients' hospital charges were greater by $6713 (95% confidence interval $1869 to $11,556; P < .001). However, the TEVAR patients were 4 times more likely to have a routine discharge to home. Conclusions The nationwide data on TEVAR for descending thoracic aortic aneurysms have associated this procedure with better in-hospital outcomes than OAR, even though TEVAR was selectively performed in patients who were almost 1 decade older than the OAR patients. Compared with OAR, TEVAR was associated with a shorter hospital LOS and fewer complications but significantly greater hospital charges.
Snooker can be an attractive life-long physical activity, given its popularity across all age groups in Asia and Europe. However, scientific research on the cueing movement is limited. This case ...study presented the biomechanical profiles of the cueing movement in an elite male snooker player (age 37 years old, height 173 cm, body mass 70 kg). Kinematics of the upper limb and cue stick, were examined in five selected snooker tasks (warm-up, stun, top spin, back spin, and stop shots) using the Vicon motion capture system. Ground reaction forces and centre of pressure characteristics were recorded using two Kistler force platforms. Results showed that the cueing movement was contributed primarily by elbow flexion/extension and much less wrist flexion/extension. The high degree of cue stick position overlap between the practice swing and final stroke indicated high level of cueing precision. Weight transfer between feet revealed a slight lean towards the left foot throughout the final stroke, confirming that the elite player was able to maintain high stance stability when executing the cueing movement. Results presented in the present study can serve as a reference for practitioners and scientists to detect error, enhance training, and improve performance in snooker. For practical applications, snooker players are advised to stabilise their shoulder during the cueing movement and deliver the cue stick primarily via elbow movements.
Background We performed a meta-analysis of reconstructed time-to-event data from randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing transcatheter versus surgical ...aortic valve replacement (TAVR versus SAVR) to evaluate midterm outcomes in patients considered low risk for SAVR. Methods and Results Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of RCTs and PSM studies published by December 31, 2022 was conducted. Eight studies (3 RCTs, 5 PSM studies) met our eligibility criteria and included 5444 patients; 2639 patients underwent TAVR, and 2805 patients underwent SAVR. TAVR showed a higher risk of all-cause mortality at 8 years of follow-up (hazard ratio HR 1.22, 95% CI, 1.03-1.43,
=0.018). Up to 2 years of follow-up, TAVR was not inferior to SAVR (HR, 1.08 95% CI, 0.89-1.31,
=0.448); however, we observed a statistically significant difference after 2 years with higher mortality with TAVR (HR, 1.51 95% CI, 1.14-2.00;
=0.004). This difference was driven by PSM studies; our sensitivity analysis showed a statistically significant difference between TAVR and SAVR when we included only PSM studies (HR, 1.41 95% CI, 1.16-1.72,
=0.001) but no statistically significant difference when we included only RCTs (HR, 0.89 95% CI, 0.69-1.16,
=0.398). Conclusions In comparison with TAVR, SAVR appeared to be associated with improved survival beyond 2 years in low-risk patients. However, the survival benefit of SAVR was observed only in PSM studies and not in RCTs. The addition of data from ongoing RCTs as well as longer follow-up in previous RCTs will help to confirm if there is a difference in mid- and long-term survival between TAVR versus SAVR in the low-risk population.
Objective Prolonged intubation has been implicated in the poor outcomes after adult cardiac surgery. Accelerated postoperative extubation has been a quality focus, but operating room (OR) extubation ...after cardiopulmonary bypass is rare. We examined the outcomes and direct costs of protocolized OR extubation versus early postoperative intensive care unit (ICU) extubation after nonemergency open cardiac surgery. Methods From January 2012 to June 2013, 652 consecutive patients who had undergone various cardiac operations, including redo and multivalve operations, were extubated within 12 hours, 165 in the OR. The OR extubation patients were propensity matched from multivariable logistic regression to derive 106 matched pairs for OR extubation versus extubation < 12 hours (group 1) and 98 independently matched pairs for OR extubation versus extubation < 6 hours (group 2). Results OR versus ICU extubation conveyed significant reductions in ICU hours (26.3, interquartile range IQR, 22.0-31.0; vs 29.0, IQR, 25.0-51.0; P = .001, for group 1; 27.0, IQR, 22.0-32.0; vs 29.0, IQR, 25.0-54.0; P = .0002, for group 2) and postoperative length of stay (5 days, IQR, 4-6; vs 6 days, IQR, 5-7; P = .0008, for group 1; 5 days, IQR, 4-6; vs 6 days, IQR, 4-7; P = .0002, for group 2) but did not affect the reintubation rate (1.9% 2 of 106 vs 0.0% 0 of 106, P = .5, group 1; 3.1% 3 of 98 vs 2.0% 2 of 98, P = 1.0, group 2). OR versus ICU extubation conferred a >20% cost reduction from surgery completion to discharge ($3055, IQR, $2576-$3964; vs $3977, IQR, $3028-$4947; P = .0007, group 1; $3025, IQR, $2598-$3965, vs $3877, IQR, $2998-$5458; P = .007, group 2). Conclusions After cardiac surgery, OR extubation is safe and might provide improvement in length of stay and cost compared with early postoperative ICU extubation.
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