Objectives Antegrade cerebral perfusion and hypothermic circulatory arrest, with or without retrograde cerebral perfusion, are 2 major types of brain protection that are used during aortic arch ...surgery. We conducted a comparative study of these methods in patients undergoing total arch replacement to evaluate the clinical outcomes in Japan, based on the Japan Adult Cardiovascular Surgery Database. Methods A total of 16,218 patients underwent total arch replacement between 2009 and 2012. Patients with acute aortic dissection or ruptured aneurysm, or who underwent emergency surgery were excluded, leaving 8169 patients for analysis. For the brain protection method, 7038 patients had antegrade cerebral perfusion and 1141 patients had hypothermic circulatory arrest/retrograde cerebral perfusion. A nonmatched comparison was made between the 2 groups, and propensity score analysis was performed among 1141 patients. Results The matched paired analysis showed that the minimum rectal temperature was lower in the hypothermic circulatory arrest/retrograde cerebral perfusion group (21.2°C ± 3.7°C vs 24.2°C ± 3.2°C) and that the duration of cardiopulmonary bypass and cardiac ischemia was longer in the antegrade cerebral perfusion group. There were no significant differences between the antegrade cerebral perfusion and hypothermic circulatory arrest/retrograde cerebral perfusion groups with regard to 30-day mortality (3.2% vs 4.0%), hospital mortality (6.0% vs 7.1%), incidence of stroke (6.7% vs 8.6%), or transient neurologic disorder (4.1% vs 4.4%). There was no difference in a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, stroke, and infection (antegrade cerebral perfusion 28.4% vs hypothermic circulatory arrest 30.1%). However, hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a significantly higher rate of prolonged stay in the intensive care unit (>8 days: 24.2% vs 15.6%). Conclusions Hypothermic circulatory arrest/retrograde cerebral perfusion and antegrade cerebral perfusion provide comparable clinical outcomes with regard to mortality and stroke rates, but hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a higher incidence of prolonged intensive care unit stay. Antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures.
The present study aimed to determine whether aortic cross-clamp duration (ACCD) was directly related to postoperative morbidity and mortality rates and to identify the inflection point of ACCD for ...increased mortality and morbidity rates in patients who had undergone isolated aortic valve replacement (AVR) for aortic stenosis.
From the Japan Cardiovascular Surgery Database, we extracted data from 16,272 patients with AS who underwent isolated AVR between January 2008 and December 2012. We evaluated postoperative mortality and morbidity rates after stratifying patients into five groups based on ACCD (<60 minutes, ≥60 to <90 minutes, ≥90 to <120 minutes, ≥120 to <150 minutes, and ≥150 minutes).
The overall hospital mortality rate was 2.8%. Multivariate logistic analysis revealed that the odds ratio for operative mortality increased as ACCD incrementally increased and was markedly higher for ACCD of 150 minutes or longer (odds ratio, 2.68; 95% confidence interval, 1.66 to 4.32; p < 0.001). There were significant increases in risks of reoperation for bleeding for ACCD of120 minutes or longer, stroke for ACCD of 60 minutes or longer, deep sternal infection for ACCD of 120 minutes or longer, ventilation for more than 24 hours for ACCD of 90 minutes or longer, and new requirement for dialysis for ACCD of 150 minutes or longer.
Prolonged ACCD offers an independent predictor of postoperative morbidity and mortality after isolated AVR for AS despite recent technologic advances and surgical refinements.
The Japan Cardiovascular Surgery Database (JCVSD) is a nationwide benchmarking project to improve the quality of cardiovascular surgery in Japan. This study aimed to develop new JACVD risk models not ...only for operative mortality but also for each postoperative complication for coronary artery bypass grafting (CABG) operations, valve operations, and thoracic aortic operations.
We analyzed 24,704 isolated CABG operations, 26,137 valve operations, and 18,228 thoracic aortic operations. Risk models were developed for each operation for operative death, permanent stroke, renal failure, prolonged ventilation (>24 hours), deep sternal wound infection, and reoperation for bleeding. The population was divided into an 80% development sample and a 20% validation sample. The statistical model was constructed by multiple logistic regression analysis. Model discrimination was tested using the area under the receiver operating characteristic curve (C index).
The 30-day mortality rates for isolated CABG, valve, and thoracic aortic operations were 1.5%, 2.5%, and 6.0%, respectively, and operative mortality rates were 2.4%, 3.8%, and 8.4%, respectively. The C indices for the end points of isolated CABG, valve, and aortic thoracic operations were 0.6358 for (deep sternal infection) to 0.8655 (operative mortality), 0.6114 (reoperation for bleeding) to 0.8319 (operative death), and 0.6311 (gastrointestinal complication) to 0.7591 (operative death), respectively.
These risk models increased the discriminatory power of former models. Thus, our models can be said to reflect the current state of Japan. With respect to major complications, useful feedback can now be provided through the Japan Cardiovascular Surgery Database Web-based system.
We evaluated the current results and the predictors of in-hospital complications for a pericardiectomy procedure for constrictive pericarditis in Japan.
A total of 346 patients who underwent isolated ...pericardiectomy for constrictive pericarditis nationwide between 2008 and 2012 were identified from the Japan Adult Cardiovascular Surgery Database.
The patients were a mean age of 65.7 ± 11.7 years. The operative approach was through a median sternotomy in 90% of the patients. Cardiopulmonary bypass was used in 28.9%. The operative mortality rate was 10.0%, and the composite operative mortality or major morbidity (stroke, reoperation for bleeding, need for mechanical ventilation for more than 24 hours postoperatively due to respiratory failure, renal failure with newly required dialysis or mediastinitis) was 15.0%. Logistic regression analysis revealed that the predictive factors for composite operative mortality or major morbidity were preoperative chronic lung disease (odds ratio OR, 4.75; p < 0.001), New York Heart Association functional class IV (OR, 3.85; p < 0.001), previous cardiac operation (OR, 2.68; p = .006), preoperative renal failure (OR, 2.62; p = .014), and cardiopulmonary bypass during the operation (OR, 2.46; p = .015). The frequency of using cardiopulmonary bypass was 2.9% in the patients treated through a left thoracotomy approach vs 31.8% in the patients treated through a median sternotomy approach (p < 0.0001).
Pericardiectomy is associated with high morbidity and mortality rates. Careful consideration should be given to these risk factors in the process of patient selection and perioperative management.
Abstract Objective Using data from the Japan Adult Cardiovascular Surgery Database, we evaluated the prognostic influence of off-pump technique in patients with low ejection fraction who underwent ...coronary artery bypass grafting. Methods We analyzed 2187 patients with an ejection fraction <0.30 who underwent primary, nonemergency, isolated coronary artery bypass grafting between 2008 and 2012, as reported in the Japan Adult Cardiovascular Surgery Database. Patients were divided into on-pump (n = 1134; 51.1%) and off-pump (n = 1053; 48.9%) coronary artery bypass grafting groups. Propensity-score matching for 20 preoperative variables was performed, and early mortality and morbidity were compared between matched groups. Results Propensity-score matching created 918 pairs. Of the 918 patients in the off-pump group, conversion to an on-pump procedure occurred in 56 (6.1%). Compared with on-pump, off-pump technique was associated with significantly lower incidences of 30-day death (1.7% vs 3.7%; P = .01), operative death (3.3% vs 6.1%; P = .006), mediastinitis (1.9% vs 3.4%; P = .041), reoperation for bleeding (0.9% vs 3.5%; P < .001), and prolonged ventilation (8.2% vs 13.4%; P < .001). Comparison of patients undergoing off-pump versus on-pump procedures demonstrated no significant differences in the incidence of stroke (1.5% vs 2.1%; P = .38), renal failure (6.1% vs 7.4%; P = .26), and postoperative dialysis (3.1% vs 4.4%; P = .14). Institutional volume-adjusted analysis confirmed most of these results. Conclusions Off-pump coronary artery bypass grafting is associated with significantly reduced early mortality and morbidity in patients with an ejection fraction <0.30.
Adverse effects of previous percutaneous coronary intervention (PCI) on clinical outcomes after coronary artery bypass grafting (CABG) are unclear. This study aimed to evaluate the effect of previous ...PCI on early outcomes after subsequent CABG by using data from the Japanese national database.
This study analyzed data from 48,051 consecutive patients that were retrieved from the Japan Adult Cardiovascular Surgery Database. These patients underwent primary, isolated, elective CABG between January 2008 and December 2013. Early mortality and morbidity rates in patients with previous PCI (n = 12,457, 25.9%) were compared with those in patients with no PCI (n = 35,594, 74.1%) by using multivariate logistic regression analysis and propensity score analysis.
Operative mortality rates (no PCI, 1.2%; previous PCI, 1.2%; P = 0.970) and morbidity rates (no PCI, 7.4%; previous PCI, 7.2%; p = 0.436) were similar between the two groups. In risk-adjusted multivariate logistic-regression analysis, previous PCI (odds ratio OR, 1.00; 95% confidence interval CI, 0.82 to 1.22; p = 0.995) and morbidity (OR, 0.97; 95% CI, 0.89 to 1.05; p = 0.391) were not significant risk factors of operative mortality. Inverse probability of treatment weighting using the propensity score confirmed these results.
This study shows that a previous PCI procedure does not increase postoperative adverse events after subsequent CABG. In the setting of repeat coronary revascularization, the most appropriate method of revascularization should be selected by the heart team, without being affected by a history of a previous PCI procedure.
Risk models of coronary artery bypass grafting (CABG) using a large database are useful for improving surgical quality. To obtain accurate, high-quality assessments of the surgical outcomes, each ...country should maintain its own database. This study was conducted to collect Japanese data and prepare a risk stratification of isolated CABG procedures using the Japan Adult Cardiovascular Surgery Database (JACVSD).
We analyzed 7133 CABG-only records from 97 participating sites throughout Japan using a data entry form with 255 variables that was sent to the JACVSD office by our Web-based data collection system. The statistical model was constructed by multiple logistic regression. Model discrimination was tested using the area under the receiver operating characteristic curve (C index). Model calibration was tested by the Hosmer-Lemeshow test.
Of 7133 operations, 47.2% had diabetes mellitus, 14.0% were urgent, and 15.6% involved peripheral vascular disease. The observed 30-day and operative mortality rates were 2.02% and 2.72%, respectively. Significant variables with high odds ratios included emergency or salvage status (3.71), preoperative creatinine value exceeding 3.0 mg/dL (3.59), aortic valve stenosis (3.01), and moderate to severe chronic lung disease (2.86). Hosmer-Lemeshow test and C-index values for 30-day mortality were satisfactory at 0.96 and 0.85, respectively.
The results obtained in Japan were at least as good as those reported elsewhere. The performance of our risk model also matched those of the Society of Thoracic Surgeons National Adult Cardiac Database and the European Society Database.
Postoperative atrial fibrillation (POAF) increases considerably the chances of morbidity and mortality after cardiac surgery. The objective of this study was to identify the major risk factors ...responsible for POAF after thoracic aortic surgery in order to define preventive measures.
We analyzed 12,260 records (between January 1, 2004, and December 31, 2008) obtained from the Japan Adult Cardiovascular Surgery Database. Patients with history of AF were excluded. Data were collected for 12 preoperative and 10 operative risk factors that had been proven or believed to influence POAF. The relationship between the risk factors and outcome was assessed by the Fisher exact test, Student t test, and multiple logistic regression analysis.
The patients' mean age (± standard deviation) was 67.5 ± 12.7 years, and 27% of the subjects were women. The incidence of POAF was 17.1%. The following risk factors were associated with increased POAF: age (p < 0.0001), history of smoking (p < = 0.020), hypertension (p = 0.020), congestive heart failure (p < 0.0001), urgent operation (p = 0.023), and concomitant with nonelective coronary artery bypass (p = 0.022). Postoperative mortality and postoperative stroke were significantly increased in patients with POAF (p < 0.0001 in both cases). The odds ratios for the POAF risk factors were as follows: replacement of the ascending aorta, 1.67; aortic arch, 1.62; aortic root, 1.42; concomitant with valve operation, 1.35; age, 1.27; and urgent operation, 1.22.
Several risk factors contribute to the incidence of POAF after thoracic aortic surgery. We found that POAF significantly increased 30-day operative mortality (p < 0.0001). Our findings can be used to develop a risk stratification system for the prediction of POAF.
We report a case of aortic stenosis associated with ochronosis in a 70-year-old man who underwent biologic aortic valve replacement. Intraoperative findings included ochronosis of a severely ...calcified pigmented aortic valve along with pigmentation of the intima of the aorta.
Objectives Cardiovascular allografts in the young have limited durability because of early graft calcification. The objective of this study was to examine the hypothesis that growth-associated ...hyperphosphatemia in youth accelerates aortic allograft calcification by osteogenic transformation of graft medial smooth muscle cells (SMCs). Methods The descending aortas of donor rats were subcutaneously transplanted into recipients. Syngeneic (Lewis-to-Lewis) transplantations between 3-week-old “young” (Y) rats and between 10-week-old “adult” (A) rats were combined with standard (ST, 0.9% phosphate) and low-phosphate (LP, 0.2%) diets, resulting in Y-ST, Y-LP, and A-ST groups. Allotransplantations (Brown-Norway–to–Lewis) involving these ages and diets were also made. The grafts and sera were retrieved from recipients after 14 days. Cultured rat aortic SMCs were used to analyze the effects of tumor necrosis factor-alpha (TNF-α) and phosphate on SMC calcification. Results In vivo, serum phosphate levels were higher in Y-ST (11.5 mg/dL) than those in Y-LP (8.9 mg/dL) and A-ST (8.5 mg/dL). Graft medial calcification appeared severe only in Y-ST. Allotransplants did not affect these outcomes. Graft medial cells showed phenotypic changes (contractile to synthetic) and osteogenic transformation (α-smooth muscle actin to Runx2 and osteocalcin), together with up-regulated proinflammatory TNF-α and sodium–phosphate cotransporter, Pit-1, despite ages and diets. In vitro, TNF-α induced phenotypic changes and osteogenic transformation of SMCs with Pit-1 up-regulation, but SMC calcification occurred only with high phosphate (4.5 mmol/L). Conclusions Growth-associated hyperphosphatemia with inflammatory responses may be essential for accelerating allograft calcification in youth and could be a therapeutic target.
PDF
