OBJECTIVES
This study evaluated the effect of preoperative symptoms on long-term survival and valve reintervention in patients undergoing aortic valve repair (AVr) for severe degenerative aortic ...insufficiency (AI).
METHODS
Between March 1996 and June 2010, 274 patients underwent AVr for severe AI. Seventy-seven were performed in asymptomatic patients (Group I) and 197 were performed in symptomatic (Group II). Patients in Group I were younger (43.9 ± 15.0 vs 54.1 ± 15.5 years; P < 0.001) with a higher proportion of bicuspid valves (n = 40, 51.9% vs n = 68, 30.4%; P = 0.008). Group II had more patients with impaired left ventricular (LV; n = 36, 18.3% vs n = 5, 6.4%; P = 0.013). The mean follow-ups for Group I and Group II were 43.0 ± 34.0 and 61.3 ± 39.5 months, respectively.
RESULTS
There was no in-hospital mortality. Overall, leaflet repair and reimplantation were higher in Group I (P = < 0.001 and P = 0.002, respectively), whereas subcommissural annuloplasty for tricuspid AV was higher in Group II (P = 0.002). Leaflet shaving and plication were performed in more patients in Group I (P = 0.002 for both). There was no difference in early complications, but during follow-up atrial fibrillation was more frequent in Group II (P = 0.03). There were 10 late cardiac deaths, all in Group II (P = 0.04). Overall, 10-year cardiac survival was better in Group I (100 vs 77.3 ± 8.6%) but not significant (P = 0.1). At 10 years, freedom from ≥AI2+ was 63.2 ± 8.1 vs 56.4 ± 4.5% (P = 0.4), and freedom from AV reintervention was 81.8 ± 7.1 vs 89.0 ± 2.8% (P = 0.36), in Groups I and II, respectively. In the whole cohort, 10-year freedom from AV reintervention was greater in patients with an end-diastolic diameter of <60 mm (90.0 ± 7.6 vs 76.3 ± 5.5%; P = 0.003). Multivariate analysis identified increasing age as the only independent predictor of overall survival (P = 0.03). The incidence of valve-related complications was similar.
CONCLUSION
In asymptomatic patients with severe degenerative AI, AVr is associated with excellent long-term outcomes, while symptoms are associated with reduced long-term survival. In dilated LV, freedom from reoperation is lower. If feasible, early AVr is recommended in experienced centres.
Objective‘Core information sets’ (CISs) represent baseline information, agreed by patients and professionals, to stimulate individualised patient-centred discussions. This study developed a CIS for ...use before colorectal cancer (CRC) surgery.DesignThree phase consensus study: (1) Systematic literature reviews and patient interviews to identify potential information of importance to patients, (2) UK national Delphi survey of patients and professionals to rate the importance of the information, (3) international consensus meeting to agree on the final CIS.SettingUK CRC centres.ParticipantsPurposive sampling was conducted to ensure CRC centre representation based upon geographical region and caseload volume. Responses were received from 63/81 (78%) centres (90 professionals). Adult patients who had undergone CRC surgery were eligible, and purposive sampling was conducted to ensure representation based on age, sex and cancer location (rectum, left and right colon). Responses were received from 97/267 (35%) patients with a wide age range (29–87), equal sex ratio and cancer location. Attendees of the international Tripartite Colorectal Conference were eligible for the consensus meeting.OutcomesPhase 1: Information of potential importance to patients was extracted verbatim and operationalised into a Delphi questionnaire. Phase 2: Patients and professionals rated the importance information on a 9-point Likert scale, and resurveyed following group feedback. Information rated of low importance were discarded using predefined criteria. Phase 3: A modified nominal group technique was used to gain final consensus in separate consensus meetings with patients and professionals.ResultsData sources identified 1216 pieces of information that informed a 98-item questionnaire. Analysis led to 50 and 23 information domains being retained after the first and second surveys, respectively. The final CIS included 11 concepts including specific surgical complications, short and long-term survival, disease recurrence, stoma and quality of life issues.ConclusionsThis study has established a CIS for professionals to discuss with patients before CRC surgery.
Background We sought to determine the long-term performance of homograft and truncal valve after complete repair of common arterial trunk. Methods From January 1964 to June 2008, 32 patients (median ...age, 14 days; range, 5 days to 2.5 years) underwent primary homograft repair of common arterial trunk. Twenty-four (75%) were neonates. The homograft used in the right ventricular outflow tract was aortic in 24 patients and pulmonary in 8 patients (mean diameter, 15.8 ± 3.5 mm; median diameter, 16 mm range, 8–24 mm). The median follow-up was 24.5 years (range, 5.6 months to 43.5 years). Results There were 3 hospital deaths and 1 late death. The actuarial survival at 30 years was 83.1% ± 6.6%. Of the 28 survivors, 25 reoperations were performed in 19 (76%) patients. The mean and median times to homograft reoperation were 11.5 ± 7.4 and 12.1 years (range, 1.0–26.1 years), respectively. Overall freedom from homograft reoperation after 10, 20, and 30 years was 68.4% ± 8.7%, 37.4% ± 9.5%, and 26.7% ± 9.3%, respectively. Twelve patients retained the original homografts at a median follow-up of 16.4 years (range, 0–30.2 years). Six underwent a truncal valve replacement with a mechanical prosthesis at a median of 10.5 years (range, 3.4–22 years) after truncus repair. Freedom from truncal valve replacement at 10 and 30 years was 93.1% ± 4.7% and 81.8% ± 8.9%, respectively. In the 22 surviving patients who did not undergo truncal valve replacement, the peak truncal valve gradient was 8.9 ± 8.3 mm Hg at a median follow-up of 24.5 years (range, 5.6 months to 32.9 years). At the last follow-up, 27 (96.4%) patients had good left ventricular function, and 24 patients (85.7%) were New York Heart Association class I. Conclusions Oversizing the homograft at the time of the initial repair can lead to a homograft lasting more than 12 years. During long-term follow-up, 20% of patients require truncal valve replacement.
Abstract
Objective: The Carpentier-Edwards (CE) Physio II ring is a new prosthetic ring designed to accommodate the changing pathology seen in the spectrum of degenerative valve disease, particularly ...the larger anterior leaflet in repair of the Barlow valve. The aim of our study was to assess the safety and efficacy of mitral valve (MV) repair with the CE Physio II ring. Methods: Between April 2009 and March 2010, 100 patients underwent MV repair using the Physio II ring. Median age of patients was 70 years (54-85 years). The left ventricle (LV) was moderately (30-50%; n = 21) or severely (<30%; n = 6) impaired in 27 patients preoperatively. Mitral regurgitation (MR) was due to degenerative disease in 87 patients (bileaflet prolapse: 34 patients). Mean logistic EuroSCORE was 10.07 ± 8.9 and mean follow-up was 6.3 ± 2.4 months. Results: Seventeen patients were non-elective (eight emergencies), five were re-do operations and 23 Maze ± pulmonary vein isolations, and 14 tricuspid annuloplasties were performed. Neo-chordae were inserted in 50 patients (50%), whereas sliding annuloplasty was performed only in three patients. The median ring size was 32 mm (range 26-40 mm). On-table trans-oesophageal echocardiography (TOE) showed trivial/no MR in 87 patients, and mild in 13 patients, and there were no cases of systolic anterior motion (SAM). There were two re-explorations for bleeding and two patients required haemofiltration. There were no strokes or deep sternal wound infections (DSWIs). There was one hospital death (1%). At discharge, mean left ventricular end-diastolic (LVEDD) was 4.8 ± 0.7 cm compared with 5.5 ± 0.8 cm preoperatively (p = 0.03) and mean left ventricular end-systolic (LVESD) was 3.3 ± 0.5 cm as compared with 3.6 ± 0.8 preoperatively (p = 0.4). There was no MR in 87 patients and mild MR in 13 patients. The mean mitral valve area (MVA) was 2.8 ± 0.7 cm2. The mean systolic pulmonary artery pressure (SPAP) was 26.6 ± 7.3 mmHg as compared with 50.9 ± 17.2 mmHg preoperatively (p = 0.02). During follow-up, there were no thrombo-embolic complications, re-operation, endocarditis or deaths. Conclusions: MV repair with the Physio II ring has excellent short-term results, including subgroups with large anterior mitral valve leaflet (AMVL). Moreover, the dimensional ratios of the ring may allow it to be used for MV repair for degenerative MV disease, irrespective of anterior leaflet size.
During recent years there has been an increase in the referral pattern for surgery for non-rheumatic calcific mitral stenosis (CMS). Valve replacement for this condition presents some unique ...challenges, yet the management of CMS remains inadequately described. Herein are discussed the techniques and outcomes of surgery for CMS.
OBJECTIVES
This study aimed to investigate the early and late outcomes of patients undergoing aortic valve replacement (AVR) with previous coronary artery bypass grafting (CABG) and patent grafts.
...METHODS
Between January 2000 and March 2010, 104 patients (87 males) with previous CABG ± concomitant surgery and patent grafts underwent AVR. The median age of the patients was 75 years (range: 37-90 years; inter-quartile range: 69-79 years) and the mean logistic EuroScore was 25.37 ± 16.8. The median time since the previous operation was 9 years (range 1-25; inter-quartile range: 7-14 years). The left internal mammary artery (LIMA) had been used in 75 patients (72.1%) and remained patent in 72 cases (96.0%).
RESULTS
Thirty-day mortality was 7.7% (n = 8), which is less than the predicted mean logistic EuroScore. Isolated AVR was performed in 66 patients (63.5%). The LIMA was dissected and isolated (clamped or blocked with balloon) in 60 patients. The median hospital stay was 10 days (range: 4-183 days; inter-quartile range: 7-15.25 days). Nineteen patients (18.3%) had pulmonary complications, while 12 (11.5%) had acute kidney injury. Seven patients (6.7%) required permanent pacemaker. Six LIMAs (8.3%) were injured and repaired. Prolonged aortic cross-clamp (AXC) time (P = 0.038) and the presence of a previous LIMA graft (P = 0.045) were identified as independent predictors of 30-day mortality. The actuarial survival at 1 and 5 years was 89.4 ± 0.3 and 81.5 ± 0.5%, respectively. Perioperative intra-aortic balloon pump use (P = 0.036), prolonged AXC time (P = 0.004) and prolonged cardiopulmonary bypass time (P = 0.022) were associated with worse long-term overall survival on multivariate analysis.
CONCLUSIONS
AVR post-CABG with patent grafts can be performed in high-risk patients with excellent short- and long-term outcomes and appears to be superior to published catheter-based interventions. In the absence of randomized trial data, we believe that open AVR remains the treatment of choice for aortic valve disease following prior CABG.
Purpose This study tested the scale properties and validity of the ten-item body image scale (BIS) in patients undergoing surgery for colorectal cancer (CRC). Methods Patients completed the BIS and a ...validated measure of health-related quality of life (European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30) after open or laparoscopic resection. A sample of the patients had also previously completed questionnaires before and after surgery. Multi-trait scaling and factor analysis were used to examine the questionnaire scaling, and tests of reliability, clinical and construct validity were performed. Results Eighty-two patients (48 male, 59 open, 23 laparoscopic) participated. Scaling analyses suggested a nine-item scale and one single item. This revised scale structure demonstrated good test-retest reliability (r = 0.94) and no overlap with the key domains of the EORTC QLQ-C30 (r < 0.40). Patients with a stoma reported significantly poorer BIS scores than those undergoing simple resection (p = 0.005). Conclusions This study provides psychometric and clinical evidence for a revised scale structure for the BIS in CRC, and the questionnaire is suitable to assess body image in CRC clinical trials.
The aim of this systematic review is to scrutinize and summarize the design, conduct and reporting standards of articles recently published describing health-related quality of life (HRQL) outcomes ...of treatment of upper gastrointestinal cancer.
Some 2312 abstracts were published between January and July 2009 and initial elimination of papers reduced this number to 22 articles. Of these, 17 were judged to have robust HRQL methodology, but a further seven were excluded due to a high risk of bias in the study design. Ten articles (four randomized trials) were finally included in the review. Studies in curative treatments for oesophagogastric cancer show that surgery and chemoradiation therapy has a major short-term detrimental effect on HRQL, but recovery occurs within 6 months in long-term survivors but those not achieving a survival benefit report very poor HRQL. In advanced oesophageal cancer, 18 mm self-expandable metal stents and nonstent therapies lead to better short-term HRQL scores than nonexpandable stents and are the recommended standard of care. A small survival advantage and improved HRQL is conferred by adjuvant and palliative gemcitabine chemotherapy in patients with pancreatic cancer.
This review identified few well-designed studies that also included a robust assessment of HRQL. High-quality trials with reliable HRQL methods are required for outcomes to inform health policy and clinical decision-making.
Trials are robust sources of data for clinical practice; however, trial outcomes may not reflect what is important to communicate for decision-making. The study compared clinicians' views of outcomes ...to include in a core outcome set for colorectal cancer (CRC) surgery, with what clinicians considered important information for clinical practice (core information).
Potential outcome/information domains were identified through systematic literature reviews, reviews of hospital information leaflets and interviews with patients. These were organized into six categories and used to design a questionnaire survey that asked surgeons and nurses from a sample of CRC centers to rate the importance of each domain as an outcome or as information on a nine-point Likert scale. Respondents were re-surveyed (round 2) following group feedback (Delphi methods). Comparisons were made by calculating the difference in mean scores between the outcomes and information domains, and paired t tests were used to explore the difference between mean scores of the six outcome/information categories.
Data sources identified 1216 outcome/information items for CRC surgery that informed a 94-item questionnaire. First-round questionnaires were returned from 63/81 (78 %) of centers. Clinicians rated 76/94 (84 %) domains of higher importance to measure in trials than information to communicate to patients in round 1. This was reduced to 24/47 (51 %) in round 2. The greatest difference was evident in domains regarding survival, which was rated much more highly as a trial outcome than an important piece of information for decision-making (difference in mean 2.3, 95 % CI 1.9 to 2.8, p <0.0001). Specific complications and quality-of-life domains were rated similarly (difference in mean 0.18, 95 % CI -0.1 to 0.4, p = 0.2 and difference in mean 0.2, 95 % CI -0.1 to 0.5, p = 0.2, respectively).
Whilst clinicians want to measure key outcomes in trials, they rate these as less important to communicate in decision-making with patients. This discrepancy needs to be explored and addressed to maximize the impact of trials on clinical practice.
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