Composite Of Adverse Events Research Articles

Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy

ObjectiveIn patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. MethodsWe retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. ResultsThe overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. ConclusionsIn patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.

Hemiarch versus extended arch repair for acute type A dissection: Results from a multicenter national registry

ObjectiveWe compared perioperative outcomes of patients with acute type A aortic dissection undergoing hemiarch (HA) versus extended arch (EA) repair with or without descending aortic intervention. MethodsNine hundred twenty-nine patients underwent acute type A aortic dissection repair (2002-2021, 9 centers) including open distal repair (HA) with or without additional EA repair. EA with intervention on the descending aorta (EAD) included elephant trunk, antegrade thoracic endovascular aortic replacement, or uncovered dissection stent. EA with no descending intervention (EAND), included unstented suture-only methods. Primary outcomes were in-hospital mortality, permanent neurologic deficit, computed tomography malperfusion resolution, and a composite. Multivariable logistic regression was also performed. ResultsMean age was 66 ± 18 years, 30% (278 out of 929) were women, and HA was performed more frequently (75% [n = 695]) than EA (25% [n = 234]). EAD techniques included: dissection stent (39 out of 234 [17%]), thoracic endovascular aortic replacement (18 out of 234 [7.7%]), and elephant trunk (87 out of 234 [37%]). In-hospital mortality (EA: n = 49 [21%] and HA: n = 129 [19%]; P = .42), and neurological deficit (EA: n = 43 [18%] and HA: n = 121 [17%]; P = .74) were similar. EA was not independently associated with death (EA vs HA odds ratio, 1.09; 95% CI, 0.77-1.54; P = .63) or neurologic deficit (EA vs HA odds ratio, 0.85; 95% CI, 0.47-1.55; P = .59). Composite adverse events differed significantly (EA vs HA odds ratio, 1.47; 95% CI, 1.16-1.87; P = .001). Malperfusion resolved more frequently after EAD (EAD: n = 32 [80%], EAND: n = 18 [56%], HA: n = 71 [50%]; P = .004), although multivariable analysis was not significant (EAD vs HA odds ratio, 2.17; 95% CI, 0.83-5.66; P = .10). ConclusionsExtended arch interventions pose similar perioperative mortality and neurologic risks as Hemiarch. Descending aortic reinforcement may promote malperfusion restoration. Extended techniques should be approached with caution in acute dissection due to increased risk of adverse events.

The natural history of QTc interval and its clinical impact in coronavirus disease 2019 survivors after 1 year.

Prolonged QTc interval on admission and a higher risk of death in SARS-CoV-2 patients have been reported. The long-term clinical impact of prolonged QTc interval is unknown. This study examined the relationship in COVID-19 survivors of a prolonged QTc on admission with long-term adverse events, changes in QTc duration and its impact on 1-year prognosis, and factors associated with a prolonged QTc at follow-up. We conducted a single-center prospective cohort study of 523 SARS-CoV-2-positive patients who were alive on discharge. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval and repeated in 421 patients 7 months after discharge. Mortality, hospital readmission, and new arrhythmia rates 1 year after discharge were reviewed. Thirty-one (6.3%) survivors had a baseline prolonged QTc. They were older, had more cardiovascular risk factors, cardiac disease, and comorbidities, and higher levels of terminal pro-brain natriuretic peptide. There was no relationship between prolonged QTc on admission and the 1-year endpoint (9.8% vs. 5.5%, p = 0.212). In 84% of survivors with prolonged baseline QTc, it normalized at 7.9 ± 2.2 months. Of the survivors, 2.4% had prolonged QTc at follow-up, and this was independently associated with obesity, ischemic cardiomyopathy, chronic obstructive pulmonary disease, and cancer. Prolonged baseline QTc was not independently associated with the composite adverse event at 1 year. Prolonged QTc in the acute phase normalized in most COVID-19 survivors and had no clinical long-term impact. Prolonged QTc at follow-up was related to the presence of obesity and previously acquired chronic diseases and was not related to 1-year prognosis.

Cardiovascular Safety in Type 2 Diabetes With Sulfonylureas as Second-Line Drugs: A Nation-Wide Population-Based Comparative Safety Study.

To assess the real-world cardiovascular (CV) safety for sulfonylureas (SU), in comparison with dipeptidylpeptidase-4 inhibitors (DPP4i) and thiazolidinediones (TZD), through development of robust methodology for causal inference in a whole nation study. A cohort study was performed including people with type 2 diabetes diagnosed in Scotland before 31 December 2017, who failed to reach HbA1c 48 mmol/mol despite metformin monotherapy and initiated second-line pharmacotherapy (SU/DPP4i/TZD) on or after 1 January 2010. The primary outcome was composite major adverse cardiovascular events (MACE), including hospitalization for myocardial infarction, ischemic stroke, heart failure, and CV death. Secondary outcomes were each individual end point and all-cause death. Multivariable Cox proportional hazards regression and an instrumental variable (IV) approach were used to control confounding in a similar way to the randomization process in a randomized control trial. Comparing SU to non-SU (DPP4i/TZD), the hazard ratio (HR) for MACE was 1.00 (95% CI: 0.91-1.09) from the multivariable Cox regression and 1.02 (0.91-1.13) and 1.03 (0.91-1.16) using two different IVs. For all-cause death, the HR from Cox regression and the two IV analyses was 1.03 (0.94-1.13), 1.04 (0.93-1.17), and 1.03 (0.90-1.17). Our findings contribute to the understanding that second-line SU for glucose lowering are unlikely to increase CV risk or all-cause mortality. Given their potent efficacy, microvascular benefits, cost effectiveness, and widespread use, this study supports that SU should remain a part of the global diabetes treatment portfolio.

Recurrent cardiovascular events in patients with type 2 diabetes and haemodialysis: analysis from the 4D Study.

In the 'Die Deutsche Diabetes Dialyse Studie' (4D Study), treatment of patients with type 2 diabetes mellitus (T2DM) on haemodialysis (HD) with atorvastatin compared with placebo had no significant effect on the first composite primary major adverse cardiovascular event (MACE) endpoint of death from cardiac causes, fatal stroke, non-fatal myocardial infarction or non-fatal stroke. In this study we analysed first and recurrent events in 1255 patients from the 4D Study. We conducted an event history analysis to investigate the effects of previous clinical events on the risk of different endpoints in the total patient group and after stratification by randomization group. During a median follow-up of 4years, a total of 548 MACEs occurred, with 469 first and 79 recurrent events. The most frequent event was sudden cardiac death, followed by death due to infection/sepsis. Of the 548 total MACEs, 260 occurred in the atorvastatin group and 288 in the placebo group [hazard ratio 0.91 (95% confidence interval 0.76-1.07), P=.266]. Interestingly, analyses of the baseline hazard functions for first and recurrent events as a function of time after randomization demonstrated that the risks of the composite primary endpoint continually increased in the placebo group with increasing time in the study, whereas the risk in the atorvastatin group remained constant after ≈1.5years. This recurrent and total event analysis from the 4D Study underscores the high risk of sudden cardiac death and death due to infection/sepsis in patients with T2DM receiving HD and raises the hypothesis that atorvastatin may stabilize cardiovascular risk only after 1-2years in this high-risk population.

Randomized Trial of Targeted Transendocardial Mesenchymal Precursor Cell Therapy in Patients With Heart Failure

BackgroundMesenchymal precursor cells (MPCs) are allogeneic, immunoselected cells with anti-inflammatory properties that could improve outcomes in heart failure with reduced ejection fraction (HFrEF). ObjectivesThis study assessed the efficacy and safety of MPCs in patients with high-risk HFrEF. MethodsThis randomized, double-blind, multicenter study evaluated a single transendocardial administration procedure of MPCs or sham-control in 565 intention-to-treat patients with HFrEF on guideline-directed therapies. The primary endpoint was time-to-recurrent events caused by decompensated HFrEF or successfully resuscitated symptomatic ventricular arrhythmias. Hierarchical secondary endpoints included components of the primary endpoint, time-to-first terminal cardiac events, and all-cause death. Separate and composite major adverse cardiovascular events analyses were performed for myocardial infarction or stroke or cardiovascular death. Baseline and 12-month echocardiography was performed. Baseline plasma high-sensitivity C-reactive protein levels were evaluated for disease severity. ResultsThe primary endpoint was similar between treatment groups (HR: 1.17; 95% CI: 0.81-1.69; P = 0.41) as were terminal cardiac events and secondary endpoints. Compared with control subjects, MPCs increased left ventricular ejection fraction from baseline to 12 months, especially in patients with inflammation. MPCs decreased the risk of myocardial infarction or stroke by 58% (HR: 0.42; 95% CI: 0.23-0.76) and the risk of 3-point major adverse cardiovascular events by 28% (HR: 0.72; 95% CI: 0.51-1.03) in the analysis population (n = 537), and by 75% (HR: 0.25; 95% CI: 0.09-0.66) and 38% (HR: 0.62; 95% CI: 0.39-1.00), respectively, in patients with inflammation (baseline high-sensitivity C-reactive protein ≥2 mg/L). ConclusionsThe primary and secondary endpoints of the trial were negative. Positive signals in prespecified, and post hoc exploratory analyses suggest MPCs may improve outcomes, especially in patients with inflammation.

Pregnancy outcomes in women with heart disease: the Madras Medical College Pregnancy And Cardiac (M-PAC) Registry from India.

To evaluate the feto-maternal outcome, identify the adverse outcome predictors and test the applicability of modified WHO (mWHO) classification in pregnant women with heart disease (PWWHD) from Tamil Nadu, India. One thousand and five pregnant women (mean age: 26.04 ± 4.2) with 1029 consecutive pregnancies were prospectively enrolled from July 2016 to December 2019 in the Madras medical college pregnancy and cardiac (M-PAC) registry. Majority (60.5%; 623/1029) had heart disease (HD) diagnosed for the first time during pregnancy. Rheumatic HD (42%; 433/1029) was most common. One third (34.2%; 352/1029) had pulmonary hypertension (PH). Maternal mortality and composite maternal cardiac events (MCEs) were the primary outcomes. Secondary outcomes were foetal loss and composite adverse foetal events (AFEs). MCEs occurred in 15.2% (156/1029; 95% CI: 13.0-17.5) pregnancies. Heart failure was the most common MCE (66.0%; 103/156; 95% CI: 58.0-73.4). Maternal mortality was 1.9% (20/1029; 95% CI: 1.1-2.8), with highest rates in patients with prosthetic heart valves (PHVs) (8.6%; 6/70). Left ventricular systolic dysfunction (LVSD), PHVs, severe mitral stenosis, PH and current pregnancy diagnosis of HD were independent predictors of MCE. The c-statistic of mWHO classification for predicting MCE and maternal death were 0.794 (95% CI: 0.763-0.826) and 0.796 (95% CI: 0.732-0.860). 91.2% (938/1029; 95% CI: 89.392.8) of pregnancies resulted in live births. 33.7% (347/1029; 95% CI: 30.8-36.7) of pregnancies reported AFEs. Maternal mortality is high in PWWHD from India. Highest death rates occurred in women with PHVs, PH and LVSD. The mWHO classification for risk stratification may require further adaptation and validation in India.

Transcatheter Edge-to-Edge Repair in Patients With Anatomically Complex Degenerative Mitral Regurgitation

BackgroundMitral valve transcatheter edge-to-edge repair is safe and effective in treating degenerative mitral regurgitation (DMR) patients at prohibitive surgical risk, but outcomes in complex mitral valve anatomy patients vary. ObjectivesThe PASCAL IID registry assessed safety, echocardiographic, and clinical outcomes with the PASCAL system in prohibitive risk patients with significant symptomatic DMR and complex mitral valve anatomy. MethodsPatients in the prospective, multicenter, single-arm registry had 3+ or 4+ DMR, were at prohibitive surgical risk, presented with complex anatomic features based on the MitraClip instructions for use, and were deemed suitable for the PASCAL system by a central screening committee. Enrolled patients were treated with the PASCAL system. Safety, effectiveness, and functional and quality-of-life outcomes were assessed. Study oversight also included an echocardiographic core laboratory and clinical events committee. ResultsThe study enrolled 98 patients (37.2% ≥2 independent significant jets, 15.0% severe bileaflet/multi scallop prolapse, 13.3% mitral valve orifice area <4.0 cm2, and 10.6% large flail gap and/or large flail width). The implant success rate was 92.9%. The 30-day composite major adverse event rate was 11.2%. At 6 months, 92.4% patients achieved MR ≤2+ and 56.1% achieved MR ≤1+ (P < 0.001 vs baseline). The Kaplan-Meier estimates for survival, freedom from major adverse events, and heart failure hospitalization at 6 months were 93.7%, 85.6%, and 92.6%, respectively. Patients experienced significant symptomatic improvement compared with baseline (P < 0.001). ConclusionsThe outcomes of the PASCAL IID registry establish the PASCAL system as a useful therapy for prohibitive surgical risk DMR patients with complex mitral valve anatomy. (PASCAL IID Registry within the Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID] NCT03706833)

Mortality Risk and Serious Cardiopulmonary Events in Moderate-to-Severe COPD: Post Hoc Analysis of the IMPACT Trial.

In the InforMing the Pathway of COPD Treatment (IMPACT) trial, single-inhaler fluticasone furoate (FF) /umeclidinium (UMEC) /vilanterol (VI) significantly reduced severe exacerbation rates and all-cause mortality (ACM) risk versus UMEC/VI among patients with chronic obstructive pulmonary disease (COPD). This post hoc analysis aimed to define the risk of ACM during and following a moderate/severe exacerbation, and further determine the benefit-risk profile of FF/UMEC/VI versus FF/VI and UMEC/VI using a cardiopulmonary composite adverse event (AE) endpoint. The 52-week, double-blind IMPACT trial randomized patients with symptomatic COPD and ≥1 exacerbation in the prior year 2:2:1 to once-daily FF/UMEC/VI 100/62.5/25mcg, FF/VI 100/25mcg, or UMEC/VI 62.5/25mcg. Post hoc endpoints included the risk of ACM during, 1-90 and 91-365 days post moderate or severe exacerbation and time-to-first cardiopulmonary composite event. Of the 10,355 patients included, 5034 (49%) experienced moderate/severe exacerbations. Risk of ACM was significantly increased during a severe exacerbation event compared with baseline (hazard ratio [HR]: 41.22 [95% confidence interval (CI) 26.49-64.15]; p<0.001) but not significantly different at 1-90 days post-severe exacerbation (HR: 2.13 [95% CI: 0.86-5.29]; p=0.102). Moderate exacerbations did not significantly increase the risk of ACM during or after an exacerbation. Cardiopulmonary composite events occurred in 647 (16%), 636 (15%), and 356 (17%) patients receiving FF/UMEC/VI, FF/VI, and UMEC/VI, respectively; FF/UMEC/VI significantly reduced cardiopulmonary composite event risk versus UMEC/VI by 16.5% (95% CI: 5.0-26.7; p=0.006). Results confirm a substantial mortality risk during severe exacerbations, and an underlying CV risk. FF/UMEC/VI significantly reduced the risk of a composite cardiopulmonary AE versus UMEC/VI.

Prevalence and predictive factors for clinical outcomes of isolated functional tricuspid regurgitation

BackgroundA substantial number of patients have functional tricuspid regurgitation (TR).Isolated functional TR has been undertreated and may be a next target for transcatheter intervention. However, the prevalence, patient characteristics, and predictive factors for prognosis remain unclear. MethodsFrom patients in our echocardiographic database (N = 64,242), we extracted those with severe TR and examined prognosis according to etiologies of TR. Thereafter, we focused on two types of isolated functional TR; progressive TR after left-sided valve surgery (postoperative TR) and TR associated with annular dilatation (atrial TR). Composite adverse events were defined as all-cause death or hospitalization for heart failure (HF). ResultsOf 1001 patients with severe TR (median age, 77 years; female, 58 %), 71 (7 %) patients were classified as postoperative TR, and 149 (15 %) as atrial TR. During the follow-up period (median, 1.6 years), 30 composite adverse events were observed (postoperative TR, n = 14; atrial TR, n = 16). Composite adverse events were less frequent in these two types of functional TR than TR of other etiologies. Multivariate analysis adjusted for age and sex showed that a history of hospitalization for HF, history of cardiac surgery >2 times, loop diuretics, estimated glomerular filtration rate, blood urea nitrogen, hemoglobin, platelet level, left ventricular ejection fraction, and right ventricular dimension were associated with clinical adverse events (p < 0.05), while B-type natriuretic peptide level was not. ConclusionsA considerable number of patients had isolated functional TR. Extracardiac factors such as renal function, hemoglobin and platelet are important in determining clinical outcomes.

Risk of bleeding after percutaneous coronary intervention and its impact on further adverse events in clinical trial participants with comorbid peripheral arterial disease

BackgroundBoth patients with obstructive coronary artery disease (CAD) and patients with peripheral arterial disease (PADs) have an increased bleeding risk. Information is scarce on bleeding in CAD patients, treated with percutaneous coronary intervention (PCI), who have comorbid PADs. We assessed whether PCI patients with PADs have a higher bleeding risk than PCI patients without PADs. Furthermore, in PCI patients with PADs we evaluated the extent by which bleeding increased the risk of further adverse events. MethodsThree-year pooled patient-level data of two randomized PCI trials (BIO-RESORT, BIONYX) with drug-eluting stents were analyzed to assess mortality and the composite endpoint major adverse cardiac events (MACE: all-cause mortality, any myocardial infarction, emergent coronary artery bypass surgery, or target lesion revascularization). ResultsAmong 5989 all-comer patients, followed for 3 years, bleeding occurred in 7.7% (34/440) with comorbid PADs and 5.0% (279/5549) without PADs (HR: 1.59, 95%CI: 1.11–2.23, p = 0.010). Of all PADs patients, those with a bleeding had significantly higher rates of all-cause mortality (HR: 4.70, 95%CI: 2.37–9.33, p < 0.001) and MACE (HR: 2.39, 95%CI: 1.23–4.31, p = 0.003). Furthermore, PADs patients with a bleeding were older (74.4 ± 6.9 vs. 67.4 ± 9.5, p < 0.001). After correction for age and other potential confounders, bleeding remained independently associated with all-cause mortality (adj.HR: 2.97, 95%CI: 1.37–6.43, p = 0.006) while the relation of bleeding with MACE became borderline non-significant (adj.HR: 1.85, 95%CI: 0.97–3.55, p = 0.06). ConclusionPCI patients with PADs had a higher bleeding risk than PCI patients without PADs. In PADs patients, bleeding was associated with all-cause mortality, even after adjustment for potential confounders.

Outcome of Nonagenarians Undergoing Transfemoral Transcatheter Aortic ValveReplacement: A Nationwide Registry Analysis From Japan.

Nonagenarians are a growing age group in patients undergoing transcatheter aortic valve replacement (TAVR); however, the appropriate use of TAVR in this population remains discussed because of their limited life expectancy and worse outcome reported. The authors aimed to evaluate clinical characteristics and the prognostic impact of nonagenarians. We analyzed consecutive patients undergoing transfemoral TAVR and were registered in the nationwide registry for TAVR in Japan (Japanese Transcatheter Valvular Therapies registry) between 2013 and 2018. The rate of 30-day and 1-year mortality and composite adverse event, comprising all-cause death, all stroke, and life-threatening/major bleeding, were assessed. Of the 15,028 registered patients during the study period, 2,215 (14.7%) were nonagenarians. Although the nonagenarians were less likely to have comorbid conditions (eg, diabetes mellitus and malignancy) than patients aged <90 y, they had a higher Society of Thoracic Surgeons risk score (8.8% vs 5.6%), mainly owing to their advanced age. The procedural characteristics were identical between 2 groups. The rate of 30-day mortality and composite endpoint was similar, whereas 1-year mortality and composite adverse events were increased among nonagenarians (10.3% vs 6.8% and 13.5% vs 9.2%, respectively), and nonagenarians were independently associated with these endpoints (HR: 1.21; 95%CI: 1.03-1.42; P=0.023; HR: 1.24; 95%CI: 1.07-1.42; P=0.004). Of the 15,028 TAVR procedures performed in Japan between 2013 and 2018, 14.7% were performed in nonagenarians. These patients were carefully selected by a multidisciplinary heart team and showed 21% and 24% increase of 1-year mortality and composite adverse outcome.

Clinical Outcomes of Radiologic Relapse in Patients With Cardiac Sarcoidosis Under Immunosuppressive Therapies

Although nuclear imaging can detect cardiac involvement of cardiac sarcoidosis (CS), including subclinical states, little is known about the prevalence and outcomes of radiologic relapse under prednisolone (PSL) therapy. This study aimed to investigate the clinical characteristics and outcomes in patients with radiologic relapse. A total of 80 consecutive patients with CS whose disease activity on nuclear imaging decreased at least once after initiation of immunosuppressive therapy were identified through a retrospective chart review. Radiologic relapse of CS was diagnosed using 18F-fluoro-2-deoxyglucose positron emission tomography or gallium-67 scintigraphy. Composite adverse events were defined as at least 1 of the following: all-cause death, hospitalization for heart failure, or lethal arrhythmia. During the follow-up period (median 2.9 years), radiologic relapse was observed in 31 patients (38.8% of overall patients) at 30 months (median) after immunosuppressive therapy initiation. After radiologic relapse was detected, all patients were treated with intensified immunosuppressive therapies (increasing PSL, n=26 [83.9%], adding other immunosuppressive therapies to PSL, n=5 [16.1%]). There were no differences in occurrences of composite adverse events in patients with and patients without radiologic relapse. Radiologic relapse under immunosuppressive therapy was observed in many patients with CS, but it was not associated with clinical outcomes under intensified immunosuppressive therapy.

Abstract 12744: Outcomes of Patients With Myeloproliferative Neoplasms Admitted for Myocardial Infarction: Insights From National Inpatient Sample

Introduction: Myeloproliferative neoplasms (MPNs) are chronic clonal stem cell neoplasms with high risk of thrombosis and cardiovascular events. However, outcomes after acute myocardial infarction (AMI) and risk factors for cardiovascular events after AMI in patients with MPN have not been well characterized. Methods: Adult patients with a primary admission of AMI from September 2015 to December 2018 (N = 699,786) with (N = 3,156) and without (N = 696,586) a diagnosis of MPN were identified using the National Inpatient Sample. Primary outcome was composite inpatient major adverse cardiac events (MACE) of arterial and venous thrombosis, non-fatal cardiac arrest, and mortality. Patients with and without MPN were compared using propensity score estimation using Generalized Boosted Models(GBM). Outcomes between groups were compared using multivariable logistic regression. Results: Patient characteristics are described in Table 1. Patients with MPN were more likely to have a history of heart failure and less likely to have a history of coronary artery disease compared with patients without MPN. Patients with MPN were less likely to undergo revascularization despite similar rates of STEMI. After propensity score weighting with GBM and multivariable logistic regression, MPN patients had increased risk of MACE, arterial thrombosis, VTE and bleeding (Figure). Conclusions: Among patients hospitalized with AMI, those with MPN are at increased risk of MACE compared with patients without MPN. Revascularization is less utilized in patients with MPN. More investigation is needed in order to improve post-AMI outcomes in patients with MPN.

The impact of prophylactic ascending aorta replacement on the long-term prognosis of zone 0 hybrid arch repair.

To investigate the impact of prophylactic zone 0 replacement with prosthetic grafts on the long-term prognosis and perioperative safety of zone 0 hybrid arch repair (HAR) when zone 0 is neither dilated nor pathologic. We retrospectively reviewed 115 patients whose zone 0 aorta was neither dilated nor pathologic and who underwent zone 0 HAR from January 2009 to December 2020 and divided then into two groups depending on whether zone 0 was replaced, with 46 patients in the no-replacement group and 69 patients in the replacement group. Inverse probability of treatment weighting (IPTW) was used to balance the baseline difference, and outcomes were compared after IPTW adjustment. The primary end points were overall survival and adverse aortic events (AAEs). The secondary end points were early composite adverse events and other perioperative complications. Subgroup analysis was performed by age, diagnosis, zone 0 maximum diameter and risk stratification. The 5-year IPTW-adjusted overall survival rate was 84% in the no-replacement group 90% in the replacement group (P= .61). With death as a competing risk, the IPTW-adjusted cumulative incidence of AAEs at 5 and 10years was 23% and 41% in the no-replacement group, and 14% and 25% in the replacement group, respectively (subdistribution hazard ratio [sHR], 0.56; 95% confidence interval [CI], 0.23-1.39; P= .23). Considering proximal complications alone, the replacement group exhibited lower 5-year (3% vs 18%) and 10-year (6% vs 36%) cumulative incidences of proximal complications (sHR, 0.11; 95% CI, 0.01-0.91; P= .04) after IPTW adjustment. A subgroup analysis demonstrated that the benefits of zone 0 replacement in decreasing AAEs were observed in those aged 60years or less (sHR, 0.15; 95% CI, 0.03-0.75; P= .02) and those with type B aortic dissection (sHR, 0.24; 95% CI, 0.07-0.82; P= .02). Additionally, zone 0 replacement did not increase early composite adverse event morbidity (9% vs 21%; P= .08) or early mortality (7% vs 6%; P= .87). Although zone 0 was neither dilated nor pathologic, prophylactic zone 0 replacement in zone 0 HAR significantly decreased the incidence of proximal complications, without impairing perioperative safety. Additionally, this strategy was associated with benefits in reducing AAEs in younger patients and patients with type B aortic dissection. Thus, prophylactic zone 0 replacement should be considered for reconstructing a stable proximal landing zone in zone 0 HAR.

Elephant trunk simplifies thoracoabdominal aortic aneurysm repair without impacting operative risk.

An open two-stage elephant trunk (ET) technique may aid in the technical ease of subsequent thoracoabdominal aortic aneurysm (TAAA) repair. We analyze whether the presence of an ET improves outcomes for patients undergoing extent I and II TAAA repair. From September 1997 to October 2020, 469 patients underwent extent I or II TAAA repair. We compared those with prior ET to those without. Primary outcome was composite major adverse events (MAE) including operative mortality, myocardial infarction, permanent spinal cord injury, cerebrovascular accident, need for tracheostomy, and new need for dialysis. Thirty-eight (8.1%) patients had prior ET and 431 (91.9%) did not. There were no differences in baseline characteristics. The no ET group was more likely to undergo urgent or emergent procedures. Composite MAE occurred in 82 (19%) of the no ET group and 5 (15.8%) of the ET group (p = .785). Operative mortality was 5.5% and not significantly different between the groups (p = 1.00). No patients in the ET group experienced stroke or recurrent laryngeal nerve injury. Median partial bypass and cross-clamp times were significantly greater in the no ET group (28 [24-32] versus19 [16-22] min; p ≤ .001and 42 [32-53] versus 30 [25-39] min; p ≤ .001). Extent I and II TAAA repair after ET can be safely performed in a tertiary referral center with shorter bypass and cross-clamp times. ET eliminates the need for circulatory arrest or clamping a hostile arch.

Postoperative adverse events and re-treatment among patients who have undergone laparoscopic and robotic sacrocolpopexy for pelvic organ prolapse in Japan.

To describe and compare the postoperative adverse events and re-treatment for recurrence after laparoscopic and robotic-assisted sacrocolpopexy in Japanese patients with pelvic organ prolapse (POP). This was a retrospective cohort study using the DeSC database, which contains claims and medical check-up data provided by DeSC Healthcare Inc., Tokyo, Japan. We identified all patients who had undergone either laparoscopic or robotic-assisted sacrocolpopexy from April 2014 to May 2021. Patient backgrounds and postoperative outcomes were compared between the laparoscopic and robotic-assisted sacrocolpopexy groups. Moreover, the composite adverse event comprising vaginal erosion, postoperative urinary incontinence, postoperative dysuria, urinary tract injury, and abdominal incisional hernia was evaluated. Re-treatment for POP recurrence included pessary use and surgery for POP was also evaluated. Among 28 748 patients diagnosed with POP, 409 (1.4%) had undergone laparoscopic sacrocolpopexy and 52 (0.2%) had undergone robotic-assisted sacrocolpopexy. The prevalence of postoperative adverse events was 20.8% and 13.5% in the laparoscopic and robotic-assisted sacrocolpopexy groups, respectively (P= 0.270). One patient (1.9%) underwent surgery after robotic-assisted sacrocolpopexy, and none of the patients was administered pessaries postoperatively in both groups. In Japan, postoperative outcomes after laparoscopic and robotic-assisted sacrocolpopexy are similar and comparable to those reported in western countries.

Obstetric and fetal/neonatal outcomes in pregnant women with frequent premature ventricular complexes and structurally normal heart

BackgroundHigh premature ventricular complex (PVC) burden may increase the risk of left ventricular dysfunction and all-cause mortality. We aimed to evaluate maternal and neonatal outcomes of pregnant women with structurally normal heart having PVC burden ≥1%. MethodsThis retrospective cohort study used data from Chang Gung Research Database. Pregnancies from January 1, 2005, through June 30, 2020, with documented maternal PVC burden ≥1% by 24-h Holter monitor were identified. Pregnant women with a diagnosis of structural heart disease or arrhythmias other than PVC were excluded. We used propensity score matching (PSM) to balance the covariates between the PVC group and normal control group. The PVC group was classified into low-PVC (<10%) and high-PVC burden subgroups. The maternal and neonatal outcomes were assessed through 6 months after delivery or termination. ResultsAfter PSM, there were 214, 61, and 46 pregnant women enrolled in the normal control group, low-PVC burden, and high-PVC burden subgroups, respectively. The high-PVC and low-PVC burden subgroups had composite adverse maternal and neonatal events similar to the control group without use of antiarrhythmic drugs (AADs), but a higher proportion of placental abruption was observed in the high-PVC burden subgroup. Maternal age, diabetes, and overweight were significant predictors of composite adverse maternal events, whereas only maternal age was a significant predictor of composite adverse neonatal events. ConclusionsHigh PVC burden was not associated with poor composite adverse maternal and neonatal outcomes with no need of AADs therapy in pregnant women with structurally normal heart.

Relationship between nonalcoholic fatty liver disease and coronary plaque stability and risk factors for composite cardiovascular adverse events

Relationship between nonalcoholic fatty liver disease and coronary plaque stability and risk factors for composite cardiovascular adverse events

Association of dysglycemia with post-operative outcomes in pediatric surgery

BackgroundPerioperative dysglycemia is associated with adverse surgical outcomes in adults. We sought to determine the association between perioperative dysglycemia and 30-day adverse surgical events in pediatric patients undergoing non-cardiac surgery. MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) database from 2016 to 2021 at two academic tertiary care hospitals. The primary outcomes were individual 30-day adverse events, composite serious adverse events, composite hospital acquired infections and composite morbidity. ResultsA total of 5410 records were analyzed: the cohort was 52.6% male and 52.6% non-Hispanic White, and 1472 (27.2%) had dysglycemia. Children undergoing procedures in general surgery (48.4%), neurosurgery (25.4%), and orthopedic surgery (16.0%) had higher rates of dysglycemia compared to other surgical specialties. Patients with dysglycemia were more likely to have surgical site infection (4.3% dysglycemic vs. 3.1% normoglycemic, p = 0.028), cardiac arrest (2.6% vs. 0.1%, p < 0.001), and sepsis (3.7% vs. 1.3%, p < 0.001); more likely to undergo reoperation (11.3% vs. 5.8%, p < 0.001); and more likely to remain hospitalized after 30 days (33.0% vs. 6.1%, p < 0.001). After controlling for patient and case demographics, perioperative dysglycemia was associated with more composite serious adverse events (OR 1.85, 95% CI 1.49–2.29, p = 0.000), composite hospital acquired infections (OR 1.42, 95% CI 1.04–1.93, p = 0.026), and composite morbidity (OR 2.52, 95% CI 2.13–2.97, p = 0.000). ConclusionsPerioperative dysglycemia in children undergoing non-cardiac surgery is associated with increased risk of adverse events and outcomes. Interventions that screen and normalize blood glucose in the perioperative period may mitigate risk and improve quality of care.