Contemporary Long-term Outcomes Research Articles

Severity of native pulmonary annular hypoplasia and late outcomes of tetralogy of Fallot: retrospective cohort study.

Pulmonary annular hypoplasia and valvar dysplasia are key morphological features affecting long-term outcomes of tetralogy of Fallot. This retrospective study aimed to analyse factors affecting contemporary long-term outcomes with a focus on pulmonary annular growth and function over time. 131 consecutive isolated tetralogy of Fallot repairs performed between 2004 and 2014 at University Children's Hospital Zurich were included. Median age and weight at the time of repair were 4.8 (interquartile range [IQR] 3.2-6.3) months and 6.1 (IQR 5.1-7) kg, respectively. Based on the severity of native pulmonary annular hypoplasia, the cohort was divided into group 1 (preoperative pulmonary annular Z score < -4; n = 20), group 2 (Z score -2 to -4; n = 56) and group 3 (Z score > -2; n = 54). A transannular patch was used in 88/131 (67.2%) patients: 80%, 67.9% and 61.1% in groups 1, 2 and 3, respectively. The primary outcome was defined as right ventricular outflow tract (RVOT) reoperation or pulmonary valve replacement. Secondary outcome was composite pulmonary valve dysfunction defined as peak gradient >40 mm Hg or severe pulmonary regurgitation at follow-up. A multiple Cox regression model was used to quantify the association of age at tetralogy of Fallot repair, preoperative pulmonary annular Z score and RVOT approach with primary and secondary outcome. Follow-up was 98.5% complete, with a median follow-up duration of 9.6 (95% confidence interval [CI] 9-10.4) years. All patients were alive at last follow-up resulting in 100% survival. 20/131 patients underwent pulmonary valve replacement (14 surgical and 6 catheter interventional) while 5/131 underwent RVOT reoperations other than valve replacement. The Kaplan-Meier 10-year freedom from primary outcome was 85% (95% CI 78-92%); 69% (46-100%), 91% (82-100%) and 84% (74-95%) for groups 1, 2 and 3, respectively (log rank p = 0.16). Composite dysfunction at follow-up was observed in 29.8% (overall): 45%, 28.6% and 25.9% for groups 1, 2 and 3, respectively (p = 0.12). The multiple Cox regression analysis for primary outcome indicated that the use of a transannular patch results in a Hazard Ratio (HR) of 3.3 (95% CI 0.7-14.7, p = 0.13). Additionally, the presence of composite dysfunction at discharge results in a HR of 2.1 (95% CI 0.8-5.4, p = 0.1). Age (in months) with a HR of 0.8 (95% CI 0.6-1, p = 0.06) and group 2 with a HR of 0.4 (95% CI 0.14-1.2, p = 0.11) showed a trend to being protective for the primary outcome. However, the 95% CI of all estimates included the HR of 1. Transannular patch use and composite dysfunction at discharge, although not statistically significant at 5% level, may be associated with pulmonary valve replacement and RVOT reoperation. Avoiding the use of a transannular patch or using reconstructive techniques to achieve a better composite dysfunction at discharge could reduce the primary outcome. Large multicentre studies are needed to demonstrate more precisely the impact of pulmonary annulus Z scores on outcome.

Long-term outcomes after hospitalization for atrial fibrillation or flutter.

Atrial fibrillation (AF) and flutter are common causes of hospitalizations but contemporary long-term outcomes following these episodes are uncertain. This study assessed outcomes up to 10 years after an acute AF or flutter hospitalization. Patients hospitalized acutely with a primary diagnosis of AF or flutter from 2008-17 from all public and most private hospitals in Australia and New Zealand were included. Kaplan-Meier methods and flexible parametric survival modelling were used to estimate survival and loss in life expectancy, respectively. Competing risk model accounting for death was used when estimating incidence of non-fatal outcomes. A total of 260 492 adults (mean age 70.5 ± 14.4 years, 49.6% female) were followed up for 1 068 009 person-years (PY), during which 69 167 died (incidence rate 6.5/100 PY) with 91.2% survival at 1 year, 72.7% at 5 years, and 55.2% at 10 years. Estimated loss in life expectancy was 2.6 years, or 16.8% of expected life expectancy. Re-hospitalizations for heart failure (2.9/100 PY), stroke (1.7/100 PY), and myocardial infarction (1.1/100 PY) were common with respective cumulative incidences of 16.8%, 11.0%, and 7.1% by 10 years. Re-hospitalization for AF or flutter occurred in 21.3% by 1 year, 35.3% by 5 years, and 41.2% by 10 years (11.6/100 PY). The cumulative incidence of patients undergoing catheter ablation of AF was 6.5% at 10 years (1.2/100 PY). Patients hospitalized for AF or flutter had high death rates with an average 2.6-year loss in life expectancy. Moreover, re-hospitalizations for AF or flutter and related outcomes such as heart failure and stroke were common with catheter ablation used infrequently for treatment, which warrant further actions.

Survival outcomes used to generate version 9 American Joint Committee on Cancer staging system for anal cancer.

The American Joint Committee on Cancer (AJCC) staging system for all cancer sites, including anal cancer, is the standard for cancer staging in the United States. The AJCC staging criteria are dynamic, and periodic updates are conducted to optimize AJCC staging definitions through a panel of experts charged with evaluating new evidence to implement changes. With greater availability of large data sets, the AJCC has since restructured and updated its processes, incorporating prospectively collected data to validate stage group revisions in the version 9 AJCC staging system, including anal cancer. Survival analysis using AJCC eighth edition staging guidelines revealed a lack of hierarchical order in which stage IIIA anal cancer was associated with a better prognosis than stage IIB disease, suggesting that, for anal cancer, tumor (T) category has a greater effect on survival than lymph node (N) category. Accordingly, version 9 stage groups have been appropriately adjusted to reflect contemporary long-term outcomes. This article highlights the changes to the now published AJCC staging system for anal cancer, which: (1) redefined stage IIB as T1-T2N1M0 disease, (2) redefined stage IIIA as T3N0-N1M0 disease, and (3) eliminated stage 0 disease from its guidelines altogether.

Longitudinal risk of death, hospitalizations for atrial fibrillation, and cardiovascular events following catheter ablation of atrial fibrillation: a cohort study.

Population studies reporting contemporary long-term outcomes following catheter ablation of atrial fibrillation (AF) are sparse.We evaluated long-term clinical outcomes following AF ablation and examined variation in outcomes by age, sex, and the presence of heart failure. We identified 30601 unique patients (mean age 62.7±11.8 years, 30.0% female) undergoing AF ablation from 2008 to 2017 in Australia and New Zealand using nationwide hospitalization data. The primary outcomes were all-cause mortality and rehospitalizations for AF or flutter, repeat AF ablation, and cardioversion. Secondary outcomes were rehospitalizations for other cardiovascular events. During 124858.7 person-years of follow-up, 1900 patients died (incidence rate 1.5/100 person-years) with a survival probability of 93.0% (95% confidence interval (CI) 92.6-93.4%) by 5 years and 84.0% (95% CI 82.4-85.5%) by 10 years. Rehospitalizations for AF or flutter (13.3/100 person-years), repeat ablation (5.9/100 person-years), and cardioversion (4.5/100 person-years) were common, with respective cumulative incidence of 49.4% (95% CI 48.4-50.4%), 28.1% (95% CI 27.2-29.0%), and 24.4% (95% CI 21.5-27.5%) at 10 years post-ablation. Rehospitalizations for stroke (0.7/100 person-years), heart failure (1.1/100 person-years), acute myocardial infarction (0.4/100 person-years), syncope (0.6/100 person-years), other arrhythmias (2.5/100 person-years), and new cardiac device implantation (2.0/100 person-years) occurred less frequently. Elderly patients and those with comorbid heart failure had worse survival but were less likely to undergo repeat ablation, while long-term outcomes were comparable between the sexes. Patients undergoing AF ablations had good long-term survival, a low incidence of rehospitalizations for stroke or heart failure, and about half remained free of rehospitalizations for AF or flutter, including for repeat AF ablation, or cardioversion.

Long-term Outcomes of Isolated Thoracic Aortic Replacement in Congenital versus Degenerative Aortopathy in a 15-year Institutional Cohort

Open aortic replacement represents the only approved option to address thoracic aortopathy among patients with connective tissue disorders (CTDs). The aim of our study was to investigate contemporary long-term outcomes of isolated thoracic aortic replacement in patients with CTDs vs degenerative pathology in a large institutional cohort.

B-PO02-082 LONG-TERM OUTCOMES OF PATIENTS UNDERGOING CATHETER ABLATION OF ATRIAL FIBRILLATION: A BI-NATIONAL COHORT STUDY

Population studies reporting contemporary long-term outcomes following catheter ablation of atrial fibrillation (AF) are sparse. To evaluate long-term clinical outcomes of AF ablations. Patients undergoing AF ablation from 2008-17 in Australia and New Zealand were identified using hospitalization data. The primary outcome was all-cause mortality while all-cause and cause-specific rehospitalizations were secondary endpoints. A total of 30,601 unique patients (mean age 62.7±11.8y, 30.0% female, CHA2DS2-VASc score 1.0±1.1, 94.0% elective, median length of stay 1 day) underwent AF ablation and the median follow-up time was 3.8 years (range: 0-9.97 years). Overall, 1,505 patients (incident rate 1.2 per 100 person-years) died during the study with a survival probability of 88.6% by 9 years (95%CI 87.8%-89.3%) (Figure 1). Most patients (n=23,151, 8.4/100 person-years) had a least one re-hospitalization for any cause during follow-up (rehospitalization-free probability of 9.3% by 9 years). Re-hospitalization for AF/atrial flutter (n=11,114, 8.8/100 person-years) and repeat ablation (n=6,212, 4.9/100 person-years) were common. Re-hospitalization for stroke (n=883, 0.7/100 person-years), heart failure (n=1,385, 1.1/100 person-years), and acute myocardial infarction (n=548, 0.4/100 person-years) occurred less frequently. Nearly 90% of patients undergoing AF ablation survive at up to 9-years post-discharge while rates of rehospitalizations for stroke or heart failure were low. However, more than 90% patients are re-hospitalized, mostly due to atrial arrhythmia recurrence and repeat AF ablation.

Long-term Outcomes of Patients Undergoing Catheter Ablation of Atrial Fibrillation: A Bi-National Cohort Study

Population studies reporting contemporary long-term outcomes following catheter ablation of atrial fibrillation (AF) are sparse.

Long-term Outcomes in Peripartum Cardiomyopathy

Background: Prior studies of Peripartum Cardiomyopathy (PPCM) are limited by short-term follow-up. Contemporary long-term outcomes and change in myocardial function over time are poorly characterized. Methods and Results: This retrospective cohort study included women with PPCM at the University of Michigan (2000-2011), with follow-up on March 31, 2017. Subsequent pregnancies were excluded. Recovery was sustained left ventricular Ejection Fraction (EF) ≥55%. Major Adverse Events (MAE) included death, cardiac transplantation, left ventricular assist device, or inotrope-dependence. A total of 59 women were included (mean [SD] age at diagnosis, 29.5 [6.8]; 28.8% Black), with a mean follow-up of 6.3 years. Recovery occurred in 22 women (37%); of these, 8 women (36%) had delayed recovery (&gt;12 months). All cause mortality was 20% (12/59) with median survival 4.2 years; of these, 9 women (75%) died after the first year (range 2 - 10 years). MAE occurred in 19 women (32%); of these, 11 women (42%) had MAE &gt;12 months from time of diagnosis (range 2-20 years). Deterioration in EF by &gt;10% from the time of diagnosis occurred in 16 women (27%). This group had worse long-term outcomes, including lower final EF (mean 25 vs 42%, p=0.010), less recovery (12 vs 46%, p=0.016), and higher rates of death (38 vs 14%, p=0.046) and MAE (56 vs 23%, p=0.016). Conclusion: Women with PPCM have long-term risks of mortality, MAE, and subsequent decline in EF, even in the absence of a subsequent pregnancy. Deterioration in EF is associated with adverse events; thus, long-term management is important.

Three-Piece Inflatable Penile Prosthesis Placement Following Pelvic Radiation: Technical Considerations and Contemporary Outcomes

BackgroundPelvic radiation is a known risk factor for the development and progression of erectile dysfunction. When medical therapy fails, the 3-piece inflatable penile prosthesis (IPP) can offer patients a definitive treatment option. Because of radiation-induced vascular changes and tissue fibrosis, a careful surgical approach is necessary to avoid intraoperative complications and attain successful outcomes. Despite its widespread use in prostate cancer treatment, there are no contemporary studies examining the effects that pelvic radiation can have on 3-piece IPP placement and device survival. AimTo present technical considerations and contemporary outcomes of placing a 3-piece IPP for refractory erectile dysfunction in patients with a history of pelvic radiation. MethodsWe retrospectively reviewed 78 patients who underwent placement of a 3-piece IPP (AMS 700; Boston Scientific, Marlborough, MA, USA) after being treated with pelvic radiotherapy from 2003 through 2016. All patients had been treated with external beam and/or brachytherapy for treatment of prostate malignancy. An infrapubic approach was used in all patients, with reservoir placement in the space of Retzius or in the lateral retroperitoneal space. Patient demographics, perioperative data, and postoperative outcomes including prosthetic infection and mechanical failure were examined and statistical analysis was performed. OutcomesRates of device infection, revision surgery, and reservoir complications. ResultsNo intraoperative complications were observed. After a mean follow-up of 49.0 months (6.6–116.8), 2 patients developed an infection of their prosthesis that required explantation. These patients underwent successful IPP removal and immediate reimplantation. 11 patients (14.1%) required revision surgery (pump replacement, n = 4; pump relocation, n = 2; cylinder replacement, n = 4; reservoir replacement owing to leak, n = 1). No reservoir-related complications such as herniation or erosion into adjacent structures were observed. Clinical ImplicationsThe 3-piece IPP can be placed safely in a broad range of patients treated with pelvic radiotherapy. Strengths and LimitationsThis study describes contemporary long-term outcomes of the IPP in patients treated with pelvic radiation and includes patients with prior pelvic surgery and artificial urinary sphincter, which are commonly encountered in practice. It is limited by its single-center experience and lacks a comparison group of patients. Objective patient satisfaction data were not available for inclusion. ConclusionsThe 3-piece IPP can be placed successfully in patients with a history of pelvic radiation without a significant increase in infectious complications, reservoir erosion, or mechanical failure compared with the global literature.Loh-Doyle J, Patil MB, Nakhoda Z, et al. Three-Piece Inflatable Penile Prosthesis Placement Following Pelvic Radiation: Technical Considerations and Contemporary Outcomes. J Sex Med 2018;15:1049–1054.

Contemporary Outcomes for Open Infrainguinal Bypass in the Endovascular Era

The role of infrainguinal bypasses in this era of increasing endovascular interventions remains the subject of significant debate. In this study, we evaluate contemporary long-term outcomes of lower-extremity open revascularization for peripheral arterial disease (PAD). We evaluated all patients who underwent infrainguinal bypass with autogenous vein conduits for claudication or critical limb ischemia in our institution between January 1st, 2007 and July 31st, 2014. Kaplan-Meier and Cox regression analyses were used to evaluate graft failure and identify its predictors. Outcomes were defined per the Society for Vascular Surgery standards. There were 428 autogenous vein grafts (femoro-popliteal: 32%, femoro-tibial: 39%, popliteo-tibial: 27%, and tibio-tibial: 2%) placed in 368 patients (mean age of 67 ± 11.4 years). Most patients were male (59%), white (73%), and presented with critical limb ischemia (81%). Sixty-five cases (15%) were redo bypasses. Arm veins and spliced vein conduits were used in 15% and 14% of cases, respectively. Primary patency at 1, 3, and 5 years was 66%, 59%, and 55%, respectively. Primary-assisted patency was 78%, 69%, and 64% at 1, 3, and 5 years, respectively. Secondary patency was 88%, 84%, and 82% at 1, 3, and 5 years, respectively. Patency was higher for grafts harvested from the lower versus upper extremities and for proximal versus distal bypass (all P < 0.05). Limb salvage rate was 88% after a mean follow-up of 2 ± 1.8 years. Significant predictors of graft failure were younger age, diabetes mellitus, and hyperlipidemia (all P < 0.05). In this contemporary cohort of patients, we have demonstrated that infrainguinal bypass for lower-extremity revascularization has good long-term outcomes in patients with symptomatic PAD. Patency and limb salvage rates are optimized with careful selection of autogenous conduits, close monitoring of high-risk groups and management of comorbidities.

Contemporary long-term outcomes of an aggressive approach to mitral valve repair in children: is it effective and durable for both congenital and acquired mitral valve lesions?

We analysed the long-term outcomes of mitral valve (MV) repair in children and compared the repairs for both congenital and acquired lesions. A review of 634 children (≤18 years) who underwent MV repair from 1992 to 2011 was conducted [excluding patients with complete atrioventricular septal defect (AVSD), single ventricle and atrioventricular (AV) discordance]. Associated cardiac anomalies were present in 473 patients (75%). Congenital mitral lesions were found in 270 (43%) patients compared with an acquired aetiology in 364 (57%) [mainly rheumatic: 329 patients (90%)]. Mitral regurgitation (MR) was predominant in 606 (96%) patients, and 544 (86%) of these showed ≥3+ MR. Modified techniques of MV reconstructions were used. The early mortality rate was 2% (14 patients). The mean follow-up was 55 months (1-240 months; 85% complete). The late mortality rate was 4% (23 patients) and survival rates at 10 and 15 years were 91 and 86%, respectively. There was no significant difference in 10-year survival between repairing the congenital (98%) and acquired lesions (87%) (P = 0.17). The rate of freedom from reoperation after MV repair for the entire population was 79% at 10 years, with no significant difference between congenital (80%) and acquired lesions (79%) (P = 0.20). Fifty-six patients (9%) required reoperation. Mixed MV lesions, commissural fusions and residual MR (≥2+) were the predictors of valve failure and reoperation. All survivors remain in New York Heart Association class I and none had thromboembolism or pacemaker insertion. MV repair can be successfully applied to both congenital and acquired MV disease in children. Aggressive repair techniques and avoidance of residual MR have improved durability and survival.

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Long-Term Survival After Aortic Valve Replacement Among High-Risk Elderly Patients in the United States

Background— Surgical aortic valve replacement (AVR) remains the standard of care for the treatment of operable, symptomatic aortic valve disease; however, to date, there are limited national data on the contemporary long-term outcomes after AVR in older individuals. Methods and Results— We examined long-term survival among 145 911 AVR patients ≥65 years of age undergoing AVR at 1026 centers with participation in the Society of Thoracic Surgeons Adult Cardiac Surgery Database from 1991 to 2007. In-hospital complications and long-term survival were stratified by age, Society of Thoracic Surgeons perioperative risk of mortality, and several comorbidities. The median patient age was 76 years; 16% had chronic lung disease, 6% had preoperative renal failure, 38% had heart failure, and 12% had prior cardiac surgery. The median survival in patients 65 to 69, 70 to 79, and ≥80 years of age undergoing isolated AVR was 13, 9, and 6 years, respectively. For AVR plus coronary artery bypass graft procedures, median survival was 10, 8, and 6 years, respectively. Although only 5% of isolated AVR patients had a high Society of Thoracic Surgeons perioperative risk of mortality (≥10%), their median survival was 2.5 to 2.7 years. Severe lung disease and renal failure were each associated with a ≥50% reduction in median survival among all age groups compared with those who did not have these comorbidities, whereas left ventricular dysfunction and prior cardiac operation were associated with a 25% reduction in median survival. Conclusion— Long-term survival after surgical AVR in the elderly is excellent, although patients with a high Society of Thoracic Surgeons perioperative risk of mortality and those with certain comorbidities carry a particularly poor long-term prognosis.

LONG-TERM SURVIVAL FOLLOWING AORTIC VALVE REPLACEMENT AMONG HIGH-RISK ELDERLY PATIENTS IN THE UNITED STATES: INSIGHTS FROM THE STS ADULT CARDIAC SURGERY DATABASE, 1991-2007

Background —Surgical aortic valve replacement (AVR) remains the standard of care for the treatment of operable, symptomatic aortic valve disease; however, to date, there are limited national data on the contemporary long-term outcomes following AVR in older individuals. Methods and Results —We examined long-term survival among 145,911 AVR patients ≥65 years of age undergoing AVR at 1,026 centers with participation in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 1991-2007. In-hospital complications and long-term survival were stratified by age, STS perioperative risk of mortality (PROM), and several comorbidities. The median patient age was 76 years, with 16% having chronic lung disease, 6% preoperative renal failure, 38% heart failure, and 12% prior cardiac surgery. The median survival in patients aged 65-69, 70-79, and ≥80 years undergoing isolated AVR was 13, 9, and 6 years, respectively. For AVR plus coronary artery bypass graft (CABG) procedures, median survival was 10, 8, and 6 years, respectively. While only 5% of isolated AVR patients had a high STS PROM (≥10%), their median survival was 2.5 to 2.7 years. Severe lung disease and renal failure were each associated with a 50% or greater reduction in median survival among all age groups when compared with those who did not have these comorbidities, while left ventricular dysfunction and prior cardiac operation were associated with a 25% reduction in median survival. Conclusions —Long-term survival following surgical AVR in the elderly is excellent, although patients with a high STS PROM and those with certain comorbidities carry a particularly poor long-term prognosis.