Heart Valve Procedures Research Articles

Predictors of aortic clamp time duration and intensive care unit length of stay in elective adult cardiac surgery

BackgroundAortic cross-clamp utilized during cardiac surgery facilitates motionless and bloodless surgical field. However, the duration of clamp time has an inverse effect on early post-operative recovery period. In this study, we sought to examine the predictors of aortic clamp duration and intensive care unit length of stay.ResultsSix hundred and nine adult patients presented for elective cardiac surgery between December 2019 and December 2020 were enrolled. The age of patients ranged from 18 to 82 years (mean 55.62 years, SD ± 12.3 years). Male/female ratio is 4.6:1. Most patients (87.2%) were planned for coronary artery bypass grafting (CABG) and 78 patients (12.8%) for single heart valve procedure. Operative time (OT) ranged from 120 to 402 min and averaged 259.4 min (SD ± 45.9 min). ACC time ranged from 15 to 159 min and averaged 50.56 min (SD ± 19.4 min). Factors associated with significantly longer ACCT were: smoking (OR = 1.89 (95% CI 1.3–2.74), p value = 0.01), respiratory disease (OR = 0.48 (95% CI 0.24–0.96), p value = 0.039), obesity (OR = 1.76 (95% CI 1.18–2.63), p value = 0.005) and AVR (OR = 2.11 (95% CI 1.17–3.83), p value = 0.013). Low cardiac output syndrome (LCOS) was observed in 19.2% of patients. Longer than average ACCT was associated with increased use of inotropes (p value < 0.001), intra-aortic balloon pump (p value < 0.001) and first 24 h post-operative blood loss (p value < 0.001). The average intensive care unit length of stay (ICULOS) was 1.64 days (SD ± 1.1 days). Patients' ACCT converged positively and significantly on ICULOS (Beta coefficient = 1.013 (95% CI 1.01–1.015), p value < 0.001).ConclusionAortic cross-clamping is a crucial method in cardiac surgery to achieve motionless field; however, prolongation of this method had an incremental risks for the development of low cardiac output syndrome, increased first 24 h post-operative blood loss and longer stay in the intensive care unit.

German Heart Surgery Report 2020: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic and vascular surgery procedures performed in 78 German heart surgery departments during the year 2020 are analyzed. Under the more than extraordinary conditions of the ongoing worldwide coronavirus disease 2019 pandemic, a total of 161,817 procedures were submitted to the registry. A total of 92,809 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 29,444 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.6:1) was 97.2%. For the 35,469 isolated heart valve procedures, (17,471 transcatheter interventions included), the survival rate was 96.7%. Concerning short- and long-term circulatory support, a total of 2,852 extracorporeal life support/extracorporeal membrane oxygenation implantations, respectively, 843 assist device implantations (left/right/biventricular assist device, total artificial device), were registered. In 2020, the number of isolated heart transplantations increased to 340, a rise of 2.1% compared with the previous year. The isolated lung transplantations amounted to 291, a decrease of 6.4%.This annually updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine, and represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.

Sarcopenia in cardiac surgery: Dual X-ray absorptiometry study from the McGill frailty registry

To determine the prevalence and prognostic value of sarcopenia measured by dual x-ray absorptiometry (DXA) and physical performance tests in patients undergoing coronary artery bypass surgery or heart valve procedures. Adults undergoing cardiac surgery were prospectively enrolled and completed a questionnaire, physical performance battery, and a DXA scan (GE Lunar) to measure appendicular muscle mass indexed to height2 (AMMI). Patients were categorized as sarcopenic based on European Working Group 2 guidelines if they had low AMMI defined as <7 kg/m2 for men or <5.5 kg/m2 for women, and low muscle strength defined as 5 chair rise time ≥15 seconds. Cox proportional hazards regression was used to test the association between sarcopenia and all-cause mortality over a median follow-up of 4.3 years. The cohort consisted of 141 patients with a mean age of 69.7 ± 10.0 years and 21% females. The prevalence rates of low AMMI, slow chair rise time, and sarcopenia (low AMMI and slow chair rise time) were 24%, 57%, 13%, respectively. The 4-year survival rate was 79% in the non-sarcopenic group as compared to 56% in the sarcopenic group (Log-rank P = 0.01). In the multivariable model, each standard deviation of decreasing AMMI and increasing chair rise time was associated with a hazard ratio for all-cause mortality of 1.84 (95% CI 1.18, 2.86) and 1.79 (95% CI 1.26, 2.54), respectively. Lower-extremity muscle strength and DXA-based muscle mass are objective indicators of sarcopenia that are independently predictive of all-cause mortality in older cardiac surgery patients.

Need for protocolized opioid prescribing after cardiac surgery.

An analysis of a large US administrative claims database suggests that new persistent opioid use occurred in nearly 10% of opioid-naive patients undergoing cardiac surgery. Given the variation in the amounts of opioid prescribed and the increased risk of persistent use with greater amounts of opioid received, protocolized prescribing should be adopted to standardize and improve the care of these patients. The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use. A new study by Brown and colleagues evaluates opioids prescribed at discharge from hospital after coronary artery bypass graft surgery and heart valve procedures.

Midterm outcomes after the rescue THV-in-THV procedure: Insights from the multicenter prospective OCEAN-TAVI registry.

To confirm whether the rescue transcatheter heart valve in the transcatheter heart valve (THV-in-THV) procedure is effective and feasible, we aimed to assess the midterm outcomes following rescue THV-in-THV procedures. The trends in the usage of the rescue THV-in-THV procedure at the time of transcatheter aortic valve implantation (TAVI) have also been explored. Midterm outcomes of the rescue THV-in-THV procedure have been poorly defined, though it is popular as an effective method to bail-out some complications in TAVI. We reviewed data from the Optimized transCathEter vAlvular iNtervention-Transcatheter Aortic Valve Implantation (OCEAN-TAVI) registry and compared the outcomes of TAVI with rescue THV-in-THV and TAVI without rescue THV-in-THV. We also examined the annual rates of rescue THV-in-THV procedures in all the TAVI procedures between 2013 and 2017. Among 2,588 patients who underwent TAVI, 26 patients have required rescue THV-in-THV for valve malposition (n = 23) or severe transvalvular regurgitation because of stuck THV leaflets (n = 3). Three cases needed an open conversion, and two died in the hospital. The rates of new permanent pacemaker implantation, acute kidney injury, and stroke were higher in the THV-in-THV group. A two-year cumulative survival and echocardiographic outcomes succeeding rescue THV-in-THV procedure were comparable to non-THV-in-THV cases. The rate of rescue THV-in-THV procedure lessened from 2.6% in 2013 to 0.6% in 2017. The rescue THV-in-THV procedure is an effective and feasible option for THV malpositioning and stuck valve. It has given a comparable survival and a stable valve function over midterm observation periods.

Clinical burden associated with postsurgical complications in major cardiac surgeries in Asia-Oceania countries: A systematic review and meta-analysis.

Evidence on the burden of postsurgical complications is mainly from studies in western countries, and little is highlighted in the Asia-Oceania region. This study aimed to identify and compare the burden of postsurgical complications in major cardiac surgeries in Asia-Oceania countries. A systematic search was performed in PubMed, Embase, and CENTRAL between January 2000 and July 2018. Inclusion criteria were: (a) observational studies or randomized control trials; (b) studied in coronary artery bypass graft (CABG) and/or heart valve procedures; (c) measured postsurgical clinical outcomes; and (d) conducted in Asia-Oceania countries. Pooled effects were calculated using a random-effects model. Of the 6032 articles screened, 472 studies with a total of 614 161 patients met the inclusion criteria. The pooled incidences (95% confidence interval) of hospital mortality and 30-day mortality were similar at 2.38% (2.16%-2.59%) and 2.33% (2.16%-2.50%), respectively. Length of stay (LOS) was 14.07 days (13.44-14.71 days). The incidence for atrial fibrillation (AF) and stroke/cerebrovascular accident (CVA) was 17.49% (15.99%-18.99%) and 1.64% (1.51%-1.78%), respectively. Below outcomes tended to be better in studies on CABG compared to heart valve procedures, including the incidence of hospital mortality (1.97%[1.75%-2.18%] vs 3.97% [3.29%-4.65%]), AF (16.47% [14.85%-18.10%] vs 21.98% [17.41%-26.54%]), stoke/CVA (1.51% [1n 37%-1.65%] vs 2.55% [2.07%-3.04%]), and mean LOS (days) (13.08 [12.51-13.65] vs 19.58 [16.72-22.45]). Similarly, all postsurgical complications tended to be higher in studies involving high-risk patients vs non-high-risk patients. There are opportunities to improve clinical outcomes of patients with high surgical risks and those undertaking heart valve procedures, as they tend to have poorer survival and higher risk in developing postsurgical complications.

Development of Persistent Opioid Use After Cardiac Surgery

The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use. To determine the proportion of opioid-naive patients who develop persistent opioid use after cardiac surgery and investigate the association between the initial amount of opioids prescribed at discharge and the likelihood of developing new persistent opioid use. This retrospective cohort study used data from a national administrative claims database from January 1, 2004, to December 31, 2016 and included 35 817 patients who underwent coronary artery bypass grafting (CABG) (25 673 [71.7%]) and heart valve (10 144 [28.3%]) procedures. All patients were opioid-naive within 180 days before the index procedure and filled an opioid prescription within 14 days after surgery. Opioid medications after cardiac surgery. The proportion of opioid-naive patients who developed new persistent opioid use within 90 to 180 days after surgery was determined. Oral morphine equivalents (OMEs) were calculated for the first opioid prescription filled after discharge. A multivariable logistic regression with cubic splines was used to analyze the association among the OMEs at discharge and likelihood of developing persistent opioid use. Of the 25 673 patients who underwent CABG, the mean (SD) age for those without (n = 23 064) vs with (n = 2609) persistent opioid use was 62.9 (9.8) years vs 61.6 (9.7) years, respectively, and the number who were men were 18 758 (81.3%) vs 1998 (76.6%). Of the 10 144 patients who underwent heart valve surgery, the mean (SD) age for those without (n = 9343) vs with (n = 821) persistent opioid use was 63.2 (12.4) years vs 61.2 (12.5) years, respectively, and the number who were men were 6378 (68.3%) vs 511 (62.2%). Persistent opioid use is a substantial concern after cardiac surgery and occurred in 2609 patients undergoing CABG (10.2%) and 821 valve surgery patients (8.1%; P = .001). The likelihood for developing persistent opioid use was decreased among heart valve surgery recipients (odds ratio [OR], 0.78; P < .001) and increased for patients who were women; younger; with preoperative congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and alcoholism; and those taking preoperative benzodiazepines and muscle relaxants (women: OR, 1.15 [95% CI, 1.03-1.26]; younger age: OR, 1.02 [95% CI, 1.01-1.02]; congestive heart failure: OR, 1.17 [95% CI, 1.06-1.30]; chronic lung disease: OR, 1.32 [95% CI, 1.19-1.45]; diabetes: OR, 1.27 [95% CI, 1.15-1.40]; kidney failure: OR, 1.17 [95% CI, 1.00-1.37]; chronic pain: OR, 2.71 [95% CI, 2.10-3.56]; alcoholism: OR, 1.56 [95% CI, 1.23-2.00]; benzodiazepines: OR, 1.71 [95% CI, 1.52-1.91]; muscle relaxants: OR, 1.74 [95% CI, 1.51-2.02]; all P < .001). Furthermore, we found that when patients were prescribed more than approximately 300 mg of OMEs at discharge, they had a significantly increased risk of new persistent opioid use than with lower opioid prescriptions. Opioids are used extensively after cardiothoracic surgery and nearly 1 of 10 patients will continue to use opioids over 90 days after surgery. Furthermore, higher OMEs prescribed at discharge were significantly associated with developing persistent use. Centers must adopt protocols to increase patient education and limit opioid prescriptions after discharge.

German Heart Surgery Report 2019: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2019 are analyzed. For this period, a total of 175,705 procedures were submitted to the registry, 100,446 summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 34,224 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.8:1) was 97.3%. For the 36,650 isolated heart valve procedures (16,625 transcatheter interventions included), it was 96.4%. Concerning short- and long-term circulatory support, a total of 2,716 extracorporeal life support/extracorporeal membrane oxygenation implantations, resp. 953 assist device implantations (L-/ R-/ BVAD, TAH) were registered. In 2019, the number of isolated heart transplantations increased to 333, a rise of 6.7% compared to the previous year. The isolated lung transplantations amounted to 311, a decrease of 8.5%. This annually updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine, and represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.

Relationship Between Hospital Surgical Aortic Valve Replacement Volume and Transcatheter Aortic Valve Replacement Outcomes

ObjectivesThe aim of this study was to examine whether hospital surgical aortic valve replacement (SAVR) volume was associated with corresponding transcatheter aortic valve replacement (TAVR) outcomes. BackgroundRecent studies have demonstrated a volume-outcome relationship for TAVR. MethodsIn total, 208,400 fee-for-service Medicare beneficiaries were analyzed for all aortic valve replacement procedures from 2012 to 2015. Claims for patients <65 years of age, concomitant coronary artery bypass grafting surgery, other heart valve procedures, or other major open heart procedures were excluded, as were secondary admissions for aortic valve replacement. Hospital SAVR volumes were stratified on the basis of mean annual SAVR procedures during the study period. The primary outcomes were 30-day and 1-year post-operative TAVR survival. Adjusted survival following TAVR was assessed using multivariate Cox regression. ResultsA total of 65,757 SAVR and 42,967 TAVR admissions were evaluated. Among TAVR procedures, 21.7% (n = 9,324) were performed at hospitals with <100 (group 1), 35.6% (n = 15,298) at centers with 100 to 199 (group 2), 22.9% (n = 9,828) at centers with 200 to 299 (group 3), and 19.8% (n = 8,517) at hospitals with ≥300 SAVR cases/year (group 4). Compared with group 4, 30-day TAVR mortality risk-adjusted odds ratios were 1.32 (95% confidence interval: 1.18 to 1.47) for group 1, 1.25 (95% confidence interval: 1.12 to 1.39) for group 2, and 1.08 (95% confidence interval: 0.82 to 1.25) for group 3. These adjusted survival differences in TAVR outcomes persisted at 1 year post-procedure. ConclusionsTotal hospital SAVR volume appears to be correlated with TAVR outcomes, with higher 30-day and 1-year mortality observed at low-volume centers. These data support the importance of a viable surgical program within the heart team, and the use of minimum SAVR hospital thresholds may be considered as an additional metric for TAVR performance.

Utility of 90-Day Mortality vs 30-Day Mortality as a Quality Metric for Transcatheter and Surgical Aortic Valve Replacement Outcomes

Questions have recently arisen as to whether 30-day mortality is a reasonable metric for understanding institutional practice differences after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). To examine the utility of 30-day vs 90-day mortality after TAVR and SAVR as a mortality quality metric. This nationally representative, multicenter, cohort study analyzed data from Medicare beneficiaries undergoing TAVR and SAVR procedures from January 1, 2012, to December 31, 2015. Concomitant coronary artery bypass grafting and other heart valve or other major open-heart procedures were excluded. Hospitals that performed fewer than 50 TAVR or 70 SAVR procedures per year were excluded to ensure reliable estimates and to reduce the risks of inflated results because of small institutional sample sizes. Data were analyzed from October 2018 to August 2019. Hospitals were ranked into top- (10%), middle- (80%), and bottom-performing (10%) groups based on their 4-year mean 30-day mortality. Changes in hospital performance rankings at 90 days and 1 year and correlation of 30- and 90-day mortality with 1-year mortality were examined. A total of 30 329 TAVR admissions at 184 hospitals and 26 021 SAVR admissions at 191 hospitals were evaluated. For TAVR, 40 hospitals (21.7%) changed performance rankings at 90 days: 13 (48.1%) in the top-performing group and 8 (29.6%) in the bottom-performing group. At 1 year, 56 hospitals (30.4%), which included 21 (77.8%) in the top-performing group and 12 (44.4%) in the bottom-performing group, changed rankings. Similar findings were observed for SAVR, with an overall 90-day conversion rate of 17.3% and a 1-year rate of 30.3%. These findings persisted after adjusting for the differences in patient risk profiles among the 3 groups. Capturing 90-day events was also more robustly informative regarding expected 1-year outcomes after both TAVR and SAVR, largely owing to the observed plateau in the instantaneous hazard observed beyond this point. The findings suggest that evaluation of hospital performance based on 30-day mortality may underestimate outcomes and therefore substantially misrepresent institutional performance after TAVR and SAVR compared with 90-day mortality, even after risk adjustment. Although 30-day mortality has been validated, 90-day mortality may be a more reliable outcome metric for measuring hospital performance and capturing procedure-related mortality.

German Heart Surgery Report 2018: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2018 are analyzed. For this period, a total of 174,902 procedures were submitted to the registry, 98,707 summarized as heart surgery procedures in the classical meaning. The unadjusted in-hospital survival rate for 33,999 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.8:1) was 97.1% and for 34,915 isolated heart valve procedures, 14,396 transcatheter interventions included, it was 96.0%. Concerning short- and long-term circulatory supports, a total of 2,871 extracorporeal life support (ECLS)/extracorporeal membrane oxygenation (ECMO) implants, respectively, 942 assist device implantations (L-/R-/BVAD, TAH) were registered. In 2018, the number of isolated heart transplantations increased to 312, a growth of 23% compared with the previous year. The isolated lung transplantations reached 340, a rise of nearly 19%. This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine, and is a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate and nationwide patient treatment is guaranteed all the time.

Advanced interventional cardiac procedures and perioperative care required to prevent the epidemic of end-stage heart disease in Sri Lanka

Cardiovascular disease is the the leading cause of morbidity and mortality in the world and in Sri Lanka. This epidemic with multiple aetiologies lead to a final common path of heart failure, which can be averted by timely delivery of state-of-the art interventional cardiac procedures. The expansion of Primary PCI, complex coronary interventions for ischaemic heart disease with calcific vessels and CTO using Rotablation, Transcatheter heart valve (TAVI/Mitraclip) procedures for valve disease, Intracoronary transplantation of autologous stem cells for failing hearts, septal ablations and multiple device therapies for congenital heart diseases are examples of the discussed novel interventional cardiac therapies that are gaining pace as treatment modalities available for complex cardiac patients in Sri Lanka.

PSU31 TRENDS IN QUALITY AND COST IN SURGICAL CARE

This study documents trends in risk-adjusted quality and cost for a variety of surgical procedures, and explores innovation in treatment among Medicare beneficiaries from 2002 through 2011. We consider 11 classes of surgery, characterized by AHRQ’s Clinical Classification System; the surgical classes studied range from tracheostomy to heart valve procedures to colorectal resection to wound debridement. For each surgical class, we assess trends in treatment costs and health outcomes among Medicare beneficiaries receiving these procedures during hospital stays. Quality was defined as rate of 30-day survival with the avoidance of unplanned readmissions, while costs include hospital costs and concurrent physician and ancillary services. Quality and costs are adjusted for patient severity based on demographics, comorbidity, and community context. Surgical innovations are operationalized as clinically distinctive procedures with nonexistent or limited use in 2002, identified using ICD-9 procedure codes. Analysis found significant and positive quality growth for 6 surgical classes: heart valve procedures (3.49%), CABG (2.00%), gastrostomy (5.32%), tracheostomy (5.01%), wound debridement (2.78%), and excision of lysis peritoneal adhesions (1.68%). Preliminary analysis also found significant and negative cost trends for 3 surgical classes: tracheostomy (-15.05%), PTCA (-11.11%) and wound debridement (-9.69%). In addition, significant cost increases were observed for gastrostomy (5.51%), colorectal resection (4.06 %), and exploratory laparotomy (30.72 %). Substantial treatment innovation occurred with respect to surgical procedures utilized for colorectal resection. In 2 out of 11 surgical classes, the quality of surgical care improved while treatment costs declined. Four other surgical classes exhibited either a cost decrease or quality improvement. While cost increased for 3 other surgical classes, only 1 of them was associated with improved quality of care. In the remaining 2 surgical classes, there was no significant change in quality or cost. These trends were associated with measurable innovation in treatment for only one surgical class.

Pol-CDRIE registry - 1-year observational data on patients hospitalized due to cardiac device-related infective endocarditis in Polish referential cardiology centres.

The rate of cardiac device-related infective endocarditis (CDRIE) is increasing worldwide, but no detailed data are available for Poland. We aimed to evaluate clinical, diagnostic, and therapeutic data of patients hospitalized due to CDRIE in 22 Polish referential cardiology centers from May 1, 2016 to May 1, 2017. Participating cardiology departments were asked to fill in a questionnaire that included data on the number of hospitalized patients, number and types of implanted cardiac electrotherapy devices, and number of infective endocarditis cases. We also collected clinical data and data regarding the management of patients with CDRIE. Overall, 99 621 hospitalizations were reported. Infective endocarditis unrelated to cardiac device was the cause of 596 admissions (0.6%), and CDRIE, of 195 (0.2%). Pacemaker was implanted in 91 patients with CDRIE (47%); cardioverter‑defibrillator, in 51 (26%); cardiac resynchronization therapy‑defibrillator, in 48 (25%); and cardiac resynchronization therapy‑pacemaker, in 5 (2.5%). The most common symptoms were malaise (62%), fever/chills (61%), cough (21%), chest pain (19.5%), and inflammation of the device pocket (5.6%). Cultures were positive in 77.5% of patients. The cardiac device was removed in 91% of patients. The percutaneous approach was most common for cardiac device removal. All patients received antibiotic therapy, and 3 patients underwent a heart valve procedure. Transesophageal echocardiography was performed in 80% of patients. The most common complication was heart failure (25% of patients). The clinical profile, pathogen types, and management strategies in Polish patients with CDRIE are consistent with similar data from other European countries. Transesophageal echocardiography was performed less frequently than recommended. The removal rate in the Polish population is consistent with the general rates observed for interventional treatment in patients with CDRIE.

Impact of postoperative acute kidney failure in long-term survival after heart valve surgery.

We investigated the impact of acute kidney failure after a heart valve procedure among patients with or without chronic kidney disease (CKD). All patients who had undergone a surgical valve procedure between 2005 and 2017 at our institution were divided into 2 groups depending on whether they had previous history of CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2) or not. Homogeneous groups were obtained by propensity score matching. Long-term mortality was compared between the 2 groups and according to the occurrence of postoperative acute kidney failure. Level of significance was set at P-value <0.008 for multiple comparison tests. From the 3907 patients included to this study, 1476 (37.78%) had previous history of CKD. After adjusting for propensity score 1:1, patients with preoperative impaired renal function were at a higher risk of acute kidney failure (26.83% vs 10.16%, P < 0.001) and postoperative mortality (8.48% vs 5.17%, P = 0.001). In the follow-up, they had a poorer survival at 1, 5 and 10 years as compared to patients with normal renal function (88% vs 91.95%, 78.29% vs 81.11% and 56.13% vs 66.29%, respectively; P < 0.001). Patients without postoperative kidney failure had similar survival whether they had preoperative CKD or not [hazard ratio (HR) 1.16, 99.2% confidence interval (CI) 0.87-2.52; P = 0.142]. As compared to patients with postoperative preserved renal function, those with postoperative kidney failure had a higher long-term mortality either if they had previous kidney disease or not [(HR 2.18, 99.2% CI 1.75-2.72; P < 0.001) and (HR 1.48, 99.2% CI 1.33-1.65; P < 0.001), respectively]. Preoperative CKD was the strongest predictor of acute kidney failure (odds ratio 4.45; 95% CI 3.59-5.53; P < 0.001). Patients with CKD are at higher risk of postoperative adverse events and have poorer long-term outcomes. Postoperative acute kidney failure increases long-term mortality.

Comparative effectiveness, safety, and costs of rivaroxaban and warfarin among morbidly obese patients with atrial fibrillation

There are limited data regarding clinical outcomes and healthcare resource utilization of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) who are morbidly obese (body mass index >40 kg/m2 or body weight >120 kg). Using data from 2 US healthcare claims databases, we identified patients initiating rivaroxaban or warfarin who had ≥1 medical claim with an AF diagnosis, a diagnostic code for morbid obesity (ICD-9: 278.01, V85.4%; ICD-10: E66.01%, E66.2%, Z68.4%), and a minimum continuous enrollment of 12 months before and 3 months after treatment initiation. Patients were excluded if they had mitral stenosis, a mechanical heart valve procedure, an organ/tissue transplant, or an oral anticoagulant prescription prior to the index date. Rivaroxaban and warfarin patients were 1:1 propensity score matched. Conditional logistic regression was used to compare ischemic stroke/systemic embolism and major bleeding risk. Generalized linear models were used to compare healthcare resource utilization and costs. A total of 3563 matched pairs of morbidly obese AF patients treated with rivaroxaban or warfarin were identified. The majority (81.4%) of patients in the rivaroxaban cohort were receiving the 20 mg dose. The rivaroxaban and warfarin cohorts were well balanced after propensity score matching. The risks of ischemic stroke/systemic embolism and major bleeding were similar for rivaroxaban and warfarin users (stroke/systemic embolism: 1.5% vs 1.7%; odds ratio [OR]: 0.88; 95% confidence interval [CI]: 0.60, 1.28; P = .5028; major bleeding: 2.2% vs 2.7%; OR: 0.80; 95% CI: 0.59, 1.08; P = .1447). Total healthcare costs including medication costs per patient per year (PPPY) were significantly lower with rivaroxaban versus warfarin ($48,552 vs $52,418; P = .0025), which was primarily driven by lower hospitalization rate (50.2% vs 54.1%; P = .0008), shorter length of stay (7.5 vs 9.1 days; P = .0010), and less outpatient service utilization (86 vs 115 visits PPPY; P < .0001). Morbidly obese AF patients treated with rivaroxaban had comparable risk of ischemic stroke/systemic embolism and major bleeding as those treated with warfarin, but lower healthcare resource utilization and costs.

Cirugía cardiovascular en España en el año 2017. Registro de intervenciones de la Sociedad Española de Cirugía Torácica-Cardiovascular

The Spanish Society of Thoracic and Cardiovascular surgery reports the results of the 2017 registry of the surgical activity in Spain. The participation in this registry is anonymous and voluntary, and it is based on the analysis of the information gathered from 62 centres with activity in cardiovascular surgery, and the confidentiality of the individual data of each centre is ensured. The registry reports the global activity Spain, the observed mortality and the estimated mortality risk, stratified into different types of procedures.The overall cardiac surgical activity in Spain remains stable, with an observed mortality that is adequately adjusted to the estimated surgical risk.During 2017, a total of 36,692 procedures of cardiovascular surgery were performed, divided into 29.056 (79.2%) procedures of adult cardiac surgery, 2.127 (5.8%) procedures of congenital cardiac surgery, and 5,509 procedures (15.0%) of peripheral vascular surgery.Among the total of 36,692 procedures, 23,261 (63.4%) were major cardiac surgical procedures: 21,134 procedures of acquired adult cardiac surgery, and 2,127 congenital cardiac surgery procedures. Furthermore, 20,895 (89.8%) of these procedures were performed with the use of the cardiopulmonary bypass machine.The results of the activity in congenital heart surgery are presented separately in another specific report.Within the 21,134 procedures of acquired adult cardiac surgery, isolated heart valve procedures were the most frequent (9,682 procedures), followed by coronary artery bypass grafting surgery (5,029 procedures), surgery of the aorta (2,249 procedures), combined heart valve and revascularisation procedures (2,172 procedures), other miscellaneous procedures with the use of cardiopulmonary bypass (1,209 procedures), and surgery of mechanical complications of myocardial infarction (142 procedures). Moreover, there were another other 5,496 procedures related to electronic implantable devices and 1,837 procedures without CPB not included in the previous groups.The information derived from this national registry allows to know the state-of-the-art of the surgical specialty in our country, through the knowledge of the surgical activity, the risk profile and the observed results, which is a keystone for an adequate evaluation of the quality of the health care that is delivered to the patients suffering from cardiovascular diseases.

German Heart Surgery Report 2017: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2017 are analyzed. In 2017, a total of 179,337 procedures were submitted to the registry, and 101,728 were summarized as heart surgery procedures in the narrower sense. About 16.8% of these patients were at least 80 years old, resulting in an increase of 1.1% compared with the data of 2016. The 36,273 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 4.2:1) were associated with an unadjusted in-hospital survival rate of 97.3%. Concerning the 34,394 isolated heart valve procedures (including 12,965 transcatheter interventions), the unadjusted in-hospital survival rate was 96.0%.This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, describes advancements in heart medicine, and is a basis for in- and external quality assurance for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate, and nationwide patient treatment is guaranteed at any time.

Cirugía cardiovascular en España en el año 2016. Registro de intervenciones de la Sociedad Española de Cirugía Torácica-Cardiovascular

The Spanish Society of Thoracic and Cardiovascular surgery (SECTCV) reports the results of the 2016 registry of the surgical activity performed in Spain. This register is based on the analysis of the information gathered by the anonymous and voluntary participation of centres with activity in cardiovascular surgery in Spain, and with the confidentiality of the individual data of each centre being guaranteed. Once again, we have obtained the highest number of participant centres, since the beginning of the publication of this registry in 1984, with the participation of 64 centres.During 2016, a total of 35,576 cardiovascular surgery procedures were performed, within these, 22,201 were major cardiac surgeries; 19,772 (89.1%) were performed with the support of the extracorporeal circulation (ECC).The overall activity is divided into 28,072 procedures (78.9%) of adult cardiac surgery, 2,074 procedures (5.8%) of congenital cardiac surgery, and 5,430 procedures (15.3%) of peripheral vascular surgery.Among the cardiac surgery of acquired adult disease, isolated heart valve procedures were the most frequent (9,401 procedures), followed by coronary artery bypass graft surgery (5,021 procedures), combined heart valve and revascularisation procedures (2,124 procedures), surgery of the thoracic aorta (2,063 procedures), and surgery of mechanical complications of myocardial infarction (130 procedures). Moreover, there were other mixed procedures using ECC (796 procedures) and without ECC (8,533 procedures). This year, the results of the activity in congenital heart surgery are presented separately in another specific report.A high percentage of centres have reported mortality data and preoperative surgical risk data, and the risk-adjusted results in terms of mortality are excellent in most of the groups of pathologies that were analysed.The information derived from this national register helps to determine the state of the art of the surgical specialty in our country, which is a keystone for an adequate evaluation of the quality of the health care that we deliver to the patients affected with cardiovascular diseases.

German Heart Surgery Report 2016: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery.

Based on a long-standing voluntary registry founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS), well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2016 are analyzed. In 2016, a total of 103,128 heart surgery procedures (implantable defibrillator, pacemaker, and extracardiac procedures excluded) were submitted to the registry. Approximately 15.7% of the patients were at least 80 years of age, resulting in an increase of 0.9% compared with the data of 2015. For 37,614 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 4.4:1), an unadjusted in-hospital mortality of 2.9% was observed. Concerning the 33,451 isolated heart valve procedures (including 11,701 catheter-based procedures), the unadjusted in-hospital mortality was 4.3%. This annual updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, describes advancements in heart medicine, and is a basis for internal and external quality assurances for all participants. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is appropriate and patients are treated nationwide at all times.