High Risk Of Operative Mortality Research Articles

Re-exploration for bleeding and long-term survival after adult cardiac surgery: a meta-analysis of reconstructed time-to-event data.

Postoperative bleeding requiring re-exploration is a serious complication that occurs in 2.8-4.6% of patients undergoing cardiac surgery. Re-exploration has previously been associated with a higher risk of short-term mortality. However, a comprehensive analysis of long-term outcomes after re-exploration for bleeding has not been published. The authors performed a systematic, three databases search to identify studies reporting long-term outcomes in patients who required re-exploration for bleeding after cardiac surgery compared to patients who did not, with at least 1-year of follow-up. Long-term survival was the primary outcome. Secondary outcomes were operative mortality, myocardial infarction, stroke, renal and respiratory complications, and hospital length of stay. Random-effects models was used. Individual patient survival data was extracted from available survival curves and reconstructed using restricted mean survival time. Six studies totaling 135456 patients were included. The average follow-up was 5.5 years. In the individual patient data, patients who required re-exploration had a significantly higher risk of death compared with patients who did not [hazard ratio (HR): 1.21; 95% CI: 1.14-1.27; P <0.001], which was confirmed by the study-level survival analysis (HR: 1.32; 95% CI: 1.12-1.56; P <0.01). Re-exploration was also associated with a higher risk of operative mortality [odds ratio (OR): 5.25, 95% CI: 4.74-5.82, P <0.0001], stroke (OR: 2.05, 95% CI: 1.72-2.43, P <0.0001), renal (OR: 4.13, 95% CI: 3.43-4.39 P <0.0001) respiratory complications (OR: 3.91, 95% CI: 2.96-5.17, P <0.0001), longer hospital length of stay (mean difference: 2.69, 95% CI: 1.68-3.69, P <0.0001), and myocardial infarction (OR: 1.85, 95% CI: 1.30-2.65, P =0.0007). Postoperative bleeding requiring re-exploration is associated with lower long-term survival and increased risk of short-term adverse events including operative mortality, stroke, renal and respiratory complications, and longer hospital length of stay. To improve both short-term and long-term outcomes, strategies to prevent the need for re-exploration are necessary.

Risk of Cardiac Reoperation: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

BackgroundThe increasing number of congenital heart disease patients undergoing reoperative cardiac surgery presents critical and growing challenges. Our objective was to evaluate the association between the number of prior cardiopulmonary bypass operations and operative mortality and morbidity in a national cohort. MethodsThe Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was reviewed for index cardiac operations on cardiopulmonary bypass during 2016 to 2021. Infants and patients with functionally univentricular physiology were excluded. Multivariable logistic regression adjusted for covariates in the STS-CHSD Mortality Risk Model, the STS-European Association for Cardio-Thoracic Surgery (STAT) Mortality Category, and institutional volume. ResultsOf 50,625 eligible operations, 22,100 (44%) were performed on patients with ≥1 prior cardiopulmonary bypass operations. Most common diagnoses were tetralogy of Fallot (4340 of 22,100 [19.6%]), pulmonary atresia/ventricular septal defect (1334 of 22,100 [6.0%]), and aortic stenosis (966 of 22,100 [4.4%]). Operative mortality correlated with number of prior cardiopulmonary bypass operations: 157 of 28,525 (0.6%) for 0, 127 of 13,488 (0.9%) for 1, 81 of 5,664 (1.4%) for 2, 61 of 2039 (3.0%) for 3, 35 of 623 (5.6%) for 4, 10 of 207 (4.8%) for 5, and 5 of 79 (6.3%) for ≥6 operations (P < .001). On multivariable analysis, patients with ≥3 prior cardiopulmonary bypass operations had higher risk of operative mortality (odds ratio, 2.31; P < .001) and major morbidity (odds ratio, 1.60; P < .001). Annual institutional volume and age were not associated with either outcome. ConclusionsThree or more prior cardiopulmonary bypass operations was an independent risk factor for operative mortality/morbidity, even after controlling for risk factors and institutional volume. Future research is needed to identify modifiable factors to optimize outcomes, particularly for those with ≥3 prior cardiopulmonary bypass operations.

Early and mid-term outcomes of open thoracoabdominal aortic aneurysm repair after thoracic endovascular aortic repair

ObjectiveTo evaluate the early and mid-term outcomes of open repair in patients with thoracoabdominal aortic aneurysm (TAAA) after thoracic endovascular aortic repair (TEVAR).MethodsThis was a retrospective single center study. Data were retrospectively collected and analyzed for consecutive patients undergoing open TAAA repair (TAAAR) after TEVAR from November 2016 to June 2021. Indications for TAAAR included aneurysm progression due to endoleak, persisted false lumen perfusion, proximal/distal disease progression, and aorta rupture. The risk factor of operative mortality was analyzed by multivariable logistic regression model and the survival was evaluated by Kaplan–Meier.ResultsSixty-three patients who met the inclusion criteria for the study were identified. The mean age at TAAAR was 41 ± 12 years and 43 (68.3%) were male. Marfan syndrome (MFS) was presented in 39 patients (61.9%). 60 (95.2%) patients presented with post-dissection aneurysm and 3 (4.8%) patients with degenerative aneurysm. The extent of TAAA was Crawford I in 9 (14.3%), II in 22 (34.9%), III in 23 (36.5%), and IV in 9 (14.3%). Emergent TAAAR was done in 10 (15.9%) patients, and deep hypothermic circulatory arrest was used in 22 (34.6%). Endograft was explanted in 31 (49.2%). Operative mortality was 11 (17.5%). Stroke, paraplegia, and acute kidney failure occurred in 5 (7.9%), 7 (11.1%), and 6 (9.5%) patients, respectively. Pulmonary complications occurred in 19 (30.2%) patients. The estimated survival was 74.8 ± 4.9% at 5 years. Late reoperations were performed in 2 patients at 2.5 years and 1.3 years, respectively.ConclusionsIn this series of TAAA after TEVAR, TAAAR was related with a high risk of operative mortality and morbidity and the midterm outcomes represented a durable treatment and were respectable.

Most hospitalized patients with significant tricuspid regurgitation have advanced disease preventing transcatheter tricuspid valve intervention

BackgroundMore than moderate tricuspid regurgitation (TR) is associated with high mortality. Surgical tricuspid valve repair and replacements are rarely performed due to high operative mortality risk, mainly attributed to late presentation. Novel transcatheter tricuspid valve intervention (TTVI) devices are being developed as an alternative to surgery. The population of patients presenting to tertiary care centers who can benefit from TTVI has not been well defined. MethodsWe retrospectively analyzed 12,677 consecutive 2D echocardiograms completed at our tertiary care center between March 2021 and March 2022 and identified hospitalized patients with more than moderate TR. A total of 569 patients were included in this study. Clinical and echocardiographic data were collected by individual chart review. We used the European Society of Cardiology (ESC) guidelines on the management of valvular disease to retrospectively assign patients to medical, surgical, or transcatheter therapy. Results458 patients (80.5 %) were assigned to medical therapy, 57 (10.0 %) were assigned to TTVI, and 54 (9.5 %) were assigned to tricuspid valve surgery. Of note, 75.7 % (431/569) of patients were precluded from any intervention due to advanced disease, and only 4.7 % (27/569) presented too early for intervention, being both asymptomatic and without RV dilatation. ConclusionOnly 10.0 % of patients presenting to a tertiary care center with significant TR would be candidates for TTVI when these technologies are approved in the United States. Earlier identification and treatment of TR could increase the number of patients who may benefit from interventions including TTVI.

Anti-inflammatory response-based risk assessment in acute type A aortic dissection: A national multicenter cohort study

BackgroundEarly identification of patients at high risk of operative mortality is important for acute type A aortic dissection (TAAD). We aimed to investigate whether patients with distinct risk stratifications respond differently to anti-inflammatory pharmacotherapy. MethodsFrom 13 cardiovascular hospitals, 3110 surgically repaired TAAD patients were randomly divided into a training set (70%) and a test set (30%) to develop and validate a risk model to predict operative mortality using extreme gradient boosting. Performance was measured by the area under the receiver operating characteristic curve (AUC). Subgroup analyses were performed by risk stratifications (low versus middle-high risk) and anti-inflammatory pharmacotherapy (absence versus presence of ulinastatin use). ResultsA simplified risk model was developed for predicting operative mortality, consisting of the top ten features of importance: platelet-leukocyte ratio, D-dimer, activated partial thromboplastin time, urea nitrogen, glucose, lactate, base excess, hemoglobin, albumin, and creatine kinase-MB, which displayed a superior discrimination ability (AUC: 0.943, 95 % CI 0.928–0.958 and 0.884, 95 % CI 0.836–0.932) in the derivation and validation cohorts, respectively. Ulinastatin use was not associated with decreased risk of operative mortality among each risk stratification, however, ulinastatin use was associated with a shorter mechanical ventilation duration among patients with middle-high risk (defined as risk probability >5.0 %) (β −1.6 h, 95 % CI [−3.1, −0.1] hours; P = 0.048). ConclusionThis risk model reflecting inflammatory, coagulation, and metabolic pathways achieved acceptable predictive performances of operative mortality following TAAD surgery, which will contribute to individualized anti-inflammatory pharmacotherapy.

Survival benefit of surgery in elderly patients with locally advanced rectal cancer.

Neoadjuvant therapy followed by radical surgery is standard for locally advanced rectal cancer (LARC). However, compared to younger patients, elderly patients often had multiple commodities and may refuse surgery due to being medically unfit or the high risk of operative mortality. This study aims to explore the effects of surgery on short- and long-term mortality in elderly LARC patients using a nationwide cancer registry. The cohort included 6211 patients aged over 65, with 2556 matched through propensity scoring for comparison between surgery (N = 1704) and non-surgery (N = 852) groups. The Cox proportional hazard model compared mortality between these groups. Our results showed that the elderly LARC patients who underwent surgery were more likely to be younger (65-75 years), have clinically-positive lymph nodes, and no comorbidities. Surgery was associated with significantly lower 3-month, 6-month, and 5-year mortality rates, with a greater absolute survival benefit (adjusted hazard ratio [aHR], 4.78; 95% CI, 2.71-8.43; aHR, 4.50; 95% CI, 3.07-6.58 and aHR, 3.81; 95% CI, 3.21-4.51). In stratified analysis, surgery remains provide significantly survival benefit according different age, gender and clinical classification. Furthermore, among non-surgical patients, those receiving chemoradiation had better survival outcomes compared to those receiving radiation, chemotherapy, or no treatment (all P < 0.001). This study highlights the survival advantage of surgery in elderly LARC patients and offers valuable guidance for clinical decision-making.

P192 POSTINFARCTION VENTRICULAR SEPTAL DEFECT: MANAGEMENT AND A NEW SURGICAL OPTION FOR CLOSURE

Abstract Postinfarction ventricular septal defect is a rare mechanical complication of myocardial infarction, with difficult management, debated closure timing and high mortality rates. Standard repair techniques – infarcectomy and infarct exclusion through a left ventriculotomy – are surgically challenging and have high risk of operative mortality and frequently suboptimal results. We report the case of a 66–year–old patient with a 1.4 cm septal rupture developed after a sub–acute STEMI. At the admission, he had chest pain and moderate dyspnoea, EKG showed inferior STEMI with increased myocardial necrosis markers. Echocardiography showed a preserved ejection fraction, akinesia of the inferior, posterolateral walls and of the posterobasal septum, with septal rupture at this level and 1.5 Qp/Qs ratio. A total occlusion of proximal right main coronary artery was found at coronary angiography. After the heart team meeting, we performed a new modified closure, in urgent setting, using two hand–made composite patches (Fig. 1) parachuted through a transversal aortotomy and a right atriotomy, without left ventriculotomy (Fig. 2). In the 7th postoperative day a second septal rupture was detected at the echocardiographic control. After two weeks follow–up in optimized medical therapy, we decided to complete the closure of the later developed septal rupture percutaneously using an Amplatzer device. Six months after the event, the patient is still asymptomatic and echocardiography documents a 50% ejection fraction, with trivial residual left–to–right shunt and normal valve function. Computed tomography scans confirmed optimal surgical result. Timing, management and surgical strategy are still on debate. Our technique is effective, simple, reproducible and provides good result (Fig. 3) and can be perfectly integrated in a hybrid approach.

Intraoperative renal hypoxia and risk of cardiac surgery-associated acute kidney injury.

Acute kidney injury (AKI) is common after cardiac surgery requiring cardiopulmonary bypass. Renal hypoxia may precede clinically detectable AKI. We compared the efficacy of two indices of renal hypoxia, (i) intraoperative urinary oxygen tension (UPO2 ) and (ii) the change in plasma erythropoietin (pEPO) during surgery, in predicting AKI. We also investigated whether the performance of these prognostic markers varies with preoperative patient characteristics. In 82 patients undergoing on-pump cardiac surgery, blood samples were taken upon induction of anesthesia and upon entry into the intensive care unit. UPO2 was continuously measured throughout surgery. Thirty-two (39%) patients developed postoperative AKI. pEPO increased during surgery, but this increase did not predict AKI, regardless of risk of postoperative mortality assessed by EuroSCORE-II. For patients categorized at higher risk by EuroSCORE-II >1.98 (median score for the cohort), UPO2 ≤10 mmHg at any time during surgery predicted a 4.04-fold excess risk of AKI (p = .04). However, UPO2 did not significantly predict AKI in lower-risk patients. UPO2 significantly predicted AKI in patients who were older, had previous myocardial infarction, diabetes, lower preoperative serum creatinine, or shorter bypass times. pEPO and UPO2 were only weakly correlated. Intraoperative change in pEPO does not predict AKI. However, UPO2 shows promise, particularly in patients with higher risk of operative mortality. The disparity between these two markers of renal hypoxia may indicate that UPO2 reflects medullary oxygenation whereas pEPO reflects cortical oxygenation.

Abstract 16763: Frailty, as Measured by the Essential Frailty Toolset, is Associated With Higher Resource Utilization in Patients Undergoing Coronary Artery Bypass Grafting

Introduction: Frailty is an important predictor of clinical outcomes, but its contribution to resource utilization remains understudied. This study investigates the impact of frailty on high resource utilization (HRU) in patients undergoing Coronary Artery Bypass Graft Surgery (CABG). Methods: We reviewed data on patients who underwent CABG at a single center between 04/2018 and 12/2019. A Frailty score (FS) was calculated using the Essential Frailty Toolset (EFT). Patients were divided into two groups: Frail (FS ≥ 3/5) &amp; Non-Frail (FS &lt;3/5). Baseline clinical characteristics and outcomes were compared in both groups. The primary outcome was HRU (post-operative length of stay &gt; 7 days or readmission within 30-days). Secondary outcomes included operative time, prolonged ventilation, &amp; direct procedure costs. Multivariable logistic regression was used to assess the effect of frailty on HRU. Results: The study included 740 patients of whom 18% (n=132) were frail. Compared to Non-Frail patients, Frail patients were older (66 vs. 70 yrs. P&lt;0.001) and more likely to be high risk for operative mortality (1.3% vs. 14%, p&lt;0.001). The incidence of HRU was 28% vs. 53%, p&lt;0.001, in Non-Frail vs. Frail patients. Frail patients had longer operative times (272 vs. 247 mins; p&lt;0.001), and a higher incidence of prolonged ventilation (9.9% vs. 4%; p&lt;0.001). Median direct costs were also higher in Frail subjects ($33,434 vs. $22, 207; p&lt;0.001). On multivariable logistic regression analysis, independent predictors of HRU were (OR: 95% C.I.) Frailty: 2.19(1.44, 3.33; p=0.003), Sex (Female): 1.66 (1.14, 2.40; p=0.008), and history of COPD: 2.32(1.53, 3.54; p&lt;0.001). Conclusions: About one out of every five patients undergoing CABG was classified as frail by the EFT. Frailty was associated with higher direct costs and found to be an independent predictor of high resource utilization. Further attention is required to optimize outcomes and resource use in this vulnerable population.

Systematic approach to diagnosis and management of infected prosthetic grafts in the proximal aorta.

ObjectivesManagement of infected prosthetic aortic grafts in the ascending and or root is complex and multifaceted. We report our diagnostic pathway, management and outcomes, identifying successful strategies.MethodsThis was a retrospective, single center, observational study. Consecutive patients who underwent management of infected aortic grafts in the ascending and/or root at our institution between October 1998 and December 2019 were included. The main outcome measures were: discharge from hospital alive with at least 1 year survival, operative mortality and success of primary treatment strategy.ResultsTwenty‐six patients presented with infection of proximal aortic grafts and were managed through a number of strategies with an overall hospital‐survival of 81% and 1 year survival of 69%. Twenty of them ultimately underwent redo surgery with 25% operative mortality (within 24 h of surgery). Five patients underwent washout and irrigation of which two were successfully treated and cured with adjunctive antibiotics and two went on to have staged explant and definitive surgery. Interval between surgery and infection was 42.5 ± 35.8 months. All patients had at least one major criterion and three minor criterions with no diagnostic uncertainty. The commonest primary strategy was 3a (definitive surgery), (13/26, 50%).ConclusionsAdopting a systematic and flexible patient specific approach to the diagnosis and management of patients with proximal aortic graft infections results in reasonable overall 1 year survival. In the majority of patients surgery is ultimately required in an attempt to achieve a curative treatment; however this comes with high operative mortality risk.

Coronary Artery Target Selection and Survival After Bilateral Internal Thoracic Artery Grafting

BackgroundThe importance of a coronary artery, based on the myocardial mass it perfuses, is well documented, but little is known about the importance of a vessel that has been bypassed and its effect on survival in the context of bilateral internal thoracic artery (BITA) grafting. ObjectivesThis study determined the effect of a dominant left anterior descending (LAD) artery and important non-LAD targets on outcomes after BITA grafting. MethodsFrom January 1972 to January 2011, of 6,127 patients who underwent BITA grafting, 2,551 received 1 ITA grafted to the LAD and had an evaluable coronary angiogram. A dominant LAD was defined as one that was wrapped around the left ventricular apex. Non-LAD targets were graded based on their terminal reach toward the apex: important: >75% (n = 1,698); and less important: ≤75% (n = 853). Mean follow-up was 14 ± 8.7 years. Multivariable analysis was performed to identify risk factors for time-related mortality. ResultsA dominant LAD was present more frequently in patients with less important additional targets (51% vs. 35%; p < 0.0001). A total of 179 patients (7.0%) received a second ITA to multiple targets, 77 (43%) of which were to multiple important target vessels. Unadjusted late survival was similar regardless of degree of importance of the second ITA target—77% at 15 years (p = 0.70) for the important and less important targets, respectively. In the multivariable model, grafting the second ITA to multiple important targets was associated with better long-term survival (p = 0.005). In patients with a nondominant LAD, a second ITA grafted to a less important artery was associated with higher risk of operative mortality (2.4% vs. 0.51%; p = 0.007). A saphenous vein graft to an important or less important target did not influence long-term survival. ConclusionsIn BITA grafting, bypassing multiple important targets to maximize myocardium supplied by ITAs improved long-term survival. In patients with a nondominant LAD, selecting an important target for the second ITA lowered operative mortality.

Optimum surgical treatment for tricuspid valve infective endocarditis: An analysis of the Society of Thoracic Surgeons national database

ObjectiveThe incidence of intravenous drug–associated tricuspid valve endocarditis in the United States is rapidly increasing. Our goal was to evaluate the outcomes of isolated tricuspid valve operations using the Society of Thoracic Surgeon Adult Cardiac Surgical Database. MethodsFrom July 2011 to December 2016, 1613 patients with intravenous drug–associated tricuspid valve endocarditis underwent isolated tricuspid valve operations for endocarditis. Patients were stratified on the basis of type of tricuspid valve operation: valvectomy in 119 (7%), repair in 532 (33%), and replacement in 962 (60%). Risk factors and 30-day outcomes were compared among groups using Kruskal–Wallis and Pearson's chi-square tests. Multivariable logistic regression evaluated risk-adjusted operative mortality and morbidity by operative technique. ResultsAge, gender, race, and renal function were comparable among groups. Compared with the repair and replacement groups, the valvectomy group had a higher rate of acute infection (90% vs 79%, 84%; P < .01), Model for End-Stage Liver Disease score (10.17 vs 8.44, 9.74, P < .01), and urgent/emergency surgery (91% vs 75%, 83%; P < .01), respectively. Operative mortality was higher in those undergoing valvectomy (16%) (P < .01) compared with repair (2%) or replacement (3%). After risk adjustment, valvectomy was associated with a higher risk of operative mortality compared with repair (odds ratio, 3.82; P < .01), whereas there was no difference in operative mortality between repair and replacement (odds ratio, 0.95; P = .89). ConclusionsThis contemporary series of intravenous drug–associated tricuspid valve endocarditis reveals that valvectomy is an independent predictor of operative mortality. When anatomically possible, repair should be the preferred management for tricuspid valve endocarditis to avoid recurrent valve infection and prosthetic valve degeneration.

5-Year Outcomes of Self-Expanding Transcatheter Versus Surgical Aortic Valve Replacement in High-Risk Patients

BackgroundThe CoreValve U.S. Pivotal High Risk Trial was the first randomized trial to show superior 1-year mortality of transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR) among high operative mortality–risk patients. ObjectivesThe authors sought to compare TAVR to SAVR for mid-term 5-year outcomes of safety, performance, and durability. MethodsSurgical high-risk patients were randomized (1:1) to TAVR with the self-expanding bioprosthesis or SAVR. VARC-1 (Valve Academic Research Consortium I) definitions were applied. Severe hemodynamic structural valve deterioration was defined as a mean gradient ≥40 mm Hg or a change in gradient ≥20 mm Hg or new severe aortic regurgitation. Five-year follow-up was planned. ResultsA total of 797 patients were randomized at 45 U.S. centers, of whom 750 underwent an attempted implant (TAVR = 391, SAVR = 359). The overall mean age was 83 years, and the STS score was 7.4%. All-cause mortality rates at 5 years were 55.3% for TAVR and 55.4% for SAVR. Subgroup analysis showed no differences in mortality. Major stroke rates were 12.3% for TAVR and 13.2% for SAVR. Mean aortic valve gradients were 7.1 ± 3.6 mm Hg for TAVR and 10.9 ± 5.7 mm Hg for SAVR. No clinically significant valve thrombosis was observed. Freedom from severe SVD was 99.2% for TAVR and 98.3% for SAVR (p = 0.32), and freedom from valve reintervention was 97.0% for TAVR and 98.9% for SAVR (p = 0.04). A permanent pacemaker was implanted in 33.0% of TAVR and 19.8% of SAVR patients at 5 years. ConclusionsThis study shows similar mid-term survival and stroke rates in high-risk patients following TAVR or SAVR. Severe structural valve deterioration and valve reinterventions were uncommon. (Safety and Efficacy Study of the Medtronic CoreValve® System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement; NCT01240902)

PP17 Comprehensive Evaluation Of A Technology With Expanding Indications

Introduction:The use of transcatheter aortic valve implantation (TAVI) is evolving. Our Cardiovascular Evaluation Unit is implementing a comprehensive approach to inform decision-makers on optimal use of TAVI, including the development of quality standards. We are implementing a multifaceted evaluation framework in collaboration with clinical stakeholders.Methods:Our unit has carried out a continuous field evaluation in collaboration with the clinical teams at all six TAVI centers in Québec for the past four years (1 April 2013–31 March 2017), with regular feedback to the teams and sharing of results with each individual center. Hospital documentation was reviewed according to established national quality indicator definitions. Field evaluation data were combined with the results of systematic literature review to establish provincial standards for practice, through a deliberation process by an interdisciplinary committee of clinical experts from each center. Systematic surveillance of the literature is ongoing.Results:In the period 2013–2017, use of TAVI in Québec was limited to very elderly patients with significant comorbidities at high risk of operative mortality. We observed improvements in both processes of care (e.g. documentation of risk scores) and clinical outcomes (e.g. 30-day and 1-year mortality) over time. Our consensus standards recognize the potential value of TAVI for patients at moderate operative risk, identify uncertainties and recommend best practices for patient evaluation and clinical decision-making about choice of treatment.Conclusions:A comprehensive, long-term evaluation process of TAVI with feedback to centers is associated with improvements in processes of care and outcomes. In the present context of expanding clinical indications, we will continue to evaluate patient selection, processes and outcomes according to the newly-established provincial quality standards. This iterative approach facilitates continued evidence generation and decision-making for optimal use of an evolving intervention. We acknowledge the contribution of the members of the expert clinical committee.

Neoadjuvant Chemotherapy in Lung Cancer: Our Results after Twelve Years of Surgical Resection

Introduction: Lung cancer is characterized by its frequency and prognosis, which remains reserved by the fact that the diagnosis is often made at the locally evolved or metastatic stages. The aim of this study is to evaluate the contribution of neoadjuvant chemotherapy to the resectability of non-small cell lung carcinoma, while highlighting its impact on the incidence of surgical complications and the effect of this therapeutic strategy on survival. Materials: We have carried out a retrospective analysis of patients who underwent surgical treatment of nonsmall cell lung cancer (NSCLC) after neoadjuvant chemotherapy (NAC), between March 2000 and October 2012 at the Thoracic Surgery Department of Abderrahmen MAMI University Hospital. Results: During the study period, 103 patients were referred to our institution for NSCLC’s curative surgery after a NAC. Ninety five (95) patients are operated and 8 were not because of tumor progression after NAC or a high risk of operative mortality. The evaluation after the NAC showed a partial response in 77 cases (75%). More than half patients (57 cases: 55.7%) had a down-staging after the NAC. Male gender, and age increase postoperative complications significantly (p=0.042). Global survival was calculated for 87 patients 85%, 56%, 50% respectively at 1 year, 2 years and 5 years. The mean survival was 25 (range: 2 to 132) months. Global survival was increased significantly with T1 status (p=0.003) and M0 status (p<0.005) before NAC and also after NAC (p=0.032). Tumor localization had a significant impact on survival (p=0.034) with best survival with tumor in middle lobe and worst survival with bilobar tumors. Conclusion: We noticed an increased survival with age <60 years, feminine gender, well differentiated tumor, patient with no parietal involvement, NAC protocol other than Gemzar-Cisplatine, complete or partial response to NAC, pneumonectomy as the type of resection, no enlargement resection, uneventful postoperative, R0 resection, N0 status after NAC and finally pN0 status.

Acute type A aortic dissection in the United Kingdom: Surgeon volume-outcome relation

ObjectivesSurgery for acute type A aortic dissection (ATAD) carries a high risk of operative mortality. We examined the surgeon volume-outcome relation with respect to in-hospital mortality for patients presenting with this pathology in the United Kingdom. MethodBetween April 2007 and March 2013, 1550 ATAD procedures were identified from the National Institute for Cardiovascular Outcomes Research database. A total of 249 responsible consultant cardiac surgeons from the United Kingdom recorded 1 or more of these procedures in their surgical activity over this period. We describe the patient population and mortality rates, focusing on the relationship between surgeon volume and in-hospital mortality. ResultsThe mean annual volume of procedures per surgeon during the 6-year period ranged from 1 to 6.6. The overall in-hospital mortality rate was 18.3% (283/1550). A mortality improvement at the 95% level was observed with a risk-adjusted mean annual volume >4.5. Surgeons with a mean annual volume <4 over the study period had significantly higher in-hospital mortality rates in comparison with surgeons with a mean annual volume ≥4 (19.3% vs 12.6%; P = .015). ConclusionsPatients with ATAD who are operated on by lower-volume surgeons experience higher levels of in-hospital mortality. Directing these patients to higher-volume surgeons may be a strategy to reduce in-hospital mortality.

P1.05-029 SABRTOOTH-A Feasibility Study of SABR Compared to Surgery in Patients with Peripheral Stage I NSCLC Considered to Be at Higher Risk from Surgery

Stereotactic Ablative Radiotherapy (SABR) is a well-established treatment for medically inoperable peripheral stage I NSCLC. Previous non-randomized evidence supports SABR as an alternative to surgery, but high quality randomized control trial (RCT) evidence is lacking due to low recruitment. The UK SABRtooth study aims to see if a large RCT is feasible. The trial management group includes pulmonologists, thoracic surgeons, nurses, patient representatives, oncologists and statisticians. Patients considered at higher-risk of operative mortality and morbidity with a peripheral stage I (<5cm) NSCLC are eligible. Defining “higher-risk” patients considers multiple criteria, but the final decision is left to the individual tumor boards. Equipoise in presenting the two interventions to patients was considered key. Bias is minimized by ensuring the initial approach is by the pulmonologist with subsequent counseling by the research nurse and randomization occurring before consultation with a surgeon or oncologist . Patients who decline the trial or do not proceed with their allocated treatment are invited to take part in qualitative interviews. The trial is open in 4 thoracic oncology centers and their referral units. The aim is to recruit on average 3 patients/month to demonstrate that a phase III RCT would be feasible. Following a launch meeting in April 2015 the trial opened in July (all centers opened October 2015). To help train research staff with introducing the trial to patients, mock patient consultations were recorded. Recruitment was initially slow. Specific research nurse meetings have taken place (December 2015 and June 2016) to understand the barriers to recruitment, center-specific issues and provide additional education to improve nurses’ confidence in recruiting patients. Regular updates are provided with monthly emails and In February 2016, the Chief Investigator and Trial Manager visited each site to promote the trial and help with any local barriers to recruitment. In response to feedback, changes to the protocol to aid patient recruitment, additional promotional and patient information provided and a video for patients were produced. The study has also been presented at various Oncology/thoracic meetings. As a result recruitment has increased with 15 patients successfully randomized into the trial. Whether SABR is an alternative to surgery is a key question in stage I NSCLC. However, SABRtooth is a challenging study but with a novel trial design and continual adaptive feedback we hope to be able to meet recruitment targets and demonstrate that a definitive phase III RCT is feasible.

Abstract 12940: Prognosis of Hemodialysis Patients With Severe Aortic Stenosis: Findings From the Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis (CURRENT AS) Registry

Background: Prognosis of hemodialysis (HD) patients with severe aortic stenosis (AS) remains unclear. Methods and Results: The CURRENT AS registry, a Japanese multicenter registry enrolled 3815 consecutive patients with severe AS. There were 1197 patients treated with the initial aortic valve replacement (AVR) strategy including surgical AVR and transcatheter aortic valve implantation and 2617 patients treated with the conservative strategy. The median follow-up duration after the index echocardiography was 1361 days, with a 90% follow-up at 2-year. HD patients accounted for 11% (405/3815 patients). The cumulative 5-year incidence of all-cause death (primary outcome measure) was significantly higher in HD patients than in non-HD patients in both the entire cohort and the initial AVR group (see Figure). Among HD patients, the initial AVR group as compared with the conservative group was associated with significantly lower cumulative 5-year incedences of all-cause death (see Figure) and sudden death (10.2% versus 31.7%, P&lt;0.001). Operative mortality rate at 30-day after AVR in HD patients was as high as 7.7% (10/131 patients). Conclusions: Being on HD indicates a grimmer prognosis in patients with severe AS, even when treated with the initial AVR strategy. The initial AVR strategy in HD patients was associated with high operative mortality risk, while it was associated with lower risk of death in long-term.

Derivation and Validation of Prognosis-Based Age Cutoffs to Define Elderly in Cardiac Surgery.

The age cutoff to define elderly is controversial in cardiac surgery, empirically ranging from ≥65 to ≥80 years. Beyond semantics, this has important implications as a starting point for clinical care pathways and inclusion in trials. We sought to characterize the relationship between age and adverse outcomes in patients undergoing cardiac surgery and to derive and validate prognosis-based age cutoffs. Six thousand five hundred seventy one consecutive adult patients undergoing cardiac surgery at 3 hospitals in the United States and Canada were included in the cohort. Logistic regression models and generalized additive models with thin-plate splines were fit to the data. The age distribution was 50 to 59 years in 1244 (18.9%), 60 to 69 years in 2144 (32.6%), 70 to 79 years in 2000 (30.4%), ≥80 years in 1183 (18.0%) patients. After controlling for sex and type of operation, the relationship between age and 30-day operative mortality was found to be nonlinear. Receiver operating characteristic analysis showed that the optimal cutoffs to identify older patients at higher risk of operative mortality were greater than 74, 78, and 75 years for isolated coronary bypass, isolated valve surgery, and coronary bypass plus valve surgery, respectively. These age cutoffs were validated in an independent cohort. The relationship between age and operative mortality is not linear, manifesting a steeper rise after age 75 for coronary bypass and approaching octogenarian age for isolated valve surgery. Rather than using arbitrary age cutoffs to define elderly, the outcomes-based cutoff of ≥75 years should be used to identify the population of older adults that has higher risk and may benefit from preoperative geriatric evaluation and optimization.

Surgical factors and complications affecting hospital outcome in redo mitral surgery: insights from a multicentre experience.

Several single-centre experiences have reported significant operative mortality and morbidity after mitral valve surgery in redo scenarios (ReMVS). Several preoperative risk factors outlining 'high-risk' categories have been reported, but scanty data on the impact of different operative techniques for these major challenging procedures have been analysed to date. The aim of the study is to investigate those intraoperative factors and postoperative events affecting early survival after redo mitral procedures. Operative mortality and major morbidity events from a large multicentre registry enrolling 832 consecutive redo mitral procedures were analysed. Intraoperative technical issues and postoperative complications impacting operative mortality were identified. ReMVS was associated with significant operative mortality (12.5%), acute myocardial infarction (AMI; 5.9%), stroke (4.9%), acute respiratory insufficiency (14.8%), pneumonia (7.0%), acute renal insufficiency (16.1%) and failure (12.6%), reintervention for bleeding (7.6%), massive transfusion (28.0%), need for permanent pacemaker (10.1%). Injury of a previous patent left internal mammary artery (LIMA) graft [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.6-11.5; P = 0.005], major cardiovascular iatrogenic lesions at re-entry (OR 19.2, 95% CI: 9.2-39.9; P < 0.001), extracellular crystalloid cardioplegia (OR 7.3, 95% CI: 1.4-37.8; P = 0.018), and incremental cardiopulmonary bypass time (OR 1.1, 95% CI: 1.0-1.2; P = 0.001) independently predicted operative mortality, whereas combined antegrade + retrograde cardioplegia (OR 0.2, 95% CI: 0.09-0.4; P = 0.001) was the only protective factor against mortality. Among complications, AMI (OR 4.1, 95% CI: 1.8-9.6; P = 0.001), need for intra-aortic balloon pumping (IABP; OR 3.1, 95% CI: 1.5-6.1; P = 0.001), prolonged intubation >48 h (OR 5.3, 95% CI: 2.9-9.4; P = 0.001) and massive (>6 units) transfusions (OR 4.4, 95% CI: 2.4-8.0; P = 0.001) also predicted operative mortality. ReMVS still carries the risk of significant early mortality and major morbidity. Major lesion to cardiovascular structures is the most dreadful iatrogenic complication, and injury of a previous LIMA graft identifies patients at higher risk of operative mortality. Prolonged cross-clamp times, extracellular crystalloid cardioplegia and massive transfusions have profound impact on early outcome, as well as the development of perioperative AMI, eventually requiring IABP and prolonged intubation. The combination of antegrade and retrograde cardioplegia seems to offer a better myocardial protection in these high-risk patients.