Higher 1-year Mortality Research Articles

Survival Analysis of Triple Negative Breast Cancer Patients Based on Ki-67 Protein Expression in Prof. Dr. I.G.N.G Ngoerah General Hospital Denpasar

Aim: To prove that 2-year mortality of triple-negative breast cancer (TNBC) patients with protein Ki-67 expression ≥ 40% is higher than patients with protein Ki-67 expression < 40% in Prof. dr. I.G.N.G. Ngoerah General Hospital Denpasar. Methods: This was a bidirectional cohort study with survival analysis. The end of follow-up was the mortality state (survived or deceased) of patients observed for 24 months (2 years) since the patient was diagnosed with TNBC. This study was conducted in the Surgical Oncology Department, Prof. dr. I.G.N.G. Ngoerah General Hospital Denpasar from January 2018 until January 2022. The sample was recruited by a consecutive sampling method. The Kaplan-Meier curve and log-rank test determined overall survival (OS) and its difference between the Ki-67 expression group. Multivariate analysis using Cox regression was also conducted. Results: 58 TNBC patients were included in this study. At the end of the study, 31 patients survived, with an OS of 53.4%. The mean OS time was 19 months (95%CI = 17.12-20.88). The two-year OS of TNBC patients with Ki-67 ≥ 40% group was 37.5%; meanwhile, in Ki-67 expression < 40% was 88.9%. It was statistically significant (p = 0.001). Multivariate analysis revealed that Ki-67 ≥ 40% expression was a significant and independent predictor factor for a high 2-year mortality rate (adjusted HR = 9.140; p = 0.008). Tumor-resection history also had a significant result in multivariate analysis (p < 0.05). Conclusion: TNBC patients with Ki-67 ≥ 40% have a higher 2-year mortality rate than patients with Ki-67 expression < 40%.

Impact of chronic kidney disease and end-stage renal disease on outcomes after complex endovascular and open aortic aneurysm repair

ObjectiveChronic kidney disease (CKD) and end-stage renal disease are traditionally associated with worse outcomes after endovascular aortic repair (EVAR) and open aneurysm repair (OAR) of abdominal aortic aneurysms (AAAs). However, there needs to be more data on complex AAA repair involving the aorta's visceral segment. This study stratifies complex AAA repair outcomes by CKD severity and dialysis dependence. MethodsAll patients undergoing elective OAR and fenestrated/branched EVAR (F-BEVAR) for complex AAA with preoperative renal function data captured by the Vascular Quality Initiative between January 2003 and September 2020 were analyzed. Patients were stratified by CKD class as follows: normal/mild (CKD 1 and 2), moderate (CKD class 3a), moderate to severe (CKD 3b), severe (CKD class 4 and 5), and dialysis. Only patients with clamp sites above one of the renal arteries were included for complex OAR. For F-BEVAR, patients with proximal landing zones below zone 5 (above celiac artery) were included, and distal landing zones between zones 1 and 5 were excluded. Primary outcomes were perioperative and 1-year mortality. Predictors of mortality were identified by Cox multivariate regression models. ResultsWe identified 7849 elective complex AAA repairs: 4230 (54%) complex OARs and 3619 (46%) F-BEVARs. Most patients were White (89%) and male (74%), with an average age of 72 ± 8 years. The patients who underwent F-BEVAR were older and had more comorbidities. Elective F-BEVAR for complex AAA started in 2012 and increased from 1.4% in 2012 to 58% in 2020 (P < .001). The OAR cohort had more perioperative complications, but less 1-year mortality. The normal/mild CKD cohort had the highest 1-year survival compared with other groups after both complex OAR and F-BEVAR. On Cox regression analysis, when compared with CKD 1-2, worsening CKD stage (CKD 3b: hazard ratio [HR], 2.5; 95% confidence interval [CI], 1.82-3.40; P < .001; CKD 4-5: HR, 1.9; 95% CI, 1.16-3.26; P = .011; and dialysis: HR, 4.4; 95% CI, 2.53-7.72; P < .001) were independently associated with 1-year survival after F-BEVAR. After complex OAR, worsening CKD stage but not dialysis was associated with 1-year mortality compared with CKD 1-2 (CKD 3b: HR, 1.6; 95% CI, 1.13-2.35; P = .009; CKD 4-5: HR, 3.4; 95% CI, 2.03-5.79; P < .001). ConclusionsCKD severity is an essential predictor of perioperative and 1-year mortality after complex AAA repair, irrespective of the treatment modality, which may reflect the natural history of CKD. Consideration should be given to raising the threshold for elective AAA repair in patients with moderate to severe CKD and end-stage renal disease, given the high 1-year mortality rate.

Higher 1-year mortality on rest days in patients with acute coronary syndromes and decompensated heart failure-A SPUM-ACS sub-study.

Acute coronary syndromes (ACS) occurring on rest days have been associated with higher mortality, but the current literature remains inconsistent in this regard. This study included ACS patients presenting with acute decompensated heart failure (ADHF) investigating the relationship between time of coronary catheterization and outcomes. Analyses were performed from the prospective, multicentric Special Program University Medicine Acute Coronary Syndromes and Inflammation (SPUM-ACS) Cohort. Patients were divided into two groups according to time of coronary catheterization on either workdays (Monday, 00:00 to Friday, 23:59) or rest days (Saturday, 00:00 to Sunday, 23:59 and public holidays). ADHF was defined by Killip Class III or IV upon presentation. Patients were followed over 1 year. Out of 4787 ACS patients enrolled in the SPUM-ACS Cohort, 207 (4.3%) presented with ADHF. 52 (25.1%) and 155 (74.9%) patients underwent coronary angiography on rest days or workdays, respectively. Baseline characteristics were similar among these groups. ACS patients with ADHF showed increased 1-year mortality on rest days (34.6% vs. 17.4%, p-value = 0.009). After correction for baseline characteristics, including the GRACE 2.0 Score, rest day presentation remained a significant predictor for 1-year mortality (adjusted hazard ratio = 2.42 [95% confidence interval: 1.14-5.17], p-value = 0.022). One-year all-cause mortality was high in ACS patients with ADHF and doubled for patients admitted on rest days. The present data support the association of a rest day effect and long-term patient survival and indicate a need for further investigations.

DAYS SPENT AT HOME BEFORE AND AFTER HIP FRACTURE AMONG MEDICARE BENEFICIARIES LIVING WITH DEMENTIA: A COHORT STUDY

Abstract Hip fracture is a disabling event experienced disproportionately by older adults with Alzheimer’s disease or related dementias (ADRD). Understanding how to better prognosticate outcomes for this population could drive more tailored clinical decision making. Our objective was to identify distinct trajectories of health before a hip fracture and determine their influences on post-fracture recovery trajectories and 1-year mortality rates among older adults with Alzheimer’s disease or related dementias (ADRD). We conducted a cohort study of 16,576 community-dwelling Medicare beneficiaries living with ADRD who experienced hip fracture between 2010 and 2017. We used latent mixture modeling to evaluate trajectories of days at home assessed monthly up to 180 days prior to hospitalization, and their associations with post-fracture days at home and 1-year mortality. Before a hip fracture, 3 distinct trajectories were identified: Robust (n=14,980, 90.3%), Impaired but Improving (n=809, 5.3%), and Impaired and Declining (n=787, 4.7%). Membership in the Impaired and Declining pre-fracture trajectory was strongly associated with membership in less favorable post-fracture recovery trajectories and 65% higher 1-year mortality rate (hazard ratio 1.65, 95% confidence interval 1.45-1.87) as compared to those in the Robust trajectory group. Similar albeit weaker associations were observed between membership in the Impaired but Improving pre-fracture trajectory and post-fracture outcomes. Overall, our results indicate that pre-fracture days at home trajectories are highly associated with post-hospitalization outcomes among older adults with ADRD and could be used to guide care management decisions.

Joint Modeling of Social Determinants and Clinical Factors to Define Subphenotypes in Out-of-Hospital Cardiac Arrest Survival: Cluster Analysis.

Machine learning clustering offers an unbiased approach to better understand the interactions of complex social and clinical variables via integrative subphenotypes, an approach not studied in out-of-hospital cardiac arrest (OHCA). We conducted a cluster analysis for a cohort of OHCA survivors to examine the association of clinical and social factors for mortality at 1 year. We used a retrospective observational OHCA cohort identified from Medicare claims data, including area-level social determinants of health (SDOH) features and hospital-level data sets. We applied k-means clustering algorithms to identify subphenotypes of beneficiaries who had survived an OHCA and examined associations of outcomes by subphenotype. We identified 27,028 unique beneficiaries who survived to discharge after OHCA. We derived 4 distinct subphenotypes. Subphenotype 1 included a distribution of more urban, female, and Black beneficiaries with the least robust area-level SDOH measures and the highest 1-year mortality (2375/4417, 53.8%). Subphenotype 2 was characterized by a greater distribution of male, White beneficiaries and had the strongest zip code-level SDOH measures, with 1-year mortality at 49.9% (4577/9165). Subphenotype 3 had the highest rates of cardiac catheterization at 34.7% (1342/3866) and the greatest distribution with a driving distance to the index OHCA hospital from their primary residence >16.1 km at 85.4% (8179/9580); more were also discharged to a skilled nursing facility after index hospitalization. Subphenotype 4 had moderate median household income at US $51,659.50 (IQR US $41,295 to $67,081) and moderate to high median unemployment at 5.5% (IQR 4.2%-7.1%), with the lowest 1-year mortality (1207/3866, 31.2%). Joint modeling of these features demonstrated an increased hazard of death for subphenotypes 1 to 3 but not for subphenotype 4 when compared to reference. We identified 4 distinct subphenotypes with differences in outcomes by clinical and area-level SDOH features for OHCA. Further work is needed to determine if individual or other SDOH domains are specifically tied to long-term survival after OHCA.

Comorbid status in patients with osteomyelitis is associated with long-term incidence of extremity amputation

IntroductionOsteomyelitis is associated with significant morbidity, including amputation. There are limited data on long-term amputation rates following an osteomyelitis diagnosis. We sought to determine the incidence of amputation in patients...

Acute muscle wasting rate assessment and long-term mortality in critically ill trauma.

To evaluate the relationship between acute muscle wasting rate and long-term mortality in critically ill trauma. A single-center, retrospective study was conducted in critically ill trauma. Patients with Computed Tomography scans including the L3 vertebra within 24 hours and at 1 week after trauma were recruited. Acute muscle wasting rate was defined as the mean percent variation per day of skeletal muscle index in the first week after trauma. Multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed to determine whether acute muscle wasting rate could help predict hospital malnutrition and 1-year mortality. Skeletal muscle index was 49.3±10.7 cm2/m2 at baseline and decreased to 45.1±9.6 cm2/m2 (p<0.001) at 1 week and 39.8±10.8cm2/m2 (p<0.001) at 1 month after trauma. A sustained decrease of skeletal muscle index was observed from baseline up to 6 months (33.7±8.4cm2/m2, p<0.001) post trauma, and lasted for 1 year (37.7±5.6cm2/m2, p=0.004). Logistic regression analysis showed that acute muscle wasting rate was an independent risk factor for hospital malnutrition and 1-year mortality. Every 1% absolute increase of acute muscle wasting rate was associated with 1.82-fold higher odds of 1-year mortality in critically ill trauma. The area under curve of acute muscle wasting rate was 0.813 for hospital malnutrition prediction and 0.715 for 1-year mortality prediction. Acute muscle wasting rate was independently associated with higher 1-year mortality and hospital malnutrition in critically ill trauma.

Long-term physical and psychiatric morbidities and mortality of untreated, deferred, and immediately treated epilepsy.

In Australia, 30% of newly diagnosed epilepsy patients were not immediately treated at diagnosis. We explored health outcomes between patients receiving immediate, deferred, or no treatment, and compared them to the general population. Adults with newly diagnosed epilepsy in Western Australia between 1999 and 2016 were linked with statewide health care data collections. Health care utilization, comorbidity, and mortality at up to 10 years postdiagnosis were compared between patients receiving immediate, deferred, and no treatment, as well as with age- and sex-matched population controls. Of 603 epilepsy patients (61% male, median age = 40 years) were included, 422 (70%) were treated immediately at diagnosis, 110 (18%) received deferred treatment, and 71 (12%) were untreated at the end of follow-up (median = 6.8 years). Immediately treated patients had a higher 10-year rate of all-cause admissions or emergency department presentations than the untreated (incidence rate ratio [IRR] = 2.0, 95% confidence interval [CI] = 1.4-2.9) and deferred treatment groups (IRR = 1.7, 95% CI = 1.0-2.8). They had similar 10-year risks of mortality and developing new physical and psychiatric comorbidities compared with the deferred and untreated groups. Compared to population controls, epilepsy patients had higher 10-year mortality (hazard ratio = 2.6, 95% CI = 2.1-3.3), hospital admissions (IRR = 2.3, 95% CI = 1.6-3.3), and psychiatric outpatient visits (IRR = 3.2, 95% CI = 1.6-6.3). Patients with epilepsy were also 2.5 (95% CI = 2.1-3.1) and 3.9 (95% CI = 2.6-5.8) times more likely to develop a new physical and psychiatric comorbidity, respectively. Newly diagnosed epilepsy patients with deferred or no treatment did not have worse outcomes than those immediately treated. Instead, immediately treated patients had greater health care utilization, likely reflecting more severe underlying epilepsy etiology. Our findings emphasize the importance of individualizing epilepsy treatment and recognition and management of the significant comorbidities, particularly psychiatric, that ensue following a diagnosis of epilepsy.

294. The Impact of Mucositis on the Oral Microbiome and Clinical Outcomes in Allogenic Hematopoietic Stem Cell Transplantation

Abstract Background Mucositis is a common complication of allogeneic hematopoietic stem cell transplantation (allo HCT) that can lead to debilitating pain, malnutrition, and bloodstream infections (BSI). We sought to characterize the oral microbiome of allo HCT recipients and correlate the oral microbiome with the development of mucositis and clinical outcomes. Methods We collected weekly oral swabs and clinical data from patients who underwent allo HCT from 2017-21. Swabs underwent 16S rRNA sequencing, amplifying the V4 region. Patients with paired pre-HCT (prior to conditioning) and day +30 samples were included in the microbiome analysis. Results 91 patients were enrolled with 178 swabs sequenced. Mucositis occurred in 66/91 patients (73%) at a median 6 days post-HCT (Table 1). Patients with mucositis were significantly more likely to receive myeloablative conditioning, methotrexate/calcineurin inhibitor for graft-versus host disease (GVHD) prophylaxis, and total parenteral nutrition. There was not a significant difference in BSI rates at day +30 between patients with mucositis and those without (20% vs. 17%; p=0.69), but there was a trend toward more acute GVHD by day +30 in the mucositis group (27% vs. 12%; p=0.12). Additionally, patients with mucositis had lower rates of relapse (18% vs. 36%; p=0.07) and all-cause mortality at 1-year post-HCT (26% vs. 36%; p=0.33) although these comparisons were not statistically significant. 39 patients had paired 16S pre- and Day +30 data (28 with mucositis, 11 without). While there was no change in α-diversity in patients who did not develop mucositis, the development of mucositis was associated with a decrease in α-diversity (Figure 1). Although β-diversity of the pre-HCT samples was not different between the two groups, patients with mucositis had a lower pre-HCT abundance of Veillonella parvula. Conclusion Post-HCT mucositis led to a reduction in day +30 microbiota diversity, with Veillonella parvula potentially being a biomarker for the development of mucositis. Mucositis was not associated with more BSIs or higher 1-year mortality. Future study includes analysis of the gut microbiome in this same cohort to identify microbial targets that attenuate mucositis without impacting the therapeutic efficacy of HCT. Disclosures Neeraj Surana, MD, PhD, Pfizer: Stocks/Bonds Anthony Sung, MD, clasado: Grant/Research Support|dsm: Grant/Research Support|merck: Grant/Research Support

Gender-specific linkages: frailty, polypharmacy, anti-cholinergic burden, and 5-year mortality risk-a real-world analysis.

With higher age, frailty escalates the risk of falls, unexpected physical dysfunction, hospitalization, and mortality. Polypharmacy in the older population is a major challenge that not only increases medical costs, but also may worsen the risk of hospitalization and death. More importantly, the properties of anti-cholinergic drugs contribute various negative effects. This study aimed to investigate the sex difference in the association of polypharmacy, anticholinergic burden, and frailty with mortality. Participants older than 65 years who attended the geriatric outpatient clinic of the study center between January 2015 and July 2020 were invited to participate in this retrospective study. Comprehensive geriatric assessment data were collected and the phenotype of frailty was determined by Fried's criteria. Cox regression and the Kaplan-Meier curve were used to identify risk factors of 5-year survival along with intergroup differences in the risks. Of the 2,077 participants, 47.5% were female. The prevalence of frailty and the rate of polypharmacy were 44.7% and 60.6%, respectively. Higher age, male sex, low body mass index, low Mini-Mental State Examination scores, low activities of daily living, frailty status, polypharmacy, and a high Charlson Comorbidity Index score, and greater anticholinergic burden were significant risk factors that were associated with the 5-year all-cause mortality. Male patients with frailty exhibited the highest risks of mortality compared with male patients without frailty and female patients with or without frailty. Polypharmacy was significantly associated with a higher 5-year mortality rate in the frail male group compared with the non-frail male. In frail female group, individuals with a higher anticholinergic burden (as indicated by the Anticholinergic Cognitive Burden Scale) from drug usage exhibited an elevated 5-year mortality rate. Polypharmacy and greater anticholinergic burden, synergistically interacted with frailty and intensified the 5-year mortality risk in a gender-specific manner. To mitigate mortality risks, clinicians should prudently identify polypharmacy and anticholinergic burden in the older population.

OGC P23 Modified Frailty Index is not a good predictive tool of postoperative mortality following minimally invasive oesophagectomy

Abstract Background Evaluating frailty in the elderly population is crucial in preoperative assessment to identify high-risk patients. The modified frailty index (m-FI) is known to predict postoperative mortality in various surgical populations, but its predictive value in oesophagectomy patients' long-term mortality is unclear. No studies have specifically quantified frailty and its association with long-term postoperative mortality in oesophagectomy patients. This study investigates the association between m-FI score and long-term mortality in patients undergoing minimally invasive oesophagectomy (MIO). Methods The m-FI is a scoring tool of 11 parameters quantifies frailty in surgical patients. Retrospective analysis (1/1/2014-31/12/2023) of patients aged ≥75 years undergoing minimally invasive oesophagectomy procedures for cancer, at a single h[ka1] igh volume tertiary referral centre was carried out. Primary outcome was defined as 1-year all-cause mortality with overall length of survival as the secondary outcome. After sensitivity analyses m-fi score of less than 1 or greater than 2 were most predictive of mortality. Results Ninety-one patients (mean age 78 years, age range 75-88, male to female ratio of 4:1) were included, with a median m-FI score of 1 (range: 0-5). Patients with an m-FI score of ≥2 had a higher 1-year mortality rate (30% vs. 19%, p=0.195) and shorter overall median survival time (34 months vs. 47 months, p=0.399) compared to those with a score of ≤1. After adjusting for covariates, including preoperative chemotherapy, age, sex, and cancer staging, an m-FI score of ≥2 had a hazard ratio of 1.65 (95% CI: 0.68 to 3.98, p=0.267) for 1-year mortality compared to ≤1. Conclusions The m-FI tool can predict post operative mortality in a range of surgical specialities. The results of our study would suggest that higher m-FI score would correlate with worse long term mortality outcomes, however at this stage the m-FI tool cannot be applied in a clinical setting to accurately define elderly patient's probable outcome following MIO. Additional multicentre data is needed to establish its true predictive value in this patient cohort.

Association between Sarcopenia and Survival in Patients Undergoing Gamma Knife Surgery for Brain Metastasis from Breast Cancer: A Retrospective Single-centre Cohort Study

AimsMany recent studies related to cancer surgery have reported that sarcopenia influences mortality in surgical patients. However, few comprehensive studies have examined the associations between sarcopenia and short- and long-term surgical outcomes of metastatic cancer, especially breast cancer with brain metastasis. In the present study, we investigated the association between sarcopenia and mortality in patients who underwent gamma knife radiosurgery (GKRS) for brain metastasis with breast cancer. Materials and methodsThis retrospective study analysed 157 patients who underwent GKRS for brain metastasis with breast cancer between January 2014 and December 2018. A Cox regression analysis was carried out to evaluate the association between sarcopenia and mortality at 90 days, 180 days, 1 year, 3 years and the overall period. ResultsIn the Cox regression analysis, sarcopenia was significantly associated with high 90-day mortality (adjusted hazard ratio 3.46, 95% confidence interval 1.24–9.67, P = 0.018), 180-day mortality (adjusted hazard ratio 2.67, 95% confidence interval 1.37–5.22, P = 0.004), 1-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.42–4.02, P = 0.001), 3-year mortality (adjusted hazard ratio 2.39, 95% confidence interval 1.53–3.74, P < 0.001) and overall mortality (adjusted hazard ratio 2.11, 95% confidence interval 1.37–3.26, P < 0.001). ConclusionSarcopenia could be a risk factor for short- and long-term mortality in patients undergoing GKRS for brain metastasis from breast cancer.

Sex differences in long-term outcomes among hospitalized heart failure patients across the spectrum of ejection fraction: findings from the Get with the guidelines - heart failure registry

Abstract Background Sex differences in 5-year outcomes across heart failure (HF) ejection fraction (EF) subtypes are not well known. Purpose To assess the interaction between sex and EF for risk of long-term adverse outcomes after hospitalization with HF. Methods Patients from American Heart Association’s Get With The Guidelines – Heart Failure registry enrolled between 1/1/2006 – 12/31/2014 with age ≥ 65 years with available 5-year follow-up data, ascertained through linkage with Medicare fee-for-service Part A administrative claims, were included. HF subtypes included HF with reduced EF (HFrEF) with EF ≤ 40%, HF with mildly reduced EF (HFmrEF) with EF 41-49%, and HF with preserved EF (HFpEF) with EF ≥ 50%. Sex differences in 5-year all-cause mortality and readmission for each HF subtype were assessed using unadjusted cumulative incidence methods and adjusted Cox models. Median survival across HF subtypes was compared to median survival of U.S. adults. Results 155,670 patients (mean age 81 years, 53.4% females) were included. Male patients were younger and had a higher prevalence of prior myocardial infarction or coronary artery bypass graft surgery and were more likely to have HFrEF, while women were more likely to have history of hypertension and HFpEF. The median post-hospitalization survival of patients with HF was substantially lower than the age- and sex-specific U.S. life expectancy across each HF subtype (Figure 1).Patients with HF had high 5-year mortality rates (HFrEF male: 81.3%, female: 78.4%; HFpEF male: 80.5% vs female 79.5%). In adjusted analysis, female (vs. male) patients had a significantly lower 5-year mortality risk (HR [95%CI]: 0.89 [0.87 – 0.90], p&amp;lt;0.01) and a higher 5-year readmission risk (all-cause: 1.03 [1.02 – 1.04]), CV: 1.05 [1.04 – 1.07]), HF: 1.06 [1.04 – 1.08], p&amp;lt;0.01 for each). HF subtype modified the association between sex and 5-year outcomes (pinteraction &amp;lt;0.05 for mortality and CV and HF readmission), with the greatest risk reduction of mortality for female vs. male patients with HFrEF and the greatest risk increase of readmission (CV and HF) among female vs. male patients with HFmrEF and HFpEF (Figure 2). Conclusion Among patients with HF, the overall survival post-HF hospitalization is very low for each HF subtype. Female patients have a lower 5-year mortality risk but a higher risk of HF or CV readmission regardless of EF.Figure 1Figure 2

Cardiovascular events following vascular endothelial growth factor inhibitor therapy with sunitinib or pazopanib in patients with renal cell carcinoma - a nationwide registry-based follow-up study

Abstract Background Use of oral vascular endothelial growth factor receptor (VEGFR) tyrosine kinase inhibitors (TKIs) with focus on sunitinib and pazopanib approved for treatment of patients with renal cell carcinoma (RCC) may be associated with cardiovascular events. However, there are limited data on the risk related to treatment with sunitinib or pazopanib. Purpose The aim of this study was to examine the risk of cardiovascular events in patients with RCC treated with sunitinib and pazopanib compared with age- and sex-matched population control subjects without cancer (1:2 ratio). Methods Patients with RCC treated with sunitinib or pazopanib from 2011 through 2018 were identified within the Danish National Patient Registry. Multivariable Cox regression standardized to the age, sex, selected comorbidity and pharmacotherapy distributions of all included subjects were used to derive absolute one-year risks of selected cardiovascular events. Results A total of 3,642 patients were included in the analysis, of whom 1,214 had RCC treated with sunitinib or pazopanib, and 2,428 were population control subjects without cancer. Differences in age, sex, prior acute coronary syndrome (ACS), chronic obstructive pulmonary disease, and peripheral artery disease were insignificant (all P&amp;gt;0.05), whereas patients with RCC more frequently had prior hypertension (51.2% vs. 35.2%), diabetes (17.1% vs. 10.3%), and transient ischemic attack (TIA) or stroke (7% vs. 4.5%), all P&amp;lt;0.05. Absolute risk of ACS was 1.4% for patients with RCC vs. 1.0% for controls (P=0.54), stroke/TIA 1.7% vs. 0.8% (P=0.10), and ventricular arrhythmia 0.3% vs. 0.1% (P=0.70). In contrast, risk of hypertension was significantly elevated with 50.7% vs. 41.8% for patients with RRC vs. controls (P&amp;lt;0.001), and this risk was similarly elevated when excluding patients with prior hypertension (30.7% vs. 5.4%, P&amp;lt;0.001). Similarly, risks of atrial fibrillation or flutter (AF) with 5.6% vs. 2.8% (P&amp;lt;0.001) and heart failure (HF) with 0.7% vs. 0.3% (P&amp;lt;0.001) were significantly elevated in patients with RCC versus controls.Risk of venous thromboembolism (VTE) was 5.6% vs. 0.9% (P&amp;lt;0.001) for patients with RCC versus controls. All-cause mortality risk was 40.1% vs. 2.6% (P&amp;lt;0.001). The corresponding relative risks for one-year outcomes are shown in Figure 1. Conclusions Patients with RCC treated with sunitinib or pazopanib did not have a significantly higher risk of ACS, stroke/TIA or ventricular arrhythmia when compared to age- and sex-matched controls. In contrast, risks of hypertension, AF, HF, and VTE at 1 year compared with population control subjects were significantly elevated. Risk of HF risk was however limited in absolute numbers and the clinical significance of the evaluated risk of this endpoint as well as other endpoints should be interpreted in the context of a significantly high 1-year mortality risk of around 40% in patients with RCC versus only around 2.5% in population controls.Figure 1

Association between High Bleeding Risk and 2-Year Mortality in Patients with Chronic Limb-Threatening Ischemia.

Patients with chronic limb-threatening ischemia (CLTI) have a high bleeding risk (HBR) and mortality rate. The 2-year life expectancy is an important factor in deciding the appropriate treatment strategy. This study aimed to assess the influence of HBR on the prognosis of patients with CLTI. A total of 259 patients with CLTI who underwent endovascular therapy (EVT) (mean age, 76.2 years; male, 62.9%) between January 2018 and December 2019 were evaluated. The Academic Research Consortium for HBR (ARC-HBR) criteria were applied to each patient, and the ARC-HBR scores were calculated. The cut-off score for predicting all-cause mortality within two years was derived using a survival classification and regression tree (CART) model. Causes of death and the association between ARC-HBR scores and major bleeding events within two years were also investigated. Based on the CART model, patients were divided into three groups (low HBR score 0-1.0, 48 patients; moderate HBR score 1.5-3.0, 176 patients; and high HBR score ≥ 3.5, 35 patients). During the study period, 82 patients (39.6%) died due to cardiac (n=23) and non-cardiac causes (n=59). All-cause mortality increased significantly with increasing ARC-HBR scores. Cox multivariate analysis revealed a significant association between high ARC-HBR scores and the risk of all-cause mortality within two years. Major bleeding events increased significantly with increasing ARC-HBR scores. The ARC-HBR score could predict 2-year mortality in patients with CLTI who underwent EVT. Thus, this score can help determine the best revascularization strategy for patients with CLTI.

Donor/recipient ascending aortic diameter ratio as a novel potential metric for donor selection and improved clinical outcomes in heart transplantation: a propensity score-matched study.

Donor/recipient size matching is paramount in heart transplantation. Body weight, height, body mass index, body surface area, and predicted heart mass (PHM) ratios are generally used in size matching. Precise size matching is important to achieve better clinical outcomes. This study aims to determine the donor/recipient ascending aortic diameter (AAoD) ratio as a metric for donor selection and its effect on postoperative clinical outcomes in heart transplant patients. We retrospectively reviewed all consecutive patients who underwent heart transplantation from January 2015 to December 2018. A cutoff value of 0.8032 for the donor/recipient AAoD ratio (independent variable for the primary endpoint during unmatched cohort analysis) was determined for predicting in-hospital mortality. The patients were divided into two groups based on the cutoff value. Group A, AAoD < 0.8032 (n = 96), and Group B, AAoD > 0.8032 (n = 265). A propensity score-matched (PSM) study was performed to equalize the two groups comprising 77 patients each in terms of risk. A Cox regression model was developed to identify the independent preoperative variables affecting the primary end-point. The primary endpoint was all-cause in-hospital mortality. A total of 361 patients underwent heart transplantation during the given period. On the multivariate analysis, donor/recipient PHM ratio [HR 16.907, 95% confidence interval (CI) 1.535-186.246, P = 0.021], donor/recipient AAoD ratio < 0.8032 (HR 5.398, 95% CI 1.181-24.681, P = 0.030), and diabetes (HR 3.138, 95% CI 1.017-9.689, P = 0.047) were found to be independent predictors of in-hospital mortality. Group A had higher 3-year mortality than Group B (P = 0.022). The surgery time was longer and postoperative RBC, plasma, and platelets transfusion were higher in Group A (P < 0.05). Although not statistically significant the use of continuous renal replacement therapy (P = 0.054), and extracorporeal membrane oxygenation (P = 0.086), was realatively higher, and ventilation time (P = 0.079) was relatively longer in Group A. The donor/recipient AAoD ratio is a potential metric for patient matching and postoperative outcomes in heart transplantation. A donor/recipient AAoD ratio > 0.8032 could improve post-heart transplantation outcomes and donor heart utilization.

Routine perioperative blood tests predict survival of resectable lung cancer

There is growing evidence that inflammatory, immunologic, and metabolic status is associated with cancer patients survival. Here, we built a simple algorithm to predict lung cancer outcome. Perioperative routine blood tests (RBT) of a cohort of patients with resectable primary lung cancer (LC) were analysed. Inflammatory, immunologic, and metabolic profiles were used to create a single algorithm (RBT index) predicting LC survival. A concurrent cohort of patients with resectable lung metastases (LM) was used to validate the RBT index. Charts of 2088 consecutive LC and 1129 LM patients undergoing lung resection were evaluated. Among RBT parameters, C-reactive protein (CRP), lymphocytes, neutrophils, hemoglobin, albumin and glycemia independently correlated with survival, and were used to build the RBT index. Patients with a high RBT index had a higher 5-year mortality than low RBT patients (adjusted HR 1.93, 95% CI 1.62–2.31). High RBT patients also showed a fourfold higher risk of 30-day postoperative mortality (2.3% vs. 0.5%, p 0.0019). The LM analysis validated the results of the LC cohort. We developed a simple and easily available multifunctional tool predicting short-term and long-term survival of curatively resected LC and LM. Prospective external validation of RBT index is warranted.

Feasibility and Outcomes of Mitral Transcatheter Edge-To-Edge Repair in Patients With Variable Degrees of Mitral Annular Calcification.

Background The clinical significance of mitral annular calcification (MAC) in patients undergoing mitral transcatheter edge-to-edge repair is not well understood. There is limited evidence regarding the feasibility, durability of repair, and the prognostic value of MAC in this population. We sought to examine the prognostic value of MAC, its severity, and its impact on procedural success and durability of mitral transcatheter edge-to-edge repair. Methods and Results We reviewed the records of 280 patients with moderate-severe or severe mitral regurgitation who underwent mitral transcatheter edge-to-edge repair with MitraClip from March 2014 to March 2022. The primary end point was cumulative survival at 1 year. Independent factors associated with the primary end point were identified using multivariable Cox regression. Among 280 patients included in the final analysis, 249 had none/mild MAC, and 31 had moderate/severe MAC. Median follow-up was 23.1 months (interquartile range: 11.1-40.4). Procedural success was comparable in the MAC and non-MAC groups (92.6% versus 91.4%, P=0.79) with similar rates of residual mitral regurgitation ≤2 at 1 year (86.7% versus 93.2%, P=0.55). Moderate/severe MAC was associated with less improvement in New York Heart Association III/IV at 30 days when compared with none/mild MAC (45.8% versus 14.3%, P=0.001). The moderate/severe MAC group had lower cumulative 1-year survival (56.8% versus 80.0%, hazard ratio [HR], 1.98 [95% CI, 1.27-3.10], P=0.002). Moderate/severe MAC and Society of Thoracic Surgeons predicted risk of mortality for mitral valve repair were independently associated with the primary end point (HR, 2.20 [1.10-4.41], P=0.02; and HR, 1.014 [1.006-1.078], P=0.02, respectively). Conclusions Mitral TEER is a safe and feasible intervention in selected patients with significant MAC and associated with similar mitral regurgitation reduction at 1 year compared with patients with none/mild MAC. Patients with moderate/severe MAC had a high 1-year mortality and less improvement in their symptoms after TEER.

Outcomes of octogenarians receiving aortic repair

ObjectiveAbdominal aortic aneurysm (AAA) repair is recommended for aneurysms greater than 5.5 cm in men and 5 cm in women. Because AAA is more common among the elderly, we sought to evaluate contemporary practices of elective AAA repair and 2-year postoperative outcomes in octogenarians. MethodsWe identified octogenarians undergoing elective AAA repair in the Vascular Quality Initiative from 2012 to 2019. We included patients undergoing endovascular (EVAR) and open (OAR) aortic repair. Demographics and comorbid conditions were compared between patient groups. Frailty was calculated using previously published methods. Patients with frailty scores above the 75th percentile of the operative cohort were considered high frailty. The primary outcome was 1- and 2-year mortality. Secondary outcomes included postoperative complications. Standard statistical methods were utilized. Cox proportional hazard models were used to identify factors that affect mortality. ResultsThe frequency of AAA repair in octogenarians has remained stable. Of all aortic operations, 21.4% were performed on octogenarians; 9735 (23.3% of 41,712) EVAR and 755 (10.3% of 7325) OARs. Among octogenarian patients, 42.0% of EVARs were under size thresholds: 48.3% males ≤5.5 cm diameter and 21.5% females ≤5.0 cm diameter compared with 18.8% OARs: 23.4% males and 10.7% females. Additionally, 25.6% had high frailty scores. Among octogenarians, 1- and 2-year mortality was 9.3% ± 0.3% and 14.8% ± 0.4% for EVAR and 15.2% ± 1.3% and 18.9% ± 1.5% for OAR patients, respectively (P < .01). In-hospital mortality rate was higher after OAR (0.87% EVAR vs 7.55% OAR; P < .01) and differed with frailty (EVAR, low frailty 0.2% vs high frailty 1.7%; OAR, low frailty 2.3% vs high frailty 15.6%). For EVAR, patient factors associated with mortality included heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.06-1.25; P = .001) and dialysis (HR, 1.71; 95% CI, 1.13-2.59; P = .012). For OAR, coronary artery disease (HR, 1.55; 95% CI, 0.98-2.44; P = .062) was associated with mortality. Statin use was protective of mortality for all patients (EVAR: HR, 0.68; 95% CI, 0.60-0.78; P < .01): OAR: HR, 0.58; 95% CI, 0.37-0.92; P = .020). Among octogenarians, high frailty was independently associated with 2-year mortality (EVAR: HR, 3.36; 95% CI, 2.62-4.31; P < .01 and OAR: HR, 2.35; 95% CI, 1.09-5.10; P = .030). ConclusionsNationally, a large portion of elective AAA repair in octogenarians is performed below recommended size thresholds, one-quarter of whom are frail with poor long-term 2-year mortality rates. High 2-year mortality following AAA repair in this age group exceeds the published risk of rupture for 5- to 5.5-cm AAA, suggesting that increase in the size threshold of elective repair among octogenarians should be explored.

Trends and Outcomes in Patients With Coronary Artery Disease Undergoing TAVR: Insights From VA CART.

Obstructive coronary artery disease (CAD) is common in patients with severe symptomatic aortic stenosis. The management and impact of obstructive CAD in patients undergoing transcatheter aortic valve replacement (TAVR) have not been fully evaluated. We aimed to determine the patient characteristics and clinical outcomes among veterans undergoing TAVR with and without obstructive CAD and to determine temporal trends and association of pre-TAVR percutaneous coronary intervention (PCI) with clinical outcomes. We identified all patients who underwent TAVR from 2012 to 2021 in the VA Health Care System. The sample population was divided into patients with and without obstructive CAD and further stratified by coronary intervention status 1 year prior to TAVR. The primary outcome was 1-year all-cause mortality, and the secondary outcome was major bleeding. During the study period, 759 patients underwent TAVR, and 282 (37%) had obstructive CAD. Obstructive CAD was associated with higher 1-year mortality (15.6% vs 7.1%; P < .01) after TAVR. The rate of PCI prior to TAVR increased from 2012 until 2016, after which it steadily declined such that 144 patients (51%) underwent PCI pre-TAVR during the entire study period. There was no difference in 1-year mortality (16.0% vs 15.2%; P = .89) or bleeding (16.7% vs 12.3%; P = .33) between patients who underwent or did not undergo pre-TAVR PCI. Among veterans undergoing TAVR, the presence of obstructive CAD is associated with higher mortality though pre-TAVR coronary intervention is not associated with improved outcomes. Further studies could identify a subset of patients who may benefit from coronary revascularization prior to TAVR.