Independent Predictor Of Reintervention Research Articles

Long-term echocardiographic data, mechanisms of failure, and reintervention outcomes of the Epic valve in mitral position—a large observational cohort

ObjectivesLong-term echocardiographic reports on mitral valve (MV) porcine xenograft bioprosthesis (Epic) are lacking, and postreintervention outcomes of failed Epic are unknown. We aimed to assess the mechanisms and independent predictors of Epic failures and to compare short- and mid-term outcomes according to reintervention type. MethodsWe included consecutive patients (n = 1397; mean age: 72 ± 8 years; 46% female; mean follow-up: 4.8 years) who received the Epic during mitral valve replacement (MVR) at our institution. Clinical, echocardiographic, reintervention, and outcomes data were retrieved from our prospective institution's database or government statistics. ResultsGradients and effective orifice area of the Epic were stable over 5-years follow-up. A total of 70 (5%) patients had a MV reintervention at median follow-up of 3.0 (0.7-5.4) years due to prosthesis failure, by redo-MVR (n = 38; 54%), valve-in-valve (n = 19; 27%), paravalvular leak (PVL) closure (n = 12; 17%), or thrombectomy (n = 1). Mechanisms of failure were 27 (1.9%) structural valve deterioration (SVD; all leaflet tear); 16 (1.1%) non-SVD (15 PVL, 1 pannus); 24 (1.7%) endocarditis; and 4 (0.3%) thrombosis. Freedom from all-cause and SVD-related MV reintervention at 10 years are 88% and 92%, respectively. Independent predictors of reintervention were age, baseline atrial fibrillation, initial MV etiology, and moderate or greater PVL at discharge (all P ≤ .05). Comparison of redo-MVR and valve-in-valve revealed no significant difference in early outcomes or mid-term mortality (all P ≥ .16). ConclusionsThe Epic Mitral valve has stable hemodynamics through 5 years and is associated with low incidence of SVD and reintervention, mostly due to endocarditis and leaflet tear without calcification. Reintervention type had no influence on early outcomes and mid-term mortality.

One year clinical outcomes of Rutherford 6 chronic limb threatening ischemia patients undergoing lower limb endovascular revascularisation from Singapore

BackgroundPercutaneous transluminal angioplasty (PTA) is widely used as a first-line revascularisation option in patients with chronic limb threatening ischemia (CLTI). This study aimed to evaluate the short-term endovascular revascularisation treatment outcomes of a cohort of Rutherford 6 (R6) CLTI patients, from a multi-ethnic Asian population in Singapore.Patients with R6 CLTI who underwent endovascular revascularisation from June 2019 to February 2020 at Singapore General Hospital, a tertiary vascular centre in Singapore, were included and followed up for one year. Primary outcome measures included number and type of reinterventions required, 3-, 6- and 12-month mortality, 6- and 12-month amputation free survival (AFS), wound healing success and changes in Rutherford staging after 3, 6 and 12 months.ResultsTwo hundred fifty-five procedures were performed on 86 patients, of whom 78 (90.7%) were diabetics, 54 (62.8%) had coronary artery disease (CAD) and 54 (62.8%) had chronic kidney disease (CKD). 42 patients (48.8%) required reintervention within 6 months. Multivariate analysis revealed that the presence of CAD was a significant independent predictor for reintervention. Mortality was 15.1%, 20.9% and 33.7% at 3, 6 and 12 months respectively. AFS was 64.0% and 49.4% at 6 and 12 months. Inability to ambulate, congestive heart failure (CHF), dysrhythmia and CKD were significant independent predictors of lower 12-month AFS.ConclusionsPTA for R6 CLTI patients was associated with relatively high mortality and reintervention rates at one year. CAD was an independent predictor of reintervention. More research is required to help risk stratify which CLTI patients would benefit from an endovascular-first approach versus conservative treatment or an immediate major lower extremity amputation policy.

Outcome and right ventricle remodelling after valve replacement for pulmonic stenosis

BackgroundComplications and need for reinterventions are frequent in patients with pulmonary valve stenosis (PVS). Pulmonary regurgitation is common, but no data are available on outcome after pulmonary valve replacement (PVR).MethodsWe...

P5545Predictors of 10-year mortality and re-intervention in patients with multivessel coronary disease, reduced systolic left ventricular function, after complete revascularization by PCI or CABG

Abstract Introduction In patients with multivessel coronary disease, the decision on revascularization should be made through a heart team. Whether there is an optimal method and what are the predictors of mortality and repeated interventions is the subject of numerous studies. Purpose To determine what are the predictors of 10-year mortality and repeated interventions in patients with multivessel coronary disease and reduced systolic left ventricular function in which complete revascularization is done through percutaneous coronary intervention (PCI) and surgical aortocoronary bypass (CABG). Methods The survey included 178 patients who underwent elective revascularization of multivessel coronary disease in one center during 2008 through PCI or bypass, according to the heart team's decision. All subjects had a reduced left ventricular systolic function, ejection fraction less than 50%. The study excluded patients with acute coronary syndrome. The basic demographic and clinical characteristics of the subjects and risk factors were analyzed. Results Ten-year mortality was 31.4%, without a significant difference between the examined groups (in the PCI group 25 patients (30.5%) in the bypass group 30 (32.3%), p>0.05). In subjects with letal outcome during 10-year follow-up, lower hemoglobin levels in discharge, enlarged cardiac cavities, increased internal diameter of left ventricle in systole (LVIDs) and enlarged left atrium, lower systolic left ventricular function, higher EUROscore and higher NYHA class in discharge. The enlarged left ventricular diameter in systole (OR 2.28 (1.27–4.11), p=0.006) and the NYHA class (OR 2.49 (1.22–5.08), p=0.012) are independent predictors ten-year mortality. In the group of patients undergoing surgical revascularization, independent predictors of 10-year mortality are higher levels of uric acid (OR 1,006 (1,000–1,011), P=0,047) and lower serum hemoglobin at discharge (OR 0,959 (0,919–0,999), P=0.046), while in PCI group LVIDs (OR 2.89 (1.351–6.196), p=0.006). During the 10-year follow-up, repeated PCI was performed in 12 (14.5%) patients in the PCI group and in 3 (3.2%) patients in the CABG group, p=0.012. No surgical revascularization was performed during follow up. Diabetes mellitus is an independent predictor of reintervention in the PCI group (OR 4.12 (1.153–14.703), p=0.029). Conclusion Mortality predictors during ten years of follow-up in subjects following a revascularization of multivessel coronary disease, and with reduced left ventricular systolic function, are increased systolic left ventricular diameter and higher NYHA class in discharge. Reintervention is more commonly performed after PCI and the presence of diabetes mellitus is an independent predictor.

The Impact of a Newly Established Multidisciplinary Team on the Interventional Treatment of Patients With Emphysema

Background:The emphysema interventional treatment involves mainly lung volume reduction surgery (LVRS) and endobronchial valve (EBV) implantation. Few institutes discuss these cases at a dedicated emphysema multidisciplinary team (MDT) meeting.Objectives:To investigate the impact of a newly established dedicated emphysema MDT meeting on the interventional treatment of such patients.Methods:During a study period of 4 years, the outcome of 44 patients who underwent intervention according to the proposal of the emphysema MDT (group A) was compared with the outcome of 44 propensity score matched patients (group B) treated without the emphysema MDT proposal.Results:More LVRS and less EBV insertions were performed in group A (P = .009). In group B, the interventions were performed sooner than in group A (P = .003). Postoperative overall morbidity and length of in-hospital stay were similar in the 2 groups (P = .918 and .758, respectively). Improvement of breathing ability was reported in more patients from group A (P = .012). In group B, the total number of re-interventions was higher (P = .001) and the time to re-intervention had the tendency to be less (P = .069). Survival was similar between the 2 groups (P = .884). Intervention without discussion at the MDT and EBV as initial intervention was an independent predictor of re-intervention.Conclusions:Interventional treatment for patients with chronic obstructive pulmonary disease (COPD) after discussion at a dedicated MDT involved more LVRS performed, required fewer interventions for their disease, and had longer re-intervention-free intervals and better breathing improvement.

Metabolic Syndrome but not Obesity Adversely Affects Outcomes after Open Aortoiliac Bypass Surgery

Although the incident risk of peripheral artery disease increases in patients with metabolic syndrome, several authors report favorable outcomes in obese patients after arterial bypass surgery. We examine the effect of the so-called "obesity paradox" and metabolic syndrome on outcomes after open aortoiliac bypass surgery. We identified patients between 2004 and 2015 who had open surgical bypass for aortoiliac occlusive disease. We excluded patients with endovascular repair and those treated primarily for aneurysmal disease. Variables that were analyzed included preoperative medical history, Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease II classification, Rutherford classification, intra-operative, and postoperative outcomes. Metabolic syndrome was defined by World Health Organization criteria: diabetes and 2 or more of dyslipidemia, hypertension, and obesity (body mass index > 30kg/m2). Data were analyzed by stratified Kaplan-Meier and multiple Cox regression for outcomes including long-term mortality and reintervention rate. There were 154 open bypass surgery patients during the study period with a median age of 60years (interquartile range [IQR] 53-68), median glomerular filtration rate 76.1mL/min (IQR 54-102), and 58% female prevalence. In all, 53 patients had metabolic syndrome (4%), and 14 patients (9%) were obese but did not have metabolic syndrome. Primary bypass graft patency was 89.0±2.7% at 1 year and 77.4±4.1% at 5 years and was not significantly different between metabolic syndrome, obese, and nonmetabolic syndrome patients. Reintervention rate for the entire cohort was 25.3±3.7% at 1 year and 40.6±4.7% at 5 years. In those with and without metabolic syndrome, reintervention rate at 1 and 5 years was 33.0±6.8% vs. 21.1±4.2% and 56.1±7.9% vs. 30.7±5.4%, respectively (log-rank P=0.003). In multivariable analyses, metabolic syndrome (hazard ratio [HR] 1.8, P=0.036) and critical limb ischemia (CLI) (HR: 3.2, P=0.001) were the only independent predictors of reintervention. Neither obesity nor the individual components comprising metabolic syndrome was a risk for reintervention. Multivariate analysis demonstrated age, female gender, CLI, and nonobesity as the independent risk factors for long-term mortality. Our study supports the "obesity paradox" that obesity by itself is not a risk factor for reintervention and was a protective factor for mortality after open aortoiliac bypass surgery. Bypass graft patency and major amputation rates were not affected. Although the individual components do not predispose to worse outcome, metabolic syndrome is a constellation of factors that, together, are associated with adverse events.

PTU-151 Predicting 30-Day Mortality and Re-Stenting Following Self Expanding Metal Stent (SEMS) Insertion for The Palliation of Dysphagia in Patients with Oesophageal Cancer

Introduction Management of dysphagia due to malignant obstruction of the oesophagus can be challenging. Endoscopically placed self-expanding metal stents (SEMS) remain an important tool and have been performed under direct vision in our institution since 2004. A previous audit suggested a significant morbidity and mortality rate and therefore the aim of this study was to identify risk factors for 30 day mortality and re-intervention. Methods A retrospective review of all patients undergoing oesophageal SEMS insertion was performed over the period 2004–2014. Data collected included patient demographics, tumour stage/position, stent type inserted, survival following SEMS insertion, bioprofile and other therapies. Univariate analysis was performed and was followed by multivariate logistic regression to identify independent variables associated with 30 day mortality and re-stenting. Results 396 patients (median age 74 years, 252 males) had 514 stents were inserted over the study period and were included in the study. Regarding 30 day mortality, univariate analysis showed association with distal tumours (OR 1.6), stent length >10 cm (OR 3.0), oncological treatment (OR 0.4), raised CRP (OR 6.1), raised white cell count (OR 6.0), anaemia (OR 2.8) and low albumin (OR 4.9). Multivariate analysis showed white cell count (OR 8.1, 2.0–21.9, p 70 (OR 0.6), junctional tumours (OR 0.5), stent length >10 cm (OR 0.6), raised CRP (OR 0.5) and raised white cell count (OR 0.4). Multivariate analysis showed age > 70 (OR 0.5, 0.3–0.9, p = 0.032) and raised white cell count (OR 0.4, 0.2–0.8, p = 0.009) were independent predictors of re-intervention. Conclusion Raised inflammatory markers were associated with poorer outcomes following oesophageal SEMS insertion and oncological treatment was protective. Longer survival appears to be associated with re-intervention following initial stent insertion. This data may provide a framework for the creation of a prognostic scoring system prior to SEMS insertion. Disclosure of Interest None Declared

Treatment of renal angiomyolipoma: pooled analysis of individual patient data.

BackgroundThis study was performed to evaluate the impact of baseline characteristics and treatment methods on the outcome of sporadic renal angiomyolipoma (AML).MethodsThis was a pooled analysis of individual data of 441 patients with AML retrieved from 58 studies and 3 institutional series.ResultsNinety-three patients underwent nephrectomy, 163 partial nephrectomy/enucleation, 128 embolisation, 19 cryoablation, 6 radiofrequency ablation, and 32 conservative treatment. Their mean follow-up period was 44.5 months. Patients who experienced major bleeding at presentation had significantly larger tumours than did those without bleeding (mean diameter, 10.1 vs. 5.9 cm, respectively; p < 0.0001). A total of 9.4 % and 26.4 % of bleeding tumours had a diameter of <4 and <6 cm, respectively. A tumour diameter of ≥8.0 cm (hazard ratio, 2.07; 95 % confidence interval, 1.20–4.77) and the treatment method (p = 0.001) were independent predictors of re-intervention. The risk of re-intervention was significantly higher after embolisation, particularly for large tumours (5-year rate of freedom from re-intervention: diameter of ≥8.0 cm, 49.2 %; diameter of <8.0 cm, 74.8 %; p = 0.018). Conservatively treated AMLs had a mean baseline diameter of 3.2 ± 2.7 cm; after 41 months, their mean diameter was 3.7 ± 3.1 cm (p = 0.109).ConclusionsThe prevalence of major bleeding is high in sporadic AMLs with a diameter of >6 cm. These results suggest that conservative treatment can be considered in AMLs of <6 cm in diameter. Among current treatment methods, embolisation was associated with a significantly higher risk of re-intervention. Further studies are needed to define risk factors for bleeding and assess the relative benefits of different treatment modalities.

Impact of Procedure Volumes and Focused Practice on Short-Term Outcomes of Elective and Urgent Colon Cancer Resection in Italy

BackgroundThe relationship between hospital volumes and short-term patients’ outcomes of colon cancer (CC) surgery is not well established in the literature. Moreover, evidence about short-term outcomes of urgent compared with elective CC procedures is scanty. The aims of this study are 1) to determine whether caseloads and other hospital characteristics are associated with short-term outcomes of CC surgery; 2) to compare the outcomes of urgent and elective CC surgery.MethodsA total of 14,200 patients undergoing CC surgery between 2005 and 2010 in the General Surgery Units (GSUs) of the hospitals of Emilia-Romagna region, Northern Italy, were identified from the hospital discharge records database. The outcomes of interest were 30-day in-hospital mortality, re-intervention and 30-day re-admission. Using multilevel analysis, we analyzed the relationship of GSU volumes and focused practice, defined as the percentage of CC operations over total operations, with the three outcomes.ResultsHigh procedure volumes were associated with a lower risk of 30-day in-hospital mortality, after adjusting for patients’ characteristics [aOR (95% CI) = 0.51 (0.33–0.81)]. Stratified analyses for elective and urgent surgery showed that high volumes were associated with a lower 30-day mortality for elective patients [aOR (95% CI) = 0.35 (0.17–0.71)], but not for urgent patients [aOR (95% CI) = 0.72 (0.42–1.24)]. Focused practice was an independent predictor of re-intervention [aOR (95% CI) = 0.67 (0.47–0.97)] and re-admission [aRR (95% CI) = 0.88 (0.78–0.98)].ConclusionsThe present study adds evidence in support of the notion that patients with CC undergoing surgery at high-volume and focused surgical units experience better short-term outcomes.

Race and Insurance Status Have Limited Effect on Long-Term Vascular Access Outcomes in Patients at an Inner City University Hospital

Insurance status and race are potential barriers to health care maintenance. We assessed their contribution to upper extremity vascular access outcomes in our population. We retrospectively reviewed outcomes of 601 vascular access patients from 2004-2012 at our institution. We recorded patient demographics, comorbidities, and complications. Primary outcomes were reintervention, long-term mortality, and kidney transplantation. Arteriovenous fistulas (AVF) accounted for majority (66%) of operations. Median age was 62, 58% were male. Race, a self-reported variable, was 50% Hispanic, 22% white, and 19% black. Most had Medicare only (42%), while 31% had private insurance and 27% had Medicaid. Black patients were less likely to get an AVF compared to whites and Hispanics (P < .05). White patients were significantly older than either Hispanics or blacks (68 vs 61 vs 58; P < .05). Overall freedom from reintervention at 5 years was 55%, with infection (HR, 2.0; 95% CI, 1.3-3.0), stenosis (HR, 3.2; 95% CI, 2.3-4.3), thrombosis (HR, 1.7; 95% CI, 1.2-2.4), and nerve injury (HR, 4.1; 95% CI, 1.5-11.5) being independent predictors of reintervention. Mortality at 5 years was 35%, predicted by AV graft placement (HR, 1.9; 95% CI, 1.4-2.7), low albumin (HR, 0.7; 95% CI, 0.6-0.9), white race (HR, 1.9; 95% CI, 1.3-2.8), and not receiving a kidney transplant (HR, 0.3; 95% CI, 0.2-0.6). Transplantation rate was 31% at 5 years and predicted by high albumin (HR, 1.9; 95% CI, 1.4-2.6), AVF (HR, 1.6; 95%, 1.1-2.6), and no CAD (HR, 0.6; 95% CI, 0.4-0.9). Race and insurance status did not affect reintervention or transplantation rate. Controlling for patient and clinical factors, insurance status did not have a significant effect on long term vascular access outcomes in our population. Race was not significantly associated with reintervention or transplantation, however more black patients had less suitable vasculature for AVF, and white patients had a lower long term survival, possibly due to more advanced age.

Reoperative aortic root replacement: short- and long-term outcomes in 111 patients

The aim of this study was to report results of aortic root reoperations and to identify predictors of in-hospital and long-term mortality. Between 1986 and 2011, 111 consecutive patients (mean age 55.4 years, 85 male [76.6%]) were reoperated on the aortic root after previous aortic surgery at our institution. An urgent/emergent operation was performed in 24 patients (21.6%). Indications for reoperation were degenerative aneurysm (n = 56), chronic post-dissection aneurysm (n = 27), active prosthetic infection (n = 14), false aneurysm (n = 10) and acute dissection (n = 4). Surgical procedures were limited to the aortic root in 68 patients (61.3%), and involved the entire proximal thoracic aorta in 43 patients (38.7%). In-hospital mortality was 12.6%, being 6.9% and 33.3% in elective and urgent cases, respectively (p=0.002). On multivariate analysis, cardiopulmonary bypass time (odds ratio 1.029/min; p=0.011) and urgent/emergent status (odds ratio 8.486; p=0.044) were independent predictors of in-hospital mortality. Follow-up was 99.1% complete. Estimated 1-, 5-, and 10-year survival rates were 82.5%, 71.9% and 50.6%, respectively. Six redo procedures were performed during follow-up. Freedom from reoperation at 1, 5, and 10 years was 100%, 91.7% and 86.1%, respectively. On Cox regression analysis, chronic aortic dissection (hazard ratio 21.2; p=0.009) was an independent predictor of reintervention at follow-up. Reoperation on the aortic root can be performed with acceptable mortality and good mid- and long-term outcomes, in particular when carried out on an elective basis. Cardiopulmonary bypass time and urgent/emergent status remain the most important risk factors for reduced survival in aortic surgery.

Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery

The proximal left anterior descending artery (LAD) is a challenging area for percutaneous interventions; therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the proximal LAD. This study compares mid-term results of LAD revascularization using drug-eluting stents (Cypher) with minimally invasive direct coronary artery bypass grafting (MIDCAB). From May 2002 to December 2003, 376 consecutive patients underwent myocardial revascularization of the LAD, 272 by Cypher and 104 by MIDCAB. After matching for age, sex, and extent of coronary artery disease, two groups of 83 patients each were used to compare the two revascularization modalities. The groups were similar; however, ejection fraction of less than 0.35 was more prevalent in the MIDCAB group and prior percutaneous coronary intervention in the Cypher group. Thirty-day mortality was 1.1% in the MIDCAB and 0% in the Cypher group. Mean follow-up was 22.5 months. Two late cardiac deaths occurred in the MIDCAB group and one in the Cypher group (p = NS). Angina returned in 35% of the Cypher group and in 8.4% of the MIDCAB group (p < 0.001). There were 14 (16.8%) reinterventions in the Cypher compared with three (3.6%) in the surgical group (p = 0.005). Cox proportional hazard model showed that assignment to the Cypher group was the only independent predictor of reangina (hazard ratio [HR], 6.17, 95% confidence interval [CI], 2.46 to 15.4). Treatment with Cypher was also an independent predictor of reintervention (HR 8.26, 95% CI, 1.68 to 40). Despite improved results of percutaneous interventions with Cypher to the LAD, mid-term clinical outcome of patients treated with MIDCAB was better.

Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Patients with Diabetes Mellitus

Reduction of restenosis and reinterventions was recently reported with percutaneous interventions (PCI) with drug-eluting stents (Cypher). This study compares results of Cypher (Cordis, Miami Lakes, FL) stenting and surgical revascularization in diabetic patients. From January 2002 to January 2005, 518 consecutive diabetic patients underwent myocardial revascularization; 176 by PCI incorporating Cyphers and 342 treated surgically. Single-vessel patients in the surgical group were treated with the left internal thoracic artery (ITA) and most multivessel patients were treated with two ITAs. After matching for age, sex, right system revascularization, and extent of coronary disease, two groups (86 patients each) were used to compare the two revascularization modalities. Both groups were similar; however, left main, poor ejection fraction, total occlusion, and bifurcation lesions were more prevalent in the surgical group, and in-stent restenosis in the PCI group. The mean number of coronary vessels treated was higher in the surgical group (2.05 vs 1.6, p < 0.001). Mean follow-up was 18 months. Overall mortality (early and late) was 2.3% and 3.5% in the Cypher and surgical groups, respectively (p = 0.65). Angina returned in 39.5% of the Cypher group and 15.1% of the surgical group, p < 0.001. There were 25 reinterventions in the Cypher group compared with five in the surgical group (p = 0.010). The Cox proportional hazard model revealed assignment to the Cypher group to be the only independent predictor of reangina (odds ratio [OR] 3.26, 95% confidence interval [CI] 1.63 to 6.53) and reintervention (OR 4.17, 95% CI 1.92 to 20.83). Despite improved results of PCI with Cyphers, midterm clinical outcome of diabetic patients treated surgically is better.