Mid-term Survival Of Patients Research Articles

Effect of Asymptomatic Common Carotid Artery Dissection on the Prognosis of Patients With Acute Type A Aortic Dissection.

Acute type A aortic dissection can extend upwards to involve the common carotid artery. However, whether asymptomatic common carotid artery dissection (CCAD) requires surgical repair remains controversial. This study aimed to explore the effect of asymptomatic CCAD without surgical intervention on the prognosis of patients who underwent surgery for acute type A aortic dissection. Between January 2015 and December 2017, 485 patients with no neurological symptoms who underwent surgery for acute type A aortic dissection were enrolled in this retrospective cohort study. The patients were divided into 2 groups based on the exposure factor of CCAD. CCAD was detected in 111 patients (22.9%), and after adjusting baseline data (standardized mean difference <0.1), the 30-day mortality (17.1% versus 6.0%, P<0.001) and incidence of fatal stroke (7.7% versus 1.6%, P=0.001) were significantly higher in the group with CCAD. Univariable and multivariable Cox regression analyses found CCAD as an independent risk factor for 30-day mortality (hazard ratio [HR], 2.8 [95% CI, 1.5-5.2]; P=0.001). At a median follow-up of 6.2 years (interquartile range, 5.6-6.9 years), landmark analysis with a cutoff value of 1 month postoperatively showed a significant increase in mortality in the group with CCAD, especially in the first month (log-rank P=0.002) and no significant difference in survival after the first month postoperatively between the 2 groups (log-rank P=0.955). Asymptomatic CCAD increased the risk of early fatal stroke and death in patients with acute type A aortic dissection after surgery but did not affect midterm survival in patients who survived the early postoperative period.

(31) Mid-Term Survival in Patients with Advanced Heart Failure Receiving an Impella Device Intended as Bridge to Transplantation

(31) Mid-Term Survival in Patients with Advanced Heart Failure Receiving an Impella Device Intended as Bridge to Transplantation

Prognostic impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection

BackgroundThis study aimed to investigate the impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection (ATAAD). MethodsBetween January 2019 and December 2020, 493 consecutive patients with angiographically confirmed ATAAD were retrospectively analysed. Preoperative computed tomography angiography parameters (branch artery involvement, longitudinal extent of dissection) were reviewed. The incidence of organ malperfusion, in-hospital mortality, and mid-term outcomes of patients with and without branch vessel involvement were compared. ResultsBranch vessel involvement was detected in 407 patients (82.6%), and organ malperfusion was observed in 234 patients (47.5%). The incidence of organ malperfusion was significantly higher in patients with branch vessel involvement compared with patients without it (52.6% vs. 23.3%, p < 0.001). Patients with coronary artery involvement (32.5%) were more likely to manifest as clinical malperfusion, whereas it occurred only 19.4% in patients with renal artery involvement. In-hospital mortality was higher in patients with branch vessel involvement (19.9% vs. 8.1%, p = 0.010). Median follow-up time was 16.1 months. Two-year survival rate was lower in patients with branch vessel involvement (76.3% vs. 84.5%, p = 0.085) or organ malperfusion (68.3% vs. 86.0%, p < 0.001). Multivariable analysis identified cardiac, cerebral, visceral and renal malperfusion as independent predictors for in-hospital mortality. ConclusionsOnly a small proportion of branch vessel involvement was associated with corresponding organ malperfusion in patients with ATAAD. Branch vessel involvement had a greater effect on short-term outcomes than mid-term survival, and organ malperfusion was related to a worse prognosis beyond it.

Efficacy of Thromboelastography-Guided Blood Transfusion Management in Thoracic Aortic Surgery

BackgroundIn thoracic aortic surgery, a large amount of blood transfusion is required because of preoperative coagulopathy and long cardiopulmonary bypass (CPB) time. This study aimed to investigate the efficacy of intraoperative thromboelastography (TEG)–guided blood transfusion management in thoracic aortic surgery. MethodsBetween 2015 and 2017 at our institution, 53 patients who underwent elective thoracic aortic surgery with hypothermic circulatory arrest through median sternotomy were divided into 2 groups: group C, conventional management (25 patients); and group T, TEG-guided management (28 patients). In group T, TEG was measured twice, before and after CPB. In both groups, red blood cells (RBCs) were transfused to maintain hemoglobin levels >10 g/dL during surgery and >8 g/dL during CPB. Fresh frozen plasma (FFP) was transfused even during CPB to correct coagulant disorder before CPB was off. The ratio of RBC/FFP was 1:1 in group C and 1:2 in group T if pre-CPB citrated functional fibrinogen–maximum amplitude (CFF-MA) was ≤20 mm. Additional FFP was transfused if the value of post-CPB CFF-MA was ≤14 mm. ResultsThe amounts of postoperative bleeding, post-CPB RBC transfusion, postoperative RBC transfusion, and postoperative FFP transfusion were significantly lower in group T than in group C (P = .025, .042, .042, and .020, respectively). However, there was no impact on early and midterm survival of patients. ConclusionsThese results suggest that intraoperative TEG-guided blood transfusion management in thoracic aortic surgery is effective in reducing postoperative bleeding and the amount of blood transfusion.

Fenestrated-branched endovascular repair for distal thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk

ObjectiveTo report the outcomes of fenestrated-branched endovascular repair (FBEVAR) for thoracoabdominal aortic pathology after total aortic arch replacement with frozen elephant trunk (TAR+FET). MethodsInterrogation of prospectively maintained databases from four high-volume aortic centers identified consecutive patients treated with distal FBEVAR after prior TAR+FET between August 2013 and September 2020. The primary end point was 30-day/in-hospital mortality. Secondary end points were technical success, early clinical success, midterm survival, and freedom from reintervention. Data are presented as median (interquartile range). ResultsA total of 39 patients (21 men; median age, 73 years [67-75 years]) with degenerative (n = 22) and postdissection thoracoabdominal aortic aneurysms (n = 17) (median diameter, 71 mm [61-78 mm]) were identified. Distal FBEVAR was intended in 27 patients (median interval, 9.8 months [6.2-16.6 months]), anticipated in 7, and unexpected in 5. A total of 31 patients had a two- (n = 24) or three-stage (n = 7) distal FBEVAR. Renovisceral target vessel preservation was 99.3% (145 of 146). Early primary and secondary technical success was 92% and 97%, respectively. Thirty-day mortality was 2.6% (n = 1; respiratory failure and spinal cord ischemia [SCI]). Six survivors also developed SCI, which was associated with complete (n = 4) or partial recovery (n = 2) at hospital discharge. No patients required renal replacement therapy or suffered a stroke. Early clinical success was 95%. Median follow-up was 30.5 months (23.7-49.7 months). Eleven patients required 16 late reinterventions. Estimated 3-year survival and freedom from reintervention were 84% ± 6% and 63% ± 10%, respectively. ConclusionsDistal FBEVAR after prior TAR+FET is associated with high technical success and low early mortality. The risk of SCI is significant although the majority of patients demonstrate full or partial recovery before hospital discharge. Midterm patient survival is favorable, but there remains a high requirement for late reintervention. FBEVAR represents an acceptable alternative to distal open thoracoabdominal aortic aneurysm repair.

Single-Center Experience With the Thoraflex™ Hybrid Prosthesis: Indications, Implantation Technique and Results.

ObjectiveThe aim of this study was to evaluate the early and mid-term results after the frozen elephant trunk (FET) procedure for the treatment of complex arch and proximal descending aortic disease in a single-center institution.MethodsFrom April 2015 to July 2021, 72 patients (25 women, 60.4 ± 10.3 years) underwent Thoraflex™ Hybrid implantation at our institution. The indications were thoracic aortic aneurysm (TAA) (n = 16, 22.2%), post-dissection aneurysm (n = 21, 29.2%), and acute aortic dissection (AAD) (n = 35, 48.6%). Antegrade cerebral perfusion under moderate hypothermia (28°C) was employed in all cases. Eighteen patients (25%) have already been operated due to heart or aortic disease.ResultsOverall in-hospital mortality was 12.5% (9 patients). Rates of permanent neurological dysfunction and spinal cord injury were 9.7 and 5.5%, respectively. The in-hospital mortality rate among patients operated on AAD, TAA, and post-dissection aneurysm were 8.6, 6.2, and 23.8%, respectively. At a mean follow-up of 26 ± 20 months, mortality was 9.7%. Furthermore, 23 patients (31.9%) required a subsequent procedure in distal aorta: endovascular stentgraft extension in 19 patients (26.4%) and open aortic surgery in 4 patients (5.5%). The mid-term survival of patients with type A aortic dissection was 97%.ConclusionsOur experience with the Thoraflex Hybrid prosthesis demonstrates its surgical applicability for different types of aortic pathologies with promising outcomes during early and midterm follow-up. Our technique and perioperative management lead to comparable or even superior neurological outcomes and mortality in urgent cases considering other high-volume centers.

Delayed Effect of Dendritic Cells Vaccination on Survival in Glioblastoma: A Systematic Review and Meta-Analysis.

Background: Dendritic cell vaccination (DCV) strategies, thanks to a complex immune response, may flare tumor regression and improve patients’ long-term survival. This meta-analysis aims to assess the efficacy of DCV for newly diagnosed glioblastoma patients in clinical trials. Methods: The study databases, including PubMed, Web of Knowledge, Google Scholar, Scopus, and Cochrane, were searched by two blinded investigators considering eligible studies based on the following keywords: “glioblastoma multiforme”, “dendritic cell”, “vaccination”, “immunotherapy”, “immune system”, “immune response”, “chemotherapy”, “recurrence”, and “temozolomide”. Among the 157 screened, only 15 articles were eligible for the final analysis. Results: Regimens including DCV showed no effect on 6-month progression-free survival (PFS, HR = 1.385, 95% CI: 0.822–2.335, p = 0.673) or on 6-month overall survival (OS, HR = 1.408, 95% CI: 0.882–2.248, p = 0.754). In contrast, DCV led to significantly longer 1-year OS (HR = 1.936, 95% CI: 1.396–2.85, p = 0.001) and longer 2-year OS (HR = 3.670, 95% CI: 2.291–5.879, p = 0.001) versus control groups. Hence, introducing DCV could lead to increased 1 and 2-year survival of patients by 1.9 and 3.6 times, respectively. Conclusion: Antitumor regimens including DCV can effectively improve mid-term survival in patients suffering glioblastoma multiforme (GBM), but its impact emerges only after one year from vaccination. These data indicate the need for more time to achieve an anti-GBM immune response and suggest additional therapeutics, such as checkpoint inhibitors, to empower an earlier DCV action in patients affected by a very poor prognosis.

Mid-term outcomes of rapid deployment aortic prostheses in patients with small aortic annulus.

The Edwards Intuity valve is a rapid deployment aortic prosthesis that favours less invasive approaches. However, evidence about the clinical behaviour of their smaller sizes is scarce. Herein, we studied haemodynamic behaviours and clinical outcomes of small Intuity prostheses (19-21 mm) in comparison to larger Intuity prostheses (>21 mm). This is an observational study including patients implanted with an Edwards Intuity rapid deployment aortic prosthesis. Patients with prosthesis sizes 19-21 and >21 mm were included. Baseline and perioperative variables, as well as adverse events during the follow-up were recorded and compared between groups. A total of 122 patients (37% female, mean age 75 ± 4.5 years) were included, of whom 54 (45%) were implanted with a small prosthesis and 68 (55%) with a prosthesis >21 mm. There were no significant differences between patients with small Intuity prostheses and patients with larger prostheses regarding in-hospital mortality (2% vs 4%, P = 0.43) or mortality during the follow-up (3.41 vs 2.45 per 100 patients-years; P = 0.58). Survival in the small Intuity valve group was 95% at 1 year and 83% at 6 years, whereas in the larger Intuity valve group was 96% at 1 year and 78% at 6 years. The presence of a small prosthesis did not influence mid-term survival (log-rank P-value = 0.62). This study showed good clinical performance of Intuity aortic prostheses with appropriate mid-term survival in patients with the small aortic annulus. Thus, the Edwards Intuity rapid deployment aortic prosthesis may be considered as a potential option in patients with the small aortic annulus.

Effect of malnutrition and frailty status on surgical aortic valve replacement.

To date, assessment of nutritional and frailty status in patients undergoing surgical aortic valve replacement remains unclear. This study aimed to assess the effect of geriatric nutritional risk index (GNRI) and Rockwood clinical frailty scale (CFS) on short-term and mid-term survival in patients who underwent surgical aortic valve replacement for aortic stenosis. In total, 219 patients who underwent aortic valve replacement for aortic stenosis between Jan 1 2011 and Dec 31 2018 were retrospectively monitored in a single center. Mid-term survival was assessed using Kaplan-Meier analysis. Logistic and Cox regression analyses were performed to detect independent predictors for early and mid-term mortality. Follow-up was 97.7% complete, and a GNRI score ≤ 98 denoted malnutrition. In the univariable analysis, GNRI [odds ratio (OR) 0.91, 95% confidence interval (CI), 0.86-0.96, p < 0.001] and CFS (OR 2.00 95% CI 1.38-2.94, p < 0.001) were identified as significant risk factors for in-hospital mortality. Mid-term survival was significantly decreased in patients with malnutrition (3 and 5year survival rates 83.9 and 76.9%, respectively, p < 0.001). Mid-term freedom from major cardiac and cerebrovascular events was significantly decreased in patients with malnutrition (p = 0.039). The CFS (hazard ratio 1.78) and GNRI (hazard ratio 0.95) were independent risk factors for mid-term survival in the univariable and multivariable analyses, respectively. A lower GNRI is associated with poor mid-term mortality and major cardiac and cerebrovascular events after surgical aortic valve replacement. A lower CFS score is associated with unfavorable mid-term outcomes.

Quality of Life and Mid-Term Survival in Patients Receiving Extracorporeal Membrane Oxygenation After Cardiac Surgery.

There is a lack of data regarding mid-term outcomes of extracorporeal membrane oxygenation (ECMO) for refractory postcardiotomy cardiogenic shock (PCS). In this context, this research aimed to assess the mid-term survival and quality of life of PCS patients who receive ECMO by comparing them with cardiac surgery patients who do not receive ECMO. A retrospective analysis was performed on the clinical data of patients who had undergone ECMO treatment after cardiac surgery from January 2013 to June 2017 in a tertiary hospital (n = 102); non-ECMO patients who had undergone cardiac surgery and were discharged successfully were selected as the control group (n = 102). Survival and mid-term quality of life were assessed and compared through the Short-Form 36 (SF-36). Both groups were followed up by telephone, and SF-36 scores were obtained from the surviving patients. The data were available for 89 patients (87.3%) and 88 patients (86.3%) in the ECMO group and the control group, respectively. After discharge, the control group outperformed the ECMO group in survival (93.1% vs. 82.4%; p = 0.013). No significant differences in complications, all-cause mortality, first readmission for any cause, or work condition between the ECMO group and the control group were observed. The SF-36 scores in general health (GH) and vitality (VT) were significantly lower among the ECMO survivors (p < 0.05). The results of this study indicate that ECMO can provide acceptable mid-term survival with good quality of life for patients with refractory cardiogenic shock.

Clinical outcomes after surgical or transcatheter aortic valve replacement in patients with chronic kidney disease: an analysis in 29 893 patients from the German Aortic Valve Registry

Abstract Background Chronic kidney disease (CKD) is a key risk factor in patients undergoing transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). Purpose We analyzed the impact of eGFR and different stages of chronic kidney disease (CKD), on short- and mid-term survival in patients undergoing TAVI or SAVR. Methods Data from 29893 patients enrolled in the German Aortic Valve registry (GARY) from January 2011 to December 2015 receiving TAVI (n=12834) or SAVR (n=17059) at 88 sites were included. The impact of renal impairment, as measured by eGFR and CKD stages, was investigated. The primary endpoint was 1-year cumulative all-cause mortality. A propensity score method was used to compare TAVI vs. SAVR in patients with intermediate risk and mild-to-moderate renal disease being eligible for both therapies. Results Higher CKD stages were significantly associated to lower in-hospital, 30-day- and 1-year survival rates. Both TAVI- and SAVR-treated patients in CKD 3a, 3b, 4, and 5 stages showed significant and gradually increasing HR values for 1-year all-cause mortality. The same trend persisted in multivariable analysis, although HR values for CKD 3a and 5 did not reach significance in TAVI patients, whereas CKD 4+5 did not reach statistical significance in SAVR. Likewise, eGFR as a continuous variable was a significant predictor for 1-year mortality, with the best cut-off points being 47.4 mL/min/1.73 m2 for TAVI and 59.8 mL/min/1.73 m2 for SAVR. Significant 8.6% and 9.0% increases in 1-year mortality were observed for every 5-mL reduction in eGFR for TAVI and SAVR, respectively. No significant differences in survival were found between TAVI and SAVR in a matched group of intermediate-risk patients potentially eligible for both therapies (HR [(95% CI] for TAVI vs SAVR 1.24 [0.76, 2.02], p=0.240). Conclusions CKD≥3b and CKD≥3a is an independent major risk factor for mortality in patients undergoing TAVI and SAVR, respectively. In the overall population of patients with severe aortic stenosis, an appropriate stratification based on CKD substage may contribute to a better selection of patients suitable for such therapies. TAVI and SAVR appear to achieve similar survival rates in intermediate-risk patients with moderate-to-severe renal dysfunction. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted grants by medical device companies (Edwards Lifesciences, JenaValve Technology, Medtronic, Sorin, St. Jude Medical, Symetis S.A.). Unrestricted support by funding statisticians by the DZHK (Deutsches Zentrum für Herz-Kreislaufforschung).

Mid-term survival of patients with chronic kidney disease after extracorporeal membrane oxygenation.

Chronic kidney disease (CKD) impairs the elimination of fluids, electrolytes and metabolic wastes, which can affect the outcomes of extracorporeal membrane oxygenation (ECMO) treatment. This study aimed to elucidate the impact of CKD on in-hospital mortality and mid-term survival of adult patients who received ECMO treatment. Patients who received first-time ECMO treatment between 1 January 2003 and 31 December 2013 were included. Those with CKD were identified and matched to patients without CKD using a 1:2 ratio and were followed for 3 years. The study outcomes included in-hospital outcomes and the 3-year mortality rate. A subgroup analysis was conducted by comparing the dialytic patients with the non-dialytic CKD patients. The study comprised 1008 CKD patients and 2016 non-CKD patients after propensity score matching. The CKD patients had higher in-hospital mortality rates [69.5% vs 62.2%; adjusted odds ratio 1.41; 95% confidence interval (CI) 1.15-1.72] than the non-CKD patients. The 3-year mortality rate was 80.4% in the CKD group and 68% in the non-CKD group (adjusted hazard ratio 1.17; 95% CI 1.06-1.28). The subgroup analysis showed that the 3-year mortality rates were 84.5% and 78.4% in the dialytic and non-dialytic patients, respectively. No difference in the 3-year mortality rate was noted between the 2 CKD subgroups (P = 0.111). CKD was associated with increased risks of in-hospital and mid-term mortalities in patients who received ECMO treatment. Furthermore, no difference in survival was observed between the patients with end-stage renal disease and non-dialytic CKD patients.

Clinical features and surgical outcomes of type A intramural hematoma.

BackgroundData on the clinical features and surgical outcomes of type A intramural hematoma (IMH) in Chinese patients are very limited. We aimed to present the surgical experiences on type A IMH in our center, and report early and late outcomes.MethodsFrom February 2012 to April 2018, 106 consecutive patients underwent open surgery for type A IMH at our hospital. We adopted emergent operation for patients with cardiac tamponade or other severe complications, and recommended initial medical treatment followed by elective surgery for stable patients. The composite endpoints included operative mortality, permanent nerve damage (stroke, paraplegia), and new-onset renal failure necessitating hemodialysis. Risk factors for operative mortality and the composite endpoints were identified using univariable and multivariable logistic regression model analysis. The survival and freedom from aortic events were analyzed using a Kaplan-Meier surviving curve and a log-rank test.ResultsExcept 1 patient receiving emergent surgery (within 24 hours from onset) because of cardiac tamponade and cerebral malperfusion, all patients received initial medical treatment and delayed surgery. Two patient developed pericardial tamponade while waiting for surgery, and then received emergent surgery. Preoperative conversion to aortic dissection (AD) was noted in no patient. The operative techniques included ascending aorta replacement in 9 patients, hemiarch replacement in 18 patients, total arch replacement (TAR) with frozen elephant trunk (FET) in 45 patient and hybrid aortic arch repair in 34 patients. The mean cardiopulmonary bypass (CPB) time and cross-clamp time were 138.7±41.6 and 79.3±27.8 min, respectively. The operative mortality was 1.9% (2/106). And the composite endpoints occurred in 7 patients. Multivariable logistic regression analysis showed CPB time ≥200 min and chronic kidney disease were risk factors for the composite endpoints. The follow-up data were available in 97 survivors, with the mean follow-up time of 30.8±16.2 months. Three patients died and 5 patients developed aortic events during the follow-up. The overall survival at 1-, 3- and 5-year were 97.0%, 95.3%, and 79.4%, respectively. And freedom from aortic events at 1-, 3- and 5-year were 97.7%, 95.3% and 89.4%, respectively.ConclusionsOur strategy had got low mortality and excellent mid-term survival in patients with type A IMH. Therefore, our strategy was suitable for the surgical repair of type A IMH in Chinese population.

Does Mild to Moderate Renal Dysfunction in Non-Dialysis Dependent Patients

Objectives: Algorithms of risk stratification for coronary artery bypass grafting (CABG) do not include a weighting for preoperative mild to moderate renal impairment defined as a serum creatinine 130 to 199mmol/L, which may impact mortality and morbidity after CABG. Hence our first objective was to ascertain the effect of a mild-to-moderate elevation in the preoperative serum creatinine level on post-operative outcomes. Our second objective was to ascertain which patient variables contributed to an increase in the serum creatinine level in association with coronary artery bypass grafting.&#x0D; Materials and methods: We reviewed the prospectively collected data from the cardiac surgical database, which holds clinical information on all the patients undergoing cardiac surgery at our department since July 2014 to June 2017. A total of 101 patients who had known pre-existing mild to moderate renal disease and who were undergoing first-time coronary artery bypass grafting with cardiopulmonary bypass were recruited for the study. Patients were divided, based on preoperative serum creatinine level, into 3 groups as follows: Group A: creatinine level of less than 130μmol/L; Group B: creatinine level of 130 to 159μmol/L; and Group C: creatinine level of 160μmol/L or greater.&#x0D; Result: Multivariate logistic regression showed that elevation of the preoperative serum creatinine level to 130μmol/L or greater increased the likelihood of hemodialysis postoperatively (P&lt;0.001), as well as the need for postoperative ICU stay (P&lt;0.001). Other factors contributing to a prolonged ICU stay were being 60 years of age or older (P=0.007), having a preoperative left ventricular ejection fraction of less than 40% (P=0.001), and having a prolonged cardiopulmonary bypass time (P&lt; 0.001). In-hospital mortality was also significantly elevated in Group B and Group C; P=0.045 and &lt;0.001 respectively with a few factors contributing to an increase in mortality on multivariable analysis were being female (P&lt;0.001), being 60 years of age or older (P=0.004), having a preoperative left ventricular ejection fraction of less than 40% (P=0.006), and having a prolonged cardiopulmonary bypass time (P&lt;0.001). Of particular note, the method of myocardial protection (cardioplegia with or without topical cooling) did not significantly influence in-hospital mortality, need for mechanical renal support, or ICU stay.&#x0D; Conclusions: Mild to moderate renal dysfunction is an important predictor of outcome in terms of inhospital mortality, morbidity, and midterm survival in patients undergoing CABG. As the preoperative serum creatinine level increases further (³160 μmol/L), this effect is more pronounced.&#x0D; Journal of Surgical Sciences (2018) Vol. 22 (2) : 104-109

Simultaneous transarterial chemoembolization and radiofrequency ablation for large hepatocellular carcinoma

BACKGROUNDHepatocellular carcinoma (HCC) is a common cancer and a leading cause of tumor-related death. Patients with large HCC (≥ 8 cm) are at an advanced stage and have poor prognosis, and hepatic resection may not be suitable, and the incidence of postoperative recurrence is high.AIMTo evaluate recurrence and mid-term survival of patients with large HCC treated by transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA).METHODSThis was a retrospective study. From 2010 to 2013, 46 consecutive patients with large HCC were treated with simultaneous TACE and RFA. Thirty-five of 46 patients had a single tumor. Progression-free survival (PFS) and overall survival (OS) were analyzed at 2 years and 3 years, respectively.RESULTSForty-six patients treated by simultaneous TACE and RFA had no significant complications and treatment was successful. After 3 years, median PFS and OS were 10.21 ± 1.58 mo and 26.44 ± 2.26 mo, retrospectively. The survival rate was 67.5% after 2 years and 55.67% after 3 years.CONCLUSIONThese preliminary data show that simultaneous TACE and RFA are safe and effective for large HCC.

Clinical significance of presenting syndromes on outcome after coronary artery bypass grafting.

Evidence of an association between postoperative survival and the presenting syndrome following coronary artery bypass grafting (CABG) is limited. Our goal was to evaluate whether the presenting symptoms of acute coronary syndrome (ACS) or stable ischaemic heart disease were associated with mid-term survival in patients undergoing CABG. We performed a single-centre retrospective study involving consecutive CABG operations from 2011 to 2016. Post-discharge survival was ascertained via patient-level data linkage with the State of Connecticut vital statistics. Baseline and postoperative variables were compared between the two groups. The multivariate Cox proportional hazard model, adjusted for demographics and comorbidity, was used to show whether the presenting syndrome category was independently associated with mid-term survival. A total of 1631 patients were included: 794 with stable ischaemic heart disease and 837 with ACS. Patients with ACS who underwent CABG showed more comorbidities. The overall 30-day mortality rate was 1.8% (ACS 2.3% vs stable ischaemic heart disease 1.3%; P = 0.12). In-hospital, postoperative outcomes revealed higher rates of prolonged ventilation (11.7% vs 4.8%; P < 0.001), pneumonia (6.6% vs 3.9%; P = 0.016) and stay in the intensive care unit (3.7 ± 4.0 vs 3.2 ± 2.7 days; P = 0.014) in patients with ACS. The overall mean duration of the long-term follow-up period was 27.9 ± 16.5 months, during which 117 deaths occurred. The multivariable Cox proportional hazard model adjusted for demographics and comorbidity showed that ACS was not a predictor of mid-term mortality [hazard ratio (HR) 1.26, 95% confidence interval (CI) 0.84-1.90; P = 0.26]. Other significant predictors were cardiogenic shock (HR 2.12, 95% CI 1.04-4.33; P = 0.039) and history of congestive heart failure (HR 1.78, 95% CI 1.18-2.69; P = 0.0062). The presenting syndrome was not an independent predictor of the mid-term mortality rate. The results indicate that the classification of the presenting syndrome may be fluid and that clinical decision-making for postoperative care of patients who have CABG directed by category of presenting syndrome needs careful consideration. These data should be interpreted in the context of the limitations of this study.

Impact of Baseline Mitral Regurgitation on Postoperative Outcomes After Left Ventricular Assist Device Implantation as Destination Therapy

BackgroundCurrently, there are no guidelines for management of moderate to severe mitral regurgitation (MR) in patients undergoing left ventricular assist device (LVAD) implantation. The present study aimed to investigate the impact of baseline MR on short and midterm survival in patients who had LVAD as destination therapy (DT). MethodsThe DT-LVAD patients were classified into 2 groups based on baseline MR status: ≥ moderate MR and < moderate MR. Baseline clinical characteristics and post-LVAD implant adverse events were compared. Unadjusted mortality rates at 30 days, 1 year, and 2 years were analyzed. ResultsOf 91 patients studied, 62 (68%) had ≥ moderate MR before LVAD implantation; ≥ moderate MR patients had a higher incidence of concomitant pulmonary disease (11% vs 0%; P = .001) and ≥ moderate tricuspid regurgitation (55% vs 23%, P = .004) than < moderate MR patients. Other baseline clinical characteristics were similar in both groups. Post-LVAD adverse events did not differ between the 2 groups. Survival rates at 30 days, 1 year, and 2 years for both groups (≥ moderate MR vs < moderate MR) were 90% vs 100% (P = .03), 63% vs 90% (P = .001), and 52% vs 83% (P = .002), respectively. On multivariable analysis, age, female sex, ≥ moderate tricuspid regurgitation, and ≥ moderate MR at baseline were found to be independent predictors of overall all-cause mortality. Overall survival was significantly lower in the ≥ moderate MR group than the < moderate MR group (log-rank test, P = .03). ConclusionIn DT LVAD patients, ≥ moderate MR is common and is associated with worse survival at both short and midterm follow-up.

Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic

ObjectiveTo study mid-term survival in patients with infective endocarditis as a result of IV drug use undergoing aortic root replacement with cryopreserved aortic homograft. MethodsPatients undergoing aortic root homograft replacement from 2011-2017 were studied retrospectively. Aortic root replacement was performed using a modified Bentall technique. Primary outcomes included both short-term and mid-term survival. Secondary outcomes included immediate postoperative complications. ResultsA total of 138 patients underwent cryopreserved homograft replacement of the aortic root for aortic root abscesses. Eighty-five patients (61.6%) underwent reoperative sternotomy, and 12 patients (8.7%) underwent second or third reoperative sternotomy. Sixty-seven (48.5%) patients had severe aortic insufficiency preoperatively. Operative mortality was 12.3% (17 patients). Five patients (3.6%) sustained a permanent stroke. Twenty-one patients (15.2%) required dialysis for renal failure, and 21 patients (15.2%) had complete heart block necessitating a permanent pacemaker. Estimated 5-year mortality for the cohort was 43%. ConclusionsCryopreserved homograft replacement is a safe and desirable option for high-risk patients with infective endocarditis and aortic root abscess. Homograft accommodation for a widely debrided aortic annular bed provides a reasonable surgical strategy for patients needing aortic root replacement with annular abscess.

Comparable perioperative outcomes and mid-term survival in prosthetic valve endocarditis and native valve endocarditis.

Cardiac surgery for prosthetic valve endocarditis (PVE) represents one of the highest risk surgeries with in-hospital mortality of 20%. Given the complex nature of the operation, the operative outcome is likely strongly susceptible to the surgeon's experience and centre case volume, as measurements often are not apparent in large observational studies. We sought to evaluate operative outcomes and mid-term survival of patients with PVE compared with those of native valve endocarditis (NVE) at a tertiary care hospital. We conducted a single-institutional retrospective review of 188 consecutive patients (146 NVE and 42 PVE) undergoing cardiac surgery for endocarditis between 2011 and 2016 at a tertiary care hospital in the USA. A logistic regression model was fit to evaluate patient characteristics and perioperative outcomes in PVE and NVE: operative mortality and composite events (death, stroke, prolonged intubation, renal failure and sepsis). The Kaplan-Meier analysis was used to estimate the mid-term survival. The Cox proportional hazard model was fit to assess the adjusted risk associated with mid-term survival. Operative mortality was 4.1% for NVE and 0% for PVE (P = 0.34). Composite events occurred in 30.6% and 38.1% of NVE and PVE, respectively (P = 0.45). Multivariable logistic regression for composite events showed that PVE was not associated with increased risk of adverse events [odds ratio 1.4, 95% confidence interval (CI) 0.6-3.4; P = 0.49]. The Kaplan-Meier analysis demonstrated no statistically significant difference in survival (P = 0.99). Finally, the Cox proportional hazard analysis for mid-term mortality demonstrated that PVE was not associated with increased risk for hazard of death: hazard ratio 0.4, 95% CI 0.2-1.1; P = 0.085. Surgery for PVE can yield a low mortality rate with mid-term survival comparable with those of NVE. The diagnosis of PVE alone should not deter surgeons from operating on this complex patient population, provided that surgical expertise and experienced multidisciplinary team equipped to handle complex clinical scenarios are available.

PC040. Aortic Anatomic Severity Grade Correlates With Midterm Survival in Patients Undergoing Aortic Aneurysm Repair

PC040. Aortic Anatomic Severity Grade Correlates With Midterm Survival in Patients Undergoing Aortic Aneurysm Repair