Mid-term Survival Research Articles

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.

Sex-Related Differences After Proximal Aortic Surgery: Outcome Analysis of 1773 Consecutive Patients

BackgroundGuidelines on the management of aortic aneurysm disease do not account for sex differences regarding surgical procedures on the proximal aorta, although faster aneurysm growth, increased rupture risk, and higher postoperative mortality have been found in women. We therefore analyzed outcome differences between men and women receiving operations on the proximal aorta. MethodsA total of 1773 patients underwent nonemergency surgical procedures on the aortic valve (AV) and proximal aorta at our institution between 2000 and 2018. Of these, 772 patients (21.8% women) received a Bentall procedure, 349 (20.3% women) had AV-sparing root replacement, and 652 (31.1% women) underwent AV and supracommissural ascending aorta replacement. Primary outcomes were in-hospital mortality and midterm survival. ResultsWhen assessing sex-related differences within the entire group of patients that received an operation on the proximal aorta, women were found to be older, had a lower body mass index, and were smokers less often. Despite shorter procedural times, median ventilation times and intensive care unit length of stay were longer in women. In-house mortality was also higher in women (3.6% vs 0.9%, P < .001). Multivariable logistic regression revealed age (odds ratio [OR], 1.8; 95% CI, 1.4-2.3 per 5 years added; P < .001), female sex (OR, 2.6; 95% CI, 1.2-5.8; P = .02), and urgent surgery (OR, 3.1; 95% CI, 1.2-7.3; P = .01) as independent risk factors for in-house death. Midterm survival was lower for women in the entire cohort (P = .02) and particularly within the Bentall subgroup (P = .004). ConclusionsFemale sex is an independent risk factor for operative mortality in patients undergoing proximal aortic surgery but is currently not addressed in guidelines. More research should focus on etiology and prevention of these worse outcomes in female patients.

Predictive factors of distal stent graft-induced new entry after frozen elephant trunk procedure for aortic dissection.

The incidence rate of distal stent graft-induced new entry (d-SINE) after frozen elephant trunk technique for aortic dissection remains controversial. The aim of this study was to investigate the incidence and seek the clinical and anatomical predictive factors. This study is a retrospective multicentre evaluation of complications including d-SINE, aortic events and reintervention after the frozen elephant trunk procedure for aortic dissection. Our cohort included a total of 177 consecutive patients who underwent the frozen elephant trunk procedure for acute and chronic aortic dissection at 5 centres in Japan from May 2014 to March 2021. The incidence rate of d-SINE was 14.1% (25/177 patients). The cumulative incidence of d-SINE was 7.1%, 12.4% and 21.4% after 12, 36 and 60 months, respectively. d-SINE was not associated with mid-term survival rate. After competing risk regression analysis, onset time >48 h (subdistribution hazard ratio, 3.80; 95% confidence interval, 1.13-12.79; P = 0.031) was detected as an independent predictor. Awareness that there is a relatively higher incidence of d-SINE after frozen elephant trunk procedures is important. Non-hyper-acute phase was detected as an independent risk factor. Pre-emptive endovascular repair may be appropriate to protect new entry in high-risk patients.

The modern Burch-Schneider antiprotrusio cage for the treatment of acetabular defects: is it still an option? A systematic review.

A number of papers have been published about the clinical performance of modern rough-blasted titanium Burch-Schneider antiprotrusio cages (BS-APCs) for the treatment of acetabular bone defects. However, no systematic review of the literature has been published to date. The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried for publications using keywords pertinent to Burch-Schneider antiprotrusio cage, revision THA, and clinical outcomes. 8 articles were found to be suitable for inclusion in the present study in which 374 cases (370 patients) had been treated with modern BS-APCs. Most acetabular bone defects were type 3 according to the Paprosky classification (type 2C: 18.1%, 3A: 51%, and 3B: 28.9%). The overall re-revision rate for the 374 acetabular reconstructions with modern BS-APCs was 11.5% (43 cases). The short-term survival rate of the modern BS-APC construct was 90.6% (339 out of 374 cases), while the mid-term survival rate was 85.6% (320 out of 374 cases), and the long-term survival rate 62% (54 out of 87 cases). The most common reasons for revision were aseptic loosening (5.6%), periprosthetic joint infection (3.8%), dislocation (2.7%), and acetabular periprosthetic fracture (1.9%). There was moderate quality evidence to show that the use of modern rough blasted titanium BS-APCs in cases of acetabular bone loss has an unacceptably high failure rate (38%). Given that antiprotrusio cages do not provide any biological fixation, we would not recommend the routine use of modern BS-APCs in complex revision THA cases. By contrast, the satisfactory short- to mid-term outcome of modern BS-APCs in combination with their low cost compared to highly porous acetabular implants, make us feel that BS-APCs might still be used in selected elderly or low-demand patients without severe superomedial acetabular bone loss.

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.

Characteristics and natural history of early-stage cardiac transthyretin amyloidosis.

AimsTransthyretin amyloid cardiomyopathy (ATTR-CM) is increasingly diagnosed at an early stage of the disease natural history, defined as National Amyloidosis Centre (NAC) ATTR Stage I. The natural history of early-stage ATTR-CM remains poorly characterized.Methods and resultsA retrospective multi-centre observational study of 879 patients with ATTR-CM, either wild-type TTR genotype or carrying the p.V142I TTR variant, and NAC ATTR Stage I biomarkers at the time of diagnosis who did not receive disease-modifying therapy for amyloidosis. Disease characteristics at diagnosis that were independently associated with mortality by Cox regression analysis were N-terminal pro-B-type natriuretic peptide (NT-proBNP), TTR genotype, and troponin T. Patients were categorized into NAC ATTR Stage Ia, defined as a furosemide equivalent diuretic requirement of <0.75 mg/kg and an NT-proBNP ≤500 ng/L or ≤1000 ng/L in the presence of atrial fibrillation, and NAC ATTR Stage Ib comprising all remaining Stage I patients. Median estimated survival among the 88% NAC ATTR Stage Ib patients was 75 (95% CI 57–93) months compared with >100 months in the 12% with Stage Ia disease [hazard ratio for death 5.06 (95% confidence interval 1.23–20.87); P = 0.025] despite significant cardiovascular morbidity at the time of diagnosis which increased during follow-up, including among patients diagnosed in NAC ATTR Stage Ia. Estimated survival among UK NAC ATTR Stage Ia patients was comparable to UK general population controls (P = 0.297).ConclusionPatients with NAC ATTR Stage I ATTR-CM can be further stratified according to NT-proBNP concentration and diuretic requirement at diagnosis. Patients with Stage Ia ATTR-CM have significant cardiovascular morbidity despite good short- and mid-term survival.

Impact of high-power and very high-power short-duration radiofrequency ablation on procedure characteristics and first-pass isolation during pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction High-power short-duration (HPSD) radiofrequency ablation has been proposed as a method for producing rapid and effective lesions for pulmonary vein isolation.We aimed to evaluate the procedural characteristics and the FPI rate of HPSD and very high-power short-duration (vHPSD) compared to low-power long-duration (LPLD) ablation techniques. Methods 156 patients with atrial fibrillation (AF) were enrolled and assigned to LPLD, HPSD, or vHPSD PVI. The energy setting was 30W, 50W, and 90W in the LPLD, HPSD, and vHPSD groups, respectively. Results Bilateral PVI was achieved in all cases. The procedure time was 85 [75-101] min, 79 [65-91] min, and 70 [53-83] min in the LPLD, HPSD, and vHPSD groups, respectively (p&amp;lt;0,0001). LA dwelling times were also decreased significantly with the increase of RF energy (61 [55-70] min, 53 [41-56] min, and 45 [34-52] min, in the LPLD, HPSD, and vHPSD groups, respectively, p&amp;lt;0.0001). The total RF ablation time was 1398 [1021-1711] sec, 1567 (1366-1761) sec, and 336 [247-386] sec in the LPLP, HPSD, and vHPSD group, respectively ( p&amp;lt;0,0001). Bilateral FPI was rate was 57%, 78% and 80% in the LPLD, HPSD, and vHPSD groups, respectively (p=0,0097). On the left side, FPI was achieved in 66% in the LPLD, in 92% in the HPSD, and in 85% in the vHPSD ablation group (p=0.0015). FPI on the right side was achieved in 72% in the LPLD, in 88% in the HPSD, and in 88% in the vHPSD ablation group (p=0,0188). FPI rates were significantly higher in the HPSD group compared to the LPLD group: both sided FPI rate was 57% vs. 78% (p=0.021), left sided FPI rate was 66% vs. 92% (p=0.0015), and right sided FPI rate was 72% vs. 88% (p=0.0401). Further increase in the RF power did not result in a significant additional increase in the FPI rate. In the HPSD vs. vHPSD group both sided FPI rate was 78% vs. 80% (p=0,8080), left sided FPI rate was 92% vs. 85% (p= 0,5275), and right sided FPI rate was 88% vs. 88% (p= 0,7561). Univariate analysis revealed that the use of HPSD ablation technique is associated with a higher probability of FPI (both sides: OR=2.72, 95% CI 1.15-6.44, p=0.023; right side: OR=2.90, 95% CI 1.02-8.20, p=0.045; left side: OR=5.91, 95% CI 1.84-19.04, p=0.003). The mid-term arrhythmia-free survival was similarly high in all three groups. Conclusion Our prospective, observational cohort study showed that both HPSD and vHPSD RF ablation is effective, as it shortens procedure time and RF time and results in a higher rate of FPI compared to LPLD ablation. Moreover, the mid-term arrhythmia-free survival was similarly high in all three groups. In our study, no safety concerns were raised due to HPSD ablation.

P47 MITRAL VALVE REPAIR FOR INFECTIVE ENDOCARDITIS: A PROPENSITY MATCHED STUDY

Abstract Background The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis remain not clearly established. We aim to review the clinical experience in mitral valve surgery for infective endocarditis looking at mid–term survival. Methods Prospectively collected data of patients who underwent cardiac surgery for infective endocarditis between 2001 and 2021 at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest–neighbour propensity score matching, including twelve preoperative variables, was performed to account for differences in patients’ profile between the repair and replacement subgroups. Results In the unmatched populations, mean age of the patients was 60±15 years and 72% were male. Active infective endocarditis was described in 226 cases (80%). Thirty–four patients (12%) suffered cerebral embolism and in 10% of the cases preoperative inotropic support and/or mechanical ventilation were required. Associated procedure were CABG, aortic valve replacement and tricuspid valve repair, 13%, 36% and 9% of the cases, respectively. Mitral valve repair was performed in 96 cases (32%). Overall in–hospital mortality was 6.7% and was not significantly different between patients who underwent repair or replacement of the mitral valve (7.2% vs 6.4%, p = 0.79). Propensity matching provided 72 well–matched pairs. Mean age was 59±15 years, 75% of the patients were male. Sixteen patients (11%) had a recent cerebral event. An emergency operation was carried out in 15% of the cases, 10% of the patients presented a NYHA class&amp;gt;III and 14 patients (10%) underwent a redo procedure. CABG and aortic valve replacement were associated in 14% and in 35% of the cases, respectively. Overall in–hospital mortality was 6.9% with no difference between the repair and the replacement cohorts 9.7% vs 4.2%, respectively (p = 0.19). Survival probabilities at 1–, 5– and 10–years were 89%, 71% and 67%, respectively after mitral repair, and 90%, 77% and 57%, respectively after mitral replacement; log–rank p = 0.90. Conclusions Mitral valve repair was associated with acceptable in–hospital mortality and survival in a high–risk and comorbid cohort of patients with mitral valve infection. We found no difference in early and mid–term survival between patients who underwent repair or replacement of the mitral valve in the setting of infective endocarditis.

Impact of Coronary Artery Anatomy in Arterial Switch Operation: In-hospital and Post-discharge Outcomes.

The influence of the coronary artery anatomy on the prognosis of patients receiving an arterial switch operation (ASO) is currently controversial, and the risk factors for this operation may change in more complicated patients. This study aimed to investigate the influence of coronary artery anomalies on the in-hospital and post-discharge outcomes of ASO in patients with transposition of the great arteries (TGA) and Taussig-Bing anomaly (TBA). We retrospectively reviewed 206 patients who underwent ASO from January 2007 to December 2019. The median age at operation was 33 [interquartile range (IQR): 20-71] days. Median follow-up time was 7.2 years (IQR: 4.0-10.3 years). Coronary anomalies were present in 86 patients (41.7%), with 9 (4.4%) of them having a single coronary artery. Additional coronary features included intramural courses in 5 (2.4%) patients, ostial stenosis in 1 (0.5%) patient, and accessory coronary artery orifices in 5 (2.4%) patients. There were 32 (15.5%) in-hospital deaths and 8 (4.6%) post-discharge deaths, yielding an overall survival of 81.3%, 80.7% and 79.9% at 1, 5 and 10 years, respectively. Mortality due to ASO has been drastically decreased since 2013. Patients with a single coronary artery had higher rate of in-hospital mortality, but this finding was not statistically significant. The earlier surgical era (OR: 2.756) and a longer cardiopulmonary bypass time (OR: 2.336) were significantly associated with in-hospital mortality, while coronary patterns were not. An intramural coronary artery (HR: 10.034) and a patient age of older than 1 year at the time of ASO (HR: 9.706) were independent predictors of post-discharge mortality. ASO remains the procedure of choice for TGA with coronary anomalies with acceptable in-hospital and post-discharge outcomes in terms of overall survival and freedom of reoperation. However, intramural coronary artery is an independent risk factor for post-discharge mortality. Timely surgery within the 1st year of life helps improve overall midterm survival of ASO.

Intracerebral bleeding in donors is associated with reduced short-term to midterm survival of heart transplant recipients.

AimThe quality of the donor heart is known to have a crucial effect on outcome after heart transplantation (HTx). Although leading to brain death in the end, the initial cause of death of the donor and its potential influences on organ quality are heterogeneous. However, it is still controversial to which extent the donor cause of death is associated with outcome or survival post‐HTx.Methods and resultsWe included all patients undergoing HTx in our centre between September 2010 and June 2021 (n = 218). Recipients were divided in five groups related to their donor cause of death: intracerebral bleeding (‘ICB’, n = 95, 44%), traumatic brain injury (‘trauma’, n = 54, 25%), hypoxic brain damage (‘hypoxic’, n = 34, 16%), cerebrovascular (‘vascular’, n = 15, 7%), or other cause (n = 20, 9%). Baseline characteristics, perioperative parameters, and survival after 30 and 90 days as well as 5 years after transplantation were collected.ResultsIntracerebral bleeding in donors compared with traumatic brain injury is associated with higher probability of need for ECLS post‐HTx (35% vs. 19%, P = 0.04) and significantly reduced survival up to 5 years post‐HTx (i.e. 1 year survival: 61% vs. 95%, P < 0.0001). Although other conditions also show significant changes in outcome and survival, the effect is strongest for ICB, where survival is also reduced compared with all other causes (1 year: 61% vs. 89%, P < 0.0001).ConclusionsIn this retrospective analysis, donor cause of death is associated with differing outcome and survival after HTx. Intracerebral bleeding hereby shows strongest decline in outcome and survival in comparison with all other causes.

Surgical repair of post-infarction ventricular free-wall rupture in the Netherlands: data from a nationwide registry.

Ventricular free-wall rupture (VFWR) is an infrequent but catastrophic complication of acute myocardial infarction (AMI). Most reports about outcome after surgical treatment are single-center experiences. We examined the early and mid-term outcomes after surgical repair of post-AMI VFWR using the Netherlands Heart Registration (NHR) database. We included data from NHR patients (>18 years old) who underwent surgery for post-AMI VFWR between 2014 and 2019. The primary end-point was in-hospital mortality. Secondary outcomes included postoperative complications and mid-term survival. The study included 148 patients (54.7% male, mean age 66.5±11.1 years). Critical preoperative status was found in 62.6% of subjects. In-hospital mortality was 31.1% (46 of 148). Multivariable analysis identified female sex [odds ratio (OR), 5.49; 95% confidence interval (CI): 2.24-13.46] and critical preoperative status (OR, 4.06; 95% CI: 1.36-12.13) as independent predictors of in-hospital mortality. The overall median postoperative follow-up was 2.2 (interquartile range, 0.7-3.8) years. Overall survival rates at three and five years were 58.9% and 55.7%, respectively. Among hospital survivors, only 15 (14.7%) patients died during follow-up, with a five-year survival rate of 80.8%. In-hospital mortality after surgical repair of post-AMI VFWR is considerable. Female sex and preoperative critical status are independent predictors of early postoperative (in-hospital) death. Logistic EuroSCORE I can reliably predict in-hospital mortality (optimal cut-off >33%). Mid-term follow-up of patients surviving in-hospital course shows excellent results.

Comparison of the mid-term clinical efficacy and short-term complications of Y-type coronary artery bypass grafting and sequential bypass grafting of the great saphenous vein: a retrospective cohort study.

BackgroundThis study sought to compare and evaluate the clinical efficacy and safety of Y-type coronary artery bypass grafting (CABG) and sequential CABG. However, the prognosis and complication rate of the two treatments are different. Therefore, we need to systematically compare the efficacy and safety of the two surgical schemes.MethodsA total of 112 patients who underwent Y-type CABG and 113 patients who underwent sequential CABG were selected from January 2020 to December 2020. The patients undergoing Y-type CABG of the great saphenous vein (SV) were classified as the experimental group, and those undergoing sequential anastomosis were classified as the control group. The intraoperative blood flow at each anastomotic site of the venous sequential CABG, left ventricular ejection fraction (LVEF), and left ventricular diastolic diameter (LVEDD) at the end of 3 months, 6 months, and 1 year after surgery, the incidence rate of major adverse cardiovascular events, and coronary angiography (CAG) after readmissions due to similar symptoms were compared between the 2 groups. The bridging vascular blockage rate was also determined.ResultsThere was no significant difference in cardiac function between the 2 groups in the short term, and the incidence of major adverse cardiovascular events in the 2 groups mainly occurred in the middle-postoperative period (1 year after surgery) or later. There was no statistical difference in the intraoperative real-time blood flow measurements at each anastomosis of the venous bridge between the 2 groups. Compared to the control group, the LVEF of the experimental group was significantly increased at the 1-year follow-up point (51.6±5.1 vs. 67.6±5.6, P=0.001). During the operation of Y-type coronary artery bypass grafting, the incidence of major adverse cardiovascular events, vascular bridge, and anastomotic blockage were significantly decreased (16 vs. 39, P=0.023).ConclusionsLarge SV Y-type CABG can improve postoperative left heart function and reduce the incidence of postoperative adverse events, which may be of great significance for improving the postoperative mid-term survival rate of patients.

Current management of acute type B dissection in 2021.

The rationale for thoracic endovascular aortic repair (TEVAR) for type B aortic dissection depends on the phase of disease: acute phase, which is 'complicated', subacute to early chronic phase, which requires 'preemptive TEVAR' and chronic phase, which entails 'prevention of further dilatation and rupture'. Low operative mortality and morbidity after TEVAR for complicated acute type B aortic dissection have been reported with significant improvement during midterm survival. 'Retrograde' type A dissection, which can be described as type B0,X (X>3) according to a new reporting standard, has reportedly been treated with TEVAR with less invasiveness. TEVAR is the first and possibly the only effective strategy for acute type B dissection, so that expansion of indications for type B0,X, as described in the new reporting standard has been validated.

The impact of radiotherapy on survival after surgical resection of chordoma with minimum five-year follow-up

BACKGROUND CONTEXTLocal control remains a vexing problem in the management of chordoma despite advances in operative techniques and radiotherapy (RT) protocols. Existing studies show satisfactory local control rates with different treatment modalities. However, those studies with minimum follow-up more than 4 years demonstrate increasing rates of local failure. Therefore, mid-term local survival rates may be inadvertently elevated by studies with less than 4 years follow-up. PURPOSEThe purpose of this study is to report the mid-term results of primary spinal chordoma treated with en bloc resection and proton-based RT with minimum 5 years of follow-up. STUDY DESIGN/SETTINGRetrospective, single-center, cohort study. PATIENT SAMPLEPatients undergoing primary surgical excision of a spine or sacral chordoma tumor between 1990 and 2016 at a single-institution were included. Patients were included if they had a local failure at any time, or they had a minimum of 5 years of follow up with no local failure. Patients were excluded if a prior surgical excision was performed or metastases were present at the time of referral. OUTCOME MEASURESThe outcome measures were local recurrence-free interval (LRFI) and overall survival (OS). METHODSDemographic, clinical, oncologic and surgical variables, including margin status, as well as radiation doses and schedule (neoadjuvant, adjuvant, or both) were compared using Wilcoxon rank-sum or chi-squared testing. The goal RT dose was 70 Gray (total) and patients were stratified based on completing (C70) or receiving incomplete (I70) dosing. Overall survival (OS) and local-recurrence free interval (LRFI) were calculated using the Kaplan-Meier method. FUNDING STATEMENTNo funding was obtained for this work. RESULTSSeventy-six patients were included in the final analysis. All patients had a minimum of 5-year follow-up (median 9.3 years, range 5.1–24.7 years). There were no significant clinical differences between the C70 and I70 RT groups. OS was greater for the C70 RT group (5-year OS 82% vs. 63%, p=.001). There was similar OS for the positive margin group (5-year OS 70% vs. 61%, p=.266). LRFI was greater for the C70 RT group (5-year OS 93% vs. 78%, p=.017). There was similar LRFI for the positive margin group (5-year OS 90% versus 87%, p=.810). CONCLUSIONChordoma outcomes trend towards diminishing LRFI rates in the literature. Here we report the results of the operative management of primary spinal chordoma with minimum five year follow-up, the addition of C70 RT to surgical excision conferred a benefit to OS and local recurrence.

The Relationship Between the Global Limb Anatomic Staging System (GLASS) and Midterm Outcomes of Retrograde Tibiopedal Access After Failure of Antegrade Recanalisation for Chronic Limb Threatening Ischaemia

To examine the relationship between the Global Limb Anatomic Staging System (GLASS) and midterm limb and survival related outcomes of retrograde tibiopedal access, after failed recanalisation of infrainguinal chronic total occlusions (CTOs) using the antegrade approach, in patients with chronic limb threatening ischaemia (CLTI). This prospective, observational study was conducted between January 2017 and April 2019, and included 213 patients (29 GLASS I, 53 GLASS II, and 131 GLASS III lesions) with infrainguinal CTO in whom a percutaneous tibiopedal access was attempted following failed recanalisation using an antegrade approach. Multivariable Cox proportional hazard regression was performed to assess possible predictors of midterm clinical outcomes. Kaplan-Meier survival curves were used to estimate limb based patency (LBP), limb salvage, amputation free survival (AFS), and overall survival. The study reported access, crossing, and treatment success of 92.5%, 89.2%, and 89.2% of all tibiopedal access attempts, respectively. In comparison with GLASS I, GLASS stage III was associated with statistically significantly worse midterm LBP (p= .005), overall survival (p= .037), limb salvage (p= .021), and AFS (p < .001). Retrograde tibiopedal access for recanalisation of infrainguinal CTOs in patients with CLTI is associated with high access, crossing, and treatment success, and low complication rates. The study suggests that GLASS stage may be a useful predictor of midterm limb and survival related outcomes of this approach. In comparison with GLASS I, GLASS III anatomy is associated with a statistically significantly worse LBP, limb salvage, AFS, and overall survival.

Outcomes of over 1,000 Heart Transplants Using Hepatitis C Positive Donors in the Modern Era

<h3>Purpose</h3> Advances in the treatment of hepatitis C (HCV) and an ongoing opioid epidemic have made HCV-positive (HCV+) donor organs increasingly available for transplantation. Recent reports of outcomes after heart transplantation (HT) using HCV+ donors have limited cohort size and follow up. This analysis reports mid-term outcomes of over 1,000 HCV+ HT performed in the United States in the modern era. <h3>Methods</h3> The United Network of Organ Sharing registry was used to identify patients undergoing HT between 2015-2021. Recipients were stratified by donor HCV serostatus and nucleic acid amplification test positivity (NAT+). The primary outcome was one-year mortality. A subanalysis comparing recipients of HCV NAT+ to NAT- organs was performed. Risk-adjustment for mortality was performed using Cox proportional hazards modeling. Kaplan-Meier analysis was used to compare post-HT survival. <h3>Results</h3> There was a significant annual increase in the frequency of HCV+ HT from 1.2% of HT in 2015 to 12.9% in 2021 (<i>p</i> < 0.001). Of 16,648 patients undergoing HT within the study period, 1,170 (7.0%) received an HCV+ organ. Recipients of HCV+ organs were more likely to be HCV seropositive, older, and white. HCV+ donors were more likely to be older, female, and white, and their organs had significantly longer cold ischemic times. In multivariable analysis, the adjusted risk for one-year mortality for an HCV+ donor was 0.87 (95% CI [0.69-1.10], <i>p</i> = 0.242). Of 1,170 HCV+ HT, 772 (61.7%) were NAT+. The adjusted risk for one-year mortality in a NAT+ HT was 0.73 (95% CI [0.47-1.13] <i>p</i> = 0.159) compared to NAT- HT. Unadjusted 3-year survival was 84.9%, 81.5%, and 85.5% in HCV-, HCV+NAT-, and HCV+ NAT+, respectively (<i>p</i> = 0.374) (Figure). <h3>Conclusion</h3> The annual proportion of HT using HCV+ donors has increased over ten-fold in the last six years. This analysis of the United States experience demonstrates that recipients of HCV+ hearts, including those that are NAT+, have acceptable outcomes with similar mid-term survival as HCV- cases.

Surgical Restoration of Antero-Apical Left Ventricular Aneurysms: Cardiac Computed Tomography for Therapy Planning.

BackgroundSurgical ventricular restoration (SVR) leads to functional improvement by volume reduction and restoration of left ventricular (LV) geometry. Our purpose was to refine the planning for SVR using cardiac computed tomography (CCT).MethodsThe possibility to anticipate the postoperative residual LV volume was assessed using CCT in 205 patients undergoing SVR combined with coronary artery bypass grafting (77%), mitral valve repair/replacement (19%) and LV thrombectomy (19%). The potential of CCT to guide the procedure was evaluated. Additionally, the predictive value of CCT characteristics on survival was addressed.Results30-day, 1- and 5-year survival was 92.6, 82.7, and 72.1%, respectively, with a marked reduction of NYHA class III-IV quota after surgery (95.1% vs. 20.5% in the follow-up). Both pre- and postoperative LV end-systolic volume index (LVESVI) were predictive of all defined endpoints according to the following tertiles: preoperative: <74 ml/m2, 74–114 ml/m2 and >114 ml/m2; postoperative: <58 ml/m2, 58–82 ml/m2 and >82 ml/m2. On average, a 50 ml/m2 increase of preoperative LVESVI was associated with a 35% higher hazard of death (p = 0.043). Aneurysms limited to seven antero-apical segments (1–7) were associated with a lower death risk (n = 60, HR 0.52, CI 0.28–0.96, p = 0.038). LVESVI predicted by CCT was found to correlate significantly with effectively achieved LVESVI (r = 0.87 and r = 0.88, respectively, p < 0.0001).ConclusionsCCT-guided SVR can be performed with good mid-term survival and significant improvement in HF severity. CCT-based assessment of achievable postoperative LV volume helps estimate the probability of therapeutic success in individual patients.

Mitral valve-in-valve and valve-in-ring procedures: Midterm outcomes in a French nationwide registry.

Report contemporary outcomes in patients included in the Mitragister registry and treated with transcatheter mitral valve implantationfor failed surgical annuloplasty rings or deteriorated bioprosthesis. Midterm survival rates have been reported, but little is known about contemporary morbimortality endpoints. The primary safety outcome was the technical success rate. The primary efficacy composite endpoint was a composite of cardiovascular mortality and heart failure hospitalizations. From 2016 to 2021, 102 patients (median age: 81 [74;84] years, 61% female, Euroscore II 11.0% [7.8;16.0]) undergoing valve-in-valve (ViV; n = 89) or valve-in-ring (ViR; n = 13) procedures were consecutively included. At baseline, ViR group patients had worse left ventricular ejection fraction (50% vs. 60%; p = 0.004) and more frequently severe regurgitation (46% vs. 15%; p = 0.014). The primary safety outcome was 95%: 77% and 98% in the ViR and ViV populations, respectively, (p = 0.014). At intermediate follow-up (6-12 months) clinical improvement was notable, 88% of the patients were in NYHA class ≤ II (vs. 25% at baseline; p < 0.001). At a mean follow-up of 17.1 ± 11.0 months, the primary efficacy composite reached 27%. By multivariate analysis, paravalvular leak (PVL) was the only independent predictor (hazard ratio:2.39, 95% confidence interval: 1.08-5.29; p = 0.031) while ViR was not found statistically associated (p = 0.456). This study confirms the safety and efficacy of the mitral ViV procedure. ViR patients appear at higher risk of procedural complications. The presence of PVL could be associated with markedly worse midterm prognosis. Whatever the intervention, procedural strategies to reduce PVL incidence remain to be assessed to prevent latter adverse outcomes.

Irreversible electroporation versus radiofrequency ablation for malignant hepatic tumor: A prospective single-center double-arm trial

ObjectiveIrreversible electroporation (IRE) is a nonthermal ablation technique for the treatment of malignant liver tumors. IRE has demonstrated efficacy and safety in the treatment of malignant liver tumors and its unique advantages in the treatment of nearby vascular lesions. This study aimed to compare the efficacy, safety, and intermediate-term outcomes of IRE and radiofrequency (RF) therapy in malignant liver tumors. MethodsTwenty-four patients with primary or secondary liver malignancies were included in this prospective, double-arm clinical trial. Patients were randomly divided into the IRE and RF groups. The primary outcome was the efficacy (local ablation control evaluation at 90 days). The secondary outcomes were safety (procedure-related complications at ​≤ ​90 days) and intermediate-term survival (at 24 months). ResultsThe ablation assessment at 90 days after surgery with mRECIST for IRE versus RF were 70%, 20%, 0%, and 10% versus 92.9%, 7.1%, 0%, and 0% (CR, PR, SD, and PD, respectively). The complication rates of IRE versus RF with Clavien-Dindo classification were 16.7%, 25%, 0%, 8.3%, and 8.3% versus 8.3%, 50%, 0%, 0%, and 0% (Grade I, II, III, IV, and V, respectively). The average overall survival (OS) was 17.55 months in the IRE group (95% CI 15.13-22.37) and 18.75 months in the RF group (95% CI 12.48-22.61). There was no statistical difference between the IRE and RF groups in terms of efficacy (p ​= ​0.48), safety(p ​= ​0.887), or 24-month OS (p ​= ​0.959). ConclusionsIRE ablation revealed similar efficacy and safety in a short-term follow-up, and similar OS in mid-term survival as RF ablation in treating malignant hepatic tumors.

Mid-term outcomes of isolated tricuspid valve surgery according to preoperative clinical and functional staging.

This study aimed at assessing mid-term outcomes of patients undergoing isolated tricuspid valve (TV) surgery based on a preoperative baseline clinical and functional classification. All patients treated with isolated TV repair or replacement from March 1997 to May 2020 at a single institution were retrospectively reviewed and assessed for mid-term postoperative outcome according to a novel classification [stages 1-5 related to the absence or presence and extent of right heart failure (RHF)]. Kaplan-Meier survival curves were used to estimate mid-term survival. Competing risk analysis for time to cardiac death and hospitalizations for RHF were also carried out. Among the 172 patients included, 129 (75%) underwent TV replacement and 43 (25%) TV repair. At follow-up (median 4.2 years [2.1-7.5]), there were 23 late deaths. At 5 years, overall survival was 100% in stage 2, 88 ± 4% in stage 3 and 60 ± 8% in stages 4-5 (P = 0.298 and P = 0.001, respectively). Cumulative incidence function of cardiac death at 5 years was 0%, 8.6 ± 3.76% and 13.2 ± 5% for stages 2, 3 and 4 and 5, respectively. At follow-up, cumulative incidence function of re-hospitalizations for RHF was 0% for stage 2, 20 ± 5% for stage 3 and 20 ± 6.7% for stages 4 and 5 (P = 0.118 and P = 0.039, respectively). Both short- and mid-term outcomes support early referral for surgery in isolated TV disease, with excellent survival at 5 years and no further hospitalizations for RHF.