Perioperative Mortality Research Articles

The Impact of Body Composition on Mortality and Hospital Length of Stay after Endovascular and Open Aortic Aneurysm Repair: A Retrospective Cohort Study.

Background: Sarcopenia is an indicator of preoperative frailty and a patient-specific risk factor for poor prognosis in elderly surgical patients. Some studies have explored the prognostic significance of body composition parameters in relation to perioperative mortality after aortic repair and to mid- and long-term survival following endovascular aneurysm repair (EVAR). This study aimed to comprehensively investigate the effects of various body composition parameters, including but not limited to sarcopenia, on short- and long-term mortality as well as the length of hospital stay in two large cohorts of patients undergoing open surgical aortic repair (OSR) or EVAR. Methods: A single-institution retrospective cohort study included patients who underwent EVAR or OSR from January 2010 to December 2017. Several parameters of body composition on axial CT angiography images were analyzed, such as skeletal muscle area (SMA) with derived skeletal muscle index (SMI), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Results: 477 patients were included: 250 treated by OSR and 227 by EVAR; the mean age was 70.8 years (OSR) and 76.3 years (EVAR), with a mean follow-up of 54 months. Sarcopenia was associated with a prolonged length of hospital stay in EVAR patients but not in OSR patients (β coefficient 3.22; p-value 0.022 vs. β coefficient 0.391; p-value 0.696). Sarcopenia was an elevated one-year mortality risk post-EVAR compared to those without sarcopenia (p-value for the log-rank test 0.05). SMA and SMI were associated with long-term mortality in EVAR patients even after adjusting for multiple confounders (HR 0.98, p-value 0.003; HR 0.97, p-value 0.032). The analysis of the OSR cohort did not show a significant correlation between short- and long-term mortality and sarcopenia indicators. Conclusions: The results suggest that body composition could predict increased mortality and longer hospital stays in patients undergoing EVAR procedures. These findings were not confirmed in the cohort of patients who underwent OSR. Patients with sarcopenia and pre-operative malnutrition should be critically assessed to define the indication for treatment in this predominantly elderly and morbid cohort, despite EVAR procedures being less invasive. Body composition evaluation is an inexpensive and reproducible tool that can contribute to an improved decision-making process by identifying patients who will benefit most from EVAR, ensuring a more personalized and cost-effective treatment strategy. Further studies are planned to explore the added value of integrating body composition into a comprehensive risk stratification before aortic surgery.

Compliance of enhanced recovery after surgery (ERAS) protocol in emergency and elective colorectal cancer surgery with a perspective from a developing country.

To evaluate compliance with enhanced recovery after surgery protocol of patients undergoing colorectal carcinoma surgery, and to compare its effect on outcomes. The retrospective study was conducted at the Maroof International Hospital, Islamabad, Pakistan, and comprised data from July 15, 2016, to March 20, 2022, of patients of either gender undergoing elective or emergency colorectal carcinoma surgery. Data included age, gender, tumour site, type of surgery, surgical approach, compliance with each of the 25 components of the enhanced recovery after surgery protocol, length of hospital stay, surgery duration, 30-day readmission rate and perioperative mortality. Data was analysed using SPSS 23. Of the 96 patients with mean age 50.03±14.86 years (range: 20-79 years), 65(67.7%) were males, 70(72.91%) were aged at least 40 years, and 75(78.12%) underwent elective surgery. Most common tumour site was rectum and sigmoid 49(51%). Laparoscopic surgery was performed in 17(17.7%) patients. No compliance was seen with carbohydrate loading of patients or limiting use of opioids in standard anaesthesia protocol. No nutritional supplementation was started from postoperative day 1. Mean compliance with all the protocol components was 74.9%±37.652 for both elective and emergency cases. Mean duration of surgery was 192.50±75.33 minutes, while mean length of hospital stay was 5.52±1.57 days. Re-admission within 30 days was needed in 2(2.1%) cases. There was no perioperative mortality. Better compliance with enhanced recovery after surgery protocol resulted in better perioperative outcomes.

Surgical treatment of graft infection combined with aortoesophageal fistula after TEVAR: a retrospective single-center, single-arm study

ObjectiveAortoesophageal fistula (AEF) secondary to thoracic aortic endovascular repair (TEVAR) is rare and fatal. The author reports the treatment methods and outcomes of 10 patients with a TEVAR graft infection and an aortoesophageal fistula.MethodA retrospective analysis was conducted on the clinical data of 10 patients who developed a secondary AEF and a graft infection after TEVAR from March 2018 to March 2024.ResultThe perioperative mortality rate was 70%. Two patients had TEVAR only and all died of bleeding and infection. Eight patients underwent open surgery, five died within 30 days, four of them died due to massive bleeding, the one patient died of a serious infection after surgery. Three patients recovered well and were discharged. One patient died of severe pneumonia 3 months after discharge, and two patients survived for 6 years and 3 months, respectively.ConclusionExtra-anatomical bypass reconstruction is feasible for treating graft infection combined with aortoesophageal fistula after TEVAR but related to bad outcomes in most of the patients. It is reserved for highly select patients and is performed at centers with experience with this procedure.

Outcome of perioperative immune enhancing nutrition in patients undergoing radical cystectomy

BackgroundSince radical cystectomy is associated with relatively high perioperative morbidity and mortality, this study was conducted to evaluate the efficacy of perioperative immune nutrition in radical cystectomy patients on postoperative outcomes including wound healing, postoperative complications, either infectious or non-infectious, and length of hospital stay.Patients and methodsThis prospective, randomized controlled study was conducted between June 2022 and November 2023. Forty-two patients who had undergone radical cystectomy with ileal conduit were randomized into two groups: the immune nutrition group, which received perioperative immune nutrition, and the conventional group, which did not receive immune nutrition. Patients were followed up for 30 days postoperatively to assess wound healing, infectious and non-infectious complications, and the length of hospital stay.ResultsPatients who received immune nutrition had significantly lower postoperative infectious complications (19.0 vs 61.9%; P = 0.004), shorter hospital stay (16.57 ± 3.74 vs 20.38 ± 5.97; P = 0.01) and shorter ICU stay (2.60 ± 1.07 vs 7.09 ± 7.50; P = 0.029). The proper wound healing was significantly higher in the immune nutrition group (90.5 vs 52.4%; P = 0.006). However, there was no significant difference between both groups in the rate of non-infectious complications (28.5% vs. 57.1%, P = 0.061).ConclusionPerioperative immune nutrition is associated with improved wound healing, reduced infectious complications, and reduced length of hospital stay.Trial registration clinicaltrials.gov, NCT05822518. Registered 1 April 2023—Retrospectively registered, https://clinicaltrials.gov/study/NCT05822518.

Outcomes after noncardiac surgery in patients with left ventricular assist devices: a systematic review.

The number of patients living with left ventricular assist devices (LVADs) has gradually increased in the past decade. Non-cardiac surgery (NCS) in patients with LVAD poses a unique situation with its inherent challenges. We conducted a comprehensive review to investigate the perioperative complications and mortality associated with emergent or elective NCS in patients with LVAD. A comprehensive literature search for any papers referring to continuous LVAD patients with NCS. All publications with at least five durable LVAD patients who had NCS were eligible for inclusion. Twenty articles matching our criteria were found and included in our study. This systematic review included 6,476 LVAD patients who underwent 6,824 NCS. There were 5-3,216 LVAD patients with NCS in each study. The median age was between 39 and 65 years, and most of the patients (78.8%) were male. Thirty-day postoperative mortality ranged from 0% to 60%. Eight studies reported no death within the 30 days of the operation. Common complications include gastrointestinal (GI) bleeding, intracranial bleeding, infection, acute kidney injury (AKI), urinary tract infection (UTI), stroke, sepsis, pneumonia, and VAD exchange. Emergent abdominal surgery had the highest (up to 60%) mortality rate, and vascular and neurological operations had the highest complication rates. Due to the diverse range of patients in each publication and the combination of outcomes presented in various publications, a meta-analysis was not conducted. In LVAD patients, noncardiac surgery may be performed effectively and safely. LVAD patients who undergo non-cardiac surgery may require more transfusions due to their complex coagulopathies. However, perioperative management of LVAD patients undergoing emergent NCS should be optimized to reduce mortality. https://osf.io/fetsb/.

The biodemography of human aging (Gompertz-Makeham law) applied to surgical mortality modelling: a retrospective national cohort study.

The Gompertz-Makeham law describes a characteristic pattern of mortality in human populations where death rate is near constant between age 18 and 30 years (Makeham's Law) and rises exponentially thereafter (Gompertz Law). This pattern has not been described in surgical populations, but if true, would have important implications for understanding surgical risk and design and interpretation of surgical risk models. The aim of this study was to determine if the Gompertz-Makeham law applies to perioperative mortality risk and the conditions under which it may apply. We examined the relationship between age and 1-month postoperative all-cause mortality risk in a 10-year New Zealand administrative dataset comprising of 5,615,100 surgical procedures from 2007 to 2016. The dataset includes patient and surgical factors including procedures, American Society of Anesthesiologist's physical status score (ASA-PS), diagnoses and other relevant details. Semi-logarithmic graphs of mortality risk and age were plotted. Linear regression models were fitted, with regression line slope and Pearson's correlation coefficient calculated. The primary outcome occurred in 114,782 (2.0%) of 5,615,100 included participants. The Gompertz-Makeham law seems to apply to the national surgical population as a whole (slope = 0.0241, R2 = 0.971). The law applies in all subgroups studied including sex, ASA-PS, surgical acuity, surgical severity category, cancer status and ethnicity (slopes 0.0066 to 0.0307, R2 0.771 to 0.990). Important interactions were found between age, mortality risk and three high risk groups (cancer diagnosis, ASA-PS 4-5 and high surgical severity). The Gompertz-Makeham law seems to apply in a national cohort of surgical patients. The inflection point for increased 1-month risk is apparent at age 30 years. A strict exponential rise in mortality risk occurs thereafter. This finding improves our understanding of surgical risk and suggests a concept-driven approach to improve modelling of age and important interactions in future surgical risk models.

Cushing syndrome from an ACTH-producing pheochromocytoma or paraganglioma: structured review of 94 cases.

Adrenocorticotropic hormone-producing pheochromocytomas/paragangliomas are rare neuroendocrine tumors that co-secrete excess catecholamines and adrenocorticotropic hormone, resulting in Cushing syndrome (CS). This review aims to summarize important patient characteristics, investigations, and outcomes in all cases reported in the English literature. A literature search was conducted to identify all English-language case reports and case series describing adrenocorticotropic hormone-producing pheochromocytomas/paragangliomas. Relevant characteristics were systematically recorded. Cases that did not provide definitive evidence of an adrenocorticotropin (ACTH)-producing pheochromocytoma/paraganglioma were excluded. Our search strategy identified 93 published cases that met the inclusion criteria. We additionally reported one patient for a total of 94 cases. Details related to patient characteristics, laboratory data, and outcomes were commonly underreported. The median age was 47 years, and females accounted for 72% of cases. A cushingoid appearance was reported in 82% of patients, and hypertension in 86%. Infections were reported in 23% of patients. Urinary metanephrines were elevated at least three-fold above normal in 74% of cases. ACTH levels were high in 88% of patients and inappropriately normal in 12%. The median 24-hour urinary cortisol was 21-fold the upper limit of normal. Adrenalectomy was performed in nearly all patients, with 88% achieving a cure for both catecholamine and glucocorticoid excess. A total of 11 patients died. Metastases were uncommon (6%). Adrenocorticotropic hormone-producing pheochromocytomas/paragangliomas are associated with considerable morbidity and mortality. It should be considered in the diagnostic workup of all patients with ectopic CS. Surgical cure is achieved in most patients, and infections are the leading cause of peri-operative mortality.

Early surgical outcome for Tetralogy Of Fallot In An African Setting; A Tanzanian experience using retrospective analysis of hospital data

BackgroundTetralogy of Fallot (TOF) is typically treated in infancy but often done late in many resource-limited countries, jeopardizing surgical outcomes. This study examined the early results of children undergoing primary complete TOF repair at the Jakaya Kikwete Cardiac Institute (JKCI) in Tanzania, an emerging cardiac center in Eastern Africa.MethodsA retrospective cohort study of children ≤ 18 years undergoing primary TOF complete repair between 2019 and 2021 was conducted. Patients with complex TOF and those with obvious genetic syndrome were excluded. Data on socio-demography, pre-and postoperative cardiac complications, Intensive Care Unit (ICU) and hospital stay, and in-hospital and 30-day mortality were analyzed. Logistic regressions were employed to find the factors for mortality, ICU, and hospital stays.ResultsThe I02 children underwent primary TOF complete repair were majority male (65.7%; n = 67), with a median age of 3.0 years (IQR: 2–6), ranging from 3 months to 17 years.Only 20 patients (19.6%) were below one year of age. Almost all (90%; n = 92) were underweight, with a mean BMI of 14.6 + 3.1 kg/m2 Haematocrits were high, with a median of 48.7 (IQR: 37.4–59.0). The median oxygen saturation was 81% (IQR:72–93). Over a third of patients (38.2%; n = 39) needed Trans annular patch (TAP) during surgery. The median ICU stay was 72 h (IQR:48–120), with ICU duration exceeding three days for most patients. The median hospital stay was 8.5 days (IQR:7–11), with 70 patients (68.2%)experiencing an extended hospital stay of > 7 days. Bacterial sepsis was more common than surgical site infection (5.6%; n = 6 vs. 0.9%;n = 1). No patient needed re-operation for the period of follow up. The in-hospital mortality rate was 5.9%, with no deaths occurring in children less than one year of age nor after discharge during the 30-day follow-up period. No statistically significant differences were observed in outcomes in relation to age, sex, levels of hematocrit and saturations, presence of medical illnesses, and placement of TAP.ConclusionTOF repairs in this African setting at a national cardiac referral hospital face challenges associated with patients’ older age and compromised nutritional status during the surgery. Perioperative mortality rates and morbidity for patients operated at an older age remain elevated. It’s important to address these issues to improve outcomes in these settings.

Perfusion Strategies for Cytoreductive Surgery With Heated Intraperitoneal Chemotherapy for Malignant Peritoneal Mesothelioma.

Cytoreductive surgery (CRS) with heated intraoperative intraperitoneal chemotherapy (HIPEC) has been shown to improve survival for patients with malignant peritoneal mesothelioma (MPM). Presently, there is no standardized HIPEC protocol with respect to chemotherapeutic agent, dose, administration temperature, or duration and limited literature comparing outcomes in different regimens. In this study, we analyze common practices and outcomes of published HIPEC regimens to gain insight into current practice to inform future directions of study. We conducted a literature search for investigational studies of CRS and HIPEC for MPM treatment in adults and identified 35 such articles. These studies were analyzed for institution type and location, drug regimens, perfusion temperatures and time, and study outcomes including median survival, complication rates, and perioperative mortality rates. On review, there is significant heterogeneity in HIPEC regimens and outcome reporting metrics, suggesting a need for multi-institutional standardized study protocols to better determine the safest and most efficacious treatment regimen.

Short-Term Results With Ozaki Valved Conduit-A Simple Solution for Patients Needing Right Ventricle to Pulmonary Artery Conduit in a Low-Resource Setting.

The repair of certain types of complex congenital cardiac defects may require a right ventricle-pulmonary artery (RV-PA) conduit. Using the Ozaki Aortic valve neocuspidization (AVNeo)technique, a valved RV-PA conduit was constructed with an Ozaki valve inside a Dacron graft. This study aims to evaluate the short-term outcome of the Ozaki valved RV-PA conduit. A total of 22 patients received the Ozaki valved RV-PA conduit from November 2019 until December 2023. The median age was 12 years (interquartile range [IQR], 5.5-21), median body weight was 35 kg (IQR, 15.8-48.5). The conduit was used in 16 patients (72.7%) under 18 years of age. Indications for conduit placement included: anatomic repair of corrected transposition of the great arteries, ventricular septal defect/pulmonary stenosis, conduit replacement, pulmonary atresia with associated anomalies, pulmonary artery aneurysm with dysplastic pulmonary valve, tetralogy of Fallot with coronary artery crossing the right ventricular outflow tract, bioprosthetic pulmonary valve regurgitation, and rheumatic heart disease. Native pericardium was used for the Ozaki valve in 12 patients and bovine pericardium for 10 patients. Conduit sizes ranged from 18 mm to 30 mm. The median intensive care unit stay was 4 (IQR, 2-6) days and the median hospital stay was 9 (IQR, 5.5-13.5) days. There were two perioperative mortalities (9.1%) both unrelated to the conduit. The median follow-up was 12.3 (IQR, 4.43-21.2) months. There was no infective endocarditis of the conduit. The median peak gradient across the conduit was 22 mm Hg (range 0-44 mm), and all were competent with trivial regurgitation on follow up. Creation of an Ozaki valved conduit is an attractive option due to low cost, reproducibility, and excellent hemodynamics. Longer-term studies are needed to confirm the durability.

Tracheal resection and anastomosis in postintubation tracheal stenosis: a systematic review.

Surgical resection of the stenotic segment with end-to-end anastomosis is considered the gold standard in postintubation tracheal stenosis. However, outcomes of this concrete aetiology are not well described. With the aim to examine the extent, range and characteristics of the existing evidence, a scoping review was performed. Data sources included MEDLINE, Scopus, Ovid and the Cochrane databases. Inclusion criteria consisted of studies in adult patients with postintubation tracheal stenosis that reported characteristics, surgical management and outcomes. A total of 125 articles were identified, of which 10 were included in the final analysis. All studies were case reports or case series (level 4 evidence) grouping 110 patients, 75 males and 35 females. The age ranged from 15 to 71 years. Cotton-Myer stenosis grade was 1 [1 (0.9%)], 2 [25 (22.7%)], 3 [70 (63.6%)] and 4 [14 (12.7%)]. Stenosis location was in the tracheal upper-third in 108 (98.2%), in the middle-third in 1 (0.9%) and in the lower-third in 1 (0.9%). Stenosis length ranged from 1 to 5.6 cm. Follow-up ranged from 1 to 60 months (2 years for the most). Most frequent complications were transitory dysphagia in 13 (11.3%), granuloma formation in 8 (7.3%), dehiscence or air leak in 5 (4.5%) and wound infection in 4 (3.6%). Restenosis rate ranged from 2% to 25%. There was no perioperative mortality. Tracheal resection and primary anastomosis in postintubation tracheal stenosis appear to be safe and effective in the short and mid-terms; however, the very low level of evidence found prevents definitive conclusions.

Endovascular Treatment of Aortoiliac Aneurysms With the Bell-Bottom Technique: A Systematic Review and Meta-Analysis.

Aneurysmal degeneration of the common iliac artery (CIA) can pose a challenge to achieve distal landing zone sealing at the time of endovascular abdominal aortic aneurysm repair (EVAR). The aim of this study was to summarize the current literature regarding the bell-bottom technique (BBT) for ectatic CIAs during EVAR. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible articles were identified through a comprehensive search of PubMed, Scopus, and Cochrane Central published until April 2023. A meta-analysis was conducted using the random effects model and the I2 statistic was used to assess for heterogeneity. The primary endpoints were type Ib/III endoleak, graft occlusion/limb embolization, and reintervention rate. Secondary endpoints included perioperative adverse events and mortality. Overall, twenty-six studies and 4332 patients with flared limbs were included. The pooled estimate for type Ib/III endoleak was 4% (95% CI: 2-6, I2 = 85.6%), for reintervention rate was 9% (95% CI: 6-12, I2 = 90.4%), and for overall mortality was 10% (95% CI: 4-19, I2 = 97.3%). No aneurysm related deaths were recorded. Comparative analysis showed similar type Ib/III endoleak, graft occlusion, and reintervention rates between the EVAR BBT, iliac branch endoprosthesis (IBE), and embolization of the internal iliac artery followed by extension of the iliac limb to the external iliac artery (EIE) groups. The use of flared limbs could be considered a reasonable first line choice for EVAR cases with CIA ectasia as it is simpler, allows for future IBE or EIE and does not increase the risk for type Ib/III endoleak or graft occlusion. Further comparative studies with longer follow-up are needed.

Radiologic myosteatosis predicts major complication risk following esophagectomy for cancer: a multicenter experience

BackgroundMyosteatosis is a measure of skeletal muscle quality that is readily identifiable on computed tomography (CT). The effect of preoperative myosteatosis on outcomes after radical esophagectomy remains unclear. This study aimed to correlate the presence of myosteatosis on CT scan with perioperative morbidity, mortality, and survival outcomes after esophagectomy in an Australian population across 3 esophageal cancer centers. MethodsA retrospective analysis was performed for all patients undergoing radical esophagectomy for cancer across 3 centers. Radiologic assessment of preoperative CT images was performed to determine the presence of myosteatosis. The outcomes measured included perioperative complication rate, overall survival (OS), and disease-free survival (DFS). ResultsA total of 462 patients were included in the analysis (male patients, 78.4%; median age, 67 years). Moreover, 353 patients (76.4%) had myosteatosis on CT. Compared to patients with normal skeletal muscle attenuation, patients with myosteatosis had a higher rate of major (Clavien-Dindo grade ≥ IIIb) complication (14.7% vs 24.9%, respectively; P = .026) and a higher rate of 30-day mortality (0.0% vs 4.0%, respectively; P = .048). Myosteatosis was associated with a major complication on multivariate analysis (hazard ratio, 1.906; 95% CI, 1.057–3.437; P = .032). There was no difference in OS and DFS between patients with and without myosteatosis (OS: 59 vs 56 months, respectively [P = .465]; DFS: 39 vs 42 months, respectively; P = .172). ConclusionThe presence of myosteatosis on radiologic imaging was associated with an increased risk of major complications and 30-day mortality. Identifying myosteatosis can be an adjunct to preoperative nutritional assessment and prognostication, facilitating early recognition of patients at risk of complications.

Optimizing Femoral Access in Emergency EVAR with a Decision-Making Algorithm.

Endovascular aneurysm repair (EVAR) has become the preferred approach over open repair for abdominal aortic aneurysms (AAAs) due to its minimally invasive nature. The common femoral artery (CFA) is the main access vessel for EVAR, with both surgical exposure and percutaneous access being utilized. However, in emergent cases, percutaneous access can be challenging and may result in complications such as bleeding or dissection thrombosis, leading to the need for surgical conversion. This study aimed to share experiences in implementing a decision-making algorithm to reduce surgical conversions due to percutaneous access failures. A total of 74 aortic patients treated with EVAR in emergency settings were included in this retrospective study. This study focused on various outcomes such as perioperative mortality, morbidity, procedure time, surgical exposure time, and surgical conversion rate. After the implementation of the decision-making algorithm, decreases in surgical conversions and operating time were observed. Percutaneous access was found to be more challenging in cases with specific anatomical characteristics of the CFA, such as severe atherosclerosis or smaller vessel diameter. This study highlighted the importance of carefully assessing patient anatomical features and utilizing a decision-making algorithm to optimize outcomes in EVAR procedures. Further research is needed to continue improving practices for managing aortic aneurysms and reducing complications in femoral artery access approaches.

Delayed admission of patients with hip fracture from the emergency department is associated with an increased mortality risk and increased length of hospital stay

BackgroundThe aims of this study were to assess whether delayed admission from the ED influenced mortality risk, length of acute hospital stay, risk of developing delirium and return to domicile...

Vascular diseases: Clinical-surgical intervention in abdominal aortic aneurysms

Introduction: Abdominal aortic aneurysms (AAAs) are dangerous dilations of the aorta that, if left untreated, can lead to rupture and sudden death. The management of AAAs has evolved with the development of techniques such as endovascular repair (EVAR) and open surgical repair. This study systematically reviews the efficacy, benefits, and limitations of each approach to determine the most appropriate intervention for different patient profiles. Methods: A systematic review was performed in the PubMed, Scopus, and Cochrane Library databases, from 2006 to 2024. Studies comparing EVAR and open surgical repair regarding mortality, complications, length of hospital stay, and quality of life were included. Methodological quality was assessed, and data were analyzed through narrative synthesis and meta-analysis when applicable. Results: Twenty-five studies with 15,432 patients were included. EVAR demonstrated lower perioperative mortality (3.2% vs. 7.8%) and fewer immediate complications compared to open repair, in addition to shorter hospital stay (3.8 days vs. 7.2 days) and better short-term quality of life. However, EVAR presented a higher need for long-term reinterventions (5.9% vs. 2.4%). Open repair showed greater durability with a lower rate of late complications. Conclusion: EVAR is advantageous for high-risk patients or those with comorbidities due to its immediate benefits. However, the higher need for reinterventions limits its long-term effectiveness. Open repair remains preferred for young patients or those with suitable anatomies due to its durability. The choice between the two techniques should be personalized, considering the patient profile and aneurysm characteristics. Future studies should focus on improving the durability of endovascular devices and reducing EVAR complications.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians.

The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques. This was a single-centre retrospective study (2007-2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan-Meier and Cox proportional hazards methods were used to compare long-term survival. Fifty octogenarian patients were included (median age-82 years; closed distal-22; open distal-28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76-130 min). Median circulatory arrest time was 26 min (IQR; 20-39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5-11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival. ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Retroperitoneal vs transperitoneal approach for nonruptured open conversion after endovascular aneurysm repair

ObjectiveSeveral studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR). MethodsWe included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression. ResultsWe identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37). ConclusionsOur findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.

Impact of Persistent Pulmonary Hypertension of the Newborn in Neonates with Dextro-transposition of the Great Arteries

This study aimed to assess the impact of persistent pulmonary hypertension of the newborn (PPHN) on perioperative morbidity and mortality in patients with dextro-transposition of the great arteries. Secondarily, we evaluated the association between postoperative outcomes and intraoperative variables including the duration of cardiopulmonary bypass, cerebral oxygen desaturation, and hypotension. Retrospective observational study. Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands, over a 14-year period from January 2005 to December 2018. The study included 99 consecutive patients with simple dextro-transposition of the great arteries with or without a ventricular septal defect. All patients received preoperative management including intravenous prostaglandin E1 and, when necessary, a balloon atrial septostomy. Patients were then scheduled for an arterial switch operation. Patients were divided into a PPHN and a non-PPHN group. The outcomes assessed included mortality (overall, preoperative, 30-day postoperative and late mortality) and postoperative morbidity (length of ventilatory support, intensive care unit and hospital stay, delayed sternal closure and resternotomy). PPHN was present in 31% of patients. Overall mortality was 8.1%, with no difference between PPHN and non-PPHN patients (9.7 v 7.4%, p = 0.70). PPHN had no effect on morbidity outcomes. A lower weight at birth was associated with preoperative mortality. Duration of cardiopulmonary bypass and intraoperative hypotension were associated with longer intensive care unit stay. Intraoperative hypotension and cerebral oxygen desaturation had no significant impact on mortality. PPHN did not significantly affect perioperative morbidity and mortality in d-TGA patients, suggesting a more favorable prognosis than previously reported.

Ventricular septation for double inlet ventricle: Avoiding conduction injury

ObjectivesAlthough conduction location can be reliably predicted in double inlet ventricle, ventricular septation continues to carry a significant risk of complete heart block. This study describes our experience using intraoperative conduction mapping during ventricular septation. MethodsPatients undergoing ventricular septation from 2017 to 2023 were identified. Conduction mapping was performed on the open, decompressed, beating heart to identify the His bundle. Mapped His bundle locations were compared with those predicted from magnetic resonance imaging diagnoses by a senior pediatric cardiac electrophysiologist blinded to mapping results. ResultsVentricular septation was performed in 31 patients, 25 with hypoplastic right ventricles and 6 with hypoplastic left ventricles. Two-stage septation was performed in 25 patients, and single-stage septation was performed in 6 patients. Mapped conduction location was performed in the last 25 consecutive patients. Mapped conduction location was concordant with expected location in 21 of 22 patients with predictions. Complete heart block requiring a permanent pacemaker occurred in 4 patients despite successful mapping, whereas 10 patients required other reoperations, most commonly to address residual atrioventricular valve regurgitation or subpulmonary obstruction from the ventricular septal defect patch. There has been no perioperative mortality, need for single-ventricle palliation, or heart transplantation. All 13 patients who have progressed to complete septation and 18 patients with interstage circulation have acceptable hemodynamics, preserved ventricular function, and no heart failure symptoms at latest follow-up. ConclusionsVentricular septation represents an alternative to the Fontan that can be performed safely in a subset of patients with acceptable early outcomes. Conduction mapping is an adjunct strategy that may add precision to well-established rules for reliably predicting conduction location.