Substantial Perioperative Mortality Research Articles

A decade's summary of transcatheter tricuspid valve repair.

Tricuspid regurgitation (TR) is the most common pathology for the tricuspid valve. Moderate to severe TR is associated with morbidity and adverse outcomes. The concept that TR resolves on its own if the underlying disease is successfully treated has proven to be false. Only a few patients with significant TR are deemed suitable for surgery. Given the late presentation of patients with high perioperative risks and substantial perioperative mortality, the development of transcatheter therapies and the experience gained with transcatheter aortic valve implantation operations have turned attention towards treating this challenging group of patients. In this article, we review the treatment options and highlight the role of transcatheter valve therapies in patients with severe TR.

The Incidence and Outcomes of Major Limb Amputation in New Zealand from 2010 to 2021.

Background: Major limb amputation (MLA) can be a common outcome due to severe peripheral artery disease (PAD) and diabetic foot disease (DFD), and it carries a significant mortality burden. In New Zealand (NZ), there is little documentation of the incidence rate and mortality after MLA. The aim was to report the national crude and standardised rates and the mortality post MLA. Methods: This retrospective observational study included all MLAs that occurred within NZ from 1/1/2010 to 31/12/2021 due to DFD and/or PAD. Two national databases (National Minimum Dataset and the Australasian Vascular Audit) were utilised. The crude rates were calculated as cases per 100,000 in the NZ population per year including all ages (using the 2013 and 2018 NZ census figures). The age-standardised rates used the World Health Organization standard population. Post-operative mortality was calculated from the date of first hospitalisation for MLA. Results: From 2010 to 2021, there were 5293 MLA procedures in 4242 patients. On average, there were 8.5 MLAs per week and 441.1 MLAs annually. The overall crude rate was 9.44 per 100,000, and the standardised rate was 6.12 per 100,000. Over the 12 years, the crude rate decreased by 22% (p < 0.001), and the standardised rate decreased by 20.4% (p < 0.001). After MLA, the 30-day and 1-year mortality was 9.5% and 29.6%, respectively. From 2010 to 2021, the relative reduction in 30-day mortality was 45.1% (p < 0.001), and the reduction in 1-year mortality was 24.5% (p < 0.001). Increasing age, female sex and end-stage renal failure were predictors of 30-day and 1-year mortality. Conclusions: A considerable number of MLAs occur in NZ, with substantial perioperative mortality; however, the national incidence rates and mortality have improved over the last 12 years. This data might serve as benchmark to further reduce MLAs and improve patient outcomes.

Simultaneous Aortic and Pulmonary Valve Replacement in Repaired Congenital Heart Disease.

Patients with congenital heart disease frequently require surgical or percutaneous interventional valve replacement after initial congenital heart defect (CHD) repair. In some of these patients, simultaneous replacement of both semilunar valves is necessary, resulting in increased procedural complexity, morbidity, and mortality. In this study, we analyze the outcomes of simultaneous aortic and pulmonary valve replacements following multiple surgical interventions for CHD. This was a retrospective study of 24 patients who after initial repair of CHD underwent single-stage aortic and pulmonary valve replacement at our institution between 2003 and 2021. The mean age of the patients was 28 ± 13 years; the mean time since the last surgery was 15 ± 11 years. Decellularized valved homografts (DVHs) were used in nine patients, and mechanical valves were implanted in seven others. In eight patients, DVHs, biological, and mechanical valves were implanted in various combinations. The mean cardiopulmonary bypass time was 303 ± 104 minutes, and aortic cross-clamp time was 152 ± 73 minutes. Two patients died at 12 and 16 days postoperatively. At a maximum follow-up time of 17 years (mean 7 ± 5 years), 95% of the surviving patients were categorized as New York Heart Association heart failure class I. Single-stage aortic and pulmonary valve replacement after initial repair of CHD remains challenging with substantial perioperative mortality (8.3%). Nevertheless, long-term survival and clinical status at the latest follow-up were excellent. The valve type had no relevant impact on the postoperative course. The selection of the valves for implantation should take into account operation-specific factors-in particular reoperability-as well as the patients' wishes.

Hepatopancreatoduodenectomy –a controversial treatment for bile duct and gallbladder cancer from a European perspective

BackgroundHepatopancreatoduodenectomy (HPD) is an aggressive operation for treatment of advanced bile duct and gallbladder cancer associated with high perioperative morbidity and mortality, and uncertain oncological benefit in terms of survival. Few reports on HPD from Western centers exist. The purpose of this study was to evaluate safety and efficacy for HPD in European centers. MethodMembers of the European-African HepatoPancreatoBiliary Association were invited to report all consecutive patients operated with HPD for bile duct or gallbladder cancer between January 2003 and January 2018. The patient and tumor characteristics, perioperative and survival outcomes were analyzed. ResultsIn total, 66 patients from 19 European centers were included in the analysis. 90-day mortality rate was 17% and 13% for bile duct and gallbladder cancer respectively. All factors predictive of perioperative mortality were patient and disease-specific. The three-year overall survival excluding 90-day mortality was 80% for bile duct and 30% for gallbladder cancer (P = 0.013). In multivariable analysis R0-resection had a significant impact on overall survival. ConclusionHPD, although being associated with substantial perioperative mortality, can offer a survival benefit in patient subgroups with bile duct cancer and gallbladder cancer. To achieve negative resection margins is paramount for an improved survival outcome.

Association of Plasma Branched Amino Acid with Surgical Adverse Events in Type A Aortic Dissection

Background: Type A aortic dissection (AAD) is associated with substantial perioperative mortality and morbidity. Methods: We conducted a study of the concentrations of plasma amino acid metabolites by ultraperformance liquid chromatography mass spectrometry to identify patients at high risk of major adverse events (MAEs) in-hospital in 391 patients undergoing surgical repair, including 111 participants in a retrospective discovery set and 280 patients in a prospective validation set. Results: In the discovery set, 31 patients (27.9%) experienced MAEs in hospital, of whom 4 (12.9%) died. Metabolite factor 3, composed of branched-chain amino acids (BCAA), including valine, isoleucine, and leucine, was associated with MAEs. Median BCAA levels in patients with and without MAEs were 267.18 pg/mL (222.06-312.93 pg/mL) and 236.72 pg/mL (200.19-274.62 pg/mL), respectively. The adjusted odds ratio (OR) for increasing tertiles of BCAA compared with the lowest tertiles was 3.259 (95% confidence interval (CI) 1.018-10.431; P = 0.047). In the validation set, the adjusted OR for the increasing tertiles of BCAA compared with the lowest tertiles was 5.82 (95% CI 2.74-12.38; P < 0.001), indicating a significant association between the preoperative BCAA levels and outcome. Conclusions: Our study shows that in patients with AAD, the pre-operative plasma BCAA level was associated with the risk of post-operative adverse events of AAD in hospital. Funding Statement: This study was supported by the Ministry of Science and Technology of China (Key Projects of Precision Medicine Program, grant no. 2016YFC0903000 and 2017YFC0908400) and the Beijing Municipal Science and Technology Commission (Z171100000417002), NSFC (Natural Science Foundation of China) (81870341) Declaration of Interests: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethics Approval Statement: The study was designed as an observational study, including consecutive patients undergoing surgical repair for nontraumatic AAD (from July 2016 to November 2018) in the DPANDA registry study for aortic aneurysm and/or dissection (NCT03233087 in ClinicalTrials.gov), which was approved by the Beijing Anzhen Hospital Ethics Review Board. All patients provided written informed consent.

Arterial Resection During Pancreatectomy for Pancreatic Cancer

The majority of pancreatic cancers are diagnosed at an advanced stage. As surgical resection remains the only hope for cure, more aggressive surgical approaches have been advocated to increase resection rates. Institutions have begun to release data on their experience with pancreatectomy and simultaneous arterial resection (AR), which has traditionally been considered a general contraindication to resection. The aim of the present meta-analysis was to evaluate the perioperative and long-term outcomes of patients with AR during pancreatectomy for pancreatic cancer. The Medline, Embase, and Cochrane Library and J-East databases were systematically searched to identify studies reporting outcome of patients who underwent pancreatectomy with AR for pancreatic cancer. Studies that reported perioperative and/or long-term results after pancreatectomy with AR were eligible for inclusion. Meta-analyses included comparative studies providing data on patients with and without AR and were performed using a random effects model. The literature search identified 26 studies including 366 and 2243 patients who underwent pancreatectomy with and without AR. All studies were retrospective cohort studies and the methodological quality was moderate to low. Meta-analyses revealed AR to be associated with a significantly increased risk for perioperative mortality [Odds ratio (OR) = 5.04; 95% confidence interval (CI), 2.69-9.45; P < 0.0001; I² = 24%], poor survival at 1 year (OR = 0.49; 95% CI, 0.31-0.78; P = 0.002; I² = 35%) and 3 years (OR = 0.39; 95% CI, 0.17-0.86; P = 0.02; I² = 49%) compared with patients without AR. The increased perioperative mortality (OR = 8.87; 95% CI, 3.40-23.13; P < 0.0001; I² = 5%) and lower survival rate at 1 year (OR = 0.50; 95% CI, 0.31-0.82; P = 0.006; I² = 40%) was confirmed in the comparison to patients undergoing venous resection. Despite substantial perioperative mortality, pancreatectomy with AR was associated with more favorable survival compared with patients who did not undergo resection for locally advanced disease. AR in patients undergoing pancreatectomy for pancreatic cancer is associated with a poor short and long-term outcome. Pancreatectomy with AR may, however, be justified in highly selected patients owing to the potential survival benefit compared with patients without resection. These patients should be treated within the bounds of clinical trials to assess outcomes after AR in the era of modern pancreatic surgery and multimodal therapy.

Beating Heart Valve Surgery Using Stentless Xenografts as a Surgical Alternative for Patients with End-Stage Renal Failure

Patients suffering from end-stage renal disease are an inhomogeneous high-risk group with a substantial perioperative mortality and morbidity when undergoing cardiac surgical procedures[1-3]. Myocardial ischemia, reperfusion injury and myocardial edema are a few of the deleterious consequences of the traditional use of cardioplegic arrest when performing valve surgery,irrespective of the type of cardioplegia used [4-7]. Novel operative techniques are required to reduce these induced perioperative risks. Clinical studies in the past have demonstrated the efficacy of beating heart valve surgery in the high-risk patient using retrograde, antegrade or combined coronary perfusion with warm oxygenated blood [8, 9]. We chose to combine the superior hemodynamic profile of stentless xenografts with the concept of performing valve replacement on the empty beating heart with continuous antegrade application of oxygenated blood in 2 chronic hemodialysis patients.

Mechanical Aortic Valve Prostheses in the Small Aortic Root: Top Hat Versus Standard CarboMedics Aortic Valve

The purpose of this study was to evaluate outcome in patients with a small aortic root receiving either a standard CarboMedics mechanical aortic valve or a Top Hat CarboMedics valve (CarboMedics, Austin, TX), specifically designed for the small aortic root. Between 1986 and 2006, 316 consecutive patients underwent 19- or 21-mm mechanical aortic valve replacement, receiving either a CarboMedics Top Hat bileaflet valve (n = 56; mean age, 66 +/- 14 years) or a standard CarboMedics aortic valve replacement (n = 260; mean age, 60 +/- 13 years) at our institution based on institutional indications for the choice of type of valve prostheses. Median follow-up time was 83.5 months. We studied survival, valve-related and non-valve-related events, and hemodynamic performance by serial echocardiographic follow-up studies. In-hospital mortality was 8.9% in the Top Hat group and 10.0% in the standard group (p = 0.354). Five- and ten-year survival in patients in the Top Hat group was 83% and 67%, respectively. Five- and ten-year survival in the standard group was 73% and 59%, respectively (log-rank = 0.331). There were no differences in regard to valve-related and non-valve-related events. Cox regression analysis revealed age (hazard ratio, 1.045; 95% confidence interval, 1.026 to 1.066), previous cardiac surgery (hazard ratio, 1.812; 95% confidence interval, 1.101 to 2.982), additional procedures at the time of valve replacement (hazard ratio, 2.604; 95% confidence interval, 1.651 to 4.108), New York Heart Association class IV (hazard ratio, 3.645; 95% confidence interval, 1.214 to 10.945), and severely impaired left ventricular ejection fraction (hazard ratio, 2.253; 95% confidence interval, 1.289 to 3.941) to be independent predictors of survival. Mechanical aortic valve replacement in the small aortic root is associated with substantial perioperative mortality, in particular in the subset of patients requiring additional cardiac surgical procedures. Nevertheless, long-term outcome is satisfying. Because the type of prosthesis does not predict outcome in the multivariate Cox model, we conclude that use of the smaller Top Hat prosthesis can be recommended for the challenging cohort of patients with a small aortic root.

Pre-Operative N-Terminal Pro-Brain Natriuretic Peptide Predicts Outcome in Type A Aortic Dissection

Acute Stanford type A aortic dissection (AAD) is associated with substantial perioperative mortality and morbidity. N-terminal pro-brain natriuretic peptide (NT-proBNP) is a prognostic biomarker of outcome in cardiovascular disease. Its predictive power in patients undergoing emergency surgery for acute type A aortic dissection is yet unknown. We prospectively measured pre-operative NT-proBNP in 104 patients (39 female, 35%; median age 61 years) undergoing emergency surgery for AAD during a 6-year study period. European System for Cardiac Operative Risk Evaluation risk scores were recorded and patients were followed for 30-day mortality and major adverse events (MAEs) as defined by the need for rethoracotomy, occurrence of postoperative heart failure, neurologic deficit, lung failure, renal failure, or sepsis. Median logistic European System for Cardiac Operative Risk Evaluation in the cohort was 12 (interquartile range 7 to 19). During the first 30 days, 23 patients (22%) died, and 53 patients (51%) experienced MAEs. Median (interquartile range) NT-proBNP levels in survivors versus nonsurvivors were 328 pg/ml (157 to 569) versus 2,240 pg/ml (515 to 4,734; p < 0.001), and in patients without versus with MAEs, 227 pg/ml (107 to 328) and 719 pg/ml (442 to 2,287; p < 0.001), respectively. Adjusted odds ratios for increasing tertiles of NT-proBNP compared with the lowest tertile were 0.98 (95% confidence interval [CI] 0.18 to 5.33; p = 0.98) and 11.67 (95% CI 2.61 to 52.09; p = 0.001) for 30-day mortality and 9.07 (95% CI 2.58 to 31.83; p = 0.001) and 50.21 (95% CI 10.85 to 232.45; p < 0.001) for MAEs, respectively, indicating a significant association between pre-operative NT-proBNP levels and outcome. Pre-operative NT-proBNP predicts outcome in patients undergoing surgery of AAD.

Chronic Obstructive Pulmonary Disease

Fifty years ago, chronic obstructive pulmonary disease (COPD) was the ideal disease for physiologically oriented clinicians to study, for a number of reasons. First, it was becoming recognized as a major health problem. Second, it could only be diagnosed reliably by physiological testing; x-rays did not work. Third, it was associated with a lot of interesting pathophysiology, including cor pulmonale, alterations in the control of ventilation, and perhaps most interesting of all, abnormalities that were primarily related to the distributions of ventilation and/or perfusion as opposed to global inadequacy of either of them.

Surgical complications requiring early relaparotomy after pancreas transplantation: a multivariate risk factor and economic impact analysis of the cyclosporine era.

To study significant surgical complications requiring early (< or = 3 months posttransplant) relaparotomy (relap) after pancreas transplants, and to develop clinically relevant surgical and peritransplant decision-making guidelines for preventing and managing such complications. Pancreas grafts are still associated with the highest surgical complication rate of all routinely transplanted solid organs. However, the impact of surgical complications on morbidity, hospital costs, and graft and patient survival rates has not been analyzed in detail to date. We retrospectively studied surgical complications requiring relap in 441 consecutive cadaver, bladder-drained pancreas transplants (54% simultaneous pancreas and kidney [SPK]; 22% pancreas after kidney [PAK]; 24% pancreas transplant alone [PTA]; 37% retransplant). Outcome and hospital charges were analyzed separately for recipients with versus without reoperation. The overall relap rate was 32% (SPK, 36%; PAK, 25%; PTA, 16%; p = 0.04). The most common causes were intraabdominal infection and graft pancreatitis (38%), pancreas graft thrombosis (27%), and anastomotic leak (15%). Perioperative relap mortality was 9%; transplant pancreatectomy was necessary in 57% of all recipients with one or more relaps. The pancreas graft was lost in 80% of recipients with versus 41% without relap (p < 0.0001). Patient survival rates were significantly lower (p < 0.05) for recipients with versus without relap. By multivariate analysis, significant risk factors for graft loss included older donor age (SPK, PAK), retransplant (PAK), relap for infection (SPK, PAK), and relap for leak or bleeding (PAK). For death, risk factors included older recipient age (SPK, PAK),retransplant (SPK, PAK), relap for thrombosis (PAK), relap for infection or leak (SPK), and relap for bleeding (PTA). Posttransplant surgical complications requiring relap were frequent, resulted in a high rate of pancreas (SPK, PAK, PTA) and kidney (SPK, PAK) graft loss, and had a major economic impact (p = 0.0001). Complications were associated with substantial perioperative mortality and decreased patient survival rates. The focus must therefore shift from graft salvage to preservation of the recipient's life once a pancreas graft-related complication requiring relap occurs. Thus, the threshold for pancreatectomy should be low. In this context, acceptance of older donors and recipients must be reconsidered.

Impact of Implant Techniques on Complications with Current Implantable Cardioverter-Defibrillator Systems

Implantable cardioverter-defibrillator (ICD) treatment has been in use since 1980 to prevent sudden cardiac death. The high efficacy of the original epicardial systems to terminate tachyarrhythmias was impaired by a substantial perioperative mortality and morbidity. The more “modern” transvenous ICD systems have shown a similar high efficacy in terminating ventricular tachyarrhythmias, but with a lower mortality and morbidity. As a background for discussing the impact on complications with present transvenous implantation techniques, the literature was reviewed. A large pacemaker series was used for comparison. Lead complications clearly related to design, material, or manufacture were not reviewed. The present review, covering 107 references over 40 years, gives support for the notion that in transvenously implanted ICD patients the incidence of acute and late complications related to implantation technique is now acceptable. The rate of hematomas, symptomatic thromboembolic complications, perforations, and to a certain degree infections could be improved, however. The major risk factors for implantation-related complications are discussed, and suggestions for future improvement are given. (Am J Cardiol 1996;78(suppl 5A):15–20)

Multimodal treatment for squamous cell esophageal cancer.

Preoperative chemotherapy (CTx) and combination radiochemotherapy (RTx/CTx) in patients with squamous cell esophageal carcinoma has recently received increasing attention. Although several prospective randomized trials could not show any benefit of neoadjuvant therapy in patients with potentially resectable tumors, preoperative CTx and combination RTx/CTx appear to increase the resection rate, the rate of complete tumor resection, and survival time in patients with locally advanced tumors. Most available studies show that a survival benefit from multimodal therapy can be expected primarily in patients who have a complete histopathologic response to preoperative treatment (i.e., no viable tumor in the resected specimen). Preoperative RTx/CTx increases the response rate and improves local tumor control compared to preoperative CTx alone, but it is associated with substantial perioperative mortality and morbidity. Distant tumor recurrences are insufficiently controlled with current combined modality protocols. These data indicate that neoadjuvant therapy must be considered investigational in patients with potentially resectable esophageal carcinoma but may soon become standard in patients with locally advanced tumors. Research must focus on modalities that allow pretherapeutic identification of those patients who will respond to neoadjuvant therapy. Furthermore, more effective and less toxic preoperative therapy regimens are required to increase the response rates and combat systemic recurrences. Finally, randomized prospective studies are essential to assess the role, extent, and timing of surgical resection for the combined modality approach to patients with squamous cell esophageal carcinoma.

Esophageal Cancer: Neoadjuvant therapy for squamous cell esophageal carcinoma

A number of studies have demonstrated that preoperative chemotherapy (CTx) and combination radiochemotherapy (RTx/CTx) in patients with potentially resectable and locally advanced squamous cell esophageal carcinoma is feasible. In patients with potentially resectable tumors, neoadjuvant therapy followed by surgical resection has, however, so far not shown an increase in the resection rate, rate of complete macroscopic and microscopic tumor resections, i.e. R0-resections according to the UICC, or survival time as compared to patients who had surgical resection alone. In this situation a survival benefit, if at all, can be expected only in those who respond to preoperative therapy. At the present time preoperative CTx or RTx/CTx in patients with potentially resectable esophageal carcinoma must therefore be considered investigational and should not be performed outside the context of clinical trials. In patients with locally advanced esophageal carcinoma, neoadjuvant therapy markedly increases the rate of R0-resections and appears to prolong survival. Combined modality therapy in this context is, however, associated with a substantial perioperative mortality and morbidity. Open questions that have to be addressed by randomized studies include the role, extent and timing of surgical resection in the combined modality approach to patients with locally advanced squamous cell esophageal carcinoma. Research has to focus on preoperative staging modalities and the development of more effective and less toxic preoperative therapy regimen to improve identification of patients that might benefit from combined modality therapy and to more effectively combat systemic recurrences.