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Journal and News Scan
Objective: The aim of the study was to determine cause-specific mortality in TBAD and to evaluate the clinical characteristics associated with aorta-related and non aorta-related mortality.
Methods: Clinical and administrative records were reviewed for patients with acute TBAD between 1995 and 2017. Demographics, comorbidities, presentation, and initial imaging findings were abstracted. Cause of death was ascertained through a multimodality approach using electronic health records, obituaries, social media, Social Security Death Index, and state mortality records. Causes of death were classified as aorta related, nonaorta related, or unknown. A Fine-Gray multivariate competing risk regression model for sub distribution hazard ratio was employed to analyze the association of clinical characteristics with aorta-related and non aorta-related mortality.
Results: A total of 275 individuals met inclusion criteria (61.1 6 13.7 years, 70.9% male, 68% white). Mean survival after discharge was 6.3 6 4.7 years. Completeness of follow-up Clark C index was 0.87. All-cause mortality was 50.2% (n . 138; mean age, 70.1 6 14.6 years) including an in-hospital mortality of 8.4%. Cause-specific mortality was aorta related, non aorta related, and unknown in 51%, 43%, and 6%, respectively. Compared with patients with non aorta-related mortality, patients with aorta-related mortality were younger at acute TBAD (69.5 6 11.2 years vs 61.6 6 15.5 years; P .001), underwent more descending thoracic aortic repairs (19.4% vs 45.8%; P . .002), and had a shorter survival duration(5.7 6 3.9 vs 3.4 6 4.5 years; P . .002). There was clear variation in cause of death by each decade of life, with higher aorta related mortality among those younger than 50 years and older than 70 years and a stepwise increase in non aorta related mortality with each increasing decade (P < .001). All-cause mortality at 1 year, 3 years, and 10 years was 15%, 24%, and 57%, respectively. After accounting for competing risks, the cumulative incidence of aorta-related mortality at
1 year, 3 years, and 10 years was 8.9%, 16.5%, and 27.2%, respectively, and that of non aorta-related mortality was 2.7%, 7.2%,and 29%, respectively. A maximum descending thoracic aortic diameter >4 cm was associated with an increase in hazard of aorta-related mortality by 84% (sub distribution hazard ratio, 1.84; 95% confidence interval, 1.03-3.28) on multivariate competing risk regression analysis.
Conclusions: TBAD is associated with high 10-year mortality. Those at risk for aorta-related mortality have a clinical phenotype different from that of individuals at risk for non aorta-related mortality. This information is important for building risk prediction models that account for competing mortality risks and to direct optimal and individualized surgical and medical management of TBAD.
The study evaluates early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery.
Included 473 patients with previous composite valve graft at a single institution: composite valve graft with a mechanical prosthesis (n = 256) or composite valve graft with a bioprosthesis (n = 217).
Primary outcome was 30-day mortality. Secondary outcome was a composite of major morbidity and operative mortality: stroke, renal failure, prolonged mechanical ventilation, deep sternal infection, or reoperation during the same admission.
Median age was 57 and 74% patients were male. Median time between index surgery and reoperation was 13 years. 38% underwent urgent or emergency intervention, 13% had active endocarditis/abscess, 19% had left ventricular ejection fraction less than 40%, and 55% had undergone more than 1 previous operation.
At the time of the re-operative Bentall, both coronary arteries were reimplanted directly in 77% patients, whereas 17% received at least 1 interposition graft.
Thirty-day mortality occurred in 7.8%, and 32% patients had major morbidity and operative mortality. On multivariable analysis, risk factors associated with increased 30-day mortality included older age and coronary reimplantation by a technique other than direct anastomosis.
In the largest reported cohort of aortic root replacement after previous cardiac surgery, re-operative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important factor associated with adverse perioperative events.
The authors review existing literature and propose recommendations to improve physical preparedness for surgery both in and outside the operating room. Cardiothoracic surgeons suffer from MSK pain, most commonly in the neck and back due to a lack of proper ergonomics during surgery. A lack of dedicated ergonomics curriculum during training may leave surgeons at a high predisposition for work-related MSK disorders. The authors reviewed relevant surgical ergonomics studies and prevalence of MSK disease among surgeons and interventionalists. Whenever possible, data from quantitative studies and meta-analyses were presented. They report high rates of work-related pain in surgeons - as high as 87% in minimally-invasive surgeons. Several optimizations regarding correct table height, monitor positioning, and loupe angles are discussed. The authors share factors, including smaller incisions and technological advancements, that led to this plight. They make a case that work-related injuries are underreported and understudied and the field of surgical ergonomics remains open for investigative study. The authors also recommend exercises that can be performed to improve MSK pain and outcomes.
A scholarly narrative on the utility of quantifying the performance of the right ventricle: the RV has been hitherto empirically assessed in many clinical setups.
Patient prosthesis mismatch is linked with significant long-term morbidity and mortality after aortic valve replacement, but the roles and conclusion of annular enlargement (AE) remain poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe patient prosthesis mismatch.
A small meta-analysis suggesting a bemefit of vascular ultrasound for access to the groin vessels in TAVI. The utility of ultrasonography may be extended in access for groin cannulation in aortovascular surgery and ECMO
A comprehensive update on the evidence on the management of acute aortic syndromes, including IMH. Of particular interest is the robust recommendation to bypass non-dedicated aortic centers even to the expense of increased transit time in order to offer management in a Comprehensive Aortic Center (CAC). The femoral cannulation appears to come gradually out of favour. The cerebral perfusion for arch work is proposed to be either ante-or retrograde. Figure 3 is particularly germane to the technical aspects. Visceral malperfusion is again heralded as a poor-outcome situation.
Pakistan has a prevalence of approximately 60,000 births with Congenital Heart Diseases (CHD) each year. With a population of 200 million and only 17 paediatric cardiac surgeons in Pakistan, the current ratio is 0.08 surgeons/milllion. This review outlines the current status and defines the need for significantly more investment in human resources and infrastructure of paediatric cardiac surgery to meet the needs ofpopulation.
There is a lack of reliable data to measure the impact of cardiovascular surgical activities in sub-Saharan Africa (SSA) and to compare with those of the other sub-regions. The Pan African Society of Cardiothoracic Surgery (PASCaTS) proposes development of an African cardiothoracic surgery database with pooled datasets similar to the practice in other continents. This would ideally serve as a working instrument to evaluate the burden of disease and to develop strategies for prevention and treatment of cardiovascular diseases and associated morbidities in these regions, ultimately with improved clincial outcomes.