Impact of Frailty on Outcomes in Acute Type A Aortic Dissection（A型急性大動脈解離におけるフレイルの影響）

信州大学(Shinshu university)博士（医学）雑誌に発表。ANNALS OF THORACIC SURGERY. 106(5):1349-1355 (2018); doi:10.1016/j.athoracsur.2018.06.055.Thesis五味渕　俊仁. Impact of Frailty on Outcomes in Acute Type A Aortic Dissection（A型急性大動脈解離におけるフレイルの影響）. 信州大学, 2018, 博士論文.doctoral thesi

Prognoseabschätzung und Prognoseverbesserung von kardiovaskulären Erkrankungen im perioperativen Umfeld der modernen Herzmedizin

Mit den von mir in dieser Habilitationsschrift vorgestellten Arbeiten habe ich versucht, anhand einer Auswahl meiner bisherigen Projekte den Gesamtablauf von Patienten mit schwerwiegenden kardiovaskulären Erkrankungen im perioperativen Umfeld zu erfassen und ausgewählte Studien in einzelnen Bereichen dieses komplexen Themenschwerpunktes darzustellen. Wichtig ist mir anzumerken, dass dies natürlich nur eine Auswahl sein kann, jedoch können diese einzelnen Bausteine dazu beitragen, den Verlauf eines Patienten an unterschiedlichen Stellen im perioperativen Kontext zu unterschiedlichen Zeitpunkten positiv zu beeinflussen. Aufgrund der Vielfältigkeit der kardiologisch-internistischen Beeinflussungsoptionen in diesem in großen Teilen akutmedizinischen Kontext ist es mir außerdem wichtig darzustellen, dass eben diese Auswahl dazu beigetragen hat, auch zukünftige, aktuell von mir bearbeitete Forschungsprojekte zu entwickeln und weiter voranzutreiben. So haben sich aus jedem Projekt zum Teil mehrere neue Ansätze ergeben. Diese Projekte wurden in der Diskussion zum Teil schon aufgegriffen, weitere möchte ich im Kommenden kurz darstellen, wobei auch diese wiederum nur Bausteine sind, um den kardiologischen Gesamtprozess in diesem Kontext in einzelnen Aspekten zu verbessern. Die Komplexität der einzelnen Bereiche zeigt die Notwendigkeit der spezialisierten Behandlung dieser Patienten in einem interdisziplinären Team, in dem sowohl kardiologische als auch herzchirurgische Betrachtungen wichtig für die Gesamtstrategie der Behandlung sind. Dies ist sowohl für den Patienten optimal als auch eine Bereicherung der ärztlichen Ausbildung von Kollegen aus verschiedenen Fachbereichen ohne starre Departmentsgrenzen. Wie wichtig diese Zusammenarbeit ist wird zum Teil erst erkennbar, wenn diese Zusammenarbeit nicht mehr besteht [83]. Im Rahmen der gesamthaften Patientenbetrachtung im Sinne des Value based Healthcare wird dieser Bereich zukünftig immer wichtiger werden, insbesondere bei schwerstkranken Patienten ohne die Möglichkeit einer tiefgreifenden ambulanten Voruntersuchung, sowohl im kardiologischinterventionellen als auch im herzchirurgisch-operativen Kontext als auch an anderen Schnittstellen zwischen internistischer und chirurgischer Behandlungsoption

The influence of gender on mortality in patients after thoracic endovascular aortic repair

Objectives: The aim of this study was to determine if gender affects mortality in patients after thoracic endovascular aortic repair (TEVAR). Methods: We retrospectively analyzed 286 consecutive patients undergoing TEVAR at our institution during a 12-year period (female 29%, median age 69 years). Chronic health conditions, risk factors, as well as early and long-term outcome were assessed. Follow-up data were available in all patients. Results: For female gender, 1-year survival and 5-year survival was 84% and 56% versus 83% and 60% for male gender. No significant gender influence was observed (odds ratio (OR) 0.96, 95% confidence interval (CI) 0.59-1.56). Furthermore, no significant gender influence could be observed according to the individual indication - atherosclerotic aneurysms (OR 0.78 95%CI 0.41-1.47), acute type B dissections (OR 0.78 95%CI 0.21-2.83), penetrating atherosclerotic ulcers/intramural hematoma (OR 1.48 95%CI 0.53-4.19), and traumatic aortic lesions (OR 1.48 95%CI 0.53-4.19). Age (OR 3.6 95%CI 1.24-10.45) and chronic obstructive pulmonary disease (COPD; OR 3.09 95%CI 0.98-9.73) were independent predictors of mortality in females. Conclusions: Gender does not affect mortality in patients after TEVAR irrespective of the underlying indication, atherosclerotic aneurysms, acute type B dissections, penetrating ulcers/intramural hematoma, and traumatic aortic lesions. Classical risk factors such as age and the presence of COPD at the time of TEVAR remain the most important risk factors in female

One year follow-up of the multi-centre European PARTNER transcatheter heart valve study

BackgroundTranscatheter aortic valve implantation (TAVI) has emerged as a new therapeutic option in high-risk patients with severe aortic stenosis.AimsPARTNER EU is the first study to evaluate prospectively the procedural and mid-term outcomes of transfemoral (TF) or transapical (TA) implantation of the Edwards SAPIEN® valve involving a multi-disciplinary approach.Methods and resultsPrimary safety endpoints were 30 days and 6 months mortality. Primary efficacy endpoints were haemodynamic and functional improvement at 12 months. One hundred and thirty patients (61 TF, 69 TA), aged 82.1 ± 5.5 years were included. TA patients had higher logistic EuroSCORE (33.8 vs. 25.7, P <0.0005) and more peripheral disease (49.3 vs. 16.4, P< 0.0001). Procedures were aborted in four TA (5.8) and six TF cases (9.8). Valve implantation was successful in the remaining patients in 95.4 and 96.4, respectively. Thirty days and 6 months survival were 81.2 and 58.0 (TA) and 91.8 and 90.2 (TF). In both groups, mean aortic gradient decreased from 46.9 ± 18.1 to 10.9 ± 5.4 mmHg 6 months post-TAVI. In total, 78.1 and 84.8 of patients experienced significant improvement in New York Heart Association (NYHA) class, whereas 73.9 and 72.7 had improved Kansas City Cardiomyopathy Questionnaire (KCCQ) scores in TA and TF cohorts, respectively.ConclusionThis first team-based multi-centre European TAVI registry shows promising results in high-risk patients treated by TF or TA delivery. Survival rates differ significantly between TF and TA groups and probably reflect the higher risk profile of the TA cohort. Optimal patient screening, approach selection, and device refinement may improve outcomes

Antegrade selective cerebral perfusion and moderate hypothermia in aortic arch surgery: clinical outcomes in elderly patients†

OBJECTIVES To evaluate the outcome in elderly patients (≥75 years) undergoing elective aortic arch surgery with the aid of selective antegrade cerebral perfusion (SACP) and moderate hypothermic circulatory arrest (HCA). METHODS A series of 95 patients ≥75 years (median age 77 years, median EuroSCORE 28) undergoing elective aortic arch surgery with SACP and moderate HCA were analysed with regard to clinical outcome. Risk factors for serious adverse events (mortality, neurological injury) were determined. RESULTS Sixty-three patients (66%) underwent ascending aorta and hemiarch replacement, whereas 32 patients (34%) underwent ascending aorta and total arch replacement. Isolated arch replacement was rare. Additionally, 27% of patients underwent aortic valve replacement and 26% underwent root replacement. In-hospital mortality was 7%. Permanent neurological deficits occurred in 5%, transient neurological deficits occurred in 2%. Median SACP time was 24min. Univariate analysis revealed femoral cannulation site (OR: 3.4; CI: 1.25-9.22, P=0.016) as well as HCA ≥40min (OR: 4.21; CI: 1.83-12.58, P=0.001) as predictors of serious adverse events (mortality, neurological injury). CONCLUSIONS Summarizing, elective aortic arch surgery in elderly patients using SACP and moderate HCA provides excellent results regarding mortality and postoperative neurological outcome. Prolonged HCA time and femoral cannulation were the only predictors of serious adverse events (mortality, neurological injury

The role of minimal access valve surgery in the elderly. A meta-analysis of observational studies

Background Minimal access valve surgery, both mitral and aortic, may be related to improvement in specific post-operative outcomes, therefore may be beneficial for the subgroup of the elderly referred for valve surgery. Methods A systematic literature review identified several different studies, of which 6 fulfilled criteria for meta-analysis. Outcomes for a total of 1347 patients (675 conventional standard sternotomy and 672 minimally invasive valve surgery) were assessed with a meta-analysis using random effects modeling. Heterogeneity, subgroup analysis with quality scoring were also assessed. The primary endpoint was early mortality. Secondary endpoints included intra and post-operative outcomes. Results In the context of elderly patients, minimal access valve surgery conferred comparable early mortality to standard sternotomy (odd ratio (OR) 0.79, CI [0.40,1.56], p\ua0=\ua00.50) with no heterogeneity (p\ua0=\ua00.13); it was also associated with reduced mechanical intubation time (OR 0.48, CI [0.30,0.78], p\ua0=\ua00.003) and reduced post-operative length of stay (weighted mean difference (WMD)\ua0 122.91, CI [ 123.09,\ua0 122.74] p\ua0<\ua00.00001), however both cardio-pulmonary bypass time and cross clamp time were longer (WMD 24.29, CI [22.97, 25.61] p\ua0<\ua00.00001 and WMD 8.61, CI [7.61, 9.61], p\ua0<\ua00.00001, respectively); subgroup analysis demonstrated statistically significant reduced post-operative length of stay for both minimally invasive aortic and mitral surgery (WMD\ua0 122.84, CI [ 123.07,\ua0 122.60] p\ua0<\ua00.00001 and WMD\ua0 122.98, CI [ 123.25,\ua0 122.71] p\ua0<\ua00.00001 respectively). Conclusions Despite a prolonged cardiopulmonary bypass and cross clamp time, minimally invasive valve surgery is a safe alternative to standard sternotomy in the elderly, with similar early mortality, and improvements in intubation time as well as length of stay

Editor's choice : European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia

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Initial Thoracic Endovascular Aortic Repair vs Medical Therapy for Acute Uncomplicated Type B Aortic Dissection

IMPORTANCE: Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data. OBJECTIVE: To assess whether initial TEVAR following uTBAD is associated with reduced mortality or morbidity compared with medical therapy alone. DESIGN, SETTING, AND PARTICIPANTS: This cohort study included Centers for Medicare & Medicaid Services inpatient claims data for adults aged 65 years or older with index admissions for acute uTBAD from January 1, 2011, to December 31, 2018, with follow-up available through December 31, 2019. EXPOSURES: Initial TEVAR was defined as TEVAR within 30 days of admission for acute uTBAD. MAIN OUTCOMES AND MEASURES: Outcomes included all-cause mortality, cardiovascular hospitalizations, aorta-related and repeated aorta-related hospitalizations, and aortic interventions associated with initial TEVAR vs medical therapy. Propensity score inverse probability weighting was used. RESULTS: Of 7105 patients with eligible index admissions for acute uTBAD, 1140 (16.0%) underwent initial TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]) and 5965 (84.0%) did not undergo TEVAR (3344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). Receipt of TEVAR was associated with region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P \u3c .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P \u3c .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P = .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P = .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P = .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). After inverse probability weighting, mortality was similar for the 2 strategies up to 5 years (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20). In a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P = .03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P = .008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P = .004). CONCLUSIONS AND RELEVANCE: In this study, 16.0% of patients underwent initial TEVAR within 30 days of uTBAD, and receipt of initial TEVAR was associated with hypertension, peripheral vascular disease, region, Medicaid dual eligibility, and year of admission. Initial TEVAR was not associated with improved mortality or reduced hospitalizations or aortic interventions over a period of 5 years, but in a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality. These findings, along with cost-effectiveness and quality of life, should be assessed in a prospective trial in the US population

Analisi dei contemporanei risultati della chirurgia riparativa delle Sindromi Aortiche Acute nei pazienti anziani: uno studio multicentrico Europeo Contemporary outcomes of surgery for Acute Aortic Syndrome in the elderly: a multicenter European study

Background. Acute type A Aortic Syndrome (ATAAS) is a critical emergency condition that necessitates immediate surgical repair due to its high morbidity and mortality rates. With the aging population, there is an increasing incidence of elderly patients with ATAAS. However, surgery remains controversial for this population due to the heightened risk of mortality and morbidity, particularly in the emergency setting. This study investigates the current outcomes of surgical repair of Acute Stanford type A aortic dissection (TAAD) in patients aged ≥ 80 years. Methods. The study analysed all patients enrolled in the European Registry of Type A Aortic Dissection (ERTAAD). This includes patients who received surgery for acute ATAAS at 18 hospitals across eight European countries (n = 3902). The octogenarians group consisted of 326 patients aged 80 years or above, while the non-octogenarians group consisted of 3576 patients under 80 years of age. The outcomes of the elderly group were compared with those of the non-elderly group in unmatched cohorts and in propensity score matched cohorts. Predictors of in-hospital mortality were identified through multilevel mixed-effect logistic regression analysis. Results. The overall in-hospital mortality rate was 31.6% for the octogenarians group and 16.4% for the control group (p&lt;0.0001). No significant difference was observed between the causes of death in the hospital. The postoperative complication rate was not different between the groups. Multilevel mixed-effect logistic regression identified age ≥85 years, preoperative estimated glomerular filtration rate, preoperative invasive ventilation, preoperative mesenteric malperfusion and aortic root replacement as independent predictors of in-hospital mortality. Conclusions. This multicenter cohort study showed that early and late postoperative mortality in older patients is higher than in the younger, despite similar rates of postoperative complications. It is important to note that age alone should not be a factor for excluding surgical repair, but a thorough assessment of the operative risk profile and frailty degree of elderly patients is essential

Decision analytical modelling of strategies for investigating suspected acute aortic syndrome

Background: Acute aortic syndrome (AAS) requires urgent diagnosis with computed tomographic angiography (CTA). Diagnostic strategies need to weigh the benefits of detecting AAS against the costs of using CTA with a low yield of AAS when the prevalence of AAS is low. We aimed to estimate the cost-effectiveness of diagnostic strategies using clinical probability scoring and D-dimer to select patients with potential symptoms of AAS for CTA.// Methods: We developed a decision analytical model to simulate the management of patients attending hospital with possible AAS. We modelled diagnostic strategies that used the Aortic Dissection Detection Risk Score (ADD-RS) and D-dimer to select patients for CTA. We used estimates from our meta-analysis, existing literature and clinical experts to model the consequences of diagnostic strategies on survival, health utility, and health and social care costs. We estimated the incremental cost per quality-adjusted life-years gained by each strategy compared with the next most effective alternative on the efficiency frontier.// Results: A strategy based on the Canadian guideline (CTA if ADD-RS&gt;1 or ADD-RS=1 with D-dimer &gt;500 ng/mL) is cost-effective but would result in high rates of CTA if applied to an unselected population (AAS prevalence 0.26%). The strategy is also cost-effective and would result in lower rates of CTA if applied to a more selected population, such as those with a non-zero clinical suspicion of AAS (prevalence 0.61%). For patients currently receiving CTA, using ADD-RS&gt;1 or D-dimer &gt;500 ng/mL to select patients for CTA is cost-effective.// Conclusions: A strategy using ADD-RS&gt;1 or ADD-RS=1 with D-dimer &gt;500 ng/mL to select patients for CTA appears cost-effective but primary research is required to evaluate this strategy in practice and determine how suspicion of AAS is identified