Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement

Paravalvular aortic regurgitation (PAR) following transcatheter aortic valve implantation (TAVI) is well acknowledged. Despite improvements, echocardiographic measurement of PAR largely remains qualitative. Cardiovascular magnetic resonance (CMR) directly quantifies AR with accuracy and reproducibility. We compared CMR and transthoracic echocardiography (TTE) analysis of pre-operative and post-operative aortic regurgitation in patients undergoing both TAVI and surgical aortic valve replacement (AVR).Gareth Crouch, Phillip J Tully, Jayme Bennetts, Ajay Sinhal, Craig Bradbrook, Amy L Penhall, Carmine G De Pasquale, Robert A Baker, and Joseph B Selvanayaga

Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications

Timing of aortic valve intervention for chronic aortic regurgitation (AR) and/or aortic stenosis (AS) potentially affects long-term survival. The 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines provide recommendations for the timing of intervention. Subsequent to the guidelines’ release, several studies have been published that suggest a survival benefit from earlier timing of surgery for severe AR and/or AS. The aim of this review was to determine whether patients who have chronic aortic regurgitation (AR) and/or aortic stenosis (AS) have a survival benefit from earlier timing of aortic valve surgery. Medical databases were systematically searched from January 2015 to April 2020 for randomized controlled trials (RCTs) and observational studies that examined the timing of aortic valve replacement surgery for chronic AR and/or AS. For chronic AR, four observational studies and no RCTs were identified. For chronic AS, five observational studies, one RCT and one meta-analysis were identified. One observational study examining mixed aortic valve disease (MAVD) was identified. All of these studies, for AR, AS, and MAVD, found long-term survival benefit from timing of aortic valve surgery earlier than the current guidelines. Larger prospective RCTs are required to evaluate the benefit of earlier surgical intervention

Selective Serotonin Reuptake Inhibitors, Venlafaxine and Duloxetine are Associated With in Hospital Morbidity but Not Bleeding or Late Mortality After Coronary Artery Bypass Graft Surgery

Background: No Australian study has reported the association between selective-serotonin reuptake inhibitor (SSRI) and serotonin noradrenaline reuptake inhibitor (SNRI) with coronary artery bypass graft (CABG) surgery morbidity and mortality. Methods: 4136 patients underwent CABG surgery between January 1996 and December 2008 and 105 (2.5%) were SSRI/SNRI users. Bleeding events included platelet, fresh frozen plasma and packed red blood cell transfusion, reoper-ation for bleeding and gastrointestinal bleeding. In-hospital morbidity included renal failure, stroke, ventilation >24 h, deep sternal wound infection, reoperation (any cause), myocardial infarction and mortality.24 h, deep sternal wound infection, reoperation (any cause), myocardial infarction and mortality.Results: Median follow-up was 4.7 years (interquartile range, 2.3–7.9 years) and there were 727 deaths (17.6% of total). Use of SSRI/SNRI was associated with new requirement for renal dialysis (adjusted OR = 2.18; 95% CI, 1.06–4.45, p = .03) and ventilation >24 h (adjusted OR = 1.69; 95% CI, 1.03–2.78, 24 h (adjusted OR = 1.69; 95% CI, 1.03–2.78, p = .04). Neither SSRI/SNRI use nor SSRI/SNRI and con-comitant anti-platelet medication increased the odds for any bleeding events (all p > .20). No association was evident with all-cause mortality (adjusted hazard ratio = 1.60; 95% CI .59–4.35, .20). No association was evident with all-cause mortality (adjusted hazard ratio = 1.60; 95% CI .59–4.35, p = .36), or cardiac mortality (adjusted hazard ratio = .31; 95% CI, .04–2.26, p = .25). Conclusions: SSRI/SNRI users experienced an increased risk of renal dysfunction and prolonged ventilation, but not bleeding events or long-term mortality after CABG surgery

COVID-19 safety: aerosol-generating procedures and cardiothoracic surgery and anaesthesia - Australian and New Zealand consensus statement

Coronavirus disease 2019 (COVID‐19) is a contagious disease that is caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Health care workers are at risk of infection from aerosolisation of respiratory secretions, droplet and contact spread. There are a number of procedures that represent a high risk of aerosol generation during cardiothoracic surgery. It is important that adequate training, equipment and procedures are in place to reduce that risk. We provide a number of key recommendations, which reduce the risk of aerosol generation during cardiothoracic surgery and help protect patients and staff. These include general measures such as patient risk stratification, appropriate use of personal protective equipment, consideration to delay surgery in positive patients, and careful attention to theatre planning and preparation. There are also recommended procedural interventions during airway management, transoesophageal echocardiography, cardiopulmonary bypass, chest drain management and specific cardiothoracic surgical procedures. Controversies exist regarding the management of low risk patients undergoing procedures at high risk of aerosol generation, and recommendations for these patients will change depending on the regional prevalence, risk of community transmission and the potential for asymptomatic patients attending for these procedures. This statement reflects changes in management based on expert opinion, national guidelines and available evidence. Our knowledge with regard to COVID‐19 continues to evolve and with this, guidance may change and develop. Our colleagues are urged to follow national guidelines and institutional recommendations regarding best practices to protect their patients and themselves. Australian and New Zealand Society of Cardiac and Thoracic Surgeons and the Anaesthetic Continuing Education Cardiac Thoracic Vascular and Perfusion Special Interest Group

Depression screening after cardiac surgery: A six month longitudinal follow up for cardiac events, hospital readmissions, quality of life and mental health

Objectives To report the 6-month longitudinal outcomes of routine depression screening in cardiac patients. Methods Routine depression screening consisted of the Patient Health Questionnaire (PHQ) administered 30-days after cardiac surgery at the Flinders Medical Centre, South Australia. Complete data was obtained on 481 patients who were subdivided into three groups; depressed-cardiac control determined by current anti-depressant use or history of depression in medical records (n = 90), depression screen-positives (PHQ ≥ 10, n = 46) and depression screen-negatives (PHQ ≤ 9, n = 345). These groups were re-assessed at 6 month follow-up for major adverse cardiac events (MACE), hospital readmission, quality of life (SF-12), symptomatic depression, and use of antidepressants, anxiolytics and psychotherapy. Results By six-month follow-up the depression screen-positive group was at a higher risk of MACE (adjusted odds ratio [OR] 2.16; 95% confidence interval [CI] .98-4.74). The depression screen-positive group was also at a higher risk of depressed mood (PHQ scores ≥10: adjusted OR 6.54; 95% CI 3.16-13.53). The depression screen-positive group also reported significantly poorer QOL in five domains (all p Conclusion Depression screening was associated with an increase in psychotropic medication use however depression, morbidity and quality of life remained poor at six months

The morbidity and mortality outcomes of indigenous Australian peoples after isolated coronary artery bypass graft surgery: the influence of geographic remoteness

Background: Though Indigenous Australian peoples reportedly have poorer survival outcome after cardiac surgery, few studies have jointly documented the experience of major morbidity, and considered the influence of patient geographic remoteness. Methods: From January 1998 to September 2008, major morbidity events and survival were recorded for 2748 consecutive patients undergoing coronary artery bypass graft surgery. Morbidity and survival analyses adjusted for propensity deciles based on patient ethnicity and age, sex, left ventricular ejection fraction, recent myocardial infarction, tobacco smoking, diabetes, renal disease and history of stroke. Sensitivity analyses controlled for the patient accessibility/remoteness index of Australia (ARIA). Results: The 297 Indigenous Australian patients (10.8% of total) had greater odds for total morbidity (adjusted odds ratio = 1.55; 95% confidence interval [CI] 1.04–2.30) and prolonged ventilation (adjusted odds ratio = 2.08; 95% confidence interval [CI] 1.25–3.44) in analyses adjusted for propensity deciles and geographic remoteness. With a median follow-up of 7.5 years (interquartile range 5.2–10.2), Indigenous Australian patients were found to experience 30% greater mortality risk (unadjusted hazard ratio = 1.30; 95% CI: 1.03–1.64, p = 0.03). The effect size strengthened after adjustment for propensity score (adjusted hazard ratio = 1.49; 95% CI: 1.13–1.96, p = .004). Adjustment for ARIA categorisation strengthened the effect size (adjusted HR = 1.54 (95% CI: 1.11–2.13, p = .009). Conclusion: Indigenous Australian peoples were at greater risk for prolonged ventilation and combined morbidity outcome, and experienced poorer survival in the longer term. Higher mortality risk among Indigenous Australians was evident even after controlling for remoteness and accessibility to services

Change in quality of life after transcatheter aortic valve implantation and aortic valve replacement surgery in Australian patients aged ≥ 75 years: The effects of EuroSCORE and patient operability

Objective To determine the extent to which differences in generic quality of life (QOL) between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) patients explained by EuroSCORE and heart-team operability assessment. Methods A total of 146 high-risk patients with EuroSCORE > 6 and aged ≥ 75 years underwent TAVI ( 6 and aged ≥ 75 years underwent TAVI (n = 80) or aortic valve replacement (n = 66) between February 2010 and July 2013. A total of 75 patients also completed preoperative and six month SF-12 QOL measures. Analyses examined incident major morbidity, compared six month QOL between groups adjusted for EuroSCORE and operability, and quantified rates of clinically significant QOL improvement and deterioration. Results The AVR group required longer ventilation (> 24 h) (TAVI 5.0% vs. AVR 20.6%, P = 0.004) and more units of red blood cells [TAVI 0 (0−1) vs. AVR 2 (0−3), 24 h) (TAVI 5.0% vs. AVR 20.6%, P = 0.004) and more units of red blood cells [TAVI 0 (0−1) vs. AVR 2 (0−3), P = 0.01]. New renal failure was higher in TAVI (TAVI 5.0% vs. AVR 0%, P = 0.06). TAVI patients reported significantly lower vitality (P = 0.01) by comparison to AVR patients, however these findings were no longer significant after adjustment for operability. In both procedures, clinically significant QOL improvement was common [range 25.0% (general health) – 62.9% (physical role)] whereas deterioration in QOL occurred less frequently [range 9.3% (physical role) – 33.3% (mental health)]. Conclusions Clinically significant improvement and deterioration in QOL was evident at six months in high risk elderly aortic valve replacement patients. Overall QOL did not differ between TAVI and AVR once operability was taken into consideration

Aortic valve prosthesis-patient mismatch and long-term outcomes: 19-year single-center experience

Background. The clinical effects of prosthesis–patient mismatch (PPM) after aortic valve replacement, with respect to morbidity and survival, remain controversial, particularly in high-risk patient subgroups. Methods. Patients undergoing aortic valve replacement from January 1992 to December 2010 were classified according to effective orifice area index into severe PPM (effective orifice area index 0.85 cm²/m²). Analyses examined major morbidity and total all-cause death. Results. Prosthesis–patient mismatch was classified as severe (92 of 1,060" 8.7%), moderate (440 of 1,060" 41.5%),or absent (528 of 1,060" 49.8%). Moderate and severe PPM were unrelated to in-hospital morbidity or mortality.There were 440 deaths (41.5%) at 5.6 years median follow- up (interquartile range, 2.9 to 9.1). Trend toward poorersurvival according to PPM group (χ2=5.46" p=0.07) was attenuated further with covariate adjustment. Sensitivity analyses demonstrated discrete mortality effects for moderate PPM in association with concomitant coronary artery bypass grafting, impaired left ventricular function, and older age (significant hazard ratios range, 1.05 to 1.57). Severe PPM also increased mortality risk in asso- ciation with older age, concomitant coronary artery bypass grafting, and New York Heart Association Class III or IV (significant hazard ratios range, 1.06 to 2.65). Conclusions. Prosthesis–patient mismatch was not associated with mortality in covariate-adjusted models. However, a discrete mortality risk was attributable to moderate and severe PPM in patients of older age, or those with left ventricular dysfunction, New York Heart Association class III or IV, and concomitant coronary artery bypass grafting

Anxiety, depression, and stress as risk factors for atrial fibrillation after cardiac surgery

OBJECTIVE: We sought to determine whether preoperative and postoperative anxiety, depression, and stress symptoms were associated with atrial fibrillation (AF) after cardiac surgery.METHODS: Two hundred and twenty-six cardiac surgery patients completed measures of depression, anxiety, and general stress before surgery, and 222 patients completed these measures after surgery. The outcome variable was new-onset AF, confirmed before the median day of discharge (day 5) after cardiac surgery during the index hospitalization.RESULTS: Fifty-six (24.8%) patients manifested incident AF, and they spent more days in hospital (mean [M], 7.3; standard deviation [SD], 4.6) than patients without AF (M, 5.5; SD, 1.4; P P = .05). This analysis also showed that age was significantly associated with AF (odds ratio, 1.07; 95% confidence interval, 1.03 to 1.12; P CONCLUSION: Anxiety symptoms in the postoperative period were associated with AF. Hospital staff in acute cardiac care and cardiac rehabilitation settings should observe anxiety as related to AF after cardiac surgery. It is not clear how anxious cognitions influence the experience of AF symptoms, and whether symptoms of anxiety commonly precede AF