The impact of surgical aortic valve replacement on quality of life-a multicenter study:a multicenter study

OBJECTIVES: To explore the effect of surgical aortic valve replacement on quality of life and the variance with age, particularly in patients at risk of deterioration. METHODS: In an observational, multicenter, cohort study of routinely collected health data, patients undergoing and electively operated between January 2011 and January 2015 with pre- and postoperative quality of life data were included. Patients were classified into 3 age groups: 5-point difference as a minimal clinically important difference. Multivariable linear regression analysis, with adjustment for confounders, was used to evaluate the association between age and quality of life. RESULTS: In 899 patients, mean physical health increased from 55 to 66 and mental health from 60 to 66. A minimal clinically important decreased physical health was observed in 12% of patients aged <65 years, 16% of patients aged 65-79 years, and 22% of patients aged ≥80 years (P = .023). A decreased mental health was observed in 15% of patients aged <65 years, 22% of patients aged 65-79 years, and 24% aged ≥80 years (P = .030). Older age and a greater physical and mental score at baseline were associated with a decreased physical and mental quality of life (P < .001). CONCLUSIONS: Patients surviving surgical aortic valve replacement on average improve in physical and mental quality of life; nonetheless, with increasing age patients are at higher risk of experiencing a deterioration

Quality of life after coronary bypass:a multicentre study of routinely collected health data in the Netherlands†

OBJECTIVES: In this study, our aim was to explore how coronary artery bypass grafting affects quality of life, and how this varies with age, particularly with patients at risk of deterioration. METHODS: In a retrospective, multicentre cohort study, patients with isolated coronary artery bypass grafting and electively operated between January 2011 and January 2015 with pre- and postoperative quality-of-life data were included. Patients were classified into 3 age groups: <65, 65-79 and ≥80 years. Quality of life was measured up to 1-year follow-up using the Short Form-12 or the Short Form-36 health survey. A multivariable, linear regression analysis, with an adjustment for confounders, was used to evaluate the association between age and quality of life. RESULTS: A total of 2606 patients were included in this study. Upon one-year of follow-up, the mean physical health of patients increased from 54 at baseline to 68, and mental health increased from 60 to 67. We observed decreased mental health in 20% of patients aged <65 years, 20% of patients aged 65-79 years and 29% of patients aged ≥80 years (P = 0.039). In this study, age was not associated with a lower physical or mental component score (P = 0.054 and P = 0.13, respectively). Independent risk factors for a decrease in quality of life consist of a better physical and mental score at baseline (P < 0.001) and a reduced left ventricular function (P < 0.001). CONCLUSIONS: Most patients experience a relevant increase in physical and mental quality of life, but a proportion of patients aged ≥80 years undergo significant deterioration in mental health

Healthcare-associated prosthetic heart valve, aortic vascular graft, and disseminated Mycobacterium chimaera infections subsequent to open heart surgery

Aims We identified 10 patients with disseminated Mycobacterium chimaera infections subsequent to open-heart surgery at three European Hospitals. Infections originated from the heater-cooler unit of the heart-lung machine. Here we describe clinical aspects and treatment course of this novel clinical entity. Methods and results Interdisciplinary care and follow-up of all patients was documented by the study team. Patients' characteristics, clinical manifestations, microbiological findings, and therapeutic measures including surgical reinterventions were reviewed and treatment outcomes are described. The 10 patients comprise a 1-year-old child and nine adults with a median age of 61 years (range 36-76 years). The median duration from cardiac surgery to diagnosis was 21 (range 5-40) months. All patients had prosthetic material-associated infections with either prosthetic valve endocarditis, aortic graft infection, myocarditis, or infection of the prosthetic material following banding of the pulmonary artery. Extracardiac manifestations preceded cardiovascular disease in some cases. Despite targeted antimicrobial therapy, M. chimaera infection required cardiosurgical reinterventions in eight patients. Six out of 10 patients experienced breakthrough infections, of which four were fatal. Three patients are in a post-treatment monitoring period. Conclusion Healthcare-associated infections due to M. chimaera occurred in patients subsequent to cardiac surgery with extracorporeal circulation and implantation of prosthetic material. Infections became clinically apparent after a time lag of months to years. Mycobacterium chimaera infections are easily missed by routine bacterial diagnostics and outcome is poor despite long-term antimycobacterial therapy, probably because biofilm formation hinders eradication of pathogen

Training in robotic thoracic surgery-the European way

The increasing demand for robot-assisted thoracic surgery (RATS) in Europe requires a structured and standardized training module. Until now, Intuitive Surgical Inc. (Sunnyvale, CA, USA) has delivered the only available robotic surgery platform. Although the training program that is organized by Intuitive is divided in an initial and an advanced course, the success of the training depends on many external factors. Until now the training focused on experienced thoracic surgeons. The aim of this article is to offer a stepwise training module, which can be adopted by experienced open (thoracotomy) surgeons or video-assisted thoracic (VATS) surgeons but is primarily meant for thoracic surgery fellows and residents, as it is our sincere opinion that we should focus on training for this type of surgery as early in their careers as possible. In order to maintain surgical technique and minimize the chance of complications, on-going training and certification of the surgeons and the team is deemed necessary

A Protocol for Diagnosis and Management of Aortic Atherosclerosis in Cardiac Surgery Patients

In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE (A-View method) was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening. At the time of clinical implementation and validation, we did not yet standardize the indications for modified TEE and the changes in patient management in the presence of aortic atherosclerosis. Therefore, we designed a protocol, which combined the diagnosis of atherosclerosis of thoracic aorta and the subsequent considerations with respect to the intraoperative management and provides a systematic approach to reduce the risk of cerebral complications

A Comparison of Measures of Endothelial Function in Patients with Peripheral Arterial Disease and Age and Gender Matched Controls

This study compared flow-mediated dilatation (FMD), peripheral artery tonometry (PAT), and serum nitric oxide (NO) measures of endothelial function in patients with peripheral artery disease (PAD) against age/gender matched controls. 25 patients (mean age: 72.4 years, M : F 18 : 7) with established PAD and an age/gender matched group of 25 healthy controls (mean age: 72.4 years, M : F 18 : 7) were studied. Endothelial function was measured using the % FMD, reactive hyperemia index (RHI) using PAT and serum NO (μmol). Difference for each method between PAD and control patients and correlation between the methods were investigated. FMD and RHI were lower in patients with PAD (median FMD for PAD = 2.16% versus control = 3.77%, p=0.034 and median RHI in PAD = 1.64 versus control = 1.92, p=0.005). NO levels were not significantly different between the groups (PAD median = 7.70 μmol, control median = 13.05 μmol, p=0.662). These results were obtained in elderly patients and cannot be extrapolated to younger individuals. FMD and PAT both demonstrated a lower hyperaemic response in patients with PAD; however, FMD results in PAD patients were unequivocally reduced whereas half the PAD patients had RHI values above the established threshold for endothelial dysfunction. This suggests that FMD is a more appropriate method for the measurement of NO-mediated endothelial function

Effect of Fibrinogen Concentrate on Intraoperative Blood Loss Among Patients With Intraoperative Bleeding During High-Risk Cardiac Surgery : A Randomized Clinical Trial

Importance: Fibrinogen concentrate might partly restore coagulation defects and reduce intraoperative bleeding. Objective: To determine whether fibrinogen concentrate infusion dosed to achieve a plasma fibrinogen level of 2.5 g/L in high-risk cardiac surgery patients with intraoperative bleeding reduces intraoperative blood loss. Design, Setting, and Participants: A randomized, placebo-controlled, double-blind clinical trial conducted in Isala Zwolle, the Netherlands (February 2011-January 2015), involving patients undergoing elective, high-risk cardiac surgery (ie, combined coronary artery bypass graft [CABG] surgery and valve repair or replacement surgery, the replacement of multiple valves, aortic root reconstruction, or reconstruction of the ascending aorta or aortic arch) with intraoperative bleeding (blood volume between 60 and 250 mL suctioned from the thoracic cavity in a period of 5 minutes) were randomized to receive either fibrinogen concentrate or placebo. Interventions: Intravenous, single-dose administration of fibrinogen concentrate (n = 60) or placebo (n = 60), targeted to achieve a postinfusion plasma fibrinogen level of 2.5 g/L. Main Outcomes and Measures: The primary outcome was blood loss in milliliters between intervention (ie, after removal of cardiopulmonary bypass) and closure of chest. Safety variables (within 30 days) included: in-hospital mortality, myocardial infarction, cerebrovascular accident or transient ischemic attack, renal insufficiency or failure, venous thromboembolism, pulmonary embolism, and operative complications. Results: Among 120 patients (mean age; 71 [SD, 10] years, 37 women [31%]) included in the study, combined CABG and valve repair or replacement surgery comprised 72% of procedures and had a mean (SD) cardiopulmonary bypass time of 200 minutes (83) minutes. For the primary outcome, median blood loss in the fibrinogen group was 50 mL (interquartile range [IQR], 29-100 mL) compared with 70 mL (IQR, 33-145 mL) in the control group (P = .19), the absolute difference 20 mL (95% CI, -13 to 35 mL). There were 6 cases of stroke or transient ischemic attack (4 in the fibrinogen group); 4 myocardial infarctions (3 in the fibrinogen group); 2 deaths (both in the fibrinogen group); 5 cases with renal insufficiency or failure (3 in the fibrinogen group); and 9 cases with reoperative thoracotomy (4 in the fibrinogen group). Conclusions and Relevance: Among patients with intraoperative bleeding during high-risk cardiac surgery, administration of fibrinogen concentrate, compared with placebo, resulted in no significant difference in the amount of intraoperative blood loss. Trial Registration: clinicaltrials.gov Identifier: NCT01124981 and EudraCT No: 2009-018086-12

Effect of Fibrinogen Concentrate on Intraoperative Blood Loss Among Patients With Intraoperative Bleeding During High-Risk Cardiac Surgery : A Randomized Clinical Trial

Importance: Fibrinogen concentrate might partly restore coagulation defects and reduce intraoperative bleeding. Objective: To determine whether fibrinogen concentrate infusion dosed to achieve a plasma fibrinogen level of 2.5 g/L in high-risk cardiac surgery patients with intraoperative bleeding reduces intraoperative blood loss. Design, Setting, and Participants: A randomized, placebo-controlled, double-blind clinical trial conducted in Isala Zwolle, the Netherlands (February 2011-January 2015), involving patients undergoing elective, high-risk cardiac surgery (ie, combined coronary artery bypass graft [CABG] surgery and valve repair or replacement surgery, the replacement of multiple valves, aortic root reconstruction, or reconstruction of the ascending aorta or aortic arch) with intraoperative bleeding (blood volume between 60 and 250 mL suctioned from the thoracic cavity in a period of 5 minutes) were randomized to receive either fibrinogen concentrate or placebo. Interventions: Intravenous, single-dose administration of fibrinogen concentrate (n = 60) or placebo (n = 60), targeted to achieve a postinfusion plasma fibrinogen level of 2.5 g/L. Main Outcomes and Measures: The primary outcome was blood loss in milliliters between intervention (ie, after removal of cardiopulmonary bypass) and closure of chest. Safety variables (within 30 days) included: in-hospital mortality, myocardial infarction, cerebrovascular accident or transient ischemic attack, renal insufficiency or failure, venous thromboembolism, pulmonary embolism, and operative complications. Results: Among 120 patients (mean age; 71 [SD, 10] years, 37 women [31%]) included in the study, combined CABG and valve repair or replacement surgery comprised 72% of procedures and had a mean (SD) cardiopulmonary bypass time of 200 minutes (83) minutes. For the primary outcome, median blood loss in the fibrinogen group was 50 mL (interquartile range [IQR], 29-100 mL) compared with 70 mL (IQR, 33-145 mL) in the control group (P = .19), the absolute difference 20 mL (95% CI, -13 to 35 mL). There were 6 cases of stroke or transient ischemic attack (4 in the fibrinogen group); 4 myocardial infarctions (3 in the fibrinogen group); 2 deaths (both in the fibrinogen group); 5 cases with renal insufficiency or failure (3 in the fibrinogen group); and 9 cases with reoperative thoracotomy (4 in the fibrinogen group). Conclusions and Relevance: Among patients with intraoperative bleeding during high-risk cardiac surgery, administration of fibrinogen concentrate, compared with placebo, resulted in no significant difference in the amount of intraoperative blood loss. Trial Registration: clinicaltrials.gov Identifier: NCT01124981 and EudraCT No: 2009-018086-12

Impact of Modified Transesophageal Echocardiography on Mortality and Stroke after Cardiac Surgery : A Large Cohort Study

The aim of this study was to investigate the impact of perioperative screening with modified transesophageal echocardiography (A-View method). We compared, in consecutive patients who underwent cardiac surgery between 2006 and 2014, 30-day mortality and in-hospital stroke incidence, operated either with perioperative modified TEE screening (intervention group) or only with conventional TEE screening (control group). Of the 8,605 study patients, modified TEE was applied in 1,391 patients (16.2%). Patients in the intervention group were on average older (71 versus 68 years, p<0.001) and more often females (31.0% versus 28.0%, p<0.001) and had a higher predicted mortality (EuroSCORE I: 5.9% versus 4.0%, p<0.001). The observed 30-day mortality was 2.2% and 2.5% in both groups, respectively, with multivariable and propensity-score adjusted relative risks (RRs) of 0.70 (95% CI: 0.50-1.00, p=0.05) and 0.67 (95% CI: 0.45-0.98, p=0.04). In-hospital stroke was 2.9% and 2.1% in both groups, respectively, with adjusted RRs of 1.03 (95% CI: 0.73-1.45) and 1.01 (95% CI: 0.71-1.43). In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening

Impact of Modified Transesophageal Echocardiography on Mortality and Stroke after Cardiac Surgery:A Large Cohort Study

The aim of this study was to investigate the impact of perioperative screening with modified transesophageal echocardiography (A-View method). We compared, in consecutive patients who underwent cardiac surgery between 2006 and 2014, 30-day mortality and in-hospital stroke incidence, operated either with perioperative modified TEE screening (intervention group) or only with conventional TEE screening (control group). Of the 8,605 study patients, modified TEE was applied in 1,391 patients (16.2%). Patients in the intervention group were on average older (71 versus 68 years, p<0.001) and more often females (31.0% versus 28.0%, p<0.001) and had a higher predicted mortality (EuroSCORE I: 5.9% versus 4.0%, p<0.001). The observed 30-day mortality was 2.2% and 2.5% in both groups, respectively, with multivariable and propensity-score adjusted relative risks (RRs) of 0.70 (95% CI: 0.50–1.00, p=0.05) and 0.67 (95% CI: 0.45–0.98, p=0.04). In-hospital stroke was 2.9% and 2.1% in both groups, respectively, with adjusted RRs of 1.03 (95% CI: 0.73–1.45) and 1.01 (95% CI: 0.71–1.43). In patients undergoing cardiac surgery, use of perioperative screening for aortic atherosclerosis with modified TEE was associated with lower postoperative mortality, but not stroke, as compared to patients operated on without such screening