Outcomes of different aortic arch replacement techniques

Background: Consensus on the best treatment for aortic arch pathology is unresolved due to an emerging variety of procedures. We aimed to compare the outcomes of two major techniques for open aortic arch replacement involving the supra-aortic branches and to identify the risk factors for specific adverse events. Methods: Between 1974 and 2017, 172 patients were treated with either the en bloc (island, n = 59; 34.3%) or branched graft technique (n = 113, 65.7%). Most of the patients were treated in an emergent/urgent setting (52.4%). Results: Patients who underwent the en bloc procedure had significantly shorter cardiopulmonary bypass (median: 241 vs 271 minutes, P =.041) and aortic cross clamp times (median: 124 vs 168 minutes, P =.005) than patients who underwent the separate graft technique. Overall, the hospital mortality was lower in the en bloc group, 8.5% vs 19.5%, although the difference was not significant (P =.077). No difference was found in the survival between the separate graft and en bloc groups at 1 (77.0 vs 86.3%), 5 (67.7 vs 66.3%) and 10 years (42.4 vs 51.3%), (P =.63). The postoperative stroke rate was comparable between the en bloc and separate graft cohorts (14.3 vs 19.6%, P =.52). Diabetics and those who underwent an elephant trunk procedure were at a higher risk for reintervention. Conclusions: The separate graft technique, which is more common today, showed no difference from the en bloc technique with regard to hospital mortality and morbidity. Furthermore, the late survival and reintervention rates were similar after both procedures

Contemporary outcomes after surgical aortic valve replacement with bioprostheses and allografts: ßA systematic review and meta-analysis

Many observational studies have reported outcomes after surgical aortic valve replacement (AVR), but there are no recent systematic reviews and meta-analyses including all available bioprostheses and allografts. The objective of this study is to provide a comprehensive and up-to-date overview of the outcomes after AVR with bioprostheses and allografts reported in the last 15 years. We conducted a systematic literature review (PROSPERO register: CRD42015017041) of studies published between 2000-15. Inclusion criteria were observational studies or randomized controlled trials reporting on outcomes of AVR with bioprostheses (stented or stentless) or allografts, with or without coronary artery bypass grafting (CABG) or valve repair procedure, with study population size n ≥ 30 and mean follow-up length ≥5 years. Fifty-four bioprosthesis studies and 14 allograft studies were included, encompassing 55 712 and 3872 patients and 349 840 and 32 419 patient-years, respectively. We pooled early mortality risk and linearized occurrence rates of valve-related events, reintervention and late mortality in a random-effects model. Sensitivity, meta-regression and subgroup analyses were performed to investigate the influence of outliers on the pooled estimates and to explore sources of heterogeneity. Funnel plots were used to investigate publication bias. Pooled early mortality risks for bioprostheses and allografts were 4.99% (95% confidence interval [CI], 4.44-5.62) and 5.03% (95% CI, 3.61-7.01), respectively. The late mortality rate was 5.70%/patient-year (95% CI, 4.99-5.62) for bioprostheses and 1.68%/patient-year (95% CI, 1.23-2.28) for allografts. Pooled reintervention rates for bioprostheses and allografts were 0.75%/patient-year (95% CI, 0.61-0.91) and 1.87%/patient-year (95% CI, 1.52-2.31), respectively. There was substantial heterogeneity in most outcomes. Meta-regression analyses identified covariates that could explain the heterogeneity: implantation period, valve type, patient age, gender, pre-intervention New York Heart Association class III/IV, concomitant CABG, study design and follow-up length. There is possible publication bias in all outcomes. This comprehensive systematic review and meta-analysis provides an overview of the outcomes after AVR with bioprostheses and allografts reported during the last 15 years. The results of this study can support patients and doctors in the prosthetic valve choice and can be used in microsimulation models to predict patient outcomes and estimate the cost-effectiveness of AVR with bioprostheses or allografts compared with current and future heart valve prostheses

Timing of pulmonary valve replacement in patients with corrected Fallot to prevent QRS prolongation

OBJECTIVES: Timing of pulmonary valve replacement (PVR) remains one of the most heavily debated topics in congenital cardiac surgery. We aimed to analyse the temporal evolution of QRS duration before and after PVR. METHODS: We included 158 consecutive patients who underwent PVR after previous correction with transannular patch. All 3549 available serial standard 12-lead surface QRS measurements of 158 (100%) patients were analysed with linear mixed-effect modelling. RESULTS: PVR was perfo

Clinical outcome and health-related quality of life after right-ventricular-outflow-tract reconstruction with an allograft conduit

Objective: Allograft conduits are used for reconstruction of the right ventricular outflow tract in congenital heart malformations (biventricular repair) and autograft procedures. A retrospective evaluation of allograft reconstruction of the right-ventricular-outflow-tract reconstruction was conducted and a cross-sectional quality of life study was performed. Methods: Between August 1986 and March 2009, 509 allografts (435 pulmonary and 74 aortic) were implanted in 463 pediatric and adult patients (308 right-sided congenital heart malformations and 155 autograft procedures). Perioperative and follow-up data were collected and analyzed. Kaplan-Meier analyses were done for survival, valve-related re-operation, and valve-related events. Cox regression analysis was used for evaluation of potential risk factors. In addition, the Short Form-36 was presented to patients to assess the perceived quality of life. The results of the Short Form-36 were compared to age-adjusted Dutch population norms. Results: The mean age at allograft implantation was 19 years (1 week-66 years). Mean follow-up was 9 years (2 days-22 years). Forty-eight patients died during follow-up. Patient survival was 93% at 10 years and 88% at 15 years. A total of 63 re-operations were required for allograft dysfunction in 58 patients. Freedom from valve-related re-operation was 89% at 10 years and 81% at 15 years. Freedom from valve-related events was 86% at 10 years and 74% at 15 years. Younger patient age (p = 0.007) and the use of an aortic allograft (p < 0.001) were identified as independent risk factors for allograft re-operation. Patients between 14 and 40 years scored significantly lower on 'physical functioning' and 'general health' subscales than the general Dutch population, but scored better on the subscales 'emotional role functioning' and 'bodily pain'. Except for the subscale 'general health', on which patients within our study population scored lower, patients between 41 and 60 years had comparable average scores as the general Dutch population. The older patient group (61 years or older) had a better average score on the subscale 'bodily pain' and similar scores on other subscales with respect to the general Dutch population. Conclusions: Right-ventricular-outflow-tract reconstruction with an allograft conduit can be performed with good patient survival, acceptable long-term allograft durability, and good perceived quality of life

A clinician’s guide for developing a prediction model: a case study using real-world data of patients with castration-resistant prostate cancer

Purpose: With the increasing interest in treatment decision-making based on risk prediction models, it is essential for clinicians to understand the steps in developing and interpreting such models. Methods: A retrospective registry of 20 Dutch hospitals with data on patients treated for castration-resistant prostate cancer was used to guide clinicians through the steps of developing a prediction model. The model of choice was the Cox proportional hazard model. Results: Using the exemplary dataset several essential steps in prediction modelling are discussed including: coding of predictors, missing values, interaction, model specification and performance. An advanced method for appropriate selection of main effects, e.g. Least Absolute Shrinkage and Selection Operator (LASSO) regression, is described. Furthermore, the assumptions of Cox proportional hazard model are discussed, and how to handle violations of the proportional hazard assumption using time-varying coefficients. Conclusion: This study provides a comprehensive detailed guide to bridge the gap between the statistician and clinician, based on a large dataset of real-world patients treated for castration-resistant prostate cancer

Värdetransportrån

Med denna rapport vill vi försöka att belysa ett brott som har blivit allt vanligare för varje dag som går, nämligen värdetransportrån. Gärningsmännen blir råare och deras metoder förfinas hela tiden. Rikskriminalpolisen fasar nu för att gärningsmännen går vidare och även försöker råna värdedepåer runt om i Sverige . Det som är skrämmande med dessa brott är att gärningsmannen inte drar sig för att använda vapen för att få det han vill. Ett stort problem för polisen är att det krävs stora resurser i spaningsarbete för att kunna lagföra de misstänkta gärningsmännen. Detta är ett väldigt tidsödande arbete och man kan anse att tidsåtgången inte är försvarlig mot den gällande straffsatsen. I dagsläget är inte förberedelse eller försök till rån i närheten av vad man döms till när det gäller fullbordat rån. En ändring i straffskalan när det gäller försök och förberedelse för grovt rån, skulle göra att dessa individer inte kan komma ut så snabbt för att fortsätta sin brottsliga bana efter avtjänat fängelsestraff. En annan typ av brott som är relativt vanligt, men mycket svårbevisat, är stämplingsbrott gällande grovt rån. Vissa individer har specialiserat sig på att ”samla” information gällande transporterna för att sedan anlita andra personer för att genomföra rånet. Man tar sedan procent på förtjänsten eller så säljer man en redan utarbetad plan. I rapporten tar vi upp ökningen av värdetransportrånen i Sverige och jämför med några andra länder i Europa och Skandinavien. Vi pekar även på att risken för upptäckt ställt i relation till de pengar som gärningsmännen kan komma åt vid brottet och det eventuella straff man kan tilldömas, inte avskräcker gärningsmännen från att begå brottet. Vi ger en redogörelse över vilka brott som kan bli aktuella vid förberedelse och genomförande av värdetransportrån, och vi avslutar med våra egna slutsatser när det gäller värdetransportrånen i Sverige