Validation of the cognitive recovery assessments with the Postoperative Quality of Recovery Scale in patients with low-baseline cognition

Patients with pre-surgery cognitive impairment cannot currently be assessed for cognitive recovery after surgery using the Postoperative Quality of Recovery Scale (PostopQRS),as they would mathematically be scored as recovered. The group nonetheless represent a frail cohort at high risk of recovering poorly. We aimed to validate a novel method to score cognitive recovery in patients with low baseline cognition, using the number of low-score tests rather than their numerical values. Face validity was demonstrated in 86 participants in whom both PostopQRS and an 11-item neuropsychological battery were performed. The PostopQRS agreed with neuropsychological categorization of low versus normal cognition 74% of the time, with all but 5 incorrectly coded participants deviating by only 1 neurocognitive test. Cognitive recovery over time was comparable for groups with differing baseline cognitive function, irrespective of whether PostopQRS or neuropsychological methods were used. Discriminant validation was demonstrated in a post hoc analysis of the Steroids in Cardiac Surgery (SIRS) substudy by allocating groups to normal (n=246) or low baseline cognition (n=231) stratified by cognitive recovery on day 1. Recovery was similar for participants with low and normal baseline cognition. Postoperative length of stay was longer in patients with failed cognitive recovery whether they had normal (10.4±10.0 vs. 8.0±5.9 days, P=0.02) or low baseline cognition (12.0±11.1 vs. 8.2±4.7 days, P<0.01). Overall quality of recovery, as well as cognitive, emotive, and physiological recovery in those who recovered was independent of baseline cognition. The modified scoring method for the PostopQRS cognitive domain therefore demonstrates acceptable face and discriminant validity

Sutureless Valve in Repeated Aortic Valve Replacement: Results from an International Prospective Registry

Objective: To report early and midterm results registry of patients undergoing repeated aortic valve replacement (RAVR) with sutureless prostheses from an international prospective registry (SURE-AVR). Methods: Between March 2011 and June 2019, 69 patients underwent RAVR with self-expandable sutureless aortic bioprostheses at 22 international cardiac centers.Results: Overall mortality was 2.9% with a predicted logistic EuroSCORE 11 of 10.7%. Indications for RAVR were structural valve dysfunction (84.1%) and infective prosthetic endocarditis (15.9%) and were performed in patients with previously implanted bioprostheses (79.7%), mechanical valves (15.9%), and transcatheter valves (4.3%). Minimally invasive approach was performed in 15.9% of patients. Rate of stroke was 1.4% and rate of early valve-related reintervention was 1.4%. Overall survival rate at 1 and 5 years was 97% and 91%, respectively. No major paravalvular leak occurred. Rate of pacemaker implantation was 5.8% and 0.9% per patient-year early and at follow-up, respectively. The mean transvalvular gradient at 1-year and 5-year follow-up was 10.5 mmHg and 11.5 mmHg with a median effective orifice area of 1.8 cm 2 and 1.8 cm 2 , respectively. Conclusions: RAVR with sutureless valves is a safe and effective approach and provides excellent clinical and hemodynamic results up to 5 years

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

Background: Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve. Methods: SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected. Results: The study population comprised 78 patients (mean \ub1 SD: age 73.6 \ub1 7.6 years, logistic EuroSCORE 18.0 \ub1 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n\ua0= 45) or replacement (n\ua0= 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean \ub1 SD overall aortic cross-clamp time was 109 \ub1 41 min and cardiopulmonary bypass time was 152 \ub1 49 min. Mean \ub1 SD aortic pressure gradients decreased from 37.6 \ub1 17.7 mmHg preoperatively to 13.0 \ub1 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 \ub1 28.7 to 23.4 \ub1 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study. Conclusions: These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes

The effect of total arterial grafting on medium-term outcomes following coronary artery bypass grafting

<p>Abstract</p> <p>Background</p> <p>While it is believed that total arterial grafting (TAG) for coronary artery bypass grafting (CABG) confers improved long-term outcomes when compared to conventional grafting with left internal mammary artery and saphenous vein grafts (LIMA+SVG), to date, this has not become the standard of care. In this study, we assessed the impact of TAG on medium-term outcomes after CABG.</p> <p>Methods</p> <p>Peri-operative data was prospectively collected on consecutive first-time, isolated CABG patients between 1995 and 2005. Patients were divided into two groups based on grafting strategy: TAG (all arterial grafts no saphenous veins) or LIMA+SVG. Patients who had an emergent status or underwent fewer than two distal bypasses were excluded. Medium term univariate and risk-adjusted comparisons between TAG and LIMA+SVG cases were performed.</p> <p>Results</p> <p>A total of 4696 CABG patients were included with 1019 patients undergoing TAG (22%). Unadjusted in-hospital mortality was 1.5% for TAG patients compared to 2.0% for LIMA+SVG (p = 0.31). The mean follow-up was 4.8 ± 2.0 years for TAG patients compared to 6.1 ± 3.0 years for LIMA+SVG patients (p < 0.0001). At follow-up total mortality (8% vs 19%; p < 0.0001), and the incidence of readmission to hospital for cardiac reasons (29% vs 38%; p < 0.0001) were significantly lower in TAG compared to LIMA+SVG patients. However, after adjusting for clinical covariates, TAG did not emerge as a significant independent predictor of long-term mortality (HR 0.92; CI 0.71–1.18), readmission to hospital (HR 1.02; CI 0.89–1.18) or the composite outcome of mortality and readmission (HR 1.00; CI 0.88–1.15). Risk adjusted survival was better than 88% in both TAG and LIMA-SVG patients at 5 years follow-up.</p> <p>Conclusion</p> <p>Patients undergoing TAG appear to experience lower rates of medium-term all-cause mortality and readmission to hospital for any cardiac cause when compared to patients undergoing LIMA+SVG. However, after adjusting for clinical variables, this difference no longer persists suggesting that at median follow-up there are no mortality or morbidity benefit based on the choice of conduit.</p

Keeping it Real : An Evaluation Audit of Five Years of Youth-led Program Evaluation

Youth are increasingly seen as competent in participating in research and program evaluation, two activities previously reserved for adults. This paper is a report of the findings from an evaluation audit of Stand Up! Help Out!, a participatory action after-school youth leadership development program for disadvantaged urban youth that utilized youth evaluations to develop a best practices service model. The youths’ feedback assisted providers in improving services so that youth engagement in the program was 99% (by comparison with national highs of 79%). Here, we describe an important aspect of the process of youth-led program evaluation leading to such high youth engagement: How youth interviewed each other so as to optimize the authenticity of their program evaluations and contributions to program design. Drawing from over five years of program evaluation data collected by youth, the authors report on the youths’ experiences as informants and co-researchers, consider strategies used to help youth best describe their experiences in the program, and describe implications for other settings looking to incorporate youth-led program evaluation. Youth-led program evaluation has considerable promise for helping service providers make programs more meaningful for disadvantaged youth

Health-related quality of life after fast-track treatment results from a randomized controlled clinical equivalence trial

Purpose This randomized clinical equivalence trial was designed to evaluate health-related quality of life (HRQoL) after fast-track treatment for low-risk coronary artery bypass (CABG) patients. Methods Four hundred and ten CABG patients were randomly assigned to undergo either short-stay intensive care treatment (SSIC, 8 h of intensive care stay) or control treatment (care as usual, overnight intensive care stay). HRQoL was measured at baseline and 1 month, and one year after surgery using the multidimensional index of life quality (MILQ), the EQ-5D, the Beck Depression Inventory and the State-Trait Anxiety Inventory. Results At one month after surgery, no statistically significant difference in overall HRQoL was found (MILQ-score P-value = .508, overall MILQ-index P-value = .543, EQ-5D VAS P-value = .593). The scores on the MILQ-domains, physical, and social functioning were significantly higher at one month postoperatively in the SSIC group compared to the control group (P-value = .049; 95% CI: 0.01-2.50 and P-value =.014, 95% CI:0.24-2.06, respectively). However, these differences were no longer observed at long-term follow-up. Conclusions According to our definition of clinical equivalence, the HRQoL of SSIC patients is similar to patients receiving care as usual. Since safety and the financial benefits of this intervention were demonstrated in a previously reported analysis, SSIC can be considered as an adequate fast-track intensive care treatment option for low-risk CABG patients