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

Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG) A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND: Approximately 15% of saphenous vein grafts (SVGs) occlude during the first year after coronary artery bypass graft surgery (CABG) despite aspirin use. The POPular CABG trial (The Effect of Ticagrelor on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting Surgery) investigated whether ticagrelor added to standard aspirin improves SVG patency at 1 year after CABG. METHODS: In this investigator-initiated, randomized, double-blind, placebo-controlled, multicenter trial, patients with ≥1 SVGs were randomly assigned (1:1) after CABG to ticagrelor or placebo added to standard aspirin (80 mg or 100 mg). The primary outcome was SVG occlusion at 1 year, assessed with coronary computed tomography angiography, in all patients that had primary outcome imaging available. A generalized estimating equation model was used to perform the primary analysis per SVG. The secondary outcome was 1-year SVG failure, which was a composite of SVG occlusion, SVG revascularization, myocardial infarction in myocardial territory supplied by a SVG, or sudden death. RESULTS: Among 499 randomly assigned patients, the mean age was 67.9±8.3 years, 87.1% were male, the indication for CABG was acute coronary syndrome in 31.3%, and 95.2% of procedures used cardiopulmonary bypass. Primary outcome imaging was available in 220 patients in the ticagrelor group and 223 patients in the placebo group. The SVG occlusion rate in the ticagrelor group was 10.5% (51 of 484 SVGs) versus 9.1% in the placebo group (43 of 470 SVGs), odds ratio, 1.29 [95% CI, 0.73-2.30]; P=0.38. SVG failure occurred in 35 (14.2%) patients in the ticagrelor group versus 29 (11.6%) patients in the placebo group (odds ratio, 1.22 [95% CI, 0.72-2.05]). CONCLUSIONS: In this randomized, placebo-controlled trial, the addition of ticagrelor to standard aspirin did not reduce SVG occlusion at 1 year after CABG. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02352402

Using real-world data to monitor and improve quality of care in coronary artery disease: results from the Netherlands Heart Registration

Worldwide, quality registries for cardiovascular diseases enable the use of real-world data to monitor and improve the quality of cardiac care. In the Netherlands Heart Registration (NHR), cardiologists and cardiothoracic surgeons register baseline, procedural and outcome data across all invasive cardiac interventional, electrophysiological and surgical procedures. This paper provides insight into the governance and processes as organised by the NHR in collaboration with the hospitals. To clarify the processes, examples are given from the percutaneous coronary intervention and coronary artery bypass grafting registries. Physicians who are mandated by their hospital to instruct the NHR to process their data are united in registration committees. The committees determine standard sets of variables and periodically discuss the completeness and quality of data and patient-relevant outcomes. In the case of significant variation in outcomes, processes of healthcare delivery are discussed and good practices are shared in a non-competitive and safe setting. To create new insights for further improvement in patient-relevant outcomes, quality projects are initiated on, for example, multivessel disease treatment, cardiogenic shock and diagnostic intracoronary procedures. Moreover, possibilities are explored to expand the quality registries through additional relevant indicators, such as resource use before and after the procedure, by enriching NHR data with other existing data resources

Impact of the coronavirus disease 2019 pandemic on volume of thoracic aortic surgery on a national level

OBJECTIVES: The aim of this study was to evaluate the effects of the coronavirus 2019 pandemic on elective and acute thoracic aortic surgery in the Netherlands. METHODS: The Netherlands Heart Registration database was used to compare the volume of elective and acute surgery on the thoracic aorta in 2019 and 2020, starting from week 11 in both years. A sub-analysis was done to assess the impact of the pandemic on high-volume and low-volume aortic centres. RESULTS: During the pandemic, the number of elective thoracic aortic operations declined by 18% [incidence rate ratio (IRR) 0.82 [0.73-0.91]; P < 0.01]. The decline in volume of elective surgery was significant in both high-volume (IRR 0.82 [0.71-0.94]; P < 0.01) and low-volume aortic centres (IRR 0.81 [0.68-0.98]; P = 0.03). The overall number of acute aortic operations during the pandemic remained similar to that in 2019 (505 vs 499; P = 0.85), but an increased share of these operations occurred at high-volume centres. The number of acute operations performed in high-volume centres increased by 20% (IRR 1.20 [1.01-1.42]; P = 0.04), while the number of acute operations performed in low-volume centres decreased by 17% (IRR 0.83 [0.69-1.00]; P = 0.04). CONCLUSIONS: The coronavirus 2019 pandemic led to a significant decrease in elective thoracic aortic surgery but did not cause a change in the volume of acute thoracic aortic surgery in the Netherlands. Moreover, the pandemic led to a centralization of care for acute thoracic aortic surgery

Impact of the coronavirus disease 2019 pandemic on volume of thoracic aortic surgery on a national level

OBJECTIVES: The aim of this study was to evaluate the effects of the coronavirus 2019 pandemic on elective and acute thoracic aortic surgery in the Netherlands. METHODS: The Netherlands Heart Registration database was used to compare the volume of elective and acute surgery on the thoracic aorta in 2019 and 2020, starting from week 11 in both years. A sub-analysis was done to assess the impact of the pandemic on high-volume and low-volume aortic centres. RESULTS: During the pandemic, the number of elective thoracic aortic operations declined by 18% [incidence rate ratio (IRR) 0.82 [0.73-0.91]; P < 0.01]. The decline in volume of elective surgery was significant in both high-volume (IRR 0.82 [0.71-0.94]; P < 0.01) and low-volume aortic centres (IRR 0.81 [0.68-0.98]; P = 0.03). The overall number of acute aortic operations during the pandemic remained similar to that in 2019 (505 vs 499; P = 0.85), but an increased share of these operations occurred at high-volume centres. The number of acute operations performed in high-volume centres increased by 20% (IRR 1.20 [1.01-1.42]; P = 0.04), while the number of acute operations performed in low-volume centres decreased by 17% (IRR 0.83 [0.69-1.00]; P = 0.04). CONCLUSIONS: The coronavirus 2019 pandemic led to a significant decrease in elective thoracic aortic surgery but did not cause a change in the volume of acute thoracic aortic surgery in the Netherlands. Moreover, the pandemic led to a centralization of care for acute thoracic aortic surgery

Randomized Controlled Trial on the Influence of Intraoperative Remifentanil versus Fentanyl on Acute and Chronic Pain after Cardiac Surgery

BACKGROUND: Remifentanil has been associated with increased acute and potentially chronic postoperative pain. The objective of this prospective randomized controlled trial was to investigate the influence of intraoperative remifentanil on acute and chronic postoperative pain after cardiac surgery. METHODS: Patients (N = 126) receiving standardized anesthesia with propofol and intermittent intravenous fentanyl at predetermined times for cardiac surgery were randomized to intraoperatively receive either a continuous remifentanil infusion or additional intermittent intraoperative fentanyl as needed. The primary endpoint was chronic thoracic pain at 12 months after surgery. Secondary endpoints were pain at 3 and 6 months after surgery and analgesic requirements and pain levels in the first 72 hours. RESULTS: There was no significant difference in incidence of chronic thoracic pain between the remifentanil and fentanyl groups, respectively (20% vs. 18%; P = 0.817). At 3 months, however, significantly more patients in the remifentanil group reported chronic thoracic pain (51% vs. 33%; P = 0.047). This effect was more pronounced in younger patients and in patients receiving a higher dose of remifentanil (both P < 0.05). The first 24 and 48 hours postoperatively, morphine consumption in the remifentanil group was significantly higher than in the fentanyl group (34.3 mg [interquartile range (IQR) 25.3 to 48.2] vs. 30.2 mg [IQR 19.2 to 38.1], P = 0.028; and 46.8 mg [IQR 33.8 to 59.2] vs. 39.0 mg [IQR 6.2 to 51.4], P = 0.047, respectively). CONCLUSIONS: Intraoperative use of remifentanil during cardiac surgery does not impact chronic postoperative pain 1 year after surgery. Nevertheless, remifentanil increases analgesic requirements and thoracic pain until 3 months after surgery, and its use is therefore less favorable during cardiac surgery

A possible stress physiological role of abscisic acid conjugates in root-to-shoot signalling

Sauter A, Dietz K-J, Hartung W. A possible stress physiological role of abscisic acid conjugates in root-to-shoot signalling. PLANT CELL AND ENVIRONMENT. 2002;25(2):223-228.Abscisic acid (ABA) conjugates, predominantly their glucose esters, have recently been shown to occur in the xylem sap of different plants. Under stress conditions, their concentration can rise substantially to levels that are higher than the concentration of free ABA. External ABA conjugates cannot penetrate apoplastic barriers in the root. They have to be hydrolysed by apoplastic enzymes in the root cortex. Liberated free ABA can then be redistributed to the root symplast and dragged directly across the endodermis to the stele. Endogenous ABA conjugates are formed in the cytosol of root cells, transported symplastically to the xylem parenchyma cells and released to the xylem vessels. The mechanism of release is unknown; it may include the action of ABC-transporters. Because of its extremely hydrophilic properties, ABA-GE is translocated in the xylem of the stem without any loss to the surrounding parenchyma. After arrival in the leaf apoplast, transporters for ABA-GE in the plasmalemma have to be postulated to redistribute the conjugates to the mesophyll cells. Additionally, apoplastic esterases can cleave the conjugate and release free ABA to the target cells and tissues. The activity of these esterases is increased when barley plants are subjected to salt stress

Minimally invasive approach compared to resternotomy for mitral valve surgery in patients with prior cardiac surgery: retrospective multicentre study based on the Netherlands Heart Registration

OBJECTIVES: Mitral valve (MV) surgery after prior cardiac surgery is conventionally performed through resternotomy and associated with increased morbidity and mortality. Alternatively, MV can be approached minimally invasively [minimally invasive mitral valve surgery (MIMVS)], but longer-term follow-up of this approach for MV surgery after prior cardiac surgery is lacking. Therefore, the aim of the current study is to evaluate short- and mid-term outcomes of MIMVS versus MV surgery through resternotomy in patients with prior sternotomy, using a nationwide registry. METHODS: Patients undergoing isolated MV surgery after prior cardiac surgery between 2013 and 2018 were included. Primary outcomes were short-term morbidity and mortality and mid-term survival. Cox proportional hazard analysis was used to investigate the association between surgical approach and mortality. Propensity score matching was used to correct for potential confounders. RESULTS: In total, 290 patients underwent MV surgery after prior cardiac surgery, of whom 205 patients were operated through resternotomy and 85 patients through MIMVS. No significant differences in 30-day mortality (3.4% vs 2%, P = 0.99) were observed between both groups. Five-year survival was 86.3% in the resternotomy group, compared to 89.4% in the MIMVS group (log-rank P = 0.45). In the multivariable analysis, surgical approach showed no relation with mid-term mortality [hazard ratio 0.73 (0.34-1.60); P = 0.44]. A lower incidence of prolonged intubation and new-onset arrhythmia was observed in MIMVS. CONCLUSIONS: MV surgery after prior cardiac surgery has excellent short- and mid-term results in the Netherlands, and MIMVS and resternotomy appear to be equally efficacious. MIMVS is associated with a lower incidence of new-onset arrhythmia and prolonged intubation