Igor Zindovic

Late survival and heart failure after transcatheter aortic valve implantation.

Background Short-term survival in patients undergoing transcatheter aortic valve implantation is favorable. Our aim was to evaluate late survival and composite clinical endpoints specified by the Valve Academic Research Consortium-2, including rehospitalization for congestive heart failure. Methods Between January 2008 and April 2014, 166 consecutive patients with severe symptomatic aortic stenosis underwent 168 transcatheter aortic valve implantation procedures at our facility. This cohort was compared with propensity score-matched aortic valve replacement patients. Event rates were estimated by the Kaplan-Meier method and compared using the log-rank test. Cox regression analysis was performed to determine predictors of outcome. Results Although 30-day mortality rates following both procedures were similar (4.2% and 4.8%; p = 0.81), significant differences were seen in corresponding rates of survival (51.7% ± 5.8% vs. 72.3% ± 4.3%; p < 0.001) and cumulative rehospitalization for congestive heart failure (41.3% ± 7.2% vs. 23% ± 4.3%; p = 0.006). New York Heart Association functional class IV preoperative status was an independent risk factor for rehospitalization due to congestive heart failure (p = 0.015). Conclusions This study confirms the merit of transcatheter aortic valve implantation in high-risk patients with aortic stenosis, although late survival proved inferior to that of aortic valve replacement in propensity score-matched subjects. Early safety was excellent for both treatment groups, however, patients undergoing transcatheter aortic valve implantation had a higher incidence of rehospitalization for congestive heart failure and myocardial infarction during follow-up. Patients with severe congestive heart failure should be carefully monitored and aggressively treated to improve outcomes.

Medium-term survival after surgery for acute Type A aortic dissection is improving

OBJECTIVES To report long-term survival and predictors of mortality in patients included in a large, contemporary, multicentre, multinational database: Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD), which consists of 8 centres in 4 Nordic countries. METHODS Currently, NORCAAD includes 1159 patients operated between 2005 and 2014. In 30-day survivors (n = 955, 82%), the Kaplan-Meier and Cox proportional hazard methods were used to analyse medium-term (up to 8 years) survival and relative survival versus a matched normal population. Pre- and intraoperative predictors were expressed as hazard ratio (HR) with 95% confidence interval (95% CI). RESULTS Cumulative follow-up was 3514 patient-years with a median of 3.2 years (range 0-10.2 years). Survival was 95% (95% CI 93-96) at 1 year, 86% (95% CI 83-88) at 5 years and 76% (95% CI 72-81) at 8 years. Relative survival versus a matched normal population was 95% (95% CI 94-97) at 1 year, 90% (95% CI 87-93) at 5 years and 85% (95% CI 80-90) at 8 years. In multivariable analysis, increased age (HR 1.05 per year, 95% CI 1.04-1.07), previous abdominal or thoracic aortic repair (HR 3.2, 95% CI 1.6-6.4) and chronic renal disease (HR 2.7, 95% CI 1.2-6.2) were associated with increased medium-term mortality. Open distal anastomosis (HR 0.55, 95% CI 0.35-0.87) and operation in the 2010-2014 period (HR 0.90, 95% CI 0.83-0.97) were associated with decreased medium-term mortality. CONCLUSIONS Medium-term survival after acute Type A aortic dissection in the NORCAAD registry is satisfactory, close to a matched normal population and improved in the later part of the study period. The use of open distal anastomosis was associated with decreased medium-term mortality.

The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD): Objectives and Design

Abstract Objectives. The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) is a collaborative effort of Nordic cardiac surgery centers to study acute type A aortic dissection (ATAAD). Here, we outline the overall objectives and the design of NORCAAD. Design. NORCAAD currently consists of eight centers in Denmark, Finland, Iceland and Sweden. Data was collected for patients undergoing surgery for ATAAD from 2005 to 2014. A total of 194 variables were retrospectively collected including demographics, past medical history, preoperative medications, symptoms at presentation, operative variables, complications, bleeding and blood transfusions, need for late reoperations, 30-day mortality and long-term survival. Results. Information was gathered in the database for 1159 patients, of which 67.6% were male. The mean age was 61.5 ± 12.1 years. The mean follow-up was 3.1 ± 2.9 years with a total of 3535 patient years. Conclusions. NORCAAD provides a foundation for close collaboration between cardiac surgery centers in the Nordic countries. Substudies in progress include: short-term outcomes, long-term survival, time interval from diagnosis until operation, effects of surgical techniques, malperfusion syndrome, renal failure, bleeding and neurological complications on outcomes and the rate of late reoperations.

Generalized ischaemia in type A aortic dissections predicts early surgical outcomes only

OBJECTIVES In patients with acute type A aortic dissection (aTAAD), early post-surgical outcomes are largely influenced by preoperative conditions, specifically localized or generalized ischaemia. Such states are reflected in the recent Penn classification. Our aim was to determine the impact of preoperative ischaemia (by Penn class) on in-hospital and long-term mortality. METHODS All consecutive patients (n = 341) surgically treated for aTAAD between 1998 and 2014 were recruited for a retrospective observational study. Parameters impacting in-hospital and long-term mortality were identified through univariable and multivariable analyses. RESULTS In-hospital mortality rates by Penn class were as follows: Class Aa, 11%; Class Ab, 14%; Class Ac, 42% and Class Abc, 29%. Both Ac [odds ratio (OR) = 4.4; 95% confidence interval (CI), 1.92-9.80] and Abc (OR = 3.72; 95% CI, 1.26-10.99) classifications independently predicted in-hospital mortality, as did cardiopulmonary bypass time (OR = 1.01; 95% CI, 1.00-1.01). Relative to Class Aa patients, survival did not differ significantly in Class Ac and Abc subsets (log-rank P = 0.365 and P = 0.716, respectively), once 30-day postoperative deaths were excluded. The leading cause of late mortality was cardiac failure or myocardial infarction (29%), followed by aortic rupture (25%). Independent predictors of long-term mortality after aTAAD were age [hazard ratio (HR) = 1.08; 95% CI, 1.05-1.10] and supracoronary replacement graft (HR = 2.27; 95% CI, 1.1-4.75). CONCLUSIONS Penn classes Ac and Abc were identified as an independent risk factor for in-hospital mortality, whereas neither Penn class nor organ-specific ischaemia significantly impacted long-term survival. Regardless of ischaemic manifestations at presentation, the prognosis of patients surviving both surgery and early postoperative period proved acceptable.

Low rate of reoperations after acute type A aortic dissection repair from The Nordic Consortium Registry

Objectives To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. Methods A retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low‐ to medium‐sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine‐Gray competing risk regression model was used to identify independent risk factors for reoperation. Results The median follow‐up was 2.7 years (range, 0‐10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. Conclusions Type A aortic dissection repair in low‐ to medium‐volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.

Hospital volumes and later year of operation correlates with better outcomes in acute Type A aortic dissection

OBJECTIVES Acute Type A aortic dissection remains a life-threatening disease, but there are indications that its surgical mortality is decreasing. The aim of this report was to study how surgical mortality has changed and what influences those changes. METHODS Nordic Consortium for Acute Type A Aortic Dissection is a retrospective database comprising 1159 patients (mean age 61.6 ± 12.2 years, 68% male) treated for acute Type A aortic dissection at 8 centres in Denmark, Finland, Iceland and Sweden from 2005 to 2014. Data gathered included demographics, symptoms, type of procedure, complications and 30-day mortality. RESULTS The annual number of operations increased significantly from 85 in 2005 to 150 in 2014 (P < 0.001). Chest pain was present in 85% of patients, 24% were hypotensive on presentation and 28% had malperfusion syndrome. Open distal anastomosis technique under hypothermic circulatory arrest was used in 85% of cases and its use increased significantly throughout the study. The 30-day mortality decreased from 24% in 2005 to 13% in 2014 (P = 0.003). Independent predictors for 30-day mortality were preoperative cardiac arrest, malperfusion syndrome, Penn Class C, Penn Class B and C and cardiopulmonary bypass time, whereas later calendar year and higher hospital operative volumes predicted improved survival. CONCLUSIONS Surgical mortality for acute Type A aortic dissection remains high but has decreased significantly over the last decade. This correlated with later year of operation and increased the number of operations performed per year, indicating that cumulative surgical experience contributes significantly to improved surgical outcomes.

Recombinant factor VIIa use in acute type A aortic dissection repair: A multicenter propensity-score-matched report from the Nordic Consortium for Acute Type A Aortic Dissection

Background: Surgery for acute type A aortic dissection (ATAAD) is often complicated by excessive bleeding. Recombinant factor VIIa (rFVIIa) effectively treats refractory bleeding associated with ATAAD surgery; however, adverse effects of rFVIIa in these patients have not been fully assessed. Here we evaluated rFVIIa treatment in ATAAD surgery using the Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database. Methods: This was a multicenter, propensity score–matched, retrospective study. Information about rFVIIa use was available for 761 patients, of whom 171 were treated with rFVIIa. We successfully matched 120 patients treated with rFVIIa with 120 controls. Primary endpoints were in‐hospital mortality, postoperative stroke, and renal replacement therapy (RRT). Survival data were presented using Kaplan‐Meier estimates. Results: Compared with controls, patients treated with rFVIIa received more transfusions of packed red blood cells (median, 9.0 U [4.0–17.0 U] vs 5.0 U [2.0–11.0 U]; P = .008), platelets (4.0 U [2.0–8.0 U] vs 2.0 U [1.0–4.4 U]; P <.001), and fresh frozen plasma (8.0 U [4.0–18.0 U] vs 5.5 U [2.0–10.3 U]; P = .01) underwent reexploration for bleeding more often (31.0% vs 16.8%; P = .014); and had greater 24‐hour chest tube output (1500 L [835–2500 mL] vs 990 mL [520–1720 mL]). Treatment with rFVIIa was not associated with significantly increased rates of in‐hospital mortality (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.34–1.55; P = .487), postoperative stroke (OR, 1.75; 95% CI, 0.82–3.91; P = .163), or RRT (OR, 1.18; 95% CI, 0.48–2.92; P = .839). Conclusions: In this propensity‐matched cohort study of patients undergoing ATAAD surgery, treatment with rFVIIa for major bleeding was not associated with a significantly increased risk of stroke, RRT, or mortality.

Predictors and impact of massive bleeding in acute type A aortic dissection

Objectives Bleeding complications associated with acute type A aortic dissection (aTAAD) are a well-known clinical problem. Here, we evaluated predictors of massive bleeding related to aTAAD and associated surgery and assessed the impact of massive bleeding on complications and survival. Methods This retrospective study of 256 patients used Blood Conservation Using Antifibrinolytics in a Randomized Trial (BART) criteria to define massive bleeding, which was met by 66 individuals (Group I) who were compared to the remaining patients (Group II). Multivariable logistic regression was used to identify independent predictors of massive bleeding and in-hospital mortality, Kaplan-Meier estimates for analysis of late survival, and Cox regression analysis to evaluate independent predictors of late mortality. Results Independent predictors of massive bleeding included symptom duration (odds ratio [OR], 0.974 per hour increment; 95% confidence interval [CI], 0.950-0.999; P  =   0.041) and DeBakey type 1 dissection (OR, 2.652; 95% CI, 1.004-7.008; P  =   0.049). In-hospital mortality was higher in Group I (30.3% vs 8.0%, P  <0.001). Kaplan-Meier estimates of survival indicated poorer survival for Group I at 1, 3 and 5 years (68.8 ± 5.9% vs 92.8 ± 1.9%; 65.2 ± 6.2% vs 85.3 ± 2.7%; 53.9 ± 6.9% vs 82.1 ± 3.3 %, respectively; log rank P  <   0.001). Re-exploration for bleeding was an independent predictor of in-hospital (OR, 3.109; 95% CI, 1.044-9.256; P  =   0.042) and late mortalities (hazard ratio, 3.039; 95% CI, 1.605-5.757; P  =   0.001). Conclusions Massive bleeding in patients with aTAAD is prompted by shorter symptom duration and longer extent of dissection and has deleterious effects on outcomes of postoperative complications as well as in-hospital and late mortalities.

Differential Outcomes of Open and Clamp-on Distal Anastomosis Techniques in Acute Type A Aortic Dissection

Objectives: Open‐distal anastomosis is the preferred technique over clamp‐on technique for surgical repair of acute type A aortic dissection (ATAAD). The aim of this study was to define how outcomes of ATAAD were affected by the use of either technique. Methods: Nordic Consortium for Acute Type A Aortic Dissection includes 8 academic cardiothoracic hospitals in 4 Nordic countries. The cohort consisted of 1134 patients, 153 clamp‐on and 981 open‐distal, from 2005 to 2014. Results: Patients who underwent operation with the clamp‐on were younger, more frequently had coronary artery disease, bicuspid aortic valve, hypotension/shock or syncope, and a greater PennClass than open‐distal patients. Postoperative cerebral vascular accident occurred less frequently in clamp‐on (14/153, 10%) compared with the open‐distal group (190/981, 20%). Clamp‐on had greater 30‐day mortality (39/153, 25%) than the open‐distal group (158/981, 16%), and 5‐year survival was also worse in clamp‐on (61.8% ± 4.4%) compared with the open‐distal group (73.0% ± 1.6%). The open‐distal technique was used more frequently in greater‐volume hospitals but was not independently associated with 30‐day mortality. Preoperative condition was an independent risk factor whereas hospital volume and later year of operation were beneficial in regard to short‐term outcome. Open‐distal was independently associated with improved mid‐term survival. Conclusions: Patients who underwent operation with the clamp‐on were sicker on presentation and had worse short‐ and mid‐term survival compared with the open‐distal group. Patients in the open‐distal group had greater rates of cerebrovascular complications. The results support the routine use of open‐distal anastomosis as the primary operative strategy for ATAAD, although clamp‐on can be performed successfully in select cases.

Perioperative Hyperlactemia Is a Poor Predictor of Outcome in Patients Undergoing Surgery for Acute Type-A Aortic Dissection

OBJECTIVE In patients presenting with acute type-A aortic dissection (aTAAD), lactic acid measurement is a frequently used analysis for diagnosis of acute ischemia, which may have a dismal prognosis. The aim of the current study was to determine the performance of perioperative arterial lactic acid measurements in predicting outcome in aTAAD patients. DESIGN Retrospective, observational study. SETTING Cardiothoracic surgery unit at a tertiary-level hospital. PARTICIPANTS The study involved 285 consecutive patients undergoing surgery for aTAAD. INTERVENTIONS Preoperative and postoperative lactic acid levels were measured and evaluated together with clinical data related to outcome, including in-hospital and 1-year mortality. MEASUREMENTS AND MAIN RESULTS Altogether, 37 patients (13%) died during the index hospital admission, and survival was 84.4 ± 2.2 at 1 year. Preoperative cardiac malperfusion (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.3-7.3) and cerebral malperfusion (OR 2.6; 95% CI 1.2-5.6) were associated significantly with poorer 1-year survival. The area under the curve (AUC) for in-hospital and 1-year mortality in relation to preoperative lactic acid levels was 0.684 and 0.673, respectively, corresponding to a lactic acid cut-off for in-hospital mortality of 2.75 mmol/L (sensitivity 56%; specificity 72%) and a cut-off for 1-year mortality of 2.85 mmol/L (sensitivity 48%; specificity 74%). The AUC for in-hospital and 1-year mortality in relation to lactic acid levels measured postoperatively on arrival at the intensive care unit was 0.582 and 0.498, respectively. CONCLUSION Although hyperlactemia in aTAAD indicates an increased risk of postoperative mortality, the sole use of lactic acid levels as a tool for accurate assessment of postoperative mortality is inadvisable due to its poor discriminatory performance.