Syed Usman Bin Mahmood

Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm

Background: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height‐based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations. Methods: Aortic diameters and long‐term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared. Results: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m2) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five‐year complication‐free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic. Conclusions: Compared with indices including weight, the simpler height‐based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA.

Spontaneous rupture of the ascending aorta

Nontraumatic, spontaneous rupture of the ascending aorta is rare and the etiology is largely unknown.

Isolated Tricuspid Valvectomy: A Series of cases with Intravenous Drug Abuse Associated Tricuspid Valve Endocarditis

INTRODUCTIONnu2003Surgical management for tricuspid valve (TV) endocarditis is usually TV repair or replacement. When repair is not feasible, and concerns for patient recidivism preclude TV replacement, tricuspid valvectomy without replacement is an option to alleviate symptoms and allow time for addiction management.nnnMETHODSnu2003We reviewed our institutions experience with isolated tricuspid valvectomy for cases of intravenous drug use (IVDU)-associated endocarditis (nu2009=u20097) from 2009 to 2017.nnnRESULTSnu2003The decision for tricuspid valvectomy was based on each patients comorbid condition and realization of active IVDU. This intervention resulted in 100% perioperative and mid-term survival with a mean follow-up of 25.4 months. One patient required a valve replacement in the long term only after appropriate substance abuse management was completed.nnnCONCLUSIONnu2003Cardiac surgeons increasingly encounter patients with active endocarditis who suffer from IVDU addiction. Drug addiction increases the risk for recurrent endocarditis and requires an effective management plan. Multidisciplinary endocarditis care teams may play a pivotal role in improving outcomes by better addressing addiction treatment.

Recidivism Is the Leading Cause of Death Among Intravenous Drug Users Who Underwent Cardiac Surgery for Infective Endocarditis

The proportional incidence of intravenous drug use (IVDU)-associated infective endocarditis (IE) cases requiring surgery has increased significantly, mirroring the national opioid crisis. Recidivism is common but its impact on postoperative outcomes is unclear. We aimed to evaluate short- and mid-term postoperative outcomes associated with recidivism in this population. We retrospectively reviewed 180 consecutive patients (54 IVDU and 126 non-IVDU) surgically treated for IE from 2011 to 2016. The institutional database was linked to the Connecticut Department of Public Health Death Index to capture statewide long-term mortality and causes of death. Regression models were fitted to evaluate the association between IVDU status and perioperative adverse events, mid-term survival, and causes of death. IVDU patients were younger and had fewer comorbidities. Diabetes, hypertension, peripheral vascular disease, and previous coronary artery bypass graft were less frequently present in IVDU patients compared to non-IVDU patients (P < 0.05 for all). The Society of Thoracic Surgeons mortality prediction score for IE was lower in IVDU patients (22.9 vs 33.6, P < 0.001). IVDU was associated with a significantly increased risk of perioperative adverse events (odds ratio 2.88, 95% confidence interval 1.02-8.12) and increased risk of mid-term mortality (hazard ratio 2.2, 95% confidence interval 1.04-4.78, P = 0.04). The leading cause of death in IVDU patients was related to recidivism whereas that of non-IVDU patients was related to chronic conditions. IVDU patients who underwent cardiac surgery for IE experienced higher risks of perioperative adverse events and inferior mid-term survival compared to non-IVDU, despite being younger and having less comorbidities. Deaths in IVDU cohort were predominantly due to recidivism. Efforts to improve long-term outcome of patients presenting with IVDU IE should include drug addiction intervention and other strategies to reduce recidivism.

Comparable perioperative outcomes and mid-term survival in prosthetic valve endocarditis and native valve endocarditis

OBJECTIVESnCardiac surgery for prosthetic valve endocarditis (PVE) represents one of the highest risk surgeries with in-hospital mortality of 20%. Given the complex nature of the operation, the operative outcome is likely strongly susceptible to the surgeons experience and centre case volume, as measurements often are not apparent in large observational studies. We sought to evaluate operative outcomes and mid-term survival of patients with PVE compared with those of native valve endocarditis (NVE) at a tertiary care hospital.nnnMETHODSnWe conducted a single-institutional retrospective review of 188 consecutive patients (146 NVE and 42 PVE) undergoing cardiac surgery for endocarditis between 2011 and 2016 at a tertiary care hospital in the USA. A logistic regression model was fit to evaluate patient characteristics and perioperative outcomes in PVE and NVE: operative mortality and composite events (death, stroke, prolonged intubation, renal failure and sepsis). The Kaplan-Meier analysis was used to estimate the mid-term survival. The Cox proportional hazard model was fit to assess the adjusted risk associated with mid-term survival.nnnRESULTSnOperative mortality was 4.1% for NVE and 0% for PVE (Pu2009=u20090.34). Composite events occurred in 30.6% and 38.1% of NVE and PVE, respectively (Pu2009=u20090.45). Multivariable logistic regression for composite events showed that PVE was not associated with increased risk of adverse events [odds ratio 1.4, 95% confidence interval (CI) 0.6-3.4; Pu2009=u20090.49]. The Kaplan-Meier analysis demonstrated no statistically significant difference in survival (Pu2009=u20090.99). Finally, the Cox proportional hazard analysis for mid-term mortality demonstrated that PVE was not associated with increased risk for hazard of death: hazard ratio 0.4, 95% CI 0.2-1.1; Pu2009=u20090.085.nnnCONCLUSIONSnSurgery for PVE can yield a low mortality rate with mid-term survival comparable with those of NVE. The diagnosis of PVE alone should not deter surgeons from operating on this complex patient population, provided that surgical expertise and experienced multidisciplinary team equipped to handle complex clinical scenarios are available.

Trends in volume and risk profiles of patients undergoing isolated surgical and transcatheter aortic valve replacement

Recent reports describe increases in the case volume of surgical aortic valve replacement (SAVR) after centers establish a transcatheter aortic valve replacement (TAVR) program. We investigate contemporary temporal trends in SAVR and TAVR case volumes and risk profiles at a high volume academic medical center.

Incidence of endophthalmitis after intravitreal injections at a tertiary care hospital

OBJECTIVEnTo report the incidence of endophthalmitis after the use of intravitreal injection for anti-vascular endothelial growth factor therapy.nnnMETHODSnThis was a single-centre retrospective study conducted at the Aga Khan University Hospital, Pakistan. A total of 11xa0128 injections were administered to 2054 patients between January 2013 and December 2015. All procedures were performed in an operating room setting, and postinjection antibiotics were prescribed.nnnRESULTSnThree cases of endophthalmitis occurred during the study period, with the per-injection risk of endophthalmitis being 0.027%.nnnCONCLUSIONnThe results highlight the benefit of administering intravitreal injections in a surgical setting in addition to enforcing quality protocols. We also recommend further investigation to scrutinize the role of antibiotics prescribed after deploying intravitreal injections so that unnecessary use of such may be curtailed.

Thoracic aortic aneurysm: unlocking the “silent killer” secrets

Thoracic aortic aneurysm (TAA) is an increasingly recognized condition that is often diagnosed incidentally. This review discusses ten of the most relevant epidemiological and clinical secrets of this disease; (1) the difference in pathogenesis between ascending and descending TAAs. TAAs at these two sites act as different diseases, which is related to the different embryologic origins of the ascending and descending aorta. (2) The familial pattern and genetics of thoracic aneurysms. Syndromic TAAs only explain 5% of the pattern of inheritance. (3) The effect of female sex on TAA growth and outcome. Females have been found to have worse outcomes compared to males. (4) Guilt by Association. TAAs are associated with abdominal aortic aneurysms, intracranial aneurysms, bicuspid aortic valve, and inflammatory disorders. (5) Natural history of TAAs. Important findings have been made regarding the expansion rate (in relation to familial pattern, location and size), and also regarding the risk of rupture or dissection. (6) The aortic size paradox. Size only is not a sufficient predictor of risk of dissection. (7) Biomarker void. Although many serum biomarkers have been studied, imaging remains the only reliable method for diagnosis and follow-up. (8) Indications for repair. Decisions are made depending on symptoms, location, size, and familial patterns. (9) Types of repair. Both open and endovascular repair options are available for certain TAAs. (10) Medical treatment. The efficacy of prescribing beta blockers, angiotensin converting enzyme inhibitors or angiotensin receptor blockers remains dubious.

The Effect of Blood Transfusion on Outcomes in Aortic Surgery

Abstract The use of blood transfusion in cardiac surgery varies widely. The beneficial effects of blood products are offset by an increase in morbidity and mortality. Despite multiple studies showing an association between blood product exposure and adverse short‐ and long‐term events, it is difficult to determine causality. Nevertheless, the implication is sufficient to warrant the search for alternative strategies to reduce the use of blood products while providing a standard of care that optimizes postoperative outcomes. Aortic surgery, in particular, is associated with an increased risk of bleeding requiring a blood transfusion. There is a paucity of evidence within aortic surgery regarding the deleterious effects of blood products. Here, we review the current evidence regarding patient outcomes after blood transfusion in cardiac surgery, with special emphasis on aortic surgery.

Precipitous Resolution of Type-A Intramural Hematoma with Medical Management in a Patient with Metastatic Stage 4 Renal Cell Carcinoma

Abstract Intramural hematoma (IMH) is a variant form of aortic dissection characterized by involvement of the aortic media without the presence of an overt intimal flap. Surgical extirpation is the standard of care for type‐A IMH in the Western world. However, a conservative approach with anti‐impulse therapy has been advocated especially in Japan as a viable alternative. Here, we report a case of an elderly male patient with a history of metastatic stage 4 renal cell carcinoma who was treated with anti‐impulse therapy for an acute type‐A IMH. Blood pressure stabilization and continuous monitoring resulted in complete resolution of the IMH within 6 days. This report illustrates how immediate medical management in patients with acute type‐A IMH who are not surgical candidates can alleviate the progression or even lead to regression as early as 1 week after initiating anti‐impulse therapy.