Publications by authors named "Fausto Biancari"

303 Publications

Sex based analysis of the impact of red blood cell transfusion and vascular or bleeding complications related to TAVI - The TRITAVI-Women Study.

Int J Cardiol 2021 Mar 1. Epub 2021 Mar 1.

CIBERCV, Hospital Clínico Universitario de Valladolid, Spain.

Background: Women present specific risks for transcatheter aortic valve replacement (TAVI) but there are scarce sex-based analysis. The aim of this study was to explore the risk of vascular/bleeding complications in females vs. males that underwent TAVI and the impact of red blood cell (RBC) transfusion.

Methods: TRITAVI-Women is a retrospective analysis in 13 European institutions. Propensity score based on pairs of different sex was performed and global outcomes, vascular/bleeding risk factors were determined. Afterwards, the female population of the study was divided into two groups according to the need of RBC transfusion and the risk for mortality, AKI, MI, stroke at 30-days and at 1-year were compared as a combined endpoint (primary endpoint) and separately (secondary endpoints).

Results: The global study population included 5837 patients. Females presented more advanced NYHA class, chronic kidney disease, and baseline anemia. Vascular/bleeding complications and RBC transfusion were more common in women. However, 1-year mortality was lower for women in the matched cohort (8.1% vs.10.3%, p = 0.028). The need for RBC transfusion was an independent predictor of higher incidence of the primary endpoint at 30-day and 1-year. The main predictor of RBC transfusion in women was the presence of baseline anemia.

Conclusions: Women present lower risk of mortality than men at 1-year follow up, but not at 30-day due to higher rates of vascular/bleeding complications. RBC transfusion was also more often required in women and was an independent predictor or poorer outcomes. The treatment of pre-existing anemia before TAVI might improve the short-term results in women.
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http://dx.doi.org/10.1016/j.ijcard.2021.02.066DOI Listing
March 2021

Five-year survival after post-cardiotomy veno-arterial extracorporeal membrane oxygenation.

Eur Heart J Acute Cardiovasc Care 2021 Jan 12. Epub 2021 Jan 12.

Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany.

Aims : Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiogenic shock (PCS) after adult cardiac surgery is associated with satisfactory hospital survival. However, data on long-term survival of these critically ill patients are scarce.

Methods And Results: Between January 2010 and March 2018, 665 consecutive patients received VA-ECMO for PCS at 17 cardiac surgery centres and herein we evaluated their 5-year survival. The mean follow-up of this cohort was 1.7 ± 2.7 years (for hospital survivors, 4.6 ± 2.5 years). In this cohort, 240 (36.1%) patients survived to hospital discharge. Five-year survival of all patients was 27.7%. The PC-ECMO score was predictive of 5-year survival in these patients (0 point, 50.9%; 1 point, 44.9%; 2 points, 40.0%; 3 points, 34.7%; 4 points, 21.0%; 5 points, 17.6%; ≥6 points, 10.7%; P < 0.0001). Age was among factors independently associated with late survival, patients >70 years old having a remarkably poor 5-year survival (<60 years: 39.2%; 60-69 years: 29.9%; 70-79 years: 12.3%; ≥80 years: 13.0%, P < 0.0001). Implantation of a ventricular assist device or heart transplant was performed in 3.2% of patients and their 5-year survival was 42.9% (for heart transplant, 63.6%).

Conclusion : Veno-arterial extracorporeal membrane oxygenation for PCS is associated with satisfactory 5-year survival in young patients without critical pre-ECMO conditions. The use of VA-ECMO for PCS in patients >70 years should be considered only after a judicious scrutiny of patient's life expectancy. Future studies should evaluate whether satisfactory mid-term survival of these patients translates into a good functional outcome.

Trial Registration: Clinicaltrials.gov-NCT03508505.
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http://dx.doi.org/10.1093/ehjacc/zuaa039DOI Listing
January 2021

A novel, comprehensive tool for predicting 30-day mortality after surgical aortic valve replacement.

Eur J Cardiothorac Surg 2021 Feb 12. Epub 2021 Feb 12.

National Centre for Global Health, Istituto Superiore di Sanità, Rome, Italy.

Objectives: We sought to develop and validate a novel risk assessment tool for the prediction of 30-day mortality after surgical aortic valve replacement incorporating a patient's frailty.

Methods: Overall, 4718 patients from the multicentre study OBSERVANT was divided into derivation (n = 3539) and validation (n = 1179) cohorts. A stepwise logistic regression procedure and a criterion based on Akaike information criteria index were used to select variables associated with 30-day mortality. The performance of the regression model was compared with that of European System for Cardiac Operative Risk Evaluation (EuroSCORE) II.

Results: At 30 days, 90 (2.54%) and 35 (2.97%) patients died in the development and validation data sets, respectively. Age, chronic obstructive pulmonary disease, concomitant coronary revascularization, frailty stratified according to the Geriatric Status Scale, urgent procedure and estimated glomerular filtration rate were independent predictors of 30-day mortality. The estimated OBS AVR score showed higher discrimination (area under curve 0.76 vs 0.70, P < 0.001) and calibration (Hosmer-Lemeshow P = 0.847 vs P = 0.130) than the EuroSCORE II. The higher performances of the OBS AVR score were confirmed by the decision curve, net reclassification index (0.46, P = 0.011) and integrated discrimination improvement (0.02, P < 0.001) analyses. Five-year mortality increased significantly along increasing deciles of the OBS AVR score (P < 0.001).

Conclusions: The OBS AVR risk score showed high discrimination and calibration abilities in predicting 30-day mortality after surgical aortic valve replacement. The addition of a simplified frailty assessment into the model seems to contribute to an improved predictive ability over the EuroSCORE II. The OBS AVR risk score showed a significant association with long-term mortality.
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http://dx.doi.org/10.1093/ejcts/ezaa375DOI Listing
February 2021

Six-Month Survival After Extracorporeal Membrane Oxygenation for Severe COVID-19.

J Cardiothorac Vasc Anesth 2021 Jan 19. Epub 2021 Jan 19.

Service de Chirurgie Thoracique et Cardio-vasculaire, Hôpital Henri-Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France.

Objectives: The authors evaluated the outcome of adult patients with coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS) requiring the use of extracorporeal membrane oxygenation (ECMO).

Design: Multicenter retrospective, observational study.

Setting: Ten tertiary referral university and community hospitals.

Participants: Patients with confirmed severe COVID-19-related ARDS.

Interventions: Venovenous or venoarterial ECMO.

Measurements And Main Results: One hundred thirty-two patients (mean age 51.1 ± 9.7 years, female 17.4%) were treated with ECMO for confirmed severe COVID-19-related ARDS. Before ECMO, the mean Sequential Organ Failure Assessment score was 10.1 ± 4.4, mean pH was 7.23 ± 0.09, and mean PaO/fraction of inspired oxygen ratio was 77 ± 50 mmHg. Venovenous ECMO was adopted in 122 patients (92.4%) and venoarterial ECMO in ten patients (7.6%) (mean duration, 14.6 ± 11.0 days). Sixty-three (47.7%) patients died on ECMO and 70 (53.0%) during the index hospitalization. Six-month all-cause mortality was 53.0%. Advanced age (per year, hazard ratio [HR] 1.026, 95% CI 1.000-1-052) and low arterial pH (per unit, HR 0.006, 95% CI 0.000-0.083) before ECMO were the only baseline variables associated with increased risk of six-month mortality.

Conclusions: The present findings suggested that about half of adult patients with severe COVID-19-related ARDS can be managed successfully with ECMO with sustained results at six months. Decreased arterial pH before ECMO was associated significantly with early mortality. Therefore, the authors hypothesized that initiation of ECMO therapy before severe metabolic derangements subset may improve survival rates significantly in these patients. These results should be viewed in the light of a strict patient selection policy and may not be replicated in patients with advanced age or multiple comorbidities.

Clinical Trial Registration: identifier, NCT04383678.
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http://dx.doi.org/10.1053/j.jvca.2021.01.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7816613PMC
January 2021

Comparative Analysis of Three-Versus Two-dimensional Imaging in Laparoscopic Cholecystectomy.

World J Surg 2021 Jan 21. Epub 2021 Jan 21.

Department of Surgery, Kainuu Central Hospital, Sotkamontie 13, 87300, Kajaani, Finland.

Background: Three-dimensional (3D) imaging has been suggested to improve learning and performance of laparoscopy. We sought to investigate whether 3D imaging could improve the outcomes after laparoscopic cholecystectomy.

Materials And Methods: Two-hundred and forty-one consecutive patients underwent elective or urgent laparoscopic cholecystectomy using 2D (n = 111) and 3D (n = 130) imaging equipments from March 2017 to March 2019 at the Kainuu Central Hospital, Finland. The main outcomes of this study were biliary tract injury, conversion to open procedure and procedure duration.

Results: In the overall series, there were 5 cases of biliary tract injury (2.1%). When compared to 3D imaging, 2D was associated with increased risk of biliary tract injury in the overall series (0% in 3D vs. 4.7% in 2D, p = 0.026) in addition to a subgroup of acute cholecystitis patients operated by senior surgeons (n = 92), 0% in 3D group (n = 60) vs. 10.0% in 2D group (n = 32), p = 0.037 in univariate analysis. The rates of conversion to open surgery did not differ between the groups in the overall series (5.3 vs 5.7%, p = 0.909) or any of the subgroups. Duration of surgery with 3D vs. 2D imaging were comparable in the elective (57.0 ± 16.3 vs. 54.1 ± 18.9 min, p = 0.228) and urgent setting (66.9 ± 15.1 vs. 67.4 ± 16.6 min, p = 0.805). Such differences were not significant in multivariate analysis.

Conclusions: The present study suggests that the use of 3D imaging is significantly associated with a reduced risk of intraoperative biliary tract injury during laparoscopic cholecystectomy especially in acute cholecystitis.
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http://dx.doi.org/10.1007/s00268-020-05934-zDOI Listing
January 2021

Neurologic Injury in Patients Treated With Extracorporeal Membrane Oxygenation for Postcardiotomy Cardiogenic Shock.

J Cardiothorac Vasc Anesth 2020 Nov 5. Epub 2020 Nov 5.

Department of Cardiothoracic Surgery, Skane University Hospital and Lund University, Lund, Sweden. Electronic address:

Objective: To investigate the frequency, predictors, and outcomes of neurologic injury in adults treated with postcardiotomy extracorporeal membrane oxygenation (PC-ECMO).

Design: A retrospective multicenter registry study.

Setting: Twenty-one European institutions where cardiac surgery is performed.

Participants: A total of 781 adult patients who required PC-ECMO during 2010 to 2018 were divided into patients with neurologic injury (NI) and patients without neurologic injury (NNI).

Measurements And Main Results: Baseline and operative data, in-hospital outcomes, and long-term survival were compared between the NI and the NNI groups. Predictors of neurologic injury were identified. A subgroup analysis according to the type of neurologic injury was performed. Overall, NI occurred in 19% of patients in the overall series, but the proportion of patients with NI ranged from 0% to 65% among the centers. Ischemic stroke occurred in 84 patients and hemorrhagic stroke in 47 patients. Emergency procedure was the sole independent predictor of NI. In-hospital mortality was higher in the NI group than in the NNI group (79% v 61%, p < 0.001). The one-year survival was lower in the NI group (17%) compared with the NNI group (37%). Long-term survival did not differ between patients with ischemic stroke and those with hemorrhagic stroke.

Conclusion: Neurologic injury during PC-ECMO is common and associated with a dismal prognosis. There is considerable interinstitutional variation in the proportion of neurologic injury in PC-ECMO-treated adults. Well-known risk factors for stroke are not associated with neurologic injury in this setting.
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http://dx.doi.org/10.1053/j.jvca.2020.11.004DOI Listing
November 2020

Lack of standard definition of active cancer in patients undergoing cardiovascular interventions.

Authors:
Fausto Biancari

Int J Cardiol 2021 Mar 28;327:175. Epub 2020 Nov 28.

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland; Department of Surgery, University of Turku, Turku, Finland. Electronic address:

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http://dx.doi.org/10.1016/j.ijcard.2020.11.057DOI Listing
March 2021

Duration of Venoarterial Extracorporeal Membrane Oxygenation and Mortality in Postcardiotomy Cardiogenic Shock.

J Cardiothorac Vasc Anesth 2020 Nov 5. Epub 2020 Nov 5.

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland; Department of Surgery, University of Turku, Turku, Finland.

Objective: The optimal duration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in patients affected by postcardiotomy cardiogenic shock (PCS) remains controversial. The present study was conducted to investigate the effect of VA-ECMO duration on hospital outcomes.

Design: Retrospective analysis of an international registry.

Setting: Multicenter study including 19 tertiary university hospitals.

Participants: Between January 2010 and March 2018, data on PCS patients receiving VA-ECMO were retrieved from the multicenter PC-ECMO registry.

Interventions: Patients were stratified according to the following different durations of VA-ECMO therapy: ≤three days, four-to-seven days, eight-to-ten days, and >ten days.

Measurements And Main Results: A total of 725 patients, with a mean age of 62.9 ± 12.9 years, were included. The mean duration of VA-ECMO was 7.1 ± 6.3 days (range 0-39 d), and 39.4% of patients were supported for ≤three days, 29.1% for four-seven days, 15.3% for eight-ten days, and finally 20.7% for >ten days. A total of 391 (53.9%) patients were weaned from VA-ECMO successfully; however, 134 (34.3%) of those patients died before discharge. Multivariate logistic regression showed that prolonged duration of VA-ECMO therapy (four-seven days: adjusted rate 53.6%, odds ratio [OR] 0.28, 95% confidence interval [CI] 0.18-0.44; eight-ten days: adjusted rate 61.3%, OR 0.51, 95% CI 0.29-0.87; and >ten days: adjusted rate 59.3%, OR 0.49, 95% CI 0.31-0.81) was associated with lower risk of mortality compared with VA-ECMO lasting ≤three days (adjusted rate 78.3%). Patients requiring VA-ECMO therapy for eight-ten days (OR 1.96, 95% CI 1.15-3.33) and >10 days (OR 1.85, 95% CI 1.14-3.02) had significantly greater mortality compared with those on VA-ECMO for 4 to 7 days.

Conclusions: PCS patients weaned from VA-ECMO after four-seven days of support had significantly less mortality compared with those with shorter or longer mechanical support.
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http://dx.doi.org/10.1053/j.jvca.2020.11.003DOI Listing
November 2020

Global and segmental absolute stress myocardial blood flow in prediction of cardiac events: [O] water positron emission tomography study.

Eur J Nucl Med Mol Imaging 2020 Nov 11. Epub 2020 Nov 11.

Turku PET Centre, Turku University Hospital and University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.

Purpose: We evaluated the value of reduced global and segmental absolute stress myocardial blood flow (sMBF) quantified by [O] water positron emission tomography (PET) for predicting cardiac events in patients with suspected obstructive coronary artery disease (CAD).

Methods: Global and segmental sMBF during adenosine stress were retrospectively quantified in 530 symptomatic patients who underwent [O] water PET for evaluation of coronary stenosis detected by coronary computed tomography angiography.

Results: Cardiovascular death, myocardial infarction, or unstable angina occurred in 28 (5.3%) patients at a 4-year follow-up. Reduced global sMBF was associated with events (area under the receiver operating characteristic curve 0.622, 95% confidence interval (95% CI) 0.538-0.707, p = 0.006). Reduced global sMBF (< 2.2 ml/g/min) was found in 22.8%, preserved global sMBF despite segmentally reduced sMBF in 35.3%, and normal sMBF in 41.9% of patients. Compared with normal sMBF, reduced global sMBF was associated with the highest risk of events (adjusted hazard ratio (HR) 6.970, 95% CI 2.271-21.396, p = 0.001), whereas segmentally reduced sMBF combined with preserved global MBF predicted an intermediate risk (adjusted HR 3.251, 95% CI 1.030-10.257, p = 0.044). The addition of global or segmental reduction of sMBF to clinical risk factors improved risk prediction (net reclassification index 0.498, 95% CI 0.118-0.879, p = 0.010, and 0.583, 95% CI 0.203-0.963, p = 0.002, respectively).

Conclusion: In symptomatic patients evaluated for suspected obstructive CAD, reduced global sMBF by [O] water PET identifies those at the highest risk of adverse cardiac events, whereas segmental reduction of sMBF with preserved global sMBF is associated with an intermediate event risk.
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http://dx.doi.org/10.1007/s00259-020-05093-2DOI Listing
November 2020

Cerebral Oximetry Monitoring in Patients Undergoing Surgery for Stanford Type A Aortic Dissection.

J Cardiothorac Vasc Anesth 2020 Oct 13. Epub 2020 Oct 13.

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland.

Objectives: The aim of this study was to evaluate the prognostic impact of cerebral regional oxygen saturation (crSO) in patients undergoing surgery for Stanford type A aortic dissection (TAAD).

Design: Observational, retrospective, institutional study.

Setting: University hospital.

Participants: A total of 152 patients who underwent surgery for TAAD from June 2009 to December 2018 at the authors' institution.

Interventions: Surgery for TAAD using continuous perioperative monitoring of crSO with near-infrared cerebral oximetry (INVOS, Medtronic, MN).

Measurements And Results: The rates of postoperative stroke/global brain ischemia were 22.4% and of hospital mortality 14.5%. Age, hemoglobin, and cardiogenic shock were independent predictors of nadir crSO from both frontal areas at arrival to the operating room. Repeated measures test showed that changes in crSO between the first measurement at operating room arrival, at the start of surgery, and at the end of surgery were not significant when measured on the right frontal area (p = 0.632), left frontal area (p = 0.608), as a nadir value from both frontal areas (p = 0.690), and as a difference between frontal areas (p = 0.826) in patients with and without major neurologic complications. Patients who had a nadir crSO <40% anytime during the perioperative period, had a numerically higher rate of major neurologic complications (27.3% v 20.4%, p = 0.354), but this difference did not reach statistical significance. The incidence of nadir of crSO value <40% at operating room arrival (5.9%, p = 1.000), at the start of surgery (5.3%, p = 0.685), and at the end of surgery (1.3%, p = 1.000) was rather low and not associated with these adverse events.

Conclusions: Derangements in crSO detected by cerebral oximetry before and during surgery for TAAD did not predict postoperative stroke and/or global brain ischemia.
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http://dx.doi.org/10.1053/j.jvca.2020.10.011DOI Listing
October 2020

Transcatheter and surgical aortic valve replacement in patients with bicuspid aortic valve.

Clin Res Cardiol 2021 Mar 24;110(3):429-439. Epub 2020 Oct 24.

Heart Center, Turku University Hospital, and University of Turku, Turku, Finland.

Objectives: To compare the outcomes after surgical (SAVR) and transcatheter aortic valve replacement (TAVR) for severe stenosis of bicuspid aortic valve (BAV).

Methods: We evaluated the early and mid-term outcome of patients with stenotic BAV who underwent SAVR or TAVR for aortic stenosis from the nationwide FinnValve registry.

Results: The FinnValve registry included 6463 AS patients and 1023 (15.8%) of them had BAV. SAVR was performed in 920 patients and TAVR in 103 patients with BAV. In the overall series, device success after TAVR was comparable to SAVR (94.2% vs. 97.1%, p = 0.115). TAVR was associated with increased rate of mild-to-severe paravalvular regurgitation (PVR) (19.4% vs. 7.9%, p < 0.0001) and of moderate-to-severe PVR (2.9% vs. 0.7%, p = 0.053). When newer-generation TAVR devices were evaluated, mild-to-severe PVR (11.9% vs. 7.9%, p = 0.223) and moderate-to-severe PVR (0% vs. 0.7%, p = 1.000) were comparable to SAVR. Type 1 N-L and type 2 L-R/R-N were the BAV morphologies with higher incidence of mild-to-severe PVR (37.5% and 100%, adjusted for new-generation prostheses p = 0.025) compared to other types of BAVs. Among 75 propensity score-matched cohorts, 30-day mortality was 1.3% after TAVR and 5.3% after SAVR (p = 0.375), and 2-year mortality was 9.7% after TAVR and 18.7% after SAVR (p = 0.268) CONCLUSIONS: In patients with stenotic BAV, TAVR seems to achieve early and mid-term results comparable to SAVR. Type 1 N-L and type 2 L-R/R-N BAV morphologies had higher incidence of PVR. Larger studies evaluating different phenotypes of BAV are needed to confirm these findings.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03385915.
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http://dx.doi.org/10.1007/s00392-020-01761-3DOI Listing
March 2021

Impact of paravalvular regurgitation on the mid-term outcome after transcatheter and surgical aortic valve replacement.

Eur J Cardiothorac Surg 2020 12;58(6):1145-1152

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.

Objectives: The aim of this study was to evaluate the incidence and prognostic impact of paravalvular regurgitation (PVR) on the outcome after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis.

Methods: The nationwide FinnValve registry included data on 6463 consecutive patients who underwent TAVR (n = 2130) or SAVR (n = 4333) with a bioprosthesis for the treatment of aortic stenosis during 2008-2017. The impact of PVR at discharge after TAVR and SAVR on 4-year mortality was herein investigated.

Results: The rate of mild PVR was 21.7% after TAVR and 5.2% after SAVR. The rate of moderate-to-severe PVR was 3.7% after TAVR and 0.7% after SAVR. After TAVR, 4-year survival was 69.0% in patients with none-to-trace PVR, 54.2% with mild PVR [adjusted hazard ratio (HR) 1.64, 95% confidence interval (CI) 1.35-1.99] and 48.9% with moderate-to-severe PVR (adjusted HR 1.61, 95% CI 1.10-2.35). Freedom from PVR-related reinterventions was 100% for none-to-mild PVR and 95.2% for moderate-to-severe PVR. After SAVR, mild PVR (4-year survival 78.9%; adjusted HR 1.29, 95% CI 0.93-1.78) and moderate-to-severe PVR (4-year survival 67.8%; adjusted HR 1.36, 95% CI 0.72-2.58) were associated with worse 4-year survival compared to none-to-trace PVR (4-year survival 83.7%), but the difference did not reach statistical significance in multivariable analysis. Freedom from PVR-related reinterventions was 99.5% for none-to-trace PVR patients, 97.9% for mild PVR patients and 77.0% for moderate-to-severe PVR patients.

Conclusions: This multicentre study showed that both mild and moderate-to-severe PVR were independent predictors of worse survival after TAVR. Mild and moderate-to-severe PVR are not frequent after SAVR, but tend to decrease survival also in these patients.

Clinical Trial Registration Number: ClinicalTrials.gov Identifier: NCT03385915.
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http://dx.doi.org/10.1093/ejcts/ezaa254DOI Listing
December 2020

Subtype of atrial fibrillation and the outcome of transcatheter aortic valve replacement: The FinnValve Study.

PLoS One 2020 11;15(9):e0238953. Epub 2020 Sep 11.

Heart Center, Turku University Hospital and University of Turku, Turku, Finland.

Whether the subtype of atrial fibrillation affects outcomes after transcatheter aortic valve replacement for aortic stenosis is unclear. The nationwide FinnValve registry included 2130 patients who underwent primary after transcatheter aortic valve replacement for aortic stenosis during 2008-2017. Altogether, 281 (13.2%) patients had pre-existing paroxysmal atrial fibrillation, 651 (30.6%) had pre-existing non-paroxysmal atrial fibrillation and 160 (7.5%) were diagnosed with new-onset atrial fibrillation during the index hospitalization. The median follow-up was 2.4 (interquartile range: 1.6-3.8) years. Paroxysmal atrial fibrillation did not affect 30-day or overall mortality (p-values >0.05). Non-paroxysmal atrial fibrillation demonstrated an increased risk of overall mortality (hazard ratio: 1.61, 95% confidence interval: 1.35-1.92; p<0.001), but not 30-day mortality (p = 0.084). New-onset atrial fibrillation demonstrated significantly increased 30-day mortality (hazard ratio: 2.76, 95% confidence interval: 1.25-6.09; p = 0.010) and overall mortality (hazard ratio: 1.68, 95% confidence interval: 1.29-2.19; p<0.001). The incidence of early or late stroke did not differ between atrial fibrillation subtypes (p-values >0.05). In conclusion, non-paroxysmal atrial fibrillation and new-onset atrial fibrillation are associated with increased mortality after transcatheter aortic valve replacement for aortic stenosis, whereas paroxysmal atrial fibrillation has no effect on mortality. These findings suggest that non-paroxysmal atrial fibrillation rather than paroxysmal atrial fibrillation may be associated with structural cardiac damage which is of prognostic significance in patients with aortic stenosis undergoing transcatheter aortic valve replacement.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238953PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7485765PMC
November 2020

Late Outcome after Surgery for Type-A Aortic Dissection.

J Clin Med 2020 Aug 24;9(9). Epub 2020 Aug 24.

Heart and Lung Center, Helsinki University Hospital, 00029 Helsinki, Finland.

The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta ≥35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316-12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193-10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067-9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.
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http://dx.doi.org/10.3390/jcm9092731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7563246PMC
August 2020

Patient-Prosthesis Mismatch Mismatch Worsens Long-Term Survival: Insights From the FinnValve Registry.

Ann Thorac Surg 2020 Aug 15. Epub 2020 Aug 15.

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.

Background: The impact of patient-prosthesis mismatch (PPM) on long-term outcome after surgical aortic valve replacement (SAVR) is controversial. We sought to investigate the incidence of PPM and its impact on survival and reinterventions in a Finnish nationwide cohort.

Methods: In the context of the nationwide FinnValve registry, we identified 4097 patients who underwent SAVR with a stented bioprosthesis with or without myocardial revascularization. The indexed effective orifice areas (EOAs) of surgical bioprostheses were calculated using literature-derived EOAs. PPM was graded as moderate (EOA 0.65-0.85 cm/m) or severe (EOA ≤0.65 cm/m).

Results: The incidence of PPM was 46.0%. PPM was moderate in 38.8% (n = 1579) patients and severe in 7.2% (n = 297) patients. Time-trend analysis showed that the proportion of PPM decreased significantly from 74% in 2009 to 18% in 2017 (P < .01). Severe PPM was associated with increased 5-year all-cause mortality (adjusted hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.07-2.76; P = .02). Severe PPM was not associated with an increased risk of repeat AVR (adjusted HR, 5.90; 95% CI, 0.95-36.5; P = .06). In a subanalysis of patients greater than or equal to 70 years of age, in comparison with no PPM, any PPM (adjusted HR, 1.23; 95% CI, 1.05-1.45; P = .01) and severe PPM (HR, 1.53; 95% CI, 1.17-2.00; P < 0.01) were associated with increased risk of 5-year mortality.

Conclusions: Severe PPM after SAVR had a negative impact on survival. This study demonstrated that the effects of PPM should not be overlooked in elderly undergoing SAVR.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.026DOI Listing
August 2020

Early and late pace-maker implantation after transcatheter and surgical aortic valve replacement.

Catheter Cardiovasc Interv 2020 Aug 7. Epub 2020 Aug 7.

Heart Center, Turku University Hospital, and University of Turku, Turku, Finland.

Background: Conduction defects requiring permanent pacemaker (PPM) implantation are frequent complications occurring after surgical (SAVR) and transcatheter aortic valve replacement (TAVR).

Methods: Patients who underwent TAVR or SAVR with a bioprosthesis from the nationwide FinnValve registry were the subjects of this study. Patients with prior PPM, who received a sutureless prosthesis, or required cardiac resynchronization therapy or implantable cardioverter defibrillator were excluded from this analysis.

Results: Four thousand and ten patients underwent SAVR and 1,897 underwent TAVR. TAVR had an increased risk of PPM implantation at 30-day (10.1% vs. 3.5%, unadjusted OR 3.11, 95%CI 2.56-3.87) and 5-year (15.7% vs. 8.6%, unadjusted SHR, 2.12, 95%CI 1.81-2.48) compared to SAVR. PPM implantation within 30 days from the index procedure did not increase the risk of 5-year mortality after either SAVR or TAVR. Among 1,042 propensity score matched pairs, TAVR had an increased risk of PPM implantation at 30-day (9.9% vs. 4.7%, p < .0001) and 5-year (14.7% vs. 11.4%, p = .001), but late (>30 days) PPM implantation at 5-year (4.7% vs. 6.9% SHR 0.72, 95%CI 0.47-1.10) was comparable to SAVR. The types of prosthesis had an impact on 30-day PPM implantation after TAVR, but not on late (>30 days) PPM implantation.

Conclusions: Although the risk of 30-day PPM implantation is higher after TAVR compared to SAVR, late (>30 days) PPM implantation was comparable with these treatment methods. PPM implantation within 30 days did not affect late survival.
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http://dx.doi.org/10.1002/ccd.29177DOI Listing
August 2020

Indications and predictors for pacemaker implantation after isolated aortic valve replacement with bioprostheses: the CAREAVR study.

Interact Cardiovasc Thorac Surg 2020 09;31(3):398-404

Heart Center, Turku University Hospital and University of Turku, Turku, Finland.

Objectives: We sought to study the indications, long-term occurrence, and predictors of permanent pacemaker implantation (PPI) after isolated surgical aortic valve replacement with bioprostheses.

Methods: The CAREAVR study included 704 patients (385 females, 54.7%) without a preoperative PPI (mean ± standard deviation age 75 ± 7 years) undergoing isolated surgical aortic valve replacement at 4 Finnish hospitals between 2002 and 2014. Data were extracted from electronic patient records.

Results: The follow-up was median 4.7 years (range 1 day to 12.3 years). Altogether 56 patients received PPI postoperatively, with the median 507 days from the operation (range 6 days to 10.0 years). The PPI indications were atrioventricular block (31 patients, 55%) and sick sinus syndrome (21 patients, 37.5%). For 4 patients, the PPI indication remained unknown. A competing risks regression analysis (Fine-Gray method), adjusted with age, sex, diabetes, coronary artery disease, preoperative atrial fibrillation (AF), left ventricular ejection fraction, New York Heart Association class, AF at discharge and urgency of operation, was used to assess risk factors for PPI. Only AF at discharge (subdistribution hazard ratio 4.34, 95% confidence interval 2.34-8.03) was a predictor for a PPI.

Conclusions: Though atrioventricular block is the major indication for PPI after surgical aortic valve replacement, >30% of PPIs are implanted due to sick sinus syndrome during both short-term follow-up and long-term follow-up. Postoperative AF versus sinus rhythm conveys >4-fold risk of PPI.

Clinical Trial Registration: clinicaltrials.gov Identifier: NCT02626871.
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http://dx.doi.org/10.1093/icvts/ivaa119DOI Listing
September 2020

Hospital Volume and Outcome after Bilateral Internal Mammary Artery Grafting.

Heart Surg Forum 2020 Jul 8;23(4):E475-E481. Epub 2020 Jul 8.

Heart Center, Turku University Hospital, and Department of Surgery, University of Turku, Turku, Finland.

Background: Bilateral internal mammary artery (BIMA) grafting largely is underutilized in patients undergoing coronary artery bypass grafting (CABG), partly because of the perceived increased complexity of the procedure.

Aims: In this study, we evaluated whether BIMA grafting can safely be performed also in centers, where this revascularization strategy infrequently is adopted.

Methods: Out of 6,783 patients from the prospective multicenter E-CABG study, who underwent isolated non- emergent CABG from January 2015 to December 2016, 2,457 underwent BIMA grafting and their outcome was evaluated in this analysis.

Results: The mean number of BIMA grafting per center was 82 cases/year and hospitals were defined as high or low volume, according to this cutoff value. Six hospitals were considered as centers with a high volume of BIMA grafting (no. of procedures ranging from 120 to 267/year; overall: 2,156; prevalence: 62.2%) and nine hospitals as centers with a low volume of BIMA grafting (no. of procedures ranging from 2 to 39/year; overall: 301; prevalence: 9.1%). Multilevel mixed-effects regression analysis showed that the low- and high-volume cohorts had similar outcomes. Propensity score one-to-one matching analysis of 292 pairs showed that the low-volume cohort had a significantly shorter intensive care unit stay (2.2 ± 2.3 versus 2.9 ± 4.8 days, P = .020). The rates of in-hospital death (1.0% versus 0.3%, P = .625), deep sternal wound infection/mediastinitis (3.8% versus 3.1%, P = .824), and 1-year survival (98.1% versus 99.7%, P = .180) as well as other outcomes were similar between the high- and low-volume cohorts.

Conclusions: BIMA grafting can be safely performed also in centers in which this revascularization strategy is infrequently performed.
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http://dx.doi.org/10.1532/hsf.2745DOI Listing
July 2020

Letter by Dell'Aquila et al Regarding Article, "Extracorporeal Membrane Oxygenation as a Bridge to Durable Mechanical Circulatory Support: an Analysis of the STS-INTERMACS Database".

Circ Heart Fail 2020 07 14;13(7):e007176. Epub 2020 Jul 14.

Department of Cardiothoracic Surgery, University Hospital Muenster, Germany (A.M.D., H.W.).

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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.007176DOI Listing
July 2020

Acute kidney injury following coronary artery bypass grafting and control angiography: a comprehensive analysis of 221 patients.

Heart Vessels 2021 Jan 11;36(1):1-6. Epub 2020 Jul 11.

Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.

Postoperative coronary angiography offers the basis for prompt management of ischemic complications after coronary artery bypass grafting (CABG). Little is known about the effects of postoperative angiography on renal function. The current study aims to assess the incidence and risk factors for acute kidney injury (AKI) following postoperative coronary angiography. A total of 221 CABG patients (mean age, 67 ± 8 years) underwent postoperative coronary angiography due to perioperative myocardial infarction (PMI). AKI was defined according to the KDIGO criteria. Logistic regression analyses were performed to find out risk factors responsible for AKI and to ascertain significant associations between AKI and in-hospital death. Mean delay from CABG operation to postoperative angiography was 1.4 ± 1.0 days. AKI occurred in 79/221 (36%) patients. Mean serum-creatinine (sCr) values peaked on the first day after the angiography and reached the lowest level at the fourth day. In the multivariable analysis, the following variables were independent predictors for AKI: postoperative peak values of CK-MB (p = 0.049, OR 1.03, 95% CI 1.00-1.06 per 10 U/l), EuroSCORE I (p = 0.011, OR 1.18, 95% CI 1.04-1.35), and AKI before re-angiography (p = 0.004, OR 3.50, 95% CI 1.51-8.16), whereas a delayed angiography (p = 0.031, OR 0.69, 95% CI 0.49-0.97) was protective against AKI. Patients with post-angiography AKI had a significantly higher mortality after multivariable adjustment than patients without AKI (15.5% vs. 2.11%, p = 0.001, OR 5.42, 95% CI 1.35-21.75). Over one-third of patients who undergo postoperatively angiography develop AKI. The occurrence of AKI must be considered during the decision-making prior to coronary angiography, especially in patients presenting the identified risk factors for AKI.
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http://dx.doi.org/10.1007/s00380-020-01655-4DOI Listing
January 2021

A Nomogram for Predicting Long Length of Stay in The Intensive Care Unit in Patients Undergoing CABG: Results From the Multicenter E-CABG Registry.

J Cardiothorac Vasc Anesth 2020 Nov 12;34(11):2951-2961. Epub 2020 Jun 12.

Department of Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome, Italy.

Objective: Many papers evaluated predictive factors for prolonged intensive care unit (ICU) stay after cardiac surgery, but efforts in translating those models in practical clinical tools is lacking. The aim of this study was to build a new nomogram score and test its calibration and discrimination power for predicting a long length of stay in the ICU among patients undergoing coronary artery bypass graft surgery (CABG).

Design: Retrospective analysis of an international registry.

Setting: Multicentric.

Participants: Based on the european multicenter study on coronary artery bypass grafting (E-CABG) registry (NCT02319083), a total of 7,352 consecutive patients who underwent isolated CABG were analyzed.

Interventions: A "long length of stay" in the ICU was considered when equal to or more than 3 days. Predictive factors were analyzed through a multivariate logistic regression model that was used for the nomogram.

Results: Long length of ICU stay was observed in 2,665 patients (36.2%). Ten independent variables were included in the final regression model: the SYNTAX score class critical preoperative state, left ventricular ejection fraction class, angina at rest, poor mobility, recent potent antiplatelet use, estimated glomerular filtration rate class, body mass index, sex, and age. Based on this 10-risk factors logistic regression model, a nomogram has been designed.

Conclusion: The authors defined a nomogram model that can provide an individual prediction of long length of ICU stay in cardiovascular surgical patients undergoing CABG. This type of model would allow an early recognition of high-risk patients who might receive different preoperative and postoperative treatments to improve outcomes.
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http://dx.doi.org/10.1053/j.jvca.2020.06.015DOI Listing
November 2020

Mid-term outcomes of Sapien 3 versus Perimount Magna Ease for treatment of severe aortic stenosis.

J Cardiothorac Surg 2020 Jun 29;15(1):157. Epub 2020 Jun 29.

Heart Center, Turku University Hospital, and Department of Surgery, University of Turku, Turku, Finland.

Background: There is limited information on the longer-term outcome after transcatheter aortic valve replacement (TAVR) with new-generation prostheses compared to surgical aortic valve replacement (SAVR). The aim of this study was to compare the mid-term outcomes after TAVR with Sapien 3 and SAVR with Perimount Magna Ease bioprostheses for severe aortic stenosis.

Methods: In a retrospective study, we included patients who underwent transfemoral TAVR with Sapien 3 or SAVR with Perimount Magna Ease bioprosthesis between January 2008 and October 2017 from the nationwide FinnValve registry. Propensity score matching was performed to adjust for differences in the baseline characteristics. The Kaplan-Meir method was used to estimate late mortality.

Results: A total of 2000 patients were included (689 in the TAVR cohort and 1311 in the SAVR cohort). Propensity score matching resulted in 308 pairs (STS score, TAVR 3.5 ± 2.2% vs. SAVR 3.5 ± 2.8%, p = 0.918). In-hospital mortality was 3.6% after SAVR and 1.3% after TAVR (p = 0.092). Stroke, acute kidney injury, bleeding and atrial fibrillation were significantly more frequent after SAVR, but higher rate of vascular complications was observed after TAVR. The cumulative incidence of permanent pacemaker implantation at 4 years was 13.9% in the TAVR group and 6.9% in the SAVR group (p = 0.0004). At 4-years, all-cause mortality was 20.6% for SAVR and 25.9% for TAVR (p = 0.910). Four-year rates of coronary revascularization, prosthetic valve endocarditis and repeat aortic valve intervention were similar between matched cohorts.

Conclusions: The Sapien 3 bioprosthesis achieves comparable midterm outcomes to a surgical bioprosthesis with proven durability such as the Perimount Magna Ease. However, the Sapien 3 bioprosthesis was associated with better early outcome.

Trial Registration: ClinicalTrials.gov Identifier: NCT03385915 .
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http://dx.doi.org/10.1186/s13019-020-01203-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325109PMC
June 2020

Early and late outcomes after transcatheter versus surgical aortic valve replacement in obese patients.

Arch Med Sci 2020 21;16(4):796-801. Epub 2019 May 21.

Center for Global Health, Istituto Superiore di Sanità, Rome, Italy.

Introduction: Data on the early and late outcome following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) in obese patients are limited. We investigated whether TAVI may be superior to SAVR in obese patients.

Material And Methods: Obese patients (body mass index ≥ 30 kg/m) who underwent either SAVR or TAVI were identified from the nationwide OBSERVANT registry, and their in-hospital and long-term outcomes were analysed. Propensity score matching was employed to identify two cohorts with similar baseline characteristics.

Results: The propensity score matching provided 142 pairs balanced in terms of baseline risk factors. In-hospital and 30-day mortality did not differ between SAVR and TAVI obese patients (4.6% vs. 3.3%, = 0.56, and 5.2% vs. 3.2%, = 0.41, respectively). Obese SAVR patients experienced a higher rate of renal failure (12.4% vs. 3.6%, = 0.0105) and blood transfusion requirement (60.3% vs. 25.7%, < 0.0001) in comparison with TAVI patients. A higher rate of permanent pacemaker implantation (14.4% vs. 3.6%, = 0.0018), and major vascular injuries (7.4% vs. 0%, = 0.0044) occurred in the TAVI group. Five-year survival was higher in the SAVR group compared to the TAVI patient cohort ( = 0.0046), with survival estimates at 1, 3 and 5 years of 88.0%, 80.3%, 71.8% for patients undergoing SAVR, and 85.2%, 69.0%, 52.8% for those subjected to TAVI procedures.

Conclusions: In obese patients, both SAVR and TAVI are valid treatment options, although in the long term SAVR exhibited higher survival rates.
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http://dx.doi.org/10.5114/aoms.2019.85253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286321PMC
May 2019

Acute Kidney Injury Following Aortic Valve Replacement in Patients Without Chronic Kidney Disease.

Can J Cardiol 2021 Jan 19;37(1):37-46. Epub 2020 Mar 19.

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland. Electronic address:

Background: The data on acute kidney injury (AKI) in patients without chronic kidney disease (CKD) after transcatheter aortic valve replacement (TAVR) are limited. The study sought to compare the incidence of AKI and its impact on 5-year mortality after TAVR and surgical aortic valve replacement (SAVR) in patients without CKD.

Methods: This registry included data from 6463 consecutive patients who underwent TAVR or SAVR. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m. AKI was defined according to the Kidney Disease Improving Global Outcomes criteria. For sensitivity analysis, propensity-score matching between TAVR and SAVR was performed.

Results: The study included 4555 consecutive patients (TAVR, n = 1215 and SAVR, n = 3340) without CKD. Propensity-score matching identified 542 pairs. Patients who underwent TAVR had a significantly lower incidence of AKI in comparison to those who underwent SAVR (unmatched 4.7% vs 16.4%, P < 0.001, multivariable analysis: odds ratio, 0.29, 95% confidence interval [CI], 0.20-0.41; matched 5.9% vs 19.0%, P < 0.001). Patients with AKI had significantly increased 5-year mortality compared with those without AKI (unmatched 36.0% vs 19.1%, log-rank P < 0.001; matched 36.3% vs 24.0%, log-rank P < 0.001). The adjusted hazard ratios for 5-year mortality were 1.58 (95% CI, 1.20-2.08) for AKI grade 1, 3.27 (95% CI, 2.09-5.06) for grade 2, and 4.82 (95% CI, 2.93-8.04) for grade 3.

Conclusions: TAVR in patients without CKD was associated with a significantly less frequent incidence of AKI compared with SAVR. AKI significantly increased the risk of 5-year mortality after either TAVR or SAVR, and increasing severity of AKI was incrementally associated with 5-year mortality.
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http://dx.doi.org/10.1016/j.cjca.2020.03.015DOI Listing
January 2021

Failure to achieve a satisfactory cardiac outcome after isolated coronary surgery in low-risk patients.

Interact Cardiovasc Thorac Surg 2020 07;31(1):9-15

Department of Surgery, Oulu University Hospital and Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland.

Objectives: This study aims to investigate the incidence and determinants of major early adverse events in low-risk patients undergoing isolated coronary artery bypass grafting (CABG).

Methods: The multicentre E-CABG registry included 7352 consecutive patients who underwent isolated CABG from January 2015 to December 2016. Patients with an European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of <2% and without any major comorbidity were the subjects of the present analysis.

Results: Out of 2397 low-risk patients, 11 (0.46%) died during the index hospitalization or within 30 days from surgery. Five deaths were cardiac related, 4 of which were secondary to technical failures. We estimated that 8 out of 11 deaths were potentially preventable. Logistic regression model identified porcelain aorta [odds ratio (OR) 34.3, 95% confidence interval (CI) 1.3-346.3] and E-CABG bleeding grades 2-3 (OR 30.2, 95% CI 8.3-112.9) as independent predictors of hospital death.

Conclusions: Mortality and major complications, although infrequently, do occur even in low-risk patients undergoing CABG. Identification of modifiable causes of postoperative adverse events may be useful to develop preventative strategies to improve the quality of care of patients undergoing cardiac surgery.

Clinical Trial Registration: NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083).
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http://dx.doi.org/10.1093/icvts/ivaa062DOI Listing
July 2020

Durability of Aortic Valve Bioprostheses: Reply.

Authors:
Fausto Biancari

Ann Thorac Surg 2020 11 7;110(5):1778-1779. Epub 2020 May 7.

Heart and Lung Center, Helsinki University Hospital, Haartmaninkatu 4, PO Box 340, 00029 Helsinki, Finland. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.03.102DOI Listing
November 2020

Venoarterial Extracorporeal Membrane Oxygenation After Surgical Repair of Type A Aortic Dissection.

Am J Cardiol 2020 06 31;125(12):1901-1905. Epub 2020 Mar 31.

Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, Faculty of Medicine, University of Oulu, Oulu, Finland; Heart Center, Turku University Hospital and Department of Surgery, University of Turku, Finland.

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support for postcardiotomy cardiogenic shock (PCS) in patients undergoing surgery for acute type A aortic dissection (TAAD) is controversial and the available evidence is confined to limited case series. We aimed to evaluate the impact of this salvage therapy in this patient population. Between January 2010 and March 2018, all TAAD patients receiving VA-ECMO for PCS were retrieved from the PC-ECMO registry. Hospital mortality and other secondary outcomes were compared with PCS patients undergoing surgery for other cardiac pathologies and treated with VA-ECMO. Among the 781 patients in the PC-ECMO registry, 62 (7.9%) underwent TAAD repair and required VA-ECMO support for PCS. In-hospital mortality accounted for 46 (74.2%) patients, while 23 (37.1%) were successfully weaned from VA-ECMO. No significant differences were observed between the TAAD and non-TAAD cohorts with reference to in-hospital mortality (74.2% vs 63.4%, p = 0.089). However, patients in the TAAD group had a higher rate of neurological events (33.9% vs 17.6%, p = 0.002), but similar rates of reoperation for bleeding/tamponade (48.4% vs 41.5%, p = 0.29), transfusion of ≥10 red blood cell units (77.4% vs 69.5%, p = 0.19), new-onset dialysis (56.7% vs 53.1%, p = 0.56), and other secondary outcomes. VA-ECMO provides a valid support for patients affected by PCS after surgery for TAAD.
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http://dx.doi.org/10.1016/j.amjcard.2020.03.012DOI Listing
June 2020

Competing Risk Analysis of the Impact of Pedal Arch Status and Angiosome-Targeted Revascularization in Chronic Limb-Threatening Ischemia.

Ann Vasc Surg 2020 Oct 9;68:384-390. Epub 2020 Apr 9.

Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland. Electronic address:

Background: In the context of chronic limb-threatening ischemia, the prognostic impact of angiosome-targeted revascularization and of the status of the pedal arch are debated.

Methods: This series includes 580 patients who underwent endovascular (n = 407) and surgical revascularization (n = 173) of the infrapopliteal arteries for chronic limb-threatening ischemia associated with foot ulcer or gangrene. The risk of major amputation after infrapopliteal revascularization was assessed by a competing risk approach. A subanalysis was made separately for patients who underwent endovascular or open surgical revascularization.

Results: At 2 years, survival was 65.1% and leg salvage was 76.1%. Multivariable competing risk analysis showed that C-reactive protein ≥10 mg/dL, diabetes, rheumatoid arthritis, increased number of affected angiosomes, and the incomplete or total absence of pedal arch compared with complete pedal arch (CPA) were independent predictors of major amputation after infrapopliteal revascularization. Multivariable analysis showed increasing risk estimates of major amputation in patients with incomplete (subdistribution hazard ratio [SHR], 2.131; 95% confidence interval [95% CI], 1.282-3.543) and no visualized pedal arch (SHR, 3.022; 95% CI, 1.553-5.883) compared with CPA. Pedal arch was important even if angiosome-targeted revascularization was achieved: Angiosome-directed revascularization in presence of CPA had a lower risk of major amputation (adjusted SHR, 0.463; 95% CI, 0.240-0.894) compared with angiosome-directed revascularization without CPA. In the subanalysis, among patients who underwent endovascular revascularization, CPA (SHR, 0.509; 95% CI, 0.286-0.905) and angiosome-targeted revascularization (SHR, 0.613; 95% CI, 0.394-0.956) were associated with a lower risk of major amputation.

Conclusions: Competing risk analysis showed that a patent pedal arch had significant impact on leg salvage and that the subset of patients undergoing endovascular procedure may most benefit of an angiosome-targeted revascularization.
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http://dx.doi.org/10.1016/j.avsg.2020.03.042DOI Listing
October 2020

Favorable outcome of cancer patients undergoing transcatheter aortic valve replacement.

Int J Cardiol 2020 09 18;315:86-89. Epub 2020 Mar 18.

Heart Center, Kuopio University Hospital, Kuopio, Finland.

Aim: The aim of this study was to assess the outcome of transcatheter aortic valve replacement (TAVR) in patients with cancer.

Methods: This is a retrospective study from the nationwide FinnValve registry on 2130 consecutive patients who underwent TAVR for severe AS from January 2008 to October 2017.

Results: In this cohort, 417 patients (19.6%) had history of cancer and 113 (5.3%) had an active malignancy at the time of TAVR. Patients with any malignancy had similar late mortality than patients without any malignancy (at 7 years, 65.1% vs. 59.3%, adjusted HR 1.105, 95%CI 0.892-1.369). At 7 years, cancer-related mortality was 22.5% among patients with preoperative cancer, and 11.0% in those without preoperative cancer (p < 0.0001). Among cancer patients, 18 died of the same disease (at 7 years, mortality 12.5%). Active malignancy was not associated with increased risk of all-cause mortality (adjusted HR 1.100, 95%CI 0.757-1.599). However, patients with blood malignancies had a significantly increased risk of mortality (at 4-year, 53.5% vs. 35.4%, adjusted HR 2.029, 95%CI 1.328-3.098).

Conclusions: This analysis showed that, when properly selected by the heart team and oncologists, most cancer patients undergoing TAVR can achieve a good survival and eventually die of other diseases. Blood malignancies seem to carry a poor prognosis in these patients.

Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT03385915; https://clinicaltrials.gov/ct2/show/NCT03385915.
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http://dx.doi.org/10.1016/j.ijcard.2020.03.038DOI Listing
September 2020