Research

Application of Clinical Databases to Contemporary Cardiac Surgery Practice: Where are we now?

by

Saxena A, Newcomb AE, Dhurandhar V, Bannon PG

Heart Lung Circ 2015 Feb;

PMID: 25778623

Abstract

Cardiac surgery has embraced and encouraged the use of large, multi-institutional datasets in clinical practice. From a research perspective, database studies have facilitated an increased understanding of cardiac surgery. Among other uses, they have allowed an investigation of disease incidence and mortality, high risk groups, disparities in health care delivery and the impact of new devices and techniques. Databases are also important tools for clinical governance and quality improvement. Despite their obvious utility, clinical databases have limitations; they are subject to treatment bias, contain missing data and cannot establish causality. Moreover, the ongoing maintenance of the database requires significant human and financial resources. In the future, inclusion of more detailed follow-up data and integration with other datasets will improve the utility of clinical databases.

Outcomes of On-Pump versus Off-Pump Coronary Artery Bypass Graft Surgery in the High Risk (AusSCORE > 5)

by

Dhurandhar V, Saxena A, Parikh R, Vallely MP, Wilson MK, Butcher JK, Black DA, Tran L, Reid CM, Bannon PG

Heart Lung Circ 2015 Feb;

PMID: 25778621

Abstract

BACKGROUND: Coronary artery bypass graft surgery (CABG) has been established as the preferred intervention for coronary revascularisation in the high-risk population. OPCAB may further reduce mortality and morbidity in this population subgroup. This study presents the largest series of high-risk (AusSCORE > 5) OPCAB patients in Australia and New Zealand.

METHODS: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons’ (ANZSCTS) database for high-risk patients (n=7822) undergoing isolated CABG surgery and compared the ONCAB (n=7277) with the OPCAB (n=545) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analysis was performed after cross-matching the database with the national death registry to identify long-term mortality.

RESULTS: The ONCAB and OPCAB groups had similar risk profiles based on the AusSCORE. Thirty-day mortality (ONCAB vs OPCAB 3.9% vs 2.4%, p=0.067) and stroke (ONCAB vs OPCAB 2.4% vs 1.3%, p=0.104) were similar between the two groups. OPCAB patients received fewer distal anastomoses than ONCAB patients (2.5±1.2 vs 3.3±1.0, p<0.001). The rates of new postoperative atrial arrhythmia (28.3% vs 33.3%, p=0.017) and blood transfusion requirements (52.1% vs 59.5%, p=0.001) were lower in the OPCAB group, while duration of ICU stay in hours (97.4±187.8 vs 70.2±152.8, p<0.001) was longer. There was a non-significant trend towards improved 10-year survival in OPCAB patients (74.7% vs. 71.7%, p=0.133).

CONCLUSIONS: In the high-risk population, CABG surgery has a low rate of mortality and morbidity suggesting that surgery is a safe option for coronary revascularisation. OPCAB reduces postoperative morbidity and is a safe procedure for 30-day mortality, stroke and long-term survival in high-risk patients.

How should I treat a complex critical left main bifurcation lesion in a patient with poor left ventricular function, an occluded dominant right coronary artery and severe peripheral vascular disease?

by

Martínez GJ, Molina J, Byrom M, Puranik R, Ng B, Bailey BP, Patel S, Dworakowski R, MacCarthy P, Ochala A, Smolka G

EuroIntervention 2015 Feb;10(11)

PMID: 25692609

Abstract

Comparative transcriptome profiling in human bicuspid aortic valve disease using RNA-sequencing

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Padang R, Bagnall RD, Tsoutsman T, Bannon PG, Semsarian C

Physiol. Genomics 2014 Dec;:physiolgenomics.00115.2014

PMID: 25547111

Abstract

Intrinsic valvular degeneration and dysfunction is the most common complication of bicuspid aortic valve (BAV) disease. Phenotypically, it ranges from calcific aortic stenosis to redundant or prolapsing regurgitant leaflets. The underlying molecular mechanism underpinning phenotype heterogeneity of valvular degeneration in BAV is poorly understood. We used RNA-sequencing to identify genes and pathways responsible for valvular degeneration in BAV, compared to tricuspid aortic valve (TAV). Comparative transcriptome analysis on total RNA of aortic valve tissues of patients with diseased BAV (n=5) and calcified TAV (n=3). A total of 59 and 177 genes were significantly up- and downregulated, respectively, in BAV compared to TAV. Hierarchical clustering indicated heterogeneity within the BAV group, separating those with heavy calcification (BAVc) from those with redundant leaflets and/or minimal calcification (BAVr). Interestingly, the gene expression profile of the BAVc group closely resembled the TAV, with shared up- and downregulation of inflammatory and NOTCH1 signaling pathways, respectively. Downregulation of matrix protease ADAMTS9 and protein aggrecan were observed in BAVr compared to TAV. Dysregulation of fetal gene programs were also present, with notable downregulation of SEMA6B and SEMA3F in BAVr and BAVc compared to TAV, respectively. Upregulation of TBX20 was observed exclusively in BAVr compared to BAVc. In conclusion, diverging molecular mechanisms underpin phenotype heterogeneity of valvular degeneration in BAV and data from the present study suggest that there may be shared mechanisms leading to calcification in BAV and TAV. Recognition of these pathways is fundamental to improve our understanding of the molecular basis of human BAV disease.

Position Statement for the Operator and Institutional Requirements for a Transcatheter Aortic Valve Implantation (TAVI) Program

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Walters DL, Webster M, Pasupati S, Walton A, Muller D, Stewart J, Williams M, MacIsaac A, Scalia G, Wilson M, Gamel AE, Clarke A, Bennetts J, Bannon P

Heart Lung Circ 2014 Oct;

PMID: 25488705

Abstract

The Cardiac Society of Australia and New Zealand (CSANZ) and the Australia and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) have joined together to provide recommendations for institutions and individual operators to assess their ability to initiate and maintain a transcatheter valve program. Transcatheter aortic valve replacement has been developed as an alternative to traditional surgical replacement of the aortic valve in high risk patients, particularly the frail elderly. The position paper has endorsed the important role of a multi-disciplinary “Heart Team” in selecting patients for TAVI as fundamental to the establishment of a successful program. The paper outlines recommendations for the cardiologist to have a background in structural intervention and the surgeon to have experience in high-risk aortic valve replacement. It is further recommended that TAVI programs be established in high volume cardiac surgical centres where on site valve surgery is performed. The paper is intended to provide guidance to individual operators and prospective institutions considering the establishment of a successful TAVI program.

Replacement of the aortic root with a composite valve-graft conduit: risk factor analysis in 246 consecutive patients

by

Woldendorp K, Starra E, Seco M, Hendel PN, Jeremy RW, Wilson MK, Vallely MP, Bannon PG

Heart Lung Circ 2014 Dec;23(12):1187-93

PMID: 25038031

Abstract

BACKGROUND: Composite valve-graft (CVG) replacement of the aortic root is a well-studied and recognised treatment for various aortic root conditions, including valvular disease with associated aortopathy. There have been few previous studies of the procedure in large numbers in an Australian setting.

METHOD: From January 2006 to June 2013, 246 successive patients underwent CVG root replacements at our institution. Mean age was 56.8 years, 85.4% were male, and 87 had evidence of bicuspid aortic valve. Indications for operation included ascending aortic aneurysm in 222 patients, annuloaortic ectasia in 67 patients, and aortic dissection in 38 patients.

RESULTS: The overall unit 30-day mortality was 5.7%, including: elective 30-day mortality of 2.2%, and emergent 30-day mortality of 17.2%. Statistically significant multivariate predictors of 30-day mortality were: acute aortic dissection (OR=20.07), peripheral vascular disease (OR=11.17), new ventricular tachycardia (OR=30.17), re-operation for bleeding (OR=14.42), concomitant mitral stenosis (OR=68.30), and cerebrovascular accident (OR=144.85).

CONCLUSIONS: Low postoperative mortality in our series matches closely with results from similar sized international studies, demonstrating that this procedure can be performed with low risk in centres with sufficient experience in the operative procedure.

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