PubMed Posts

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Repair of chronic Type B aortic dissection can be technically challenging. Here we describe a technique for the partial replacement of the descending thoracic aorta that minimises operative risk and avoids full replacement of the thoraco-abdominal aorta. This approach can be considered when there is heterogeneous perfusion of abdominal viscera by the true and false lumens of the chronically dissected aorta.

Objective: To identify predictors of early and late outcomes of cardiac surgery in patients with chronic kidney disease.

Methods: Patients (n=545) with serum creatinine≥200 μmol/L or renal dialysis were identified from databases maintained by the largest Sydney cardiothoracic surgical units with data consistent with the Australian and New Zealand Society of Cardiothoracic Surgeons data definitions. The patient data were matched against the National Dialysis Database and the New South Wales Register of Births, Deaths, and Marriages. Statistical analysis was used to identify predictors of early and late outcomes.

Results: The Kaplan-Meier estimate of 1-, 5-, and 10-year survival for all patients was 78%, 56%, and 36%, respectively. The outcomes were similar after coronary bypass surgery and valve replacement and were also similar for dialysis and nondialysis patients. The odds ratios for the significant independent predictors of outcomes were, for perioperative death, age (1.4 per decade), emergency surgery (7.0), redo surgery (3.8), left ventricular impairment (moderate, 2.7; severe, 4.4); for new early postoperative dialysis, estimated glomerular filtration rate<20 mL/min (3.8), emergency surgery (2.7), tricuspid valve surgery (4.4); for new permanent dialysis within 6 months of surgery, serum estimated glomerular filtration rate<20 mL/min (odds ratio, 4.6). The hazard ratio for the independent predictors of late death in those alive 6 months after surgery was 1.4 per decade for age and 1.4 for moderate or severe left ventricular impairment.

Conclusions: Left ventricular impairment is a risk factor for perioperative and late death in patients with kidney disease. After cardiac surgery, preoperative dialysis-dependent and dialysis-free patients had similar long-term outcomes.

Introduction: All major international guidelines for the management of infective endocarditis (IE) have undergone major revisions, recommending antibiotic prophylaxis (AP) restriction to high-risk patients or foregoing AP completely. We performed a systematic review to investigate the effect of these guideline changes on the global incidence of IE.

Methods: Electronic database searches were performed using Ovid Medline, EMBASE and Web of Science. Studies were included if they compared the incidence of IE prior to and following any change in international guideline recommendations. Relevant studies fulfilling the predefined search criteria were categorized according to their inclusion of either adult or pediatric patients. Incidence of IE, causative microorganisms and AP prescription rates were compared following international guideline updates.

Results: Sixteen studies were included, reporting over 1.3 million cases of IE. The crude incidence of IE following guideline updates has increased globally. Adjusted incidence increased in one study after European guideline updates, while North American rates did not increase. Cases of IE with a causative pathogen identified ranged from 62% to 91%. Rates of streptococcal IE varied across adult and pediatric populations, while the relative proportion of staphylococcal IE increased (range pre-guidelines 16-24.8%, range post-guidelines 26-43%). AP prescription trends were reduced in both moderate and high-risk patients following guideline updates.

Discussion: The restriction of AP to only high-risk patients has not resulted in an increase in the incidence of streptococcal IE in North American populations. The evidence of the impact of AP restriction on IE incidence is still unclear for other populations. Future population-based studies with adjusted incidence of IE, AP prescription rates and accurate pathogen identification are required to delineate findings further in these other regions.

Background: Internationally, the response to the COVID-19 pandemic has resulted in fewer cardiac surgical procedures being performed and an increase in the proportion of non-elective cases. To date there has been no study examining the impact of COVID-19 on the provision of cardiac surgery in Australia.

Aim: The aim of this study was to evaluate the impact that the COVID-19 pandemic has had on the provision of cardiac surgery in a single, large major cardiac centre and dedicated COVID-19 hospital. A retrospective cohort study was undertaken utilising prospectively collected data.

Methods: Prospectively collected patient and operative data was examined to assess whether there was a reduction in the number of cases performed and whether there was a difference in patient demographics, surgical procedures or case urgency. Data was examined from the period of COVID-restrictions in 2020 and compared with data from the same time period in 2019.

Results: From 3 March 2020 to 30 June 2020, 136 adults underwent cardiac surgery at our institution, representing an overall reduction in operative caseload of 21%. The largest impact was noticed in May and April and coincided with statewide restrictions on elective surgery. Surgical acuity was unchanged with 58% of operations classified as non-elective procedures performed during the index admission. There was a small non-significant increase in the proportion of isolated coronary artery bypass surgery and aortic valve surgeries performed.

Conclusion: From March to June 2020 our local hospital response to the COVID-19 pandemic resulted in a reduction in cardiac surgery service delivery. No change was seen in the urgency or type of surgeries performed.

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Background: Aortic valve surgery (AVS) is the gold standard treatment for symptomatic aortic valve (AV) disease patients. We report the temporal trends in the incidence of patients requiring isolated AVS in an unselected statewide population and their mortality outcomes over 17-years.

Methods: Patients were identified from the New South Wales, Australia, Admitted-Patient-Data-Collection registry between 1-July-2001 and 31-December-2018. Annual case-volumes and survival outcomes, adjusted for age, sex, referral source, endocarditis, concomitant coronary-artery-bypass-grafting, comorbidities including atrial fibrillation, hypertension and Charlson comorbidity index, were compared across calendar years.

Results: The study cohort comprised 16436 patients who underwent isolated AVS (mean age: 72.2 ± 11.3y; 67.5% males). Annual case-volume increased from 768 to 1048 cases between 2002 and 2017 (r² = 0.82; p < 0.0001). Surgical AV replacement (SAVR) with mechanical valves declined from 271 to 104 (r² = 0.87; p < 0.0001) between 2002 and 2017. In contrast, bioprosthetic SAVR increased from 342 to 729 cases (r² = 0.93; p < 0.0001). The 30-day, 6-month, and 1-year mortality rates improved progressively from 4.39%, 7.72%, and 9.19% in 2002, to 1.89%, 3.49%, and 4.68% by 2017. The adjusted odds ratio for 30-day mortality and hazard ratio for 1-year mortality were 0.33 (95% confidence interval [CI] 0.16-0.69, p < 0.01) and 0.09 (95% CI 0.07-0.12, p < 0.01), respectively. Similar improvements in outcomes were observed after implantation of mechanical or bioprosthetic aortic valves. Heart failure and sepsis were the most common cardiovascular-related and noncardiovascular-related causes death.

Conclusion: The volume of AVS has increased progressively over time and has been associated with increased use of bioprosthetic valves and markedly improved 30-day and 1-year survival.