Evolution of Risk Calculators and the Dawn of Artificial Intelligence in Predicting Patient Complications.

Risk calculators are an underused tool for surgeons and trainees when determining and communicating surgical risk. We summarize some of the more common risk calculators and discuss their evolution and limitations. We also describe artificial intelligence models, which have the potential to help clinicians better understand and use risk assessment.

Impact of Prosthesis Size and Prosthesis-Patient Mismatch on Outcomes in Younger Female Patients Undergoing Aortic Valve Replacement.

The effects of patient-prosthesis mismatch (PPM) after surgical aortic valve replacement (SAVR) suggest worse outcomes with smaller valves. We assessed clinical outcomes of younger females undergoing SAVR, using small and large prostheses, and the incremental risk of PPM. Between January 2002 and June 2015, 451 younger (age ≤65 years) female patients underwent SAVR. Patients were stratified into small prostheses (SP) ≤21 mm (n = 256) and large prostheses (LP) ≥23 mm (n = 195) groups. PPM was classified as moderate if indexed effective orifice area (iEOA) 0.65-0.85 cm2/m2, or severe if iEOA <0.65 cm2/m2. Operative mortality was not statistically different between SP and LP groups (2.4% vs 0.5%; P = 0.146). Unadjusted 10-year survival was 82% (95% confidence interval 77-87%), and was similar in both groups (P = 0.210). When grouped by standard PPM thresholds, only severe PPM was associated with significantly decreased survival (P = 0.007). A significant survival decrease was detected in LP group with iEOA ≤0.75 cm2/m2 (P < 0.001). Among SP patients, iEOA ≤0.65 cm2/m2 was associated with increased mortality (P = 0.075). After adjusting for potential confounders, Cox proportional hazard model identified iEOAs of ≤0.65 cm2/m2 (hazard ratio 1.85; P = 0.066) and ≤0.75 cm2/m2 (hazard ratio 2.3; P ≤ 0.003) as predictors of decreased long-term survival, in SP and LP groups, respectively. Among younger females who underwent SAVR, postoperative complications and in-hospital outcomes were substantially similar between the SP and LP groups. However, patients who received LP were adversely affected at lesser degrees of PPM than those who received SP. While SP patients may tolerate until iEOA ≤0.65 cm2/m2, our results suggest that moderate PPM of iEOA ≤0.75 for LP patients should be avoided.

Mitral valve repair using edge-to-edge technique in various situations: real-world experiences.

OBJECTIVES: Edge-to-edge (E2E) mitral valve repair (MVP) is a versatile technique used in various situations for mitral regurgitation (MR). This technique has been regaining attention, given the increasing use of the MitraClip procedure. This real-world study evaluates the durability of the E2E technique in different settings. METHODS: From January 2002 to May 2015, a total of 303 patients with at least moderate MR who underwent E2E MVP were identified. Patients undergoing isolated MVP (n = 133) and concomitant coronary artery bypass grafting or other valvular procedures (N = 170) were included. Cox proportional hazards modelling was used to evaluate the risk factors for cumulative survival, or MV event (i.e. MV reintervention or MR recurrence) while event-free survival-defined as time to composite outcome of either death or MV event-was determined using competing risk Kaplan-Meier analysis. Median follow-up duration was 6.9 (interquartile range 5.8) years. RESULTS: The most common MR aetiology was myxomatous (34%), followed by Barlow's disease (27.7%), and ischaemic (21.5%). E2E MVP was performed for the following indications: persistent MR (51.5%), systolic anterior motion prophylaxis (22.1%), transaortic approach (17.5%) and systolic anterior motion treatment post-MVP (8.9%). Concomitant ring annuloplasty was performed in 224 patients (73.9%). Operative mortality was 3.6% and MV event rate was 18.5%. Significant predictors of decreased survival included age, renal insufficiency, peripheral vascular disease and ischaemic MR aetiology (all P < 0.050). No ring annuloplasty (HR 2.79; P < 0.001) was the only significant predictor of MV events. Estimated event-free survival for the overall cohort was 8.5 years, and shortest for functional (non-ischaemic; 6.6 years) and ischaemic aetiology (5.5 years). CONCLUSIONS: E2E repair is a versatile MVP technique, which can be used in prevention and treatment of systolic anterior motion, transaortic approach or with concomitant techniques, with reasonable outcomes. Ischaemic aetiology and absence of ring annuloplasty were associated with worse cumulative survival and MV event rates, respectively, which raises some concern in light of the expanding indication for MitraClip system.

Proximal aortic surgery in the elderly population: Is advanced age a contraindication for surgery?

OBJECTIVE: The study objective was to describe the clinical outcomes of elderly patients undergoing ascending aortic surgery. METHODS: Patients aged 70 years or older who underwent ascending aortic surgery between January 2002 and December 2013 were examined. Of 415 included patients, 285 were elderly patients (age 70-79 years) and 130 were very elderly (age ≥80 years). Logistic regression and Cox proportional hazards models were used to evaluate operative mortality and long-term survival, respectively. RESULTS: Surgical indications included aortic aneurysm (63.1%), calcified aorta with need for other cardiac procedure (26.4%), and type A dissection (10.5%). Compared with elderly patients, the very elderly patients had a higher burden of comorbidities and operative mortality (13% vs 7%, P < .04). The very elderly patients were also more likely to be discharged to a rehabilitation facility than home (P < .001). However, risk-adjusted operative mortality and 30-day readmissions rates were similar (P > .05). Kaplan-Meier estimates of survival at 1 and 5 years were 85.6% and 72.6% for elderly patients versus 79.2% and 57.1% for the very elderly patients. Age was a strong risk variable for late mortality in the unadjusted and adjusted analyses. CONCLUSIONS: After adjusting for these comorbidities, the cause of aortic disease, and the type of procedure, age was not an independent predictor of operative mortality, but was strongly associated with reduced late survival. Thus, advanced age alone should not be an absolute contraindication for ascending aortic surgery.