Surgical ablation, left atrial appendage occlusion or both? Nationwide registry analysis of cardiac surgery patients with underlying atrial fibrillation.

OBJECTIVES: The aim of this study was to evaluate in-hospital outcomes and long-term survival of patients undergoing cardiac surgery with preoperative atrial fibrillation (AF). We compared different strategies, including no-AF treatment, left atrial appendage occlusion (LAAO) alone, concomitant surgical ablation (SA) alone or both. METHODS: A retrospective analysis using the KROK registry included all patients with preoperative diagnosis of AF who underwent cardiac surgery in Poland between between January 2012 and December 2022. Risk adjustment was performed using regression analysis with inverse probability weighting of propensity scores. We assessed 6-year survival with Cox proportional hazards models. Sensitivity analysis was performed based on index cardiac procedure. RESULTS: Initially, 42 510 patients with preoperative AF were identified, and, after exclusion, 33 949 included in the final analysis. A total of 1107 (3.26%) received both SA and LAAO, 1484 (4.37%) received LAAO alone, 3921 (11.55%) SA alone and the remaining 27 437 (80.82%) had no AF-directed treatment. As compared to no treatment, all strategies were associated with survival benefit over 6-year follow-up. A gradient of treatment was observed with the highest benefit associated with SA + LAAO followed by SA alone and LAAO alone (log-rank P < 0.001). Mortality benefits were reflected when stratified by surgery type with the exception of aortic valve surgery where LAAO alone fare worse than no treatment. CONCLUSIONS: Among patients with preoperative AF undergoing cardiac surgery, surgical management of AF, particularly SA + LAAO, was associated with lower 6-year mortality. These findings support the benefits of incorporating SA and LAAO in the management of AF during cardiac surgery.

Congenital Heart Surgery Machine Learning-Derived In-Depth Benchmarking Tool.

BACKGROUND: We previously showed that machine learning-based methodologies of optimal classification trees (OCTs) can accurately predict risk after congenital heart surgery and assess case-mix-adjusted performance after benchmark procedures. We extend this methodology to provide interpretable, easily accessible, and actionable hospital performance analysis across all procedures. METHODS: The European Congenital Heart Surgeons Association Congenital Cardiac Database data subset of 172,888 congenital cardiac surgical procedures performed in European centers between 1989 and 2022 was analyzed. OCT models (decision trees) were built predicting hospital mortality (area under the curve [AUC], 0.866), prolonged postoperative mechanical ventilatory support time (AUC, 0.851), or hospital length of stay (AUC, 0.818), thereby establishing case-adjusted benchmarking standards reflecting the overall performance of all participating hospitals, designated as the "virtual hospital." OCT analysis of virtual hospital aggregate data yielded predicted expected outcomes (both aggregate and for risk-matched patient cohorts) for the individual hospital's own specific case-mix, readily available on-line. RESULTS: Raw average rates were hospital mortality, 4.9%; mechanical ventilatory support time, 14.5%; and length of stay, 15.0%. Of 146 participating centers, compared with each hospital's overall case-adjusted predicted hospital mortality benchmark, 20.5% statistically (<90% CI) overperformed and 20.5% underperformed. An interactive tool based on the OCT analysis automatically reveals 14 hospital-specific patient cohorts, simultaneously assessing overperformance or underperformance, and enabling further analysis of cohort strata in any chosen time frame. CONCLUSIONS: Machine learning-based OCT benchmarking analysis provides automatic assessment of hospital-specific case-adjusted performance after congenital heart surgery, not only overall but importantly, also by similar risk patient cohorts. This is a tool for hospital self-assessment, particularly facilitated by the user-accessible online-platform.

Prognostic impact of preoperative atrial fibrillation in patients undergoing heart surgery in cardiogenic shock.

Surgical intervention in the setting of cardiogenic shock (CS) is burdened with high mortality. Due to acute condition, detailed diagnoses and risk assessment is often precluded. Atrial fibrillation (AF) is a risk factor for perioperative complications and worse survival but little is known about AF patients operated in CS. Current analysis aimed to determine prognostic impact of preoperative AF in patients undergoing heart surgery in CS. We analyzed data from the Polish National Registry of Cardiac Surgery (KROK) Procedures. Between 2012 and 2021, 332,109 patients underwent cardiac surgery in 37 centers; 4852 (1.5%) patients presented with CS. Of those 624 (13%) patients had AF history. Cox proportional hazards models were used for computations. Propensity score (nearest neighbor) matching for the comparison of patients with and without AF was performed. Median follow-up was 4.6 years (max.10.0), mean age was 62 (± 15) years and 68% patients were men. Thirty-day mortality was 36% (1728 patients). The origin of CS included acute myocardial infarction (1751 patients, 36%), acute aortic dissection (1075 patients, 22%) and valvular dysfunction (610 patients, 13%). In an unadjusted analysis, patients with underlying AF had almost 20% higher mortality risk (HR 1.19, 95% CIs 1.06-1.34; P = 0.004). Propensity score matching returned 597 pairs with similar baseline characteristics; AF remained a significant prognostic factor for worse survival (HR 1.19, 95% CI 1.00-1.40; P = 0.045). Among patients with CS referred for cardiac surgery, history of AF was a significant risk factor for mortality. Role of concomitant AF ablation and/or left atrial appendage occlusion or more aggressive perioperative circulatory support should be addressed in the future.

Combining Congenital Heart Surgical and Interventional Cardiology Outcome Data in a Single Database: The Development of a Patient-Centered Collaboration of the European Congenital Heart Surgeons Association (ECHSA) and the Association for European Paediatric and Congenital Cardiology (AEPC).

The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effort to expand the ECHSA-CD with a new module designed to capture data about interventional cardiology procedures. The purpose of this manuscript is to describe the concept, the structure, and the function of the new AEPC Interventional Cardiology Part of the ECHSA-CD, as well as the potentially valuable synergies provided by the shared interventional and surgical analyses of outcomes of patients. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow centers to have access to robust surgical and transcatheter outcome data from their own center, as well as robust national and international aggregate outcome data for benchmarking. Each contributing center or department will have access to their own data, as well as aggregate data from the AEPC Interventional Cardiology Part of the ECHSA-CD. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow cardiology centers to have access to aggregate cardiology data, just as surgical centers already have access to aggregate surgical data. Comparison of surgical and catheter interventional outcomes could potentially strengthen decision processes. A study of the wealth of information collected in the database could potentially also contribute toward improved early and late survival, as well as enhanced quality of life of patients with pediatric and/or congenital heart disease treated with surgery and interventional cardiac catheterization across Europe and the world.

Validation of EuroSCORE II in atrial fibrillation heart surgery patients from the KROK Registry.

The study aimed to validate the European System for Cardiac Operative Risk Evaluation score (EuroSCORE II) in patients with atrial fibrillation (AF). All data were retrieved from the National Registry of Cardiac Surgery Procedures (KROK). EuroSCORE II calibration and discrimination performance was evaluated. The final cohort consisted of 44,172 patients (median age 67, 30.8% female, 13.4% with AF). The in-hospital mortality rate was 4.14% (N = 1830), and 5.21% (N = 2303) for 30-day mortality. EuroSCORE II significantly underestimated mortality in mild- and moderate-risk populations [Observed (O):Expected (E)-1.1, 1.16). In the AF subgroup, it performed well [O:E-0.99), whereas in the very high-risk population overestimated mortality (O:E-0.9). EuroSCORE II showed better discrimination in AF (-) [area under curve (AUC) 0.805, 95% CI 0.793-0.817)] than in AF (+) population (AUC 0.791, 95%CI 0.767-0.816), P < 0.001. The worst discriminative performance for the AF (+) group was for coronary artery bypass grafting (CABG) (AUC 0.746, 95% CI 0.676-0.817) as compared with AF (-) population (AUC 0.798, 95% CI 0.774-0.822), P < 0.001. EuroSCORE II is more accurate for patients with AF. However, it underestimated mortality rates for low-to-moderate-risk patients and had a lower ability to distinguish between high- and low-risk patients with AF, particularly in those undergoing coronary artery bypass grafting.

Combining Congenital Heart Surgical and Interventional Cardiology Outcome Data in a Single Database: The Development of a Patient-Centered Collaboration of the European Congenital Heart Surgeons Association (ECHSA) and the Association for European Paediatric and Congenital Cardiology (AEPC).

The European Congenital Heart Surgeons Association (ECHSA) Congenital Database (CD) is the second largest clinical pediatric and congenital cardiac surgical database in the world and the largest in Europe, where various smaller national or regional databases exist. Despite the dramatic increase in interventional cardiology procedures over recent years, only scattered national or regional databases of such procedures exist in Europe. Most importantly, no congenital cardiac database exists in the world that seamlessly combines both surgical and interventional cardiology data on an international level; therefore, the outcomes of surgical and interventional procedures performed on the same or similar patients cannot easily be tracked, assessed, and analyzed. In order to fill this important gap in our capability to gather and analyze information on our common patients, ECHSA and The Association for European Paediatric and Congenital Cardiology (AEPC) have embarked on a collaborative effort to expand the ECHSA-CD with a new module designed to capture data about interventional cardiology procedures. The purpose of this manuscript is to describe the concept, the structure, and the function of the new AEPC Interventional Cardiology Part of the ECHSA-CD, as well as the potentially valuable synergies provided by the shared interventional and surgical analyses of outcomes of patients. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow centers to have access to robust surgical and transcatheter outcome data from their own center, as well as robust national and international aggregate outcome data for benchmarking. Each contributing center or department will have access to their own data, as well as aggregate data from the AEPC Interventional Cardiology Part of the ECHSA-CD. The new AEPC Interventional Cardiology Part of the ECHSA-CD will allow cardiology centers to have access to aggregate cardiology data, just as surgical centers already have access to aggregate surgical data. Comparison of surgical and catheter interventional outcomes could potentially strengthen decision processes. A study of the wealth of information collected in the database could potentially also contribute toward improved early and late survival, as well as enhanced quality of life of patients with pediatric and/or congenital heart disease treated with surgery and interventional cardiac catheterization across Europe and the world.

Tricuspid intervention for less-than-severe regurgitation simultaneously with minimally invasive mitral valve surgery in patients with atrial fibrillation.

BACKGROUND: While tackling moderate tricuspid regurgitation (TR) simultaneously with left-side heart surgery is recommended by the guidelines, the procedure is still seldom performed, especially in the minimally invasive setting. Atrial fibrillation (AF) is a known marker of both mortality and TR progression after mitral valve surgery. AIMS: This study aimed to investigatev the safety of performing tricuspid intervention and minimally invasive mitral valve surgery (MIMVS) in patients with preoperative AF. METHODS: We retrospectively analyzed data from the Polish National Registry of Cardiac Surgery Procedures collected between 2006 and 2021. We included all patients who underwent MIMVS (mini-thoracotomy, totally thoracoscopic, or robotic surgery) and had presented with moderate tricuspid regurgitation and AF preoperatively. The primary endpoint was death from any cause at 30 days and at the longest available follow-up after MIMVS with tricuspid intervention vs. MIMVS alone. We used propensity score (PS) matching to account for baseline differences between groups. RESULTS: We identified 1545 patients with AF undergoing MIMVS, 54.7% were men aged 66.7 (mean [standard deviation, SD], 9.2) years. Of those, 733 (47.4%) underwent concomitant tricuspid valve intervention. At 13 years of follow-up, the addition of tricuspid intervention was associated with 33% higher mortality as compared to MIMVS alone (hazard ratio [HR], 1.33; 95% confidence interval [CI], 1.05-1.69; P = 0.02). PS matching resulted in identifying 565 well-balanced pairs. Concomitant tricuspid intervention did not influence long-term follow-up (HR, 1.01; 95 CI, 0.74-1.38; P = 0.94). CONCLUSIONS: After adjusting for baseline confounders, the addition of tricuspid intervention for moderate tricuspid regurgitation to MIMVS did not increase perioperative mortality nor influence long-term survival.

The impact of sex on in-hospital and long-term mortality rates in patients undergoing surgical aortic valve replacement: The SAVR and SEX study.

BACKGROUND: Surgical aortic valve replacement (SAVR) is among the most commonly performed valvular surgeries. Despite many previous studies conducted in this setting, the impact of sex on outcomes in patients undergoing SAVR is still unclear. AIMS: This study aimed to define sex differences in short- and long-term mortality in patients undergoing SAVR. METHODS: We analyzed retrospectively all the patients undergoing isolated SAVR from January 2006 to March 2020 in the Department of Cardiovascular Surgery and Transplantology in John Paul II Hospital in Kraków. The primary endpoint was in-hospital and long-term mortality. Secondary endpoints included the duration of hospital stay and perioperative complications. Groups of men and women were compared with regard to the prosthesis type. Propensity score matching was performed to adjust for differences in baseline characteristics. RESULTS: A total number of 4 510 patients undergoing isolated surgical SAVR were analyzed. A follow- up median (interquartile range [IQR]) was 2120 (1000-3452) days. Females made up 41.55% of the cohort and were older, displayed more non-cardiac comorbidities, and faced a higher operative risk. In both sexes, bioprostheses were more often applied (55.5% vs. 44.5%; P <0.0001). In univariable analysis, sex was not linked to in-hospital mortality (3.7% vs. 3%; P = 0.15) and late mortality rates (23.37% vs. 23.52 %; P = 0.9). Upon adjustment for baseline characteristics (propensity score matching analysis) and considering 5-year survival, a long-term prognosis turned out to be better in women (86.8%) compared to men (82.7%, P = 0.03). CONCLUSIONS: A key finding from this study suggests that female sex was not associated with higher in-hospital and late mortality rates compared to men. Further studies are needed to confirm longterm benefits in women undergoing SAVR.

Comparison of Repair vs Replacement in Calcific and Rheumatic Mitral Disease.

BACKGROUND: The benefit of repair over replacement of rheumatic or calcified mitral valve (MV) is debatable. METHODS: Patients who underwent MV repair or replacement for rheumatic or calcified MV disease between 2006 and 2020 were identified in the Polish National Registry of Cardiac Surgery Procedures. Patients who underwent additional procedures other than coronary artery bypass grafting or tricuspid valve surgery, as well as redo or emergency cases, were excluded. The long-term survival was verified based on National Health Fund registry data. The survival was compared between MV repair and replacement in the whole cohort and after propensity score matching. RESULTS: We included 4338 patients: 1859 (43%) with pure mitral regurgitation and 2479 (57%) with mitral stenosis. MV was repaired in 543 patients (29%) with pure regurgitation and 126 (5.1%) with stenosis (P < .001). In total, 984 (23%) patients underwent concomitant coronary artery bypass grafting and 1358 (32%) tricuspid valve surgery. MV repair improved survival (hazard ratio 0.81; 95% CI 0.68-0.97; P = .022) in patients with no mitral stenosis, and had no effect in mitral stenosis (hazard ratio 1.17; 95% CI 0.85-1.59; P = .332). The results were confirmed in propensity-matched cohorts. The freedom from MV reoperation at 10 years was 95.5% ± 1.2% after repair and 96.0% ± 0.7% after MV replacement (P = .416) in the absence of stenosis and 91.8% ± 3.4% after repair vs 95.9% ± 0.5% after replacement in patients with mitral stenosis (P = .065). CONCLUSIONS: Repair of rheumatic/calcified mitral valve should be a preferred option in patients with no mitral stenosis, but confers no benefit if mitral stenosis is present.

TGA + IVS + LVOTO: patterns of practice and outcomes.

PURPOSE: Transposition of great arteries with intact ventricular septum and left ventricular outflow tract obstruction (TGA + IVS + LVOTO) is uncommon. We reviewed operations performed in patients with TGA + IVS + LVOTO in the European Congenital Heart Surgeons Association Congenital Database (ECHSA-CD). METHODS: All 109 patients with a diagnosis of TGA + IVS + LVOTO in ECHSA-CD who underwent cardiac surgery during a 21-year period (01/2000-02/2021, inclusive) were included. Preoperative variables, operative data, and postoperative outcomes were collected. RESULTS: These 109 patients underwent 176 operations, including 37 (21.0%) arterial switch operations (ASO), 26 (14.2%) modified Blalock-Taussig-Thomas shunts (MBTTS), 11 (6.2%) Rastelli operations, and 13 (7.3%) other palliative operations (8 superior cavopulmonary anastomosis[es], 4 Fontan, and 1 other palliative procedure). Of 37 patients undergoing ASO, 22 had a concomitant procedure.There were 68 (38.6%) reoperations, including 11 pacemaker procedures and 8 conduit operations. After a systemic-to-pulmonary artery shunt, reoperations included shunt reoperation (n = 4), Rastelli (n = 4), and superior cavopulmonary anastomosis (n = 3).Overall Operative Mortality was 8.2% (9 deaths), including three following ASO, two following "Nikaidoh, Kawashima, or LV-PA conduit" procedures, and two following Rastelli. Postoperative complications occurred after 36 operations (20.4%). The most common complications were delayed sternal closure (n = 11), postoperative respiratory insufficiency requiring mechanical ventilation >7 days (n = 9), and renal failure requiring temporary dialysis (n = 8). CONCLUSION: TGA + IVS + LVOTO is rare (109 patients in ECHSA-CD over 21 years). ASO, MBTTS, and Rastelli are the most common operations performed for TGA + IVS + LVOTO. Larger international studies with long-term follow-up are needed to better define the anatomy of the LVOTO and to determine the optimal surgical strategy.

Ten Years of Data Verification: The European Congenital Heart Surgeons Association Congenital Database Audits.

BACKGROUND: Congenital heart surgery databases are tools for internal programmatic evaluation, benchmarking institutional results to multi-institutional aggregate data, and research. Therefore, it is essential to ensure the completeness and accuracy of data. This study analyzes the results of ten years of on-site source data verification of the European Congenital Heart Surgeons Association Congenital Heart Surgery Database (ECHSA CHSD). METHODS: All data forms verified between 2009 and 2018 were analyzed. The data form consists of 12 data elements: dates of birth, admission, surgery, discharge, and death; weight; case category; cardiopulmonary bypass time; aortic cross-clamp time; validation rules; diagnoses; and procedures. Descriptive data calculation and rates of completeness and accuracy were determined. The trend of error rate of seven centers with ≥5 visits was analyzed. RESULTS: Sixty-nine on-site verification visits took place at 17 centers. A total of 26,245 cases were verified; 2,841 of these 26,245 cases (10.8%) showed an error. The total mean error rate of centers for all years was 12.3 ± 2.1%. Rates of completeness and accuracy were 99% and 89.2%, respectively. Coded diagnoses and procedure analysis revealed that 716 (2.7%) and 456 (1.7%) datasets were incorrect, respectively. Rates of completeness and accuracy of dates were 100%, and 97.1%, respectively. Validation fields showed no errors. CONCLUSION: Source data verification is an appropriate tool to determine completeness and accuracy of data. The ECHSA CHSD verification analysis of a ten-year period showed a high level of completeness and accuracy. The verified data of the ECHSA CHSD are well-suited for benchmarking and research.

Repair or Replacement for Secondary Mitral Regurgitation: Results From Polish National Registry.

BACKGROUND: The optimal surgical strategy (repair vs replacement) for patients with secondary mitral (MV) regurgitation is questionable. METHODS: Patients who underwent MV repair or replacement for functional or ischemic mitral regurgitation between 2006 and 2017 were identified in Polish National Registry of Cardiac Surgery Procedures. Patients, who underwent additional procedures other than coronary artery bypass grafting or tricuspid valve surgery, as well as redo or emergency cases, were excluded. The long-term survival was verified based on National Health Fund registry. The survival was compared between MV repair and replacement both in the whole cohort and after propensity score matching. The Cox regression was used to seek for independent predictors of survival. RESULTS: Of 7633 identified patients, 1793 (23%) underwent MV replacement and 5840 (77%) underwent MV repair. Coronary artery bypass surgery was performed together with MV repair in 3992 (69%) patients and together with MV replacement in 915 (52%) patients (P < .001). Tricuspid valve surgery was added to 1393 (24%) MV repairs and to 561 (32%) MV replacements (P < .001). The crude actuarial 5-year survival was 71% (95% confidence interval [CI], 70%-72%) in the repair group and 66% (95% CI, 63%-68%) in the replacement group (P < .001). MV replacement was an independent predictor of mortality (hazard ratio, 1.32; 95% CI, 1.17-1.49) (P < .001) in Cox regression modeling. In the propensity-matched cohort (1105 pairs), the long-term mortality was also significantly higher in the replacement group (hazard ratio, 1.24; 95% CI, 1.06-1.45; P = .008). CONCLUSIONS: Repair of secondary mitral regurgitation has an associated survival benefit compared with MV replacement.

Benchmarking in Congenital Heart Surgery Using Machine Learning-Derived Optimal Classification Trees.

Background: We have previously shown that the machine learning methodology of optimal classification trees (OCTs) can accurately predict risk after congenital heart surgery (CHS). We have now applied this methodology to define benchmarking standards after CHS, permitting case-adjusted hospital-specific performance evaluation. Methods: The European Congenital Heart Surgeons Association Congenital Database data subset (31 792 patients) who had undergone any of the 10 "benchmark procedure group" primary procedures were analyzed. OCT models were built predicting hospital mortality (HM), and prolonged postoperative mechanical ventilatory support time (MVST) or length of hospital stay (LOS), thereby establishing case-adjusted benchmarking standards reflecting the overall performance of all participating hospitals, designated as the "virtual hospital." These models were then used to predict individual hospitals' expected outcomes (both aggregate and, importantly, for risk-matched patient cohorts) for their own specific cases and case-mix, based on OCT analysis of aggregate data from the "virtual hospital." Results: The raw average rates were HM = 4.4%, MVST = 15.3%, and LOS = 15.5%. Of 64 participating centers, in comparison with each hospital's specific case-adjusted benchmark, 17.0% statistically (under 90% confidence intervals) overperformed and 26.4% underperformed with respect to the predicted outcomes for their own specific cases and case-mix. For MVST and LOS, overperformers were 34.0% and 26.4%, and underperformers were 28.3% and 43.4%, respectively. OCT analyses reveal hospital-specific patient cohorts of either overperformance or underperformance. Conclusions: OCT benchmarking analysis can assess hospital-specific case-adjusted performance after CHS, both overall and patient cohort-specific, serving as a tool for hospital self-assessment and quality improvement.

Risk evaluation in adult congenital heart surgery: analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database risk models on data from the European Congenital Heart Surgeons Association Congenital Database.

OBJECTIVES: We sought to evaluate the predictive power of the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) mortality score and the adult congenital heart surgery (ACHS) mortality score for the adults undergoing congenital heart operations entered into the European Congenital Heart Surgeons Association (ECHSA) database. METHODS: The data set comprised 17 662 major operations performed between 1997 and 2019, on patients 18 years of age or older, in European centres participating in the ECHSA database. Each operation was assigned a STAT mortality score and category and an ACHS mortality score. Operative mortality was based on the 30-day status and on the status at hospital discharge. The discriminatory power of the STAT and ACHS scores was assessed using the area under the receiver operating characteristic curve (c-index). RESULTS: A total of 17 214 (97.46%) operations were assigned ACHS scores. The 3 most frequent primary procedures were closure of the atrial septal defect (19.0%), aortic valve replacement (8.8%) and non-valve-sparing aortic root replacement (6.1%). Operative mortality for ACHS-coded operations was 2.07%. The procedures with the highest mortality were atrial septal defect creation/enlargement (19.0%), lung transplantation (18.8%) and heart transplantation (18.2%). A total of 17 638 (99.86%) operations were assigned a STAT score and category. The operative mortality for STAT-coded operations was 2.27%. The c-index for mortality was 0.720 for the STAT mortality score and 0.701 for the ACHS score. CONCLUSIONS: The ACHS mortality score and the STAT mortality score reached similar, moderate predictive power in adult patients undergoing congenital heart surgery in ECHSA database.

Pediatric Cardiac Surgical Patterns of Practice and Outcomes in Japan and Europe.

OBJECTIVES: The Japan Cardiovascular Surgery Database-Congenital section (JCVSD-Congenital) and the European Congenital Heart Surgeons Association (ECHSA) Congenital Heart Surgery Database (CHSD) share the same nomenclature. We aimed at comparing congenital cardiac surgical patterns of practice and outcomes in Japan and Europe using the JCVSD-Congenital and ECHSA-CHSD. METHODS AND RESULTS: We examined Japanese (120 units, 63,365 operations) and European (96 units, 90,098 operations) data in JCVSD-Congenital and ECHSA-CHSD from 2011 to 2017. Patients' age and weight, periprocedural times, mortality at hospital discharge, and postoperative length of stay were calculated for ten benchmark operations. There was a significantly higher proportion of ventricular septal defect closures and Glenn operations and a significantly lower proportion of coarctation repairs, tetralogy of Fallot repairs, atrioventricular septal defect repairs, arterial switch operations, truncus repairs, Norwood operations, and Fontan operations in JCVSD-Congenital compared to ECHSA-CHSD. Postoperative length of stay was significantly longer following all benchmark operations in JCVSD-Congenital compared to ECHSA-CHSD. Mean STAT mortality score (Society of Thoracic Surgeons European Association for Cardio-Thoracic Surgery mortality score) was significantly higher in JCVSD-Congenital (0.78) compared to ECHSA-CHSD (0.71). Mortality at hospital discharge was significantly lower in JCVSD-Congenital (4.2%) compared to ECHSA-CHSD (6.0%, P < .001). CONCLUSIONS: The distribution of the benchmark procedures and age at the time of surgery differ between Japan and Europe. Postoperative length of stay is longer, and the mean complexity is higher in Japan compared to European data. These comparisons of patterns of practice and outcomes demonstrate opportunities for continuing bidirectional transcontinental collaboration and quality improvement.

Adverse Outcomes Prediction for Congenital Heart Surgery: A Machine Learning Approach.

OBJECTIVE: Risk assessment tools typically used in congenital heart surgery (CHS) assume that various possible risk factors interact in a linear and additive fashion, an assumption that may not reflect reality. Using artificial intelligence techniques, we sought to develop nonlinear models for predicting outcomes in CHS. METHODS: We built machine learning (ML) models to predict mortality, postoperative mechanical ventilatory support time (MVST), and hospital length of stay (LOS) for patients who underwent CHS, based on data of more than 235,000 patients and 295,000 operations provided by the European Congenital Heart Surgeons Association Congenital Database. We used optimal classification trees (OCTs) methodology for its interpretability and accuracy, and compared to logistic regression and state-of-the-art ML methods (Random Forests, Gradient Boosting), reporting their area under the curve (AUC or c-statistic) for both training and testing data sets. RESULTS: Optimal classification trees achieve outstanding performance across all three models (mortality AUC = 0.86, prolonged MVST AUC = 0.85, prolonged LOS AUC = 0.82), while being intuitively interpretable. The most significant predictors of mortality are procedure, age, and weight, followed by days since previous admission and any general preoperative patient risk factors. CONCLUSIONS: The nonlinear ML-based models of OCTs are intuitively interpretable and provide superior predictive power. The associated risk calculator allows easy, accurate, and understandable estimation of individual patient risks, in the theoretical framework of the average performance of all centers represented in the database. This methodology has the potential to facilitate decision-making and resource optimization in CHS, enabling total quality management and precise benchmarking initiatives.

Anomalous left coronary artery from pulmonary artery repair: Outcomes from the European Congenital Heart Surgeons Association Database.

INTRODUCTION: We sought to determine the surgical outcomes of patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) enrolled in the European Congenital Heart Surgeons Association (ECHSA) database. MATERIALS AND METHODS: From 1999 to 2019, 907 patients with ALCAPA underwent surgical repair and were included in the current study. The primary outcome was in-hospital mortality. Secondary outcomes included frequency and results of concomitant mitral valve surgery and postoperative mechanical circulatory support (MCS). RESULTS: The overall in-hospital mortality was 6% (54/907) and was significantly higher in neonates (p = .01), patients with lower body surface area (BSA) (p = .01), and those requiring postoperative MCS (p = .001). Associated mitral valve surgery was performed in 144 patients (15.9%) and was associated with longer cardiopulmonary bypass (CPB) and aortic cross-clamp times (AOX) (p ≤ .0001) but was not significantly related to an increase in in-hospital mortality. Postoperative MCS was required in 66 patients (7.3%). These patients were younger (p ≤ .001), had a lower BSA (p ≤ .001), and required a longer CPB (p ≤ .001) and AOX time (p ≤ .001). CONCLUSIONS: ALCAPA repair can be achieved successfully, and with low surgical risk. Concomitant mitral valve procedures can be performed without increasing operative mortality. The use of MCS remains a valuable option, especially in younger patients.

Multiple Versus Single Arterial Coronary Arterial Bypass Grafting Surgery for Multivessel Disease in Atrial Fibrillation.

Observational studies suggest improved outcomes with multiple (MAG) as compared to single arterial grafting (SAG) in patients with multivessel coronary artery disease and undergoing coronary artery bypass grafting (CABG). Even though around 6% of CABG patients have preoperative atrial fibrillation, previous studies did not address MAG versus SAG comparison in this setting. Data from KROK (Polish National Registry of Cardiac Surgery Procedures) were retrospectively collected. 5738 patients with multivessel coronary artery disease and AF (77.9% men, mean age 69.0 ± 8.0) undergoing isolated CABG surgery between 2006 and 2019 in 37 reference centers across Poland were analyzed. Propensity score matching was performed. Primary endpoint was mid-term survival. Median follow-up was 5 years ([IQR 1.9-7.6], max.13). One-to-three Propensity score matching included 2364 patients divided into MAG (591) and SAG (1773) subsets. Subjects were no different in terms of baseline risk and surgical characteristics. Number of distal anastomoses was 2.82 ± 0.83 versus 2.80 ± 0.75 (P = 0.516) for MAG and SAG, respectively. In-hospital outcomes and mortality risk at 1-year (hazard ratio, 95% confidence intervals: 1.13 [0.81-1.58]; P = 0.469) was unchanged with MAG. Multiple arterial grafting was associated with 20% improved mid-term survival: HR 0.80; (95% confidence intervals: 0.65-0.97); P = 0.026. Benefit was sustained in subgroup analyses, yet most appraised in low risk patients (<70-year-old; EuroSCORE <2; no diabetes) and when complete revascularization was achieved. Multiple as compared to single arterial grafting in atrial fibrillation patients undergoing CABG is safe and associated with improved mid-term survival. A particular survival benefit was observed in lower risk patients.

Bioprosthetic or mechanical heart valves: prosthesis choice for borderline patients?-Results from 9,616 cases recorded in Polish national cardiac surgery registry.

BACKGROUND: In middle-aged patients undergoing aortic valve replacement (AVR), the selection of prosthesis type is a complex process. Current guidelines do not unequivocally indicate the type of prosthesis (bioprosthetic or mechanical) recommended for patients between 60-70 years of age. The aim of the study was to present the trends in AVR prosthesis selection in borderline patients over a 10-year period, based on real-life registry data. METHODS: The study population comprised of 9,616 consecutive patients aged between 60-70 years, who underwent isolated AVR between 2006 and 2016 in all cardiac surgery departments in Poland. Data were extracted from the Polish National Registry of Cardiac Surgery. RESULTS: Among 27,797 consecutive AVR procedures, patients aged 60-70 years represented 34.6% of the population operated on. From 2006 to 2016, bioprosthetic valves (BVs) were implanted in 53.9% cases, (and) mechanical valves (MVs) in 42.1%. The proportion of different valve types changed in time: from 77.5% of MVs vs. 22.5% of BVs in 2006 to 23.2% of MVs vs. 76.8% of BVs in 2016 (P<0.001). The most commonly implanted BV was the Hancock II (used in 36.4% of BV implantations), the most commonly used MV was the Saint Jude Mechanical prosthesis (implanted in 36.4% of MV implantation cases). A multivariable model identified smaller annulus [OR (95% CI) 0.89 (0.86-0.92), P<0.001], atrial fibrillation [OR (95% CI) 1.32 (1.05-1.67), P=0.017], male sex [OR (95% CI) 1.47 (1.24-1.74), P<0.001] and year of implantation [OR (95% CI) 0.75 (0.71-0.79), P<0.001] as predictors of MV implantation. CONCLUSIONS: Patients aged 60-70 years represent more than one-third of all AVR patients. Between 2006 and 2016, the proportion of implanted prostheses has changed dramatically. In 2016 BVs were implanted in nearly 75% of AVR cases, three times more often than in 2006.