Retreatment after primary spontaneous pneumothoraxes managed with primary tube thoracostomy or surgery.

BACKGROUND AND AIMS: There is a paucity of data on later healthcare visits and retreatments after primary treatment of spontaneous pneumothorax. The main purpose of this study was to describe retreatment rates up to 5 years after primary spontaneous pneumothorax treated with either surgery or tube thoracostomy (TT) at index hospitalization in Finland between 2005 and 2018 to estimate the burden of primary spontaneous pneumothorax on the healthcare system. METHODS: Retrospective registry-based study of patients with primary spontaneous pneumothorax treated with TT or surgery in Finland in 2005-2018. Rehospitalization and retreatment for recurrent pneumothorax and complications attributable to initial treatment were identified. RESULTS: The total study population was 1594 patients. At 5 years, 53.2% (384/722) of TT treated and 33.8% (295/872) of surgically treated patients had undergone any retreatment. Surgery was associated with a lower risk of recurrence than TT (hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.43-0.56, p < 0.001). Male sex was associated with a lower risk of recurrent treatment (HR 0.75, 95% CI 0.63-0.90, p = 0.001). Higher age decreased the risk of recurrent treatment (HR 0.99, 95% CI 0.99-0.99, p < 0.001). At 5 years, 36.0% (260/722) of the TT treated and 18.8% (164/872) of the surgically treated had undergone reoperation at some point. CONCLUSIONS: Reintervention rates and repeat hospital visits after TT and surgery were surprisingly high at long-term follow-up. Occurrences of retreatment and reoperation were significantly higher among primary spontaneous pneumothorax patients treated with TT at index hospitalization than among patients treated with surgery.

Anticoagulation Therapy After Biologic Aortic Valve Replacement.

Objectives: Thromboembolism prophylaxis after biologic aortic valve replacement (BAVR) is recommended for 3 months postoperatively. We examined the continuation of oral anticoagulation (OAC) treatment and its effect on the long-term prognosis after BAVR. Methods: We used nation-wide register data from 4,079 individuals who underwent BAVR. We examined the association between warfarin and the non-vitamin K antagonist oral anticoagulant use with death, stroke and major bleeding in 2010 - 2016. Results: The risk of stroke was higher (HR 2.39, 95% CI 1.62 - 3.53, p < 0.001) and the risk of death was lower (HR 0.79, 95% CI 0.65 - 0.96, p = 0.016) in OAC-users compared to individuals without OAC. We observed no significant associations between OAC use and bleeding risk. Conclusion: OAC use after BAVR was associated with increased risk of stroke and decreased risk of death. These observational findings warrant validation in randomized controlled trials before any clinical conclusions can be drawn.

Population trends in aortic valve surgery in Finland between 2001 and 2016.

Objectives. To investigate nationwide changes in procedure rates, patient selection, and prognosis after all surgical aortic valve replacements. Design. Patients undergoing primary surgical aortic valve replacement between 2001 and 2016 were identified from three nationwide registers with compulsory reporting to examine trends in aortic valve surgery over four four-year time periods. Results. A total of 12,139 surgical aortic valve replacement procedures (mean age 61.9 ± 11.8 years, 39.1% women) were performed. The total number of biological valves increased from 1001 (42.9%) to 2526 (75.5%) from 2001-2004 to 2013-2016 (p < .001). During the first and last time periods the comorbidity burden increased; share of patients with hypertension increased from 37.5% to 46.9% (p < .001), diabetes from 14% to 16.5% (p = .01) and previous stroke from 5.2% to 7.2% (p = .01). The proportion of women undergoing surgery decreased from 40% to 36.1% from 2001-2004 to 2013-2016, respectively (p = .01). Overall 28-day mortality was 3.5%. In patients with biologic valve the multivariable-adjusted risk of short-term mortality decreased steadily in every four-year period from 2001-2004 to 2005-2008 (HR, 0.66; 95% CI 0.47-9.92), 2009-2012 (HR, 0.54; 95% CI, 0.39-0.75) and 2013-2016 (HR, 0.41; 95% CI, 0.29-0.58), whereas short-term mortality remained similar in patients with mechanical valve. The risk of four-year postoperative mortality after all surgical aortic valve replacements stayed constant. Conclusions. The use of biologic aortic valve prosthesis has increased from 2001 to 2016. The proportion of women has declined markedly. The short-term mortality has decreased and the long-term mortality has stayed constant despite increasing comorbidity burden.

Population trends in mitral valve surgery in Finland between 1997 and 2014: the finnish CVD register.

OBJECTIVES: Contemporary, nationwide data on trends in mitral valve surgery are scarce. Our aim was to investigate changes in procedure rates, patient selection, and post-procedural prognosis of open-heart mitral valve surgery in Finland. DESIGN: We combined data from three nationwide administrative registers with compulsory reporting. We identified patients who had undergone first-ever open-heart mitral valve surgery between 1997 and 2014 and followed them for adverse events. We examined trends in mitral valve surgery over three six-year time periods (1997-2002, 2003-2008, and 2009-2014). RESULTS: 3684 mitral valve procedures (mean age: 67.0 ± 10.9 years, 42.6% women) were performed in 1997-2014 in Finland. During this period, mitral valve repair operations became more common than replacements and we observed an increasing trend in the use of bioprosthetic valves. Between 1997-2002 and 2009-2014, the mean age of patients undergoing mitral valve surgery and the proportion of urgent surgeries increased (p < .001 for both). The proportion of women undergoing surgery decreased while the share of patients with hypertension (p = .023) or diabetes (p = .026) increased. The multivariable-adjusted risk of 28-day (hazard ratio, 0.55; 95% confidence interval, 0.37-0.83) and 6-year (hazard ratio, 0.80; 95% confidence interval, 0.67-0.97) post-operative mortality was lower in the last six-year period than in 1994-1998. CONCLUSIONS: Short- and long-term mortality of mitral valve surgery patients in Finland has decreased from 1997 to 2014 despite the patients being older and having more comorbidities. Understanding the changing characteristics and prognosis of these patients is important for the interpretation of previous and future cohort studies and trials.

Permanent work disability in patients ≤50 years old after percutaneous coronary intervention and coronary artery bypass grafting (the CRAGS study).

Background: The aim of this study was to investigate the incidence of permanent working disability (PWD) in young patients after percutaneous or surgical coronary revascularization. Methods and Results: The study included 1035 consecutive patients ≤50 years old who underwent coronary revascularization [910 and 125 patients in percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) groups, respectively] between 2002 and 2012 at 4 Finnish hospitals. The median follow-up time was 41 months. The overall incidence of PWD was higher after CABG compared to PCI (at 5 years, 34.8 vs. 14.7%, P < 0.001). Freedom from PWD in the general population aged 45 was 97.2% at 4 years follow-up. Median time to grant disability pension was 11.6 months after CABG and 24.4 months after PCI (P = 0.018). Reasons for PWD were classified as cardiac (35.3 vs. 36.9%), psychiatric (14.7 vs. 14.6%), and musculoskeletal (14.7 vs. 15.5%) in patients undergoing CABG vs. PCI. Overall freedom from PWD was higher in patients without major adverse cardiac and cerebrovascular event (MACCE) (at 5 years, 85.6 vs. 71.9%, P < 0.001). Nevertheless, rate of PWD was high also in patients without MACCE and patients with preserved ejection fraction during follow-up. Conclusions: Although coronary revascularization confers good overall survival in young patients, PWD is common especially after CABG and mostly for cardiac reasons even without occurrence of MACCE. Supportive measures to preserve occupational health are warranted concomitantly with coronary revascularization at all levels of health care.

Trends in rates, patient selection and prognosis of coronary revascularisations in Finland between 1994 and 2013: the CVDR.

AIMS: The aim of the study was to investigate the 20-year trends in rates, patient selection and prognosis of coronary revascularisations in Finland. METHODS AND RESULTS: We identified patients from nationwide registers who had undergone first-ever percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) between 1994 and 2013. We examined changes in procedure rates, patient characteristics and estimated hazard ratios (HR) and 95% confidence intervals for cardiovascular events during this period. Between 1994 and 2013, 85,482 PCIs and 74,338 CABGs were performed. During this period, PCI rates more than quadrupled while CABG rates declined by two thirds. Between 1994-1998 and 2009-2013, the proportion of urgent procedures and mean patient age increased while the proportion of women remained stable. Although unadjusted mortality rose, the multivariable-adjusted HRs for 28-day mortality (PCI: 0.62 [0.49-0.79]; CABG: 0.62 [0.54-0.72]) and five-year incidence of cardiovascular death (PCI: 0.72 [0.66-0.80]; CABG: 0.77 [0.72-0.83]), myocardial infarction (PCI: 0.47 [0.44-0.50]; CABG: 0.31 [0.29-0.32]) and stroke (PCI: 0.37 [0.34-0.40]; CABG: 0.36 [0.33-0.38]) were lower in the last five-year period than in the period 1994-1998. CONCLUSIONS: Although revascularisation patients are older than before, post-procedural prognosis has improved drastically in recent years. Understanding the changing characteristics and prognosis of these patients is important for the interpretation of previous and future studies.

Thirty-year results after implantation of the Björk-Shiley Convexo-Concave Heart valve prosthesis.

BACKGROUND: Modifications of the Björk-Shiley valve prosthesis have shown good long-term results. The convexo-concave model, however, was recalled 27 years ago because of a propensity for breakage due to outlet strut fracture. The objective of this study is to describe the 30-year outcome after implantation of the Björk-Shiley convexo-concave mechanical heart valve prosthesis (Pfizer, Rye Brook, NY). METHODS: The study included 279 patients who were operated between 1979 and 1983 at Turku University Hospital. A total of 305 valves were implanted; 205 in the aortic position and 100 in the mitral position. Patient records were reviewed for baseline characteristics and late events, data on mortality were acquired from registries. RESULTS: Mean actuarial survival was 19.8 years and mean follow-up was 19.2 years (maximum 34 years). Freedom from reoperation was 91.3% at 30 years. There were 3 outlet strut fractures (2 fatal) during follow-up. Statistically significant predictors of mortality were age and concomitant coronary artery bypass grafting. CONCLUSIONS: Despite the possibility of structural valve failure the Björk-Shiley convexo-concave valve confers excellent 30-year survival.

Comparison of the osteoconductive properties of three particulate bone fillers in a rabbit model: allograft, calcium carbonate (Biocoral®) and S53P4 bioactive glass.

AIM: The aim of this study was to compare the osteoconductivity and suitability of three biomaterials used as particulate fillers; S53P4 bioactive glass, allogeneic fresh frozen bone and coral-derived calcium carbonate. MATERIALS AND METHODS: Materials were implanted into drill-holes in the femoral condyles of adult rabbits. Follow-ups were performed at 3, 6, 12 and 24 weeks. Host-response, osteoconductivity, bonding and filler-effect were evaluated by SEM, EDXA and histology and histomorphometry to evaluate. RESULTS: All three materials were found to be biocompatible and osteoconductive. Defects filled with allograft seemed to have more bone at 24 weeks, although no statistically significant difference in new bone growth was found. In earlier time points, coral, however, was observed to degrade more quickly, leaving more empty space in the defects, thus making it a less suitable filler for cavitary defects. CONCLUSION: At all time points there was less filler material (i.e. biomaterial and new bone) in coral-filled defects than in BAG or allograft filled defects (p < 0.05).

Left-sided diaphragmatic and pericardial ruptures with subluxation of the heart after blunt trauma.

We present a rare case of individual but simultaneous rupture of the left pericardium and diaphragm in a patient with multiple blunt trauma. Skeletal trauma was repaired uneventfully with internal plate fixation. Diaphragmatic rupture was suspected and diagnosed 13 days from the initial trauma when the patient exhibited chest pain, dyspnea, and nausea. Intraoperatively, a pericardial rupture was discovered along with subluxation of the heart and repaired with a mesh.