Long-term outcome after implementation of endovascular-first strategy to treat acute mesenteric ischemia.

OBJECTIVE: To evaluate the rationale of an aggressive endovascular-first strategy to treat elderly patients with acute mesenteric ischemia (AMI) by studying long-term survival, readmissions, and patients' discharge to home vs nursing facility a decade after an episode of AMI. METHODS: The retrospective study cohort included 66 consecutive patients (all-comers) treated for arterial occlusive AMI between 2009 and 2013. Endovascular revascularization (EVR) was attempted in 50 patients (EVR+), whereas 16 patients were treated without attempted revascularization (EVR-). All patients were followed until death or September 2022. Studied outcomes included discharge status, long-term survival and cause of death and readmissions related to AMI. RESULTS: The mean age of all 66 patients was 78 ± 10 years: 79 ± 9 years in the EVR+ group and 76 ± 12 years in the EVR- group. EVR was technically successful in 44 patients (88%); three patients underwent subsequent open revascularization after EVR failure. One-third required bowel resection after EVR. The 30-day mortality for all patients was 44%; 32% in the EVR+ group and 81% in the EVR- group. Only two survivors were permanently institutionalized, whereas all others were discharged to the same place they lived prior to the AMI episode. There were four AMI-related readmissions during the follow-up; all were in the EVR+ group. Two patients underwent reinterventions for recurrent AMI. One-year survival was 52% for EVR+ and 19% for EVR- patients. Five-year survival rates were 18% and 13%, respectively. The causes of deaths were mesenteric ischemia in 22, other cardiovascular event in 21, and non-cardiovascular cause in 19 patients. Four patients were alive at the end of the follow-up. CONCLUSIONS: In this unselected elderly population with AMI, the aggressive strategy to attempt EVR resulted in a high revascularization rate and favorable outcomes. The high proportion of patients returning to their prior living status and low readmission rate after survival from AMI encourages active treatment of high-functioning elderly patients.

Friendly Neck Anatomy Does Not Prevent Neck-Related Adverse Events After EVAR.

BACKGROUND: Life-long follow-up after endovascular aneurysm repair (EVAR) is costly and burdensome to the patient. Follow-up should be stratified based on the risk of EVAR failure. Aneurysm neck is thought to be the single most important risk factor. This study investigated neck anatomy as a predictor of neck-related adverse events after EVAR. METHODS: This retrospective single-center study included consecutive patients undergoing elective EVAR for infrarenal abdominal aortic aneurysms between 2011 and 2016 (n = 222) who were followed with yearly imaging until December 2020. Hostile neck was defined as neck length ≤15 mm, width ≥28 mm, angulation ≥60°, calcification, or thrombus ≥50% of circumference or conical neck based on preoperative computed tomography angiography. Neck-related adverse event was defined as aneurysm rupture, any neck-related reintervention or type 1a endoleak during follow-up. RESULTS: Ninety (41%) patients had hostile neck and 132 (59%) had friendly neck. There were no differences in 30-day mortality (1% vs. 1%, P = 0.78), major adverse events (20% vs. 16%, P = 0.43) or reinterventions during the hospital stay (8% vs. 4%, P = 0.20) between patients with hostile and friendly neck. Estimated survival at 1 year was 89 ± 3% for hostile neck and 95 ± 2% for friendly neck patients (P < 0.01). Five-year survival estimates were 51 ± 6% and 66 ± 4%, respectively. Aneurysm-related mortality was higher after 6 years in patients with hostile neck (P < 0.01). Twenty-four patients (11%) suffered neck-related adverse events with mean time-to-event of 3.3 ± 2.8 years; there were no differences between the groups stratified by neck anatomy. Incidentally, preoperative aneurysm diameter was found to be an independent risk factor for neck-related adverse events and aneurysm-related mortality; 53 patients (24%) had aneurysm diameter ≥70 mm, which was associated with nearly 4-fold risk of neck-related complications during the follow-up. CONCLUSIONS: Friendly neck anatomy may not protect from neck-related adverse events after EVAR in the long-term. Especially patients with large aneurysms should be followed closely.

Effect of Endovascular Treatment Rate on Population Level Outcomes and Survival After Intact Abdominal Aortic Aneurysm Repair.

OBJECTIVES: The aim was to study outcomes of endovascular aneurysm repair (EVAR) and open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) in four geographically adjacent populations with identical demographics and variable EVAR rates. METHODS: This was a multicentre cohort study based on local and national registry data from an area of 815 000 inhabitants. The study involved 527 consecutive patients with an intact AAA treated with EVAR (n = 327) or OSR (n = 200) between 2010 and 2016. The catchment area was divided into four health care districts (populations A, B, C, and D) with one central hospital in each district. Each hospital decided independently between OSR and EVAR for patients within their population; OSR was performed in all hospitals while EVAR was centralised in one of them. Patient demographics and treatment outcomes were extracted from local registries. Population demographics, overall AAA incidence, and mortality data were retrieved from a national database. RESULTS: The rate of new intact AAA diagnosis varied between 20 and 29 per 100 000 inhabitants/year with the highest incidence in population D (p < .001). The intact AAA repair rates were 9.8, 8.9, 9.9, and 8.7 per 100 000 inhabitants/year for populations A, B, C, and D, respectively (p = .64). There were no significant differences in mean age (73.6 ± 8.0 years) or mean aortic diameter (62 ± 13 mm) between the treated patient populations. Groups A and B had high EVAR rates (74% and 72%, respectively) whereas the EVAR rates were lower in groups C and D (50% and 38%, respectively) (p < .001). The 30 day mortality rates were 2%, 2%, 4%, and 1% (p = .55), and complication rates were 17%, 12%, 15%, and 11% (p = .39) for A, B, C and D, respectively. There were no significant differences in mortality, complication or re-intervention rates between the groups during the mean follow up of 3.3 ± 2.0 years. CONCLUSIONS: At population level, high EVAR rates had no measurable effect compared with lower EVAR rates on the outcomes in patients with intact AAA.

Metoprolol versus amiodarone in the prevention of atrial fibrillation after cardiac surgery: a randomized trial.

BACKGROUND: Current guidelines recommend ß-blockers as the first-line preventive treatment of atrial fibrillation (AF) after cardiac surgery. Despite this, 19% of physicians report using amiodarone as first-line prophylaxis of postoperative AF. Data directly comparing the efficacy of these agents in preventing postoperative AF are lacking. OBJECTIVE: To determine whether intravenous metoprolol and amiodarone are equally effective in preventing postoperative AF after cardiac surgery. DESIGN: Randomized, prospective, equivalence, open-label, multicenter study. (ClinicalTrials.gov registration number: NCT00784316) SETTING: 3 cardiac care referral centers in Finland. PATIENTS: 316 consecutive patients who were hemodynamically stable and free of mechanical ventilation and AF within 24 hours after cardiac surgery. INTERVENTION: Patients were randomly assigned to receive 48-hour infusion of metoprolol, 1 to 3 mg/h, according to heart rate, or amiodarone, 15 mg/kg of body weight daily, with a maximum daily dose of 1000 mg, starting 15 to 21 hours after cardiac surgery. MEASUREMENTS: The primary end point was the occurrence of the first AF episode or completion of the 48-hour infusion. RESULTS: Atrial fibrillation occurred in 38 of 159 (23.9%) patients in the metoprolol group and 39 of 157 (24.8%) patients in the amiodarone group (P = 0.85). However, the difference (-0.9 percentage point [90% CI, -8.9 to 7.0 percentage points]) does not meet the prespecified equivalence margin of 5 percentage points. The adjusted hazard ratio of the metoprolol group compared with the amiodarone group was 1.09 (95% CI, 0.67 to 1.76). LIMITATIONS: Caregivers were not blinded to treatment allocation, and the trial evaluated only stable patients who were not at particularly elevated risk for AF. The withdrawal of preoperative ß-blocker therapy may have increased the risk for AF in the amiodarone group. CONCLUSION: The occurrence of AF was similar in the metoprolol and amiodarone groups. However, because of the wide range of the CIs, the authors cannot conclude that the 2 treatments were equally effective. PRIMARY FUNDING SOURCE: The Finnish Foundation for Cardiovascular Research and the Kuopio University EVO Foundation.

Intravenous administration of metoprolol is more effective than oral administration in the prevention of atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia to occur after cardiac surgery, with an incidence of 20% to 40%. AF is associated with postoperative complications, including increased risk of stroke and need of additional treatment, as well as prolonged hospital stay and increased costs. It has been shown that prophylactic oral administration of beta-blocker therapy reduces the incidence of postoperative AF after cardiac surgery. However, it is possible that absorption of drugs is impaired after cardiopulmonary perfusion associated with cardiac surgery. The purpose of this prospective, controlled, randomized trial was to study compare intravenous and per oral metoprolol administration in the prevention of AF after cardiac surgery. METHODS AND RESULTS: 240 consecutive patients who were scheduled to undergo their first on-pump coronary artery bypass graft (CABG), aortic valve replacement, or combined aortic valve replacement and CABG were randomized to receive 48-hour infusion of metoprolol or oral metoprolol starting on the first postoperative morning. Patients were excluded if they had contraindications for beta-blocker or had to stay >1 day in the intensive care unit. Dosage of metoprolol was adjusted according to heart rate. The dosage was 1 to 3 mg/h in the intravenous group and from 25 mg twice per day to 50 mg 3 times per day in the oral group. The incidence of postoperative AF was significantly lower in the intravenous group than in the oral group (16.8% versus 28.1%, P=0.036). No serious adverse effects were associated with intravenous metoprolol therapy. CONCLUSIONS: Our study suggests that intravenous metoprolol is well-tolerated and more effective than oral metoprolol in the prevention of AF after cardiac surgery.

Right atrial overdrive pacing does not prevent atrial fibrillation after coronary artery bypass surgery.

AIMS: The purpose of this prospective randomized study was to investigate the efficacy of atrial overdrive pacing (AOP) and bradycardia prevention pacing (BPP) in the prophylaxis of atrial fibrillation (AF) after coronary artery bypass surgery (CABG). METHODS: One hundred and twenty-four on-pump CABG patients were randomized into three groups: AOP, BPP, and NP (no pacing). AOP patients were paced via epicardial wires using an atrial preference pacing algorithm, and BPP patients were paced in the AAI mode with a base rate of 60/min. Patients were paced for 48 h starting on the first postoperative day. The endpoint of the study was the first onset of AF lasting longer than 5 min. RESULTS: Preoperative risk factors and surgical data of patients did not differ between the AOP, BPP and NP groups. Pacing was technically successful in 80.5% of patients in the AOP and in 92.7% in the BPP groups. The incidence of AF in the AOP (26.8%), BPP (19.5%) and NP (28.6%) groups did not differ significantly. In the AOP group, AF in three patients was probably induced by inappropriate pacing due to sensing failure. CONCLUSIONS: Atrial overdrive pacing and bradycardia prevention pacing were not effective in the prevention of AF after CABG.