External validation of the COVID-19 4C mortality score in an urban United States cohort.

BACKGROUND: Identifying patients at risk for mortality from COVID-19 is crucial to triage, clinical decision-making, and the allocation of scarce hospital resources. The 4C Mortality Score effectively predicts COVID-19 mortality, but it has not been validated in a United States (U.S.) population. The purpose of this study is to determine whether the 4C Mortality Score accurately predicts COVID-19 mortality in an urban U.S. adult inpatient population. METHODS: This retrospective cohort study included adult patients admitted to a single-center, tertiary care hospital (Philadelphia, PA) with a positive SARS-CoV-2 PCR from 3/01/2020 to 6/06/2020. Variables were extracted through a combination of automated export and manual chart review. The outcome of interest was mortality during hospital admission or within 30 days of discharge. RESULTS: This study included 426 patients; mean age was 64.4 years, 43.4% were female, and 54.5% self-identified as Black or African American. All-cause mortality was observed in 71 patients (16.7%). The area under the receiver operator characteristic curve of the 4C Mortality Score was 0.85 (95% confidence interval, 0.79-0.89). CONCLUSIONS: Clinicians may use the 4C Mortality Score in an urban, majority Black, U.S. inpatient population. The derivation and validation cohorts were treated in the pre-vaccine era so the 4C Score may over-predict mortality in current patient populations. With stubbornly high inpatient mortality rates, however, the 4C Score remains one of the best tools available to date to inform thoughtful triage and treatment allocation.

Central cannulation strategy for extent I thoracoabdominal aneurysm repair of chronic type B aortic dissection.

INTRODUCTION: We evaluated the safety profile of a central cardiopulmonary bypass (CPB) cannulation strategy for repair of extent I thoracoabdominal aortic aneurysms (TAAA) with chronic type B dissection in comparison to traditional peripheral CPB cannulation strategies. METHODS: Patients undergoing extent I TAAA repair for chronic type B dissection from 2002 to 2011 were retrospectively reviewed. Patients were grouped by their CPB cannulation strategy. Patients in Group I underwent central aortic cannulation (n = 28) through a left thoracotomy incision. The true lumen of the descending thoracic aorta was cannulated using an echocardiogram-guided Seldinger wire technique. The right atrium was directly accessed for venous drainage. In Group II (n = 31), arterial and venous cannulation of the femoral vessels was achieved using a left-sided groin incision. All patients underwent deep hypothermic circulatory arrest for proximal aortic reconstruction. RESULTS: Preoperative aortic dimensions (6.5 ± 0.79 cm in Group I vs 7.0 ± 1.15 cm in Group II p = 0.8) were similar between groups. CPB time (240 ± 37 min in Group I vs 174 ± 68 min in Group II p < 0.01) was significantly higher in the central cannulation group whereas circulatory arrest times (43 ± 5 min Group I vs 37 ± 7 min in Group II p = 0.1) were similar between the two groups. In-hospital 30-day mortality (N = 0, 0% in Group I; N = 2, 6.5% in Group II), stroke (N = 1, 3.5% in Group I; N = 0, 0% in Group II), paraplegia (N = 1, 3.5% in Group I; N = 1, 3.2% in Group II), reoperation for bleeding (N = 1, 3.5% in Group I; N = 1, 3.2% Group II), tracheostomy rate (N = 2, 7% in Group I; N = 3, 9.7% Group II), and mean length of stay (19 days in Group I vs 17 days in Group II) were similar (p > 0.05). Median follow-up was 3.6 ± 2.0 in Group I and 5.6 ± 2.6 years in Group II. Actuarial survival at 5 years was 84.6 % for Group I and 77.6% for Group II (p = 0.52). CONCLUSIONS: Central true lumen cannulation through a left thoracotomy incision for repair of extent I TAAA with chronic type B dissection is an acceptable approach with equivalent early and midterm outcomes compared to more standard femoral cannulation techniques. It may provide a safe alternative cannulation site for patients with diseased femoral vessels.

Thoracic endografting reduces morbidity and remodels the thoracic aorta in DeBakey III aneurysms.

BACKGROUND: The efficacy of endovascular treatment of aneurysms secondary to chronic DeBakey type III aortic dissection (CD3) remains controversial. The objective of this study was to compare outcomes from open and endovascular treatment of CD3 aneurysms, and to determine the efficacy of thoracic endovascular aortic repair (TEVAR) in remodeling the chronically dissected thoracoabdominal aorta. METHODS: From 2005 to 2012, 58 patients underwent open aortic replacement (open) and 31 patients underwent endovascular therapy (TEVAR) for the treatment of CD3 aneurysms. The TEVAR patients were divided into CD3a (n = 12) or CD3b (n = 19) subgroups based upon the DeBakey classification of aortic dissection. Total aortic, true and false lumen diameters were measured at different anatomic locations. True lumen and false lumen indices were calculated to evaluate the impact of TEVAR on remodeling. RESULTS: In the open group, operative mortality was 10.3% and the incidence of pulmonary failure, renal failure, and paraplegia was 13.8%, 10.3%, and 12.1%, respectively. There were no operative mortalities in TEVAR patients, and no cases of pulmonary failure, renal failure, or paraplegia. Endovascular therapy stabilized aneurysm size and remodeled the thoracic aorta in 87% of patients. The TEVAR significantly expanded the true lumen and reduced the false lumen within the stent graft in CD3a and CD3b patients (p < 0.001). Thoracic false lumen thrombosis was achieved in 100% of CD3a and in 68% of CD3b patients. CONCLUSIONS: In these early results, TEVAR reduces operative morbidity and mortality compared with open aortic replacement in the treatment of CD3 aneurysms. The TEVAR is effective in remodeling the chronically dissected thoracic aorta. Abdominal false lumen patency is maintained in patients with thoracoabdominal dissection-related aneurysms.

Graft selection for aortic root replacement in complex active endocarditis: does it matter?

BACKGROUND: Endocarditis affecting the aortic valve, with abscess formation and root destruction, remains a challenge to treat. Aortic root homografts have been advocated because of a perceived lower risk of infective complications than with other root replacement grafts. However, the theoretical advantage of homografts has not been re-evaluated in the modern era. This report is based on an examination of our results for all aortic root replacements in complex, active endocarditis affecting the aortic valve. METHODS: From 2000 to 2010, 134 patients (70.9% male; mean age 58.3±14.8 years) at our institution underwent aortic root replacement for active endocarditis. Ninety of the patients (67.2%) had a previously implanted prosthetic aortic valve. Our findings for these patients included one or more of the following: abscess (n=110, 82.1%), valve vegetation (n=98, 73.1%), and pseudoaneurysm or rupture or both (n=62, 46.3%). We retrospectively reviewed data for the patients from hospital records and the social security data base. RESULTS: A mechanical composite graft (MC) was used in 43 of the patients (32.1%), a non-homograft biologic valve conduit (BC) in 55 patients (41.0%), and a homograft (HG) valve in 36 patients (26.9%). There was no significant difference among the groups in the incidence of major complications or in-hospital mortality. During a mean follow-up of 32.1±29.4 months, the rates of readmission, reinfection, and reoperation were similar for the three groups. The mean 5-year survival in the study was 58±9% for the MC group, 62±7% for the BC group, and 58 ± 9% for the HG group, respectively (p=0.48). CONCLUSIONS: Aortic root replacement in the presence of complex active infection is associated with significant morbidity and mortality. We report that the rates of major complications and late mortality were similar among MC, BC, and HG groups in our study.

Thoracic endovascular aortic repair: evolution of therapy, patterns of use, and results in a 10-year experience.

OBJECTIVE: The introduction of aortic stent grafting in the treatment of thoracic aortic disease has pioneered unique treatment options and gained rapid clinical adoption despite a paucity of long-term outcome data. The purpose of this analysis is to examine all operations performed using thoracic aortic stent grafts at the University of Pennsylvania Health System. METHODS: A total of 502 operations involving thoracic aortic stent grafting were performed between April 1999 and April 2009. Patients were followed in a prospectively collected clinical perioperative registry, and long-term outcomes were determined from administrative data sources. Aortic pathologies included aortic aneurysm, acute aortic dissection (types A and B), hybrid arch repairs, reinterventions with additional stents, pseudoaneurysm, chronic type B dissection, traumatic transection, penetrating aortic ulcer, and other unique indications. RESULTS: Patients' mean age at the time of thoracic endovascular aortic repair was 70.1 ± 12.4 years, and 51% of the patients were aged more than 70 years. Some 41% of patients were female, and the majority of patients (87%) were hypertensive. Overall 30-day mortality was 10.1%. Multivariable risk factors for 30-day mortality included urgent/emergency, Stanford type A aortic dissection, perioperative spinal ischemia, type C aortic coverage, hybrid arch operation, aortic transection, chronic renal failure, and age. Neurologic complications included permanent complete or incomplete paraplegia in 17 patients (3.4%), reversible spinal cord ischemia in 26 patients (5.1%), transient stroke in 16 patients (3.2%), and permanent stroke in 23 patients (4.6%). Greater extent of aortic coverage was not associated with risk of spinal cord ischemia. Access complications, stroke, and endoleaks diminished with increased operative experience over time. Risk factors for late mortality included urgent/emergency indications, hybrid procedures, traumatic aortic transection, age, perioperative paralysis, and chronic renal failure. Patients undergoing stent grafting for type B dissection were more likely to survive than patients undergoing stent grafting for aneurysms or other indications. CONCLUSIONS: Thoracic aortic stent grafting has evolved to be a viable option to complement, augment, or even replace traditional treatments for aortic disease. These data illustrate the applicability of this evolving technology in the establishment of new treatment paradigms for complex aortic pathologies.