Quality of Life Worsens After Surgical Repair of Acute Type A Aortic Dissection.

This study aimed to determine how acute type A aortic dissection (ATAAD) impacts patients' quality of life. The 36-Item Short Form Survey (SF-36) was used to measure quality of life. The eight SF-36 scales were aggregated into a two-factor summary: physical and mental component summary scales (PCS and MCS). One hundred fourteen patients were included in the ATAAD group and 81 patients in the aortic valve replacement (AVR) group. All patients underwent surgery between June 2007 and December 2018. Surveys were completed after the operation. The mean scaled score of the ATAAD group decreased significantly in all eight domains of the SF-36 survey after aortic dissection repair except mental health. Also, the postsurgery PCS score was significantly lower than the presurgery score (39 vs 49; P < 0.0001). Multivariable regression confirmed the negative impact of ATAAD on postsurgery PCS score and higher presurgery PCS score had a significant positive impact. The postsurgery MCS score did not change significantly (49 vs 50; P = 0.32), but higher preoperative MCS score had a significant positive impact on the postsurgery MCS score. Age, sex, connective tissue disorders, and stroke did not contribute significantly to the postsurgery PCS and MCS scores. The AVR group had significantly increased postsurgery PCS and MCS scores compared to the presurgery scores (47 vs 41; P < 0.0001) and (53 vs 51; P = 0.02) respectively. Patients reported significantly decreased physical health after recovery from acute type A aortic dissection repair. A multidisciplinary approach is needed to improve patients' quality of life.

Root abscess in the setting of infectious endocarditis: Short- and long-term outcomes.

OBJECTIVES: To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically. METHODS: From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data. RESULTS: Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%). CONCLUSIONS: Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis.

BACKGROUND: Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied. METHODS: Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival. RESULTS: Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively. CONCLUSIONS: In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.

Influence of Age on Longevity of a Stentless Aortic Valve.

BACKGROUND: The longevity of a stentless valve in a younger population (20-60 years old) is unknown. METHODS: From 1992 to 2015, 1947 patients underwent aortic valve/root replacement for aortic stenosis, insufficiency, root aneurysm, or aortic dissection with stentless bioprostheses (median size, 26 mm). At operation 105 patients were <40 years old, 528 were 40 to 59, 860 were 60 to 74, and 454 were ≥75 years. The data were obtained through chart review, administered surveys, and the National Death Index. RESULTS: The 30-day mortality rate was 2.6%. During follow-up 807 patients (41%) died before reoperation, 993 (51%) were alive without reoperations because of deterioration, and 113 patients (5.8%) underwent reoperation for structural valve deterioration. After adjusting death and reoperation for non-structural valve deterioration causes as competing risks, the cumulative incidence of reoperation was significantly different between the younger groups (<40, 40-59) and the older groups (60-74, ≥75; P < .0001) but not inside the younger (<40 vs 40-59) or older (60-74 vs ≥75) group. The significant hazard ratio of reoperation for <40 versus ≥75 years of age was 12, <40 versus 60 to 74 was 4, 40 to 59 versus 60 to 74 was 3, and 40 to 59 versus ≥75 was 9 (P ≤ .01). The 10- and 15-year survival in the entire cohort was 53% and 29%, respectively. CONCLUSIONS: The stentless aortic valve provides satisfactory durability as a conduit for aortic valve/root replacement for patients who prefer a bioprosthesis. However it should be judiciously considered for patients younger than 60 years because of an increased incidence of reoperation for structural valve deterioration.

Dissecting and Interpreting a Three-Dimensional Ground-Penetrating Radar Dataset: An Example from Northern Australia.

A robust 3-D GPR dataset provides interpreters with a variety of methods for extracting important information at buried archaeological sites. An iterative approach that uses reflection profile analysis, amplitude slice-mapping, and often both in conjunction is often necessary as neither method by itself is sufficient. In northern Australia, two constructed mounds contain a number of cultural and geological horizons and features, which can be imaged with GPR. The reflection profiles display the modified ground surface prior to mound construction and some initial construction layers. On the pre-mound surface, amplitude maps of reflective layers that were built-up on the ground surface indicate that they were constructed in an intentional manner. Those surfaces were later covered by sand to produce mounds used for human burial. Human internments in the mound can only be seen in reflection profiles, but once discovered, the profiles can be re-sliced to produce high definition amplitude images of these remains. No one method of analysis can provide an overall interpretation of these complex internal mound features. When the methods are varied, depending on the results of one method, a detailed and varied analysis of certain aspects of the mounds' internal features are visible, leading to the generation of a number of hypotheses about how this area of northern Australia was used in the past. The 3-D data from GPR shows that this area was an important location on the landscape in the past, and was modified by the construction of a monumental mound, which was then used for human burials, and more recently, the construction of what was likely a ritual enclosure.

The Roles of Rods, Cones, and Melanopsin in Photoresponses of M4 Intrinsically Photosensitive Retinal Ganglion Cells (ipRGCs) and Optokinetic Visual Behavior.

Intrinsically photosensitive retinal ganglion cells (ipRGCs) mediate not only image-forming vision like other ganglion cells, but also non-image-forming physiological responses to light such as pupil constriction and circadian photoentrainment. All ipRGCs respond to light through their endogenous photopigment melanopsin as well as rod/cone-driven synaptic inputs. A major knowledge gap is how melanopsin, rods, and cones differentially drive ipRGC photoresponses and image-forming vision. We whole-cell-recorded from M4-type ipRGCs lacking melanopsin, rod input, or cone input to dissect the roles of each component in ipRGCs' responses to steady and temporally modulated (≥0.3 Hz) lights. We also used a behavioral assay to determine how the elimination of melanopsin, rod, or cone function impacts the optokinetic visual behavior of mice. Results showed that the initial, transient peak in an M4 cell's responses to 10-s light steps arises from rod and cone inputs. Both the sustainability and poststimulus persistence of these light-step responses depend only on rod and/or cone inputs, which is unexpected because these ipRGC photoresponse properties have often been attributed primarily to melanopsin. For temporally varying stimuli, the enhancement of response sustainedness involves melanopsin, whereas stimulus tracking is mediated by rod and cone inputs. Finally, the behavioral assay showed that while all three photoreceptive systems are nearly equally important for contrast sensitivity, only cones and rods contribute to spatial acuity.

Cook Island artifact geochemistry demonstrates spatial and temporal extent of pre-European interarchipelago voyaging in East Polynesia.

The Cook Islands are considered the "gateway" for human colonization of East Polynesia, the final chapter of Oceanic settlement and the last major region occupied on Earth. Indeed, East Polynesia witnessed the culmination of the greatest maritime migration in human history. Perennial debates have critiqued whether Oceanic settlement was purposeful or accidental, the timing and pathways of colonization, and the nature and extent of postcolonization voyaging-essential for small founding groups securing a lifeline between parent and daughter communities. Centering on the well-dated Tangatatau rockshelter, Mangaia, Southern Cook Islands, we charted the temporal duration and geographic spread of exotic stone adze materials-essential woodworking tools found throughout Polynesia- imported for more than 300 y beginning in the early AD 1300s. Using a technique requiring only 200 mg of sample for the geochemical analysis of trace elements and isotopes of fine-grained basalt adzes, we assigned all artifacts to an island or archipelago of origin. Adze material was identified from the chiefly complex on the Austral Islands, from the major adze quarry complex on Tutuila (Samoa), and from the Marquesas Islands more than 2,400 km distant. This interaction is the only dated example of down-the-line exchange in central East Polynesia where intermediate groups transferred commodities attesting to the interconnectedness and complexity of social relations fostered during postsettlement voyaging. For the Cook Islands, this exchange may have lasted into the 1600s, at least a century later than other East Polynesian archipelagos, suggesting that interarchipelago interaction contributed to the later development of social hierarchies.

Rapid interhemispheric climate links via the Australasian monsoon during the last deglaciation.

Recent studies have proposed that millennial-scale reorganization of the ocean-atmosphere circulation drives increased upwelling in the Southern Ocean, leading to rising atmospheric carbon dioxide levels and ice age terminations. Southward migration of the global monsoon is thought to link the hemispheres during deglaciation, but vital evidence from the southern sector of the vast Australasian monsoon system is yet to emerge. Here we present a 230thorium-dated stalagmite oxygen isotope record of millennial-scale changes in Australian-Indonesian monsoon rainfall over the last 31,000 years. The record shows that abrupt southward shifts of the Australian-Indonesian monsoon were synchronous with North Atlantic cold intervals 17,600-11,500 years ago. The most prominent southward shift occurred in lock-step with Heinrich Stadial 1 (17,600-14,600 years ago), and rising atmospheric carbon dioxide. Our findings show that millennial-scale climate change was transmitted rapidly across Australasia and lend support to the idea that the 3,000-year-long Heinrich 1 interval could have been critical in driving the last deglaciation.