The Clinical Impact of the Extension of Acute Type A Aortic Surgery on Long-Term Outcomes: Should We Tend to Be Conservative?

Background and Objectives: Despite advances in surgical techniques, industry adjuncts, and cerebral perfusion techniques, the in-hospital mortality rate of type A acute dissection (TAAD) remains at 15-30%. This study aimed to investigate the influence of different extents of aortic resection on survival and quality of life (QoL) after long-term follow-up. Materials and Methods: A retrospective observational trial was performed, including 165 patients operated upon for TAAD. Patients were divided into two groups according to the extent of their aortic repair: the first group comprised patients who had ascending aorta replacement and the second included patients who had hemiarch or total arch replacement. The groups were compared with regard to their baseline characteristics, operative characteristics, survival, complications, and QoL during nine years of follow-up. Results: The mean follow-up time was 75.6 months (1-108 months). The mean survival in the ascending aorta repair group was 89.651 (81.242-98.061) months and was 54.801 (40.053-69.548) months in the hemiarch and arch group; the difference between the groups was significant (log-rank p < 0.001). The rate of new postoperative neurological deficits was statistically higher in the hemiarch and arch group (17.5% vs. 8.4%, p = 0.045), the most common being stroke, and was also more frequent in the hemiarch and arch group than in the ascending aorta group (with statistical significance (15.7% vs. 6.5%)). The mean SF-12 physical score from the QoL questionnaire was higher in the ascending aorta replacement group than in the hemiarch and arch group (50.1 ± 7.3 vs. 44.0 ± 11.9, p = 0.017). Additionally, the mean SF-12 mental score was higher in the ascending aorta replacement group (52.3 ± 7.3 vs. 47.1 ± 12.8, p = 0.032). Conclusions: A more aggressive approach involving aortic arch repair means a lower survival rate and lesser quality of life after long-term follow-up in comparison with the replacement of the ascending aorta. If clinically applicable, a more defensive strategy may be considered.

Coronary revascularisation outcome questionnaire: validation study of the Serbian version.

PURPOSE: To translate, culturally adapt and validate the Coronary Revascularisation Outcome Questionnaire (CROQ), a disease-specific tool for measuring health-related quality of life (HRQoL) in patients with ischaemic heart disease (IHD), into Serbian language (CROQ-S). METHODS: Validation study was performed at the Clinic for Cardiac Surgery and Clinic for Cardiology, University Clinical Centre of Serbia. We included a convenience sample of 600 patients with IHD divided into four groups. Acceptability, reliability and validity of the CROQ-S were assessed. RESULTS: CROQ-S was acceptable to patients as demonstrated by less than 1% of missing data for each single item. Cronbach's Alpha was higher than the criterion of 0.70 for all scales in each version except the Cognitive Functioning scale which only met this criterion in the CABG pre-revascularisation version. Mean values of item-total correlations were greater than 0.30 for all scales except the Cognitive Functioning scale in both the pre-revascularisation groups. Compared to the original version, exploratory factor analysis in our study showed more factors; however, the majority of items had a factor loading greater than 0.3 on the right scale. Correlations of CROQ-S scales with the 36-Item Short Form Health Survey and Seattle Angina Questionnaire showed the expected pattern whereby scales measuring similar constructs were most highly correlated. CONCLUSION: CROQ-S is an acceptable, reliable and valid disease-specific instrument for measuring HRQoL in this sample of Serbian speaking patients with IHD both before and after coronary revascularisation. However, the Cognitive Functioning scale did not meet all the psychometric criteria and further validation of its responsiveness is required.

Pulmonary Artery Hypertension as A Risk Factor for Long-Term Survival after Heart Transplantation.

BACKGROUND: Heart failure is the most frequent cause of pulmonary artery hypertension (PAH) and its severity may predict the development of heart failure (HF) and is known to be a prognostic factor of poor outcome after heart transplant (HTx). The aim of this study was to investigate the impact of preoperative PAH related to left-sided HF on long-term survival after HTx and to identify the hemodynamic parameters of PAH that predict survival after HTx. METHODS: A prospective observational trial was performed, and it included 44 patients subjected to heart transplantation. Patients were divided into two groups: The first one with the preoperative diagnosis of PAH and the second one without the PAH diagnosed prior to the HTx. The two groups were compared for baseline characteristics, operative characteristics, survival, and hemodynamic parameters obtained by right heart catheterization. Survival was analyzed using Kaplan Meyer analysis, and Cox regression analysis was performed to determine independent predictors of survival. RESULTS: The median follow-up time was 637.4 days (1-2028 days). The median survival within the group of patients with preoperative PAH was 1144 days (95% CI 662.884-1625.116) and 1918.920 days (95% CI 1594.577-2243.263) within the group of patients without PAH (P = .023), HR 0.279 (95% [CI]: 0.086-0.910; P = .034. The 30-day mortality in patients within PAH group was significantly higher, six versus two patients in the non PAH group (χ2 = 5.103, P < .05), while the long-term outcome after this period did not differ between the groups. Patients with preoperative PAH had significantly higher values of MPAP, PCWP, TPG and PVRI, while CO and CI did not differ between the two groups. Mean PVRI was 359.1 ± 97.3 dyn·s·cm-5 in the group with preoperative PAH and 232.2 ± 22.75 dyn·s·cm-5 in the group without PAH, P < .001. TPG values were 11.95 ± 5.08 mmHg in the PAH group while patients without PAH had mean values of 5.16 ± 1.97 mmHg, P < .001. Cox regression analysis was done for the aforementioned parameters. Hazard ratio for worse survival after HTx for elevated values of PVRI was 1.006 (95% [CI]: 1.001-1.012; P = .018) TPG had a hazard ratio of 1.172 (95% [CI]: 1.032-1.233; P = .015). CONCLUSION: Pulmonary artery hypertension is an independent risk factor for higher 30-day mortality after HTx, while it does not affect the long-term outcome. Hemodynamic parameters obtained by right heart catheterization in heart transplant candidates could predict postoperative outcome. PVRI and TPG have been identified as independent predictors of higher 30-day postoperative mortality.

Prevention, treatment and outcomes of left ventricular assist device driveline infections. A single Center experience.

INTRODUCTION: While the survival rates for patients with end-stage heart failure have dramatically improved with newer generations of left ventricular assist devices, LVAD-specific infections are important cause of morbidity, mortality, and hospital readmissions in these patients. METHODS: We performed a retrospective analysis of all driveline infections in patients who had undergone LVAD implantation at a single cardiosurgical center. Between June 2013 and March 2017, 51 patients underwent implantation of LVAD. Among these, 12 received Heart Ware LVAD,34 Heart Mate II LVAD, and 5 Heart Mate III LVAD. The end goal for LVAD therapy was destination therapy in three patients and bridge-to-transplantation in 48 patients. RESULTS: One month, six months, and one-year survival rates were 90%, 85%, and 81%, respectively. Five patients developed driveline infections. Median time from LVAD implantation to driveline infections was 126 days. One of these patients underwent heart transplantation. Two patients were treated with antibiotics and surgical driveline repositioning with extensive debridement of the wound. Two patients with a chronic infection were treated conservatively with regular wound cleaning. CONCLUSION: Driveline infections remain a serious therapeutic challenge. With the development of surgical techniques and new devices, it is possible to reduce morbidity and increase survival rate in patients with implanted LVAD. KEY WORDS: Driveline, Infections, LVAD.