Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. Endpoint
2.3. Statistical Analysis
3. Results
3.1. Baseline Characteristics
3.2. Postoperative Outcomes
4. Discussion
- Patients with a longer ACC time had a higher incidence of acute kidney failure, number of blood transfusions, prolonged hospital stay (more than 21 days), as well as respiratory failure;
- The predictors of early 30-day mortality were standard full sternotomy, EuroSCORE II, and a trend for a longer aortic cross-clamp time
5. Limitations
6. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Aortic Cross-Clamp Time | |||||||
---|---|---|---|---|---|---|---|
Overall | Q1 (13–38) | Q2 (39–51) | Q3 (52–66) | Q4 (67–656) | p | ASMD | |
N | 1404 | 351 | 351 | 351 | 351 | ||
Age, median (IQR) | 75 (69–79.5) | 76 (70–80) | 75 (68–79) | 76 (70–80) | 74 (67–79) | 0.027 | 0.186 |
Female gender (n, %) | 615 (43.8) | 163 (46.4) | 156 (44.4) | 157 (44.7) | 139 (39.6) | 0.297 | 0.138 |
Height, cm, median (IQR) | 166 (160–172) | 165 (160–172) | 165 (160–172) | 166 (160–172) | 168 (160–172) | 0.443 | 0.101 |
Weight, kg, median (IQR) | 75 (67–85) | 75 (66–85) | 77 (67–87) | 74 (65–85) | 77 (68–85) | 0.089 | 0.167 |
BMI, median (IQR) | 27.3 (24.4–30.1) | 27.2 (24.2–29.8) | 27.7 (24.7–30.9) | 27.0 (24.2–29.8) | 27.3 (24.6–30.4) | 0.110 | 0.167 |
Hypertension (n, %) | 1075 (76.6) | 255 (72.6) | 273 (77.8) | 283 (80.6) | 264 (75.2) | 0.076 | 0.189 |
Diabetes (n, %) | 352 (25.1) | 90 (25.6) | 96 (27.4) | 88 (25.1) | 78 (22.2) | 0.467 | 0.119 |
Dyslipidemia (n, %) | 825 (58.8) | 205 (58.4) | 212 (60.4) | 200 (57.0) | 208 (59.3) | 0.825 | 0.069 |
Smoke (n, %) | 567 (40.4) | 129 (36.8) | 135 (38.5) | 143 (40.7) | 160 (45.6) | 0.093 | 0.180 |
Preoperative atrial fibrillation (n, %) | 131 (9.3) | 33 (9.4) | 23 (6.6) | 38 (10.8) | 37 (10.5) | 0.192 | 0.152 |
Pacemaker (n, %) | 13 (0.9) | 1 (0.3) | 4 (1.1) | 4 (1.1) | 4 (1.1) | 0.553 | 0.102 |
NYHA class (n, %) | 0.485 | 0.164 | |||||
| 217 (15.5) | 58 (16.5) | 46 (13.1) | 52 (14.8) | 61 (17.4) | ||
| 715 (50.9) | 182 (51.9) | 178 (50.7) | 170 (48.4) | 185 (52.7) | ||
| 450 (32.1) | 104 (29.6) | 120 (34.2) | 125 (35.6) | 101 (28.8) | ||
| 22 (1.6) | 7 (2.0) | 7 (2.0) | 4 (1.1) | 4 (1.1) | ||
CCS class (n, %) | 0.885 | 0.150 | |||||
| 952 (67.8) | 246 (70.1) | 227 (64.7) | 236 (67.2) | 243 (69.2) | ||
| 293 (20.9) | 70 (19.9) | 80 (22.8) | 73 (20.8) | 70 (19.9) | ||
| 133 (9.5) | 31 (8.8) | 35 (10.0) | 35 (10.0) | 32 (9.1) | ||
| 22 (1.6) | 3 (0.9) | 8 (2.3) | 5 (1.4) | 6 (1.7) | ||
| 4 (0.3) | 1 (0.3) | 1 (0.3) | 2 (0.6) | 0 (0.0) | ||
Bicuspid aortic valve (n, %) | 127 (9.0) | 32 (9.1) | 33 (9.4) | 24 (6.8) | 38 (10.8) | 0.322 | 0.141 |
Aortic stenosis (n, %) | 1056 (75.2) | 260 (74.1) | 277 (78.9) | 265 (75.5) | 254 (72.4) | 0.224 | 0.153 |
Aortic regurgitation (n, %) | 188 (13.4) | 60 (17.1) | 40 (11.4) | 46 (13.1) | 42 (12.0) | 0.112 | 0.163 |
LVEF %, median (IQR) | 60 (55–65) | 60 (55–65) | 60 (55–65) | 60 (55–65) | 60 (55–65) | 0.678 | 0.093 |
Active endocarditis (n, %) | 61 (4.3) | 14 (4.0) | 10 (2.8) | 18 (5.1) | 19 (5.4) | 0.323 | 0.129 |
Previous stroke (n, %) | 44 (3.1) | 11 (3.1) | 14 (4.0) | 10 (2.8) | 9 (2.6) | 0.726 | 0.080 |
Previous TIA (n, %) | 31 (2.2) | 7 (2.0) | 12 (3.4) | 6 (1.7) | 6 (1.7) | 0.352 | 0.108 |
Significant carotid artery disease (n, %) | 8 (0.6) | 3 (0.9) | 1 (0.3) | 0 (0.0) | 4 (1.1) | 0.170 | 0.152 |
Creatinine, mg/dL, median (IQR) | 0.96 (0.80–1.13) | 0.95 (0.79–1.11) | 0.96 (0.80–1.14) | 1.00 (0.81–1.15) | 0.94 (0.80–1.11) | 0.271 | 0.041 |
CKD stage (n, %) | 0.400 | 0.145 | |||||
| 329 (23.4) | 84 (23.9) | 82 (23.4) | 75 (21.4) | 88 (25.1) | ||
| 709 (50.5) | 174 (49.6) | 182 (51.9) | 168 (47.9) | 185 (52.7) | ||
| 332 (23.6) | 87 (24.8) | 75 (21.4) | 101 (28.8) | 69 (19.7) | ||
| 25 (1.8) | 4 (1.1) | 9 (2.6) | 6 (1.7) | 6 (1.7) | ||
| 9 (0.6) | 2 (0.6) | 3 (0.9) | 1 (0.3) | 3 (0.9) | ||
Chronic lung disease (n, %) | 130 (9.3) | 36 (10.3) | 25 (7.1) | 36 (10.3) | 33 (9.4) | 0.432 | 0.111 |
Previous cardiac surgery (n, %) | 132 (9.4) | 37 (10.5) | 29 (8.3) | 33 (9.4) | 33 (9.4) | 0.784 | 0.078 |
EuroSCORE logistic, median (IQR) | 6.19 (3.99–9.21) | 6.31 (4.52–9.37) | 5.92 (3.99–8.90) | 6.32 (4.26–10.38) | 5.48 (3.48–8.88) | 0.006 | 0.143 |
EuroSCORE II, median (IQR) | 1.80 (1.19–3.05) | 1.89 (1.19–3.20) | 1.72 (1.19–2.92) | 1.92 (1.29–3.16) | 1.69 (1.12–2.82) | 0.025 | 0.066 |
Previous dialisys (n, %) | 6 (0.4) | 1 (0.3) | 2 (0.6) | 0 (0.0) | 3 (0.9) | 0.341 | 0.131 |
Urgency (n, %) | 170 (12.1) | 42 (12.0) | 44 (12.5) | 36 (10.3) | 48 (13.7) | 0.571 | 0.105 |
CPB minutes, median (IQR) | 63.0 (49.0–80.0) | 42.0 (37.0–46.0) | 56.0 (52.0–60.0) | 70.0 (66.0–75.0) | 91.5 (84.0–103.0) | <0.001 | / |
Aortic Cross Clamp Time | ||||||
---|---|---|---|---|---|---|
Overall | Q1 | Q2 | Q3 | Q4 | p for Trend * | |
N | 1404 | 351 | 351 | 351 | 351 | |
Atrial fibrillation (n, %) | 445 (31.7) | 101 (28.8) | 122 (34.8) | 108 (30.8) | 114 (32.5) | 0.521 |
Pacemaker (n, %) | 46 (3.3) | 14 (4.0) | 8 (2.3) | 8 (2.3) | 16 (4.6) | 0.687 |
Re-open (n, %) | 43 (3.1) | 10 (2.8) | 7 (2.0) | 11 (3.1) | 15 (4.3) | 0.188 |
Tamponade (n, %) | 11 (0.8) | 3 (0.9) | 2 (0.6) | 3 (0.9) | 3 (0.9) | 0.892 |
Cardiac arrest (n, %) | 9 (0.6) | 2 (0.6) | 2 (0.6) | 2 (0.6) | 3 (0.9) | 0.654 |
Re-intubation (n, %) | 39 (2.8) | 9 (2.6) | 9 (2.6) | 10 (2.8) | 11 (3.1) | 0.611 |
Tracheostomy (n, %) | 15 (1.1) | 4 (1.1) | 3 (0.9) | 4 (1.1) | 4 (1.1) | 0.908 |
Sepsis (n, %) | 30 (2.1) | 4 (1.1) | 11 (3.1) | 10 (2.8) | 5 (1.4) | 0.869 |
Multi organ failure (n, %) | 13 (0.9) | 2 (0.6) | 2 (0.6) | 4 (1.1) | 5 (1.4) | 0.170 |
Inotropic drug (n, %) | 56 (4.0) | 10 (2.8) | 14 (4.0) | 18 (5.1) | 14 (4.0) | 0.329 |
Delirium (n, %) | 84 (6.0) | 20 (5.7) | 13 (3.7) | 28 (8.0) | 23 (6.6) | 0.227 |
Stroke (n, %) | 15 (1.1) | 2 (0.6) | 4 (1.1) | 5 (1.4) | 4 (1.1) | 0.416 |
Dialysis (n, %) | 15 (1.1) | 4 (1.1) | 4 (1.1) | 3 (0.9) | 4 (1.1) | 0.908 |
IABP (n, %) | 13 (0.9) | 1 (0.3) | 3 (0.9) | 3 (0.9) | 6 (1.7) | 0.062 |
ECMO (n, %) | 4 (0.3) | 0 (0.0) | 1 (0.3) | 2 (0.6) | 1 (0.3) | 0.370 |
Diastasis revision (n, %) | 4 (0.3) | 2 (0.6) | 1 (0.3) | 1 (0.3) | 0 (0.0) | 0.179 |
In-hospital death (n, %) | 30 (2.1) | 5 (1.4) | 7 (2.0) | 7 (2.0) | 11 (3.1) | 0.137 |
Death at 30 days (n, %) | 32 (2.3) | 5 (1.4) | 7 (2.0) | 8 (2.3) | 12 (3.4) | 0.079 |
eGFR < 60 incidence (n, %) | 276 (19.7) | 51 (14.5) | 53 (15.1) | 73 (20.8) | 99 (28.2) | <0.001 |
Transfusion (n, %) | 790 (56.3) | 187 (53.3) | 194 (55.3) | 201 (57.3) | 208 (59.3) | 0.092 |
| 2.0 (4.6) | 1.7 (3.3) | 1.8 (4.1) | 2.1 (3.7) | 2.5 (6.6) | 0.022 |
| 64 (4.6) | 9 (2.6) | 12 (3.4) | 18 (5.1) | 25 (7.1) | 0.002 |
Ventilation hours, mean (SD) | 12.2 (52.5) | 11.0 (55.3) | 9.5 (20.8) | 13.1 (41.0) | 15.3 (76.6) | <0.001 |
>24 h (n, %) | 41 (2.9) | 8 (2.3) | 9 (2.6) | 13 (3.7) | 11 (3.1) | 0.357 |
>48 h (n, %) | 25 (1.8) | 5 (1.4) | 6 (1.7) | 8 (2.3) | 6 (1.7) | 0.652 |
>72 h (n, %) | 20 (1.4) | 3 (0.9) | 5 (1.4) | 7 (2.0) | 5 (1.4) | 0.420 |
ICU days, mean (SD) | 2.7 (2.3) | 2.7 (2.4) | 2.5 (1.9) | 2.7 (2.2) | 2.8 (2.6) | 0.363 |
| 369 (26.3) | 91 (25.9) | 80 (22.8) | 93 (26.5) | 105 (29.9) | 0.130 |
Length of stay (days), mean (SD) | 9.9 (4.0) | 10.1 (4.1) | 9.6 (3.9) | 10.1 (4.0) | 9.9 (4.1) | 0.259 |
| 170 (12.1) | 27 (7.7) | 38 (10.8) | 50 (14.2) | 55 (15.7) | <0.001 |
Sutureless (n, %) | 328 (23.4) | 147 (41.9) | 85 (24.2) | 62 (17.7) | 34 (9.7) | <0.001 |
Mini-approaches (n, %) | 1027 (73.1) | 245 (69.8) | 269 (76.6) | 246 (70.1) | 267 (76.1) | 0.247 |
| 743 (52.9) | 164 (46.7) | 194 (55.3) | 189 (53.8) | 196 (55.8) | |
| 284 (20.2) | 81 (23.1) | 75 (21.4) | 57 (16.2) | 71 (20.2) |
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Mikus, E.; Fiorentino, M.; Sangiorgi, D.; Calvi, S.; Tenti, E.; Cavallucci, A.; Tremoli, E.; Tripodi, A.; Pin, M.; Savini, C. Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement. Biomedicines 2023, 11, 2989. https://doi.org/10.3390/biomedicines11112989
Mikus E, Fiorentino M, Sangiorgi D, Calvi S, Tenti E, Cavallucci A, Tremoli E, Tripodi A, Pin M, Savini C. Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement. Biomedicines. 2023; 11(11):2989. https://doi.org/10.3390/biomedicines11112989
Chicago/Turabian StyleMikus, Elisa, Mariafrancesca Fiorentino, Diego Sangiorgi, Simone Calvi, Elena Tenti, Andrea Cavallucci, Elena Tremoli, Alberto Tripodi, Maurizio Pin, and Carlo Savini. 2023. "Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement" Biomedicines 11, no. 11: 2989. https://doi.org/10.3390/biomedicines11112989