The atrial switch procedure dramatically improved the prognosis of children with complete transposition of the great arteries (TGA). Overall actuarial survival was approximately 75% after 25 years and was better in patients with simple TGA than in those with complex TGA. Mortality by any cause (16%) and cardiovascular mortality (12% and 13%) were comparable in both centers. Progressive congestive heart failure and sudden death were the principal modes of death. Most of the survivors denied any symptoms or had mild limitations in their daily activities. However, long-term problems in this growing population of adults are challenging and include late arrhythmias (up to two thirds of the patients), systemic ventricular (SV) failure, systemic atrioventricular valve regurgitation and reoperations, such as baffle reconstruction, being the most frequent. Objective assessment of SV function obtained by echocardiography is difficult. It may include fractional area change and tricuspid annular motion. Survivors after an atrial switch procedure are unique and have a good quality of life. However, the definitive and true history of the RV supporting the systemic circulation is not as yet known.
According to the data provided by the Moscow ENT hospitals, the number of resurgery on the middle ear in children rose 3-fold. This is due to frequent failure of antrodrain surgery, higher prevalence of mycotic infection and recurrent inflammation in the middle ear. When planning otic surgery in children it is necessary to take into consideration both the involvement of the middle ear and medical personnel ability to provide proper postoperative care. Resurgery is justified in complicated disease course after primary intervention.
To report the reoperation rate in a large group of pediatric and adult strabismus patients over a 21-year period in Northern Alberta, Canada.
A retrospective review of 6177 strabismus surgeries from July 1995 to June 2015 on 5125 pediatric and adult patients was conducted to determine the reoperation rate at a single major referral centre. A set of guidelines was implemented in November 2014 recommending delaying reintervention for at least 12 weeks from the initial surgery, with specific exceptions.
The historical strabismus reoperation rate over a 21-year period was 15.7%. Of those surgeries requiring reoperation, 77.7% required only 1 reoperation, 17.1% required 2 reoperations, 3.1% required 3 reoperations, and 2.1% required 4 or more reoperations. The mean time between surgeries for patients undergoing reoperation was 2.3 years and the median time was 1.0 years.
Our study provides insight into the strabismus reoperation rate and the number of subsequent surgeries performed for patients over a 21-year period. Although preoperative ocular alignment, comorbidities, and the status of the operative eye modify the probability of reoperation, our results from a large cohort of patients provide an impression of the rate of reoperation and may be of benefit in the preoperative counseling of patients. Furthermore, we highlight the scarcity of guidelines for the appropriate timing of reoperation. The implementation of specific guidelines may encourage future investigation into trends in reoperation over time and promote ways to avoid unnecessary surgeries, lower health care costs to stakeholders, and ultimately improve patient care.
Anastomotic pseudoaneurysms continue to be a late complication of vascular surgery, particularly following prosthetic graft procedures. The purpose of this study was to investigate if a previously reported increase in interval between the original operation and the development of pseudoaneurysm was still valid.
Retrospective study.
We reviewed the records of 76 patients who presented with 90 femoral aneurysms. The median age was 69 years (range: 39-83). The commonest previous vascular surgery was a aortofemoral bypass in 61 cases.
The interval between the original operation and the repair of the pseudoaneurysms was 9 years (range 1 month to 26 years).
This study confirms the previously noted trend of an increasing time to aneurysm formation from 3 years before 1975, 5 years between 1976 and 1980, and 6 years between 1981 and 1990.
OBJECTIVES. This study was designed to compare the results of aortic valve replacement in patients greater than or equal to 80 years old with those in patients 65 to 75 years old. BACKGROUND. Aortic valve replacement may be potentially more complicated and require the use of more resources when performed in octogenarians rather than in younger patients. Few hard data on this possibility are available. METHODS. The study group comprises all 44 patients greater than or equal to 80 years old (mean age 82 years) who underwent aortic valve replacement at our institution between January 1981 and July 1989. A control group of 83 patients with a mean age of 70 years was matched with the study group for gender and approximate date of valve replacement. Before operation, 86% of the older patients versus 36% of the younger patients were in New York Heart Association functional class III or IV (p less than 0.001). Data were retrospectively collected from hospital records and a self-assessment telephone interview was conducted. RESULTS. The early mortality rate was 14% in the older group versus 4% in the younger group (p = 0.045). The duration of respirator support, intensive care and the total duration of the hospital stay did not differ significantly between groups. The incidence of postoperative low cardiac output syndrome was higher in the older group (p = 0.049), but the incidence of late valve-related complications was similar in the two groups. The 2-year survival rate (including data on patients who died early) was 73% in the older group and 90% in the younger group (p = NS). Six months postoperatively all patients but one were in functional class I or II. CONCLUSIONS. Although the patients greater than or equal to 80 years old had a poorer preoperative status than that of younger patients, aortic valve replacement in this group did not require more use of hospital resources and resulted in a clinical improvement comparable to that of younger patients.
The purpose of this study was to compare the clinical outcomes and valve durability after aortic valve replacement with a Hancock II bioprothesis with and without supracoronary replacement of the ascending aorta (RAA).
From a cohort of 1,076 patients who had aortic valve replacement with a Hancock II bioprothesis who were prospectively followed for a median of 12.2 years, a propensity score analysis matched patients with and without RAA in a 1:4 ratio. Statistical analysis was performed using the ?2 test or Fisher's exact test for categorical variables, t tests or Wilcoxon rank sum test for continuous variables, and Kaplan-Meier estimates and log rank test for time-to-event data.
The propensity score analysis selected 89 patients with RAA and 356 without RAA whose mean age was 66±12 years. Preoperative variables were similar in both groups, except that the ascending aorta was aneurysmal in patients who had RAA. Operative mortality was 2.3% and 3.9% in the RAA and non-RAA groups, respectively (p=0.75). Perioperative morbidity was also similar. Only 3 and 13 patients lived beyond 20 years in the RAA and non-RAA groups, respectively. For the non-RAA group and RAA group, respectively, at 10, 15, and 20 years, respectively, the Kaplan-Meier estimates for freedom from death were 62.2%±2.8%, 36.5%±3.3%, 20.8%±3.6%, and 56.8%±6.1%, 31.8%±6.7%, 17.2%±6.6% (p=0.51); for reoperation on the aortic valve for any reason, 95.3%±1.4%, 81.6%±3.9%, 70.5%±6.4%, and 91.7%±3.6, 85.7%±6.8%, 53.5%±18.8% (p=0.51); and for structural valve degeneration, 98.5%±0.9%, 85.0%±3.8%, 66.8%±7.1%, and 94.4%±3.2%, 84.3%±7.5%, and 70.2%±14.3% (p=0.38).
Aortic valve replacement with a Hancock II bioprothesis with or without RAA has similar clinical outcomes. Supracoronary RAA does not affect the rate of structural valve degeneration of this bioprosthesis.
Earlier studies have reported socioeconomic differences in coronary heart disease incidence and mortality and in coronary treatment, but less is known about outcomes of care. We examined trends in income group differences in outcomes of coronary revascularizations among Finnish residents in 1998-2010.
First revascularizations for 45-84-year-old Finns were extracted from the Hospital Discharge Register in 1998-2009 and followed until 31 December 2010. Income was individually linked to them and adjusted for family size. We examined the risk of major adverse cardiac events (MACEs), coronary mortality and re-revascularization. We calculated age-standardized rates with direct method and Cox regression models.
Altogether 69 076 men and 27 498 women underwent revascularization during the study period. Among men [women] in the 1998 cohort, 41% [35%] suffered MACE during 29 days after the operation and 30% [28%] in the 2009 cohort. Myocardial infarction mortality within 1 year was 2% among both genders in both cohorts. Among men [women] 9% [14%] underwent revascularization within 1 year after the operation in 1998 and 12% [12%] in 2009. Controlling for age, co-morbidities, year, previous infarction and disease severity, an inverse income gradient was found in MACE incidence within 29 days and in coronary mortality. The excess MACE risk was 1.39 and excess mortality risk over 1.70 among both genders in the lowest income quintile. All income group differences remained stable from 1998 to 2010.
In health care, more attention should be paid to prevention of adverse outcomes among persons with low socioeconomic position undergoing revascularization.
Division of Vascular Surgery, London Health Sciences Centre & The University of Western Ontario, 800 Commissioners Road E., E2-119, London, ON, Canada. Tom.Forbes@lhsc.on.ca
The purpose of the present study was to determine whether an institution's prior endovascular experience influenced the learning curve of subsequent surgeons. A prospective analysis of the initial 70 endovascular abdominal aortic aneurysm repair (EVAR) cases attempted by an individual surgeon was performed with the primary outcome variable being achievement and 30-day maintenance of initial clinical success. Along with standard statistical analyses, the cumulative sum failure method (CUSUM) was used to analyze the learning curve, with a predetermined acceptable failure rate of 10%. Seventy elective EVAR cases were performed by this surgeon during a 4-year period (2000-2004) (mean age, 73.7 -/+ 5.4 years; mean aneurysm diameter 63.3 -/+ 7.2 mm). Initial clinical success was achieved in 68 of 70 cases (97%), which differed significantly with that of our initial surgeon (88.5%, P = .01). Causes of failure in the present series included 1 early mortality (1.4%) and 1 case of conversion to open repair with no instances of type I endoleak or endograft limb thrombosis. Both surgeons' cases were plotted sequentially with CUSUM curves revealing a significantly shorter learning curve for the second surgeon. Optimal results were achieved following 10 to 20 EVAR cases, as opposed to 60 cases in the initial series. Such an analysis confirms that as an institution's experience with EVAR increases, an individual surgeon's learning curve shortens considerably.
Cohort studies, mainly based on questionnaires and interviews, have reported high rates of reflux recurrence after antireflux surgery, which may have contributed to a decline in its use. Reflux recurrence after laparoscopic antireflux surgery has not been assessed in a long-term population-based study of unselected patients.
To determine the risk of reflux recurrence after laparoscopic antireflux surgery and to identify risk factors for recurrence.
Nationwide population-based retrospective cohort study in Sweden between January 1, 2005, and December 31, 2014, based on all Swedish health care and including 2655 patients who underwent laparoscopic antireflux surgery according to the Swedish Patient Registry. Their records were linked to the Swedish Causes of Death Registry and Prescribed Drug Registry.
Primary laparoscopic antireflux surgery due to gastroesophageal reflux disease in adults (>18 years).
The outcome was recurrence of reflux, defined as use of antireflux medication (proton pump inhibitors or histamine2 receptor antagonists for >6 months) or secondary antireflux surgery. Multivariable Cox regression was used to assess risk factors for reflux recurrence.
Among all 2655 patients who underwent antireflux surgery (median age, 51.0 years; interquartile range, 40.0-61.0 years; 1354 men [51.0%]) and were followed up for a median of 5.6 years, 470 patients (17.7%) had reflux recurrence; 393 (83.6%) received long-term antireflux medication and 77 (16.4%) underwent secondary antireflux surgery. Risk factors for reflux recurrence included female sex (hazard ratio [HR], 1.57 [95% CI, 1.29-1.90]; 286 of 1301 women [22.0%] and 184 of 1354 men [13.6%] had recurrence of reflux), older age (HR, 1.41 [95% CI, 1.10-1.81] for age =61 years compared with =45 years; recurrence among 156 of 715 patients and 133 of 989 patients, respectively), and comorbidity (HR, 1.36 [95% CI, 1.13-1.65] for Charlson comorbidity index score =1 compared with 0; recurrence among 180 of 804 patients and 290 of 1851 patients, respectively). Hospital volume of antireflux surgery was not associated with risk of reflux recurrence (HR, 1.09 [95% CI, 0.77-1.53] for hospital volume =24 surgeries compared with =76 surgeries; recurrence among 38 of 266 patients [14.3%] and 271 of 1526 patients [17.8%], respectively).
Among patients who underwent primary laparoscopic antireflux surgery, 17.7% experienced recurrent gastroesophageal reflux requiring long-term medication use or secondary antireflux surgery. Risk factors for recurrence were older age, female sex, and comorbidity. Laparoscopic antireflux surgery was associated with a relatively high rate of recurrent gastroesophageal reflux disease requiring treatment, diminishing some of the benefits of the operation.
