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Objective: Decision-making concerning the extent of the repair of acute type A aortic dissection (ATAAD) includes functional and anatomical assessment of the aortic valve. We hypothesized that bicuspid aortic valve (BAV) does not impact outcome after surgery for ATAAD. We therefore evaluated the outcome after ATAAD surgery in relation to the presence of BAV, acute aortic regurgitation (AR), and surgical approach, using the Nordic Consortium for Acute Type A Aortic Dissection database., Methods: Eight participating Nordic centers collected data from 1122 patients undergoing ATAAD surgery during the years 2005 to 2014. Early complications, reoperations and survival were compared between patients with BAV and tricuspid aortic valves (TAV) before and after propensity score matching for sex, age, AR, organ malperfusion, hemodynamic instability, and site of the tear. Mean follow-up (range) for patients with TAV and BAV was 3.1 years (0-10.4 years) and 3.2 years (0-9.0 years), respectively., Results: Altogether, 65 (5.8%) of the patients had BAV. Root replacement was more frequently performed in the BAV as compared with the TAV group (60% vs 23%, P < .001). Survival, however, did not differ significantly between patients with BAV or TAV, either before (P = .230) or after propensity score-matching (P = .812). Even so, in cohort as a whole, patients presenting with AR had less favorable survival., Conclusions: Early and mid-term survival did not differ significantly between patients with BAV and TAV., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Sweden, Denmark, Finland, Norway, and Iceland form the 5 culturally uniform Nordic countries. Each of the countries owns a high-standard tradition of individual steering in cardiothoracic education aiming at securing the needs and features of the local area. Indisputably, mastering a Nordic language and applying a high-standard individual steering in education ensure that a dedicated trainee is selected to the cardiothoracic program in accordance with the needs and features of the local area., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Open-distal anastomosis is the preferred technique over clamp-on technique for surgical repair of acute type A aortic dissection (ATAAD). The aim of this study was to define how outcomes of ATAAD were affected by the use of either technique., Methods: Nordic Consortium for Acute Type A Aortic Dissection includes 8 academic cardiothoracic hospitals in 4 Nordic countries. The cohort consisted of 1134 patients, 153 clamp-on and 981 open-distal, from 2005 to 2014., Results: Patients who underwent operation with the clamp-on were younger, more frequently had coronary artery disease, bicuspid aortic valve, hypotension/shock or syncope, and a greater PennClass than open-distal patients. Postoperative cerebral vascular accident occurred less frequently in clamp-on (14/153, 10%) compared with the open-distal group (190/981, 20%). Clamp-on had greater 30-day mortality (39/153, 25%) than the open-distal group (158/981, 16%), and 5-year survival was also worse in clamp-on (61.8% ± 4.4%) compared with the open-distal group (73.0% ± 1.6%). The open-distal technique was used more frequently in greater-volume hospitals but was not independently associated with 30-day mortality. Preoperative condition was an independent risk factor whereas hospital volume and later year of operation were beneficial in regard to short-term outcome. Open-distal was independently associated with improved mid-term survival., Conclusions: Patients who underwent operation with the clamp-on were sicker on presentation and had worse short- and mid-term survival compared with the open-distal group. Patients in the open-distal group had greater rates of cerebrovascular complications. The results support the routine use of open-distal anastomosis as the primary operative strategy for ATAAD, although clamp-on can be performed successfully in select cases., (Published by Elsevier Inc.)

Objectives: To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) registry., Methods: We studied 1159 patients who underwent ATAAD surgery between January 2005 and December 2014 at 8 Nordic centers. Multivariable logistic and Cox regression analyses were performed to identify independent predictors of 30-day and late mortality., Results: Preoperative malperfusion was identified in 381 of 1159 patients (33%) who underwent ATAAD surgery. Thirty-day mortality was 28.9% in patients with preoperative malperfusion and 12.1% in those without. Independent predictors of 30-day mortality included any malperfusion (odds ratio, 2.76; 95% confidence interval [CI], 1.94-3.93), cardiac malperfusion (odds ratio, 2.37; 95% CI, 1.34-4.17), renal malperfusion (odds ratio, 2.38; 95% CI, 1.23-4.61) and peripheral malperfusion (odds ratio, 1.95; 95% CI, 1.26-3.01). Any malperfusion (hazard ratio, 1.72; 95% CI, 1.21-2.43), cardiac malperfusion (hazard ratio, 1.89; 95% CI, 1.24-2.87) and gastrointestinal malperfusion (hazard ratio, 2.25; 95% CI, 1.18-4.26) were predictors of late mortality. Malperfusion was associated with significantly poorer survival at 1, 3, and 5 years (95.0% ± 0.9% vs 88.7% ± 1.9%, 90.1% ± 1.3% vs 84.0% ± 2.4%, and 85.4% ± 1.7% vs 80.8% ± 2.7%; log rank P = .009)., Conclusions: Malperfusion has a significant influence on early and late outcomes in ATAAD surgery. Management of preoperative malperfusion remains a major challenge in reducing mortality associated with surgical treatment of ATAAD., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection., Methods: A retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation., Results: The median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease., Conclusions: Type A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To estimate the association between congenital heart defects (CHD) and indices of fetal growth in Down and 22q11.2 deletion syndromes., Study Design: We established 2 Danish nationwide cohorts of newborn singletons with either Down syndrome (n = 670) or 22q11.2 deletion syndrome (n = 155), born 1997-2011. In both cohorts, we analyzed the association between CHD, CHD severity, and indices of fetal growth by multivariable linear regression adjusted for potential confounders. We report mean differences in gestational age specific z-scores compared with newborns without CHD., Results: Down syndrome and 22q11.2 deletion syndrome were both associated with lower mean birth weight and head circumference z-scores. We found no association between CHD or CHD severity and indices of fetal growth. In Down syndrome, the association between any CHD and the mean difference in head circumference z-score was 0.03 (95% CI -0.12, 0.18), and the estimate regarding birth weight z-score was 0.09 (95% CI -0.08, 0.25). The corresponding estimates in 22q11.2 deletion syndrome were 0.00 (95% CI -0.33, 0.32) and -0.09 (95% CI -0.45, 0.26)., Conclusions: We found no association between CHD and fetal growth measures in newborns with Down syndrome or 22q11.2 deletion syndrome. Thus, in certain subtypes of CHD, the contribution of genetic factors to prenatal growth impairment may be more important than circulatory disturbances., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: Although aminoglycoside treatment has been associated with nephrotoxic effects, single-dose gentamicin has been considered safe in surgery. However, the effect of a single-dose prophylactic aminoglycoside on the risk of acute kidney injury among patients undergoing cardiac surgery remains uncertain., Methods: A population-based cohort study with matched-pair analysis of 2892 consecutive patients undergoing cardiac surgery at Aarhus University Hospital, Denmark, was performed. Two different prophylactic antibiotic regimens were used during the study period. The patients exposed to a single dose of prophylactic gentamicin were compared with those had not received gentamicin. Statistical analysis for matched data was performed. The data were retrieved from the Western Denmark Heart Registry., Results: Matching resulted in 668 patient pairs. Patients receiving gentamicin had higher maximum serum creatinine during the first postoperative 72 hours (median, 96 vs 90 mmol/L; P=.0002). Also, a greater fraction of patients receiving gentamicin developed acute kidney injury according to the Acute Kidney Injury Network criteria (22% vs 17%; P=.02). The hospital length of stay was shorter in the control group (5.0 vs 5.6 days; P<.0001). No difference was found in the incidence of patients requiring postoperative dialysis, 30-day and 1-year mortality, or the incidence of sternal infection between the 2 groups., Conclusions: A single-dose prophylactic aminoglycoside in adult cardiac surgery patients was associated with an increased risk of acute kidney injury but not with a greater frequency of postoperative dialysis or mortality. No differences in the incidence of sternal infections between groups were observed., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Aminoglycoside treatment has been associated with nephrotoxic effects. However, the effect of perioperative aminoglycoside treatment on the risk of acute kidney injury requiring dialysis among patients undergoing cardiac surgery remains uncertain., Methods: We performed a register study based on prospectively collected data from population-based health care databases of 3625 consecutive patients undergoing cardiac surgery at the Aarhus University Hospital, Skejby, Denmark. Patients requiring preoperative dialysis were excluded, leaving a total of 3587 patients (99% of original patient cohort), of whom 89 received perioperative aminoglycosides., Results: The cumulative risk of in-hospital dialysis-dependent acute kidney injury was 3.2% (n = 115). Perioperative use of aminoglycosides was associated with an increased risk of postoperative dialysis (adjusted odds ratio [OR], 4.41; 95% confidence interval [CI], 1.83-10.59). Other predictors included reoperation because of bleeding (adjusted OR, 2.80; 95% CI, 1.63-4.80), use of inotropic support during anesthesia (adjusted OR, 2.10; 95% confidence interval, 1.49-2.95), and cardiopulmonary bypass lasting longer than 120 minutes (adjusted OR, 1.95; 95% CI, 1.19-3.20) along with EuroSCORE variables. Postoperative dialysis was associated with higher 30-day mortality (10.9% vs 2.5%, P < .0001, χ(2) test), but use of aminoglycosides was not independently associated with mortality., Conclusions: Perioperative use of aminoglycosides in adults undergoing cardiac surgery was associated with increased risk of postoperative dialysis., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: The optimal treatment of pediatric empyema remains controversial. The objective of this study is to compare the use of conventional management versus primary thoracoscopic drainage and decortication in children with empyema., Methods: Conventional management has consisted of chest drain insertion under general anesthesia plus intravenous antibiotics. Thoracoscopic drainage and decortication has consisted of primary thoracoscopic drainage and decortication plus antibiotics. The clinical course of 54 patients treated conventionally between 1989 and 1997 was compared with that of 21 patients treated by means of thoracoscopic drainage and decortication between September 2000 and September 2001., Results: Results of the study demonstrated that patients in the drainage-decortication group had fewer invasive interventions per patient than those in the conventional management group (1.0 vs 1.26). Patients undergoing thoracoscopic drainage and decortication also had significantly shorter durations of intravenous antibiotic therapy (7.6 +/- 1.2 vs 18.2 +/- 7.5 days), chest tube drainage (4.0 +/- 0.5 vs 10.2 +/- 6.1 days), and hospital stays (7.4 +/- 0.8 vs 15.4 +/- 7.4). Moreover, there were no open thoracotomies and decortications in the thoracoscopic drainage and decortication group, whereas in the conventional management group 39% (21/54) of patients underwent an open procedure., Conclusion: Although the 2 groups were not prospectively randomized and they were treated in different time periods, the results of this study support the use of thoracoscopic surgery as the primary therapeutic modality in children presenting with pleural empyema. This strategy appears to offer significant benefits over conventional treatment in terms of duration of treatment and the need for more invasive surgery.