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Background: Valve sparing aortic root reconstruction (VSARR) has become an alternative to traditional aortic root replacement with a valved conduit. There have been various modifications but the two broad types are aortic root reimplantation and the aortic root remodelling procedure. We present the early and late outcomes following valve sparing aortic root reconstruction surgery in Australia., Methods: We reviewed the ANZSCTS database for patients undergoing these procedures. Preoperative, intraoperative and postoperative variables were analysed. Multivariable regression was performed to determine independent predictors of 30-day mortality. We also obtained five- and 10-year survival estimates by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index., Results: Between January 2001 and January 2012, 169 consecutive patients underwent VSARR procedures. The mean age of the study population was 54.4 years with 31.4% being females. Overall, nine patients (5.9%) died within 30 days post procedure and five patients (3%) had permanent strokes. However, out of 132 elective cases, only five patients died (3.8%). Independent predictors of 30-day mortality were female gender [OR 5.65(1.24-25.80), p=0.025], preoperative atrial arrhythmia [OR 6.07(1.14-32.35), p=0.035] and acute type A aortic dissection [OR 7.71(1.63-36.54), p=0.01]. Long-term survival was estimated as 85.3% and 72.7% at five- and 10-years, respectively., Conclusions: Along with an acceptable rate of early mortality and stroke, VSARR procedures provide good long-term survival according to the ANZSCTS database. As promising procedure for pathologies that impair the aortic root integrity, they can be adopted more widely, especially in Australian and New Zealand centres with experienced aortic units. Future studies are planned to assess freedom from valve deterioration and repeat surgery., (Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a paucity of data on the effects of POAF on short-term and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting (AVR-CABG )., Methods: We retrospectively reviewed data on patients without preexisting arrhythmia who underwent isolated first-time AVR-CABG between June 2001 and December 2009 using the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program. Preoperative characteristics, early postoperative outcomes and late survival were compared between patients who developed POAF and those who did not. Propensity score matching was performed to account for the differences between the two groups., Results: Isolated AVR-CABG surgery was performed in 2028 patients without preexisting arrhythmias at 18 Australian institutions, of whom 894 (44.1%) developed POAF. POAF patients were generally older (mean age, 75 vs. 73 years, P < 0.001). From the initial study population, 715 propensity-matched patient-pairs were derived; the overall matching rate was 80.0%. In the matched groups, 30-day mortality was similar in both groups (3.5 vs. 2.1%, P = 0.16). Patients with POAF, however, were more likely to develop perioperative complications, including new renal failure, prolonged ventilation (>24 h), multisystem failure and readmission within 30 days of surgery (all P < 0.05). Patients with POAF also had a significantly greater length of hospital stay (P < 0.001). Seven-year survival was not significantly different between the two groups (72 vs. 75%, P = 0.11)., Conclusion: POAF was not associated with an increased risk of early or late mortality. It is, however, associated with poorer perioperative outcomes. It is important to evaluate potential treatment strategies for POAF.

Background: There is a paucity of data on the impact of smoking status on outcomes after concomitant aortic valve replacement and coronary artery bypass graft (AVR-CABG) surgery., Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were nonsmokers, previous smokers, and current smokers using chi-square test and t-test. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively., Results: Concomitant AVR-CABG surgery was performed in 2,563 patients; smoking status was recorded in 2,558 (99.8%) patients. Of these, 1,052 (41.1%) patients had no previous smoking history, 1,345 (52.6%) patients were previous smokers, and 161 (6.3%) patients were current smokers. The 30-day mortality rate was 3.5% in nonsmokers, 4.1% in previous smokers, and 3.1% in current smokers (p = nonsignificant). The incidence of perioperative complications was similar in the three groups. The mean follow-up period for this study was 36 months (range, 0-105 months). After adjusting for differences in patient variables, the incidence of late mortality was higher in previous smokers (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.14-1.81; p = 0.002) compared with nonsmokers. A trend toward increased late mortality in current smokers was noted (HR, 1.34; 95% CI, 0.86-2.08; p = 0.201)., Conclusion: Smoking is not associated with adverse outcomes after concomitant AVR-CABG surgery. Smoking status should not, therefore, preclude these patients from undergoing this procedure. Given the adverse effect of smoking on overall cardiovascular morbidity and mortality and late postoperative mortality, patients should be encouraged to quit smoking., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Few studies have addressed the effect of "trainee surgeon" status on outcomes after isolated aortic valve replacement (AVR)., Methods and Results: A retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program between June 2001 and December 2009 was performed. Patient demographics, intra-operative characteristics and early morbidity were compared between trainee and staff cases. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality. Isolated AVR was performed in 2747 patients; of these, 369 (13.4%) were by trainees. Compared to staff cases, trainee cases were less likely to present with renal failure (1.1% vs. 3.7%, p = 0.010) or in a critical preoperative state (1.4% vs. 3.7%, p = 0.020). The mean EuroSCORE was lower in trainee patients, compared to staff patients (8.11 ± 2.80 vs. 8.81 ± 3.09, p < 0.001). Trainee cases had longer mean perfusion (117.9 min vs. 98.9 min, p < 0.001) and cross-clamp (88.8 min vs. 73.2 min, p < 0.001) times. The incidence of early complications was similar between the two groups, except for post-operative myocardial infarction (1.1% vs. 0.3%, p = 0.008) and red blood cell transfusion (43.9 vs. 40.0%, p = 0.006). On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.2% vs. 2.4%, p = 0.823). Moreover, there was no significant difference in long-term outcomes and 5-year survival was comparable in both groups (89.9% vs. 84.8%, p = 0.274)., Conclusions: Isolated AVR can be safely and effectively performed by trainee surgeons who are strictly supervised in the operating theatre especially during the technically complex parts of the procedure.

Background: Preoperative atrial fibrillation (preop-AF) has been associated with poorer early and late outcomes after cardiac surgery. Few studies, however, have evaluated the impact of preop-AF on early and late outcomes after isolated aortic valve replacement (AVR)., Methods: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program was retrospectively analyzed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients undergoing isolated AVR who presented with preop-AF and those in sinus rhythm. The independent effect of preop-AF on 12 short-term complications and long-term survival was determined using binary logistic and cox regression, respectively., Results: Isolated AVR surgery was performed in 2789 patients; 380 (13.6%) presented with preop-AF. Preop-AF patients were generally older (mean age, 73 vs 68 years; P < 0.001) and presented more often with comorbidities including congestive heart failure, diabetes, and cerebrovascular disease (all P < 0.05). There was a trend toward increased 30-day mortality in patients with preop-AF on multivariate analysis (P = 0.051). The incidence of early complications was similar in both groups on multivariate analysis (P > 0.05). Preop-AF was independently associated with reduced long-term survival (hazard ratio, 1.36; 95% confidence interval, 1.01-1.83; P = 0.041)., Conclusions: Preop-AF is associated with an increased risk of late mortality after isolated AVR. As such, concomitant atrial ablation with AVR should be prospectively studied., (Copyright © 2013 Canadian Cardiovascular Society. All rights reserved.)

Objective: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training., Methods: A retrospective analysis of data collected prospectively by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database between June 2001 and December 2009 was performed. Concomitant aortic valve replacement and coronary artery bypass grafting was performed in 2540 patients; of these procedures, 290 (11.4%) were by trainees. Patient demographics, intraoperative characteristics, and early morbidity were compared between trainee and staff cases using chi-square analysis and t tests. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality., Results: Compared with staff cases, trainee cases were younger (mean age, 73.0 vs 74.2 years; P = .025) and less likely to present with triple vessel disease (27.9% vs 38.3%, P = .001) or previous cardiac surgery (6.3% vs 2.8%, P = .016). Trainee cases had longer mean perfusion (160.4 vs 144.6 minutes, P < .001) and crossclamp (125.2 vs 114.6 minutes, P < .001) times. The incidence of early complications was similar between the 2 groups. On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.4% vs 4.0%, P = .348). Moreover, there was no significant difference in long-term outcomes, and 5-year survival was comparable in both groups (79.6% vs 77.4%, P = .200)., Conclusions: Concomitant aortic valve replacement and coronary artery bypass grafting can be safely and effectively performed by properly supervised trainees in the contemporary era. It is imperative to offer training opportunities to junior surgeons in this complex procedure to ensure quality patient outcomes in the future., (Crown Copyright © 2013. Published by Mosby, Inc. All rights reserved.)

Background: An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with left ventricular (LV) dysfunction. The aim of this study was to evaluate the early outcomes and late survival of patients with different degrees of LV function undergoing concomitant AVR and CABG., Methods: Between June 2001 and December 2009, patients undergoing concomitant AVR-CABG were identified from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program. Demographic, operative data and post-operative outcomes were compared between patients with normal (> 60%), moderately impaired (30- -60%), and severely impaired (< 30%) estimated LV ejection fraction (LVEF). Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively., Results: AVR-CABG was performed in 2,563 patients with a mean follow up of 36 months (range 0-106). 144 (5.6%) had severely impaired LVEF, 983 (38.3%) had moderately impaired LVEF while the remaining 1377 (53.7%) had normal LVEF. The 30-day mortality in patients with severely impaired, moderately impaired and normal LVEF was 9.0%, 4.3% and 2.9%, respectively. This was significant on univariate (p < 0.001) but not multivariate analysis (p = NS). Severely impaired, moderately impaired and normal LVEF patients experienced 5-year survivals of 63.7%, 77.1% and 82.5%, respectively. Severely impaired LVEF was an independent multivariable predictor of late mortality (HR 1.71; 95% CI 1.22-2.40; p = 0.002)., Conclusions: Patients with severely impaired LVEF experience worse outcomes. However, in the era of modern surgery, this alone should not predicate exclusion, given the established benefits of surgery in this high-risk group.

Background: Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short-term and long-term outcomes after general cardiac operations. There is, however, a paucity of data on the impact of POAF on outcomes after isolated aortic valve replacement (AVR)., Methods: Data for all patients undergoing isolated first-time AVR between June 2001 and December 2009 was obtained from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) National Cardiac Surgery Database Program and a retrospective analysis was conducted. Preoperative characteristics, early postoperative outcome, and late survival were compared between patients in whom POAF developed and those in whom it did not. Propensity score matching was performed to correct for differences between the 2 groups., Results: Excluding patients with preoperative arrhythmia, isolated first-time AVR was performed in 2,065 patients. POAF developed in 725 (35.1%) of them. Patients with POAF were significantly older (mean age, 72 versus 65 years; p < 0.001) and presented more often with comorbidities, including hypertension, respiratory disease, and hypercholesterolemia (all p < 0.05). From the initial study population, 592 propensity-matched patient pairs were derived; the overall matching rate was 81.7%. In the matched groups, 30-day mortality was not significantly different between the POAF and non-POAF groups (1.5% versus 1%; p = 0.48). Patients with POAF were, however, at an independently increased risk of perioperative complications, including new renal failure, gastrointestinal complications, and 30-day readmission (p < 0.05). Seven-year mortality was not significantly different between POAF and non-POAF groups (78% versus 83%; p = 0.63)., Conclusions: POAF is a risk factor for short-term morbidity but is not associated with a higher rate of early or late mortality after isolated AVR., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Women undergoing isolated coronary artery bypass graft (CABG) surgery have been previously shown to be at an independently increased risk for post-operative morbidity and mortality. However, there are considerably less data on whether this trend remains true in patients undergoing concomitant aortic valve replacement (AVR) and CABG surgery. The aim of our study was to investigate this pertinent issue., Methods: Data obtained between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analysed. Demographic, operative data and post-operative complications were compared between male and female patients using χ(2) and t tests. Long-term survival analysis was performed using Kaplan-Meier survival curves and the log-rank test. Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively., Results: Concomitant AVR and CABG surgery was undertaken in 2,563 patients; 31.8% were female. Female patients were older (mean age 76 vs. 73 years; p < 0.001) and presented more often with hypertension (p < 0.001) but less often with severely impaired ejection fraction (p < 0.001), peripheral vascular disease (p < 0.001) and triple vessel disease (p < 0.001). Women did not demonstrate an increased risk of 30-day mortality (4.8 vs. 3.3%) on univariate (p = 0.069) or multivariate (p = 0.236) analysis. Female gender was independently associated with post-operative myocardial infarction (p = 0.022) and red blood cell transfusion (p < 0.001). There was no difference in long-term survival between men and women on multivariate analysis (p = 0.413)., Conclusion: Female gender is not associated with poorer short- or long-term outcomes after concomitant CABG and AVR surgery., (Copyright © 2011 S. Karger AG, Basel.)