European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 9, 2015
Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal sol... more Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients. Between 1990-2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0-24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years. The early (30-day) mortality rate was 1.1% (n = 19). Late (>30 day) survival of the adult population was comparable with the age- and gender-matched general population (observed deaths: 101, expected deaths: 91; P = 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7...
The Journal of Thoracic and Cardiovascular Surgery, 2012
Reinterventions after the Ross procedure are a concern for patients and treating physicians. The ... more Reinterventions after the Ross procedure are a concern for patients and treating physicians. The scope of the present report was to provide an update on the reinterventions observed in the large patient population of the German-Dutch Ross Registry. From 1988 to 2011, 2023 patients (age, 39.05 ± 16.5 years; male patients, 1502; adults, 1642) underwent a Ross procedure in 13 centers. The mean follow-up was 7.1 ± 4.6 years (range, 0-22 years; 13,168 patient-years). In the adult population, 120 autograft reinterventions in 113 patients (1.03%/patient-year) and 76 homograft reinterventions in 67 patients (0.65%/patient-year) and, in the pediatric population, 14 autograft reinterventions in 13 patients (0.91%/patient-year) and 42 homograft reinterventions in 31 patients (2.72%/patient-year) were observed. Of the autograft and homograft reinterventions, 17.9% and 21.2% were performed because of endocarditis, respectively. The subcoronary technique in the adult population resulted in significantly superior autograft durability (freedom from autograft reintervention: 97% at 10 years and 91% at 12 years; P < .001). The root replacement technique without root reinforcement (hazard ratio, 2.4; 95% confidence interval, 1.4-4.1) and the presence of pure aortic insufficiency preoperatively (hazard ratio, 2.3; 95% confidence interval, 1.5-3.5) were statistically significant predictors for a shorter time to reoperation. The center volume had a significant influence on the long-term results. The freedom from homograft reoperation for the adults and pediatric population was 97% and 87% at 5 years and 93% and 79% at 12 years, respectively (P < .001), with younger recipient and donor age being significant predictors of a shorter time to homograft reoperation. The autograft principle remains a valid option for young patients requiring aortic valve replacement. The risk of reoperation depends largely on the surgical technique used and the preoperative hemodynamics. Center experience and expertise also influence the long-term results. Adequate endocarditis prophylaxis might further reduce the need for reoperation.
We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated c... more We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated coronary artery bypass graft (CABG) surgery in relation to risk stratification in the fully equipped university location (FE) and the low volume, limited facility location (LVLF) of our department. Between September 1995 and December 1996, 832 patients were referred to our department to undergo a primary isolated CABG operation. The surgical team selected 482 patients (58%) as being at low-risk. These were treated in the LVLF hospital. The other 350 patients with mixed-risk were treated in the FE hospital. The selection consisted primarily of exclusion of patients with moderate or poor left ventricular function, severe COPD or renal impairment, from surgery in the LVLF location. Finally, the prognostic value of the EuroSCORE and the Parsonnet score was tested on our patient population. Overall in-hospital mortality was 1.6% (13 patients). One patient died in the LVLF group (0.2%) and 12 patients (3.4%) in the FE group. LVLF patients experienced less complications during the hospital period compared to the FE patients (5 versus 21%; P=0.0001). The Parsonnet risk model and the EuroSCORE risk model showed both a good relation with in-hospital mortality. After discharge, an increased risk of late mortality was observed up to 1 year postoperative in the FE group compared to the LVLF group (2.7 versus 0.5%; P=0.01). Risk factors for 5-year mortality were pre-operative renal impairment (blood creatinine >150 micromol/l) (hazard ratio (HR): 2.8; 95% confidence interval (CI): 1.4-5.5), diabetes (HR: 2.1; 95% CI: 1.3-3.5), impaired LVEF (HR: 1.9; 95% CI: 1.2-3.0), COPD (HR: 1.9; 95% CI: 1.1-3.5) and older age (HR: 1.07 per year; 95% CI: 1.01-1.10). Lipid-lowering therapy was a predictor of lower mortality at 5-years (HR: 0.5; 95% CI: 0.4-0.9). By careful decision making, selection of low-risk patients for a low volume and limited facility location resulted in excellent in-hospital survival with very low complication rates.
The Journal of thoracic and cardiovascular surgery, 2015
It is hypothesized that by performing radical aortic root manipulation and then autologous suppor... more It is hypothesized that by performing radical aortic root manipulation and then autologous support for the pulmonary autograft in the Ross procedure, this will maintain aortic root size and should, in turn, lead to the demonstrated low incidence of late aortic regurgitation and need for reoperation on the aortic root and valve. Aortic root size was measured echocardiographically both preoperatively and then at second yearly intervals in 322 consecutive patients who underwent a Ross operation between October 1992 and June 2013 with autologous support of the pulmonary autograft root using the patient's own aorta. This technique, a variant of the inclusion cylinder method, has been developed with the aim of minimizing prosthetic materials in the aortic root. Measures to reduce aortic root size included annulus reduction in 201 patients (62.4%) and reduction in aortic sinus or sinotubular junction in 159 patients (49.4%). Maximal aortic root diameter postoperatively at 5, 10, and 15...
The study aims to report results of re-operations after aortic allograft root implantation. All c... more The study aims to report results of re-operations after aortic allograft root implantation. All consecutive patients in our prospective allograft database, who underwent aortic allograft root implantation, were selected for analysis, and additional information for patients who subsequently underwent re-operation was obtained from hospital records. From 1989 to 2009, 262 aortic allograft root implantations were performed. Thirty-day mortality was 5.7%. During follow-up, 69 patients died. The actuarial survival was 77.0% (95% confidence interval (CI) 71-83%) after 10 years, and 65.1% (95% CI 57-74%) after 14 years. A total of 52 patients required re-operation. The actuarial freedom from allograft re-operation was 82.9% (Standard Error (SE) 2.9%) after 10 years and 55.7% (SE 5.7%) after 14 years. The actuarial median time to re-operation was 14.8 years. The indications for re-operation were structural valve dysfunction in 46 patients, endocarditis in two patients and non-structural valve dysfunction in four patients. The re-operations included 23 aortic valve replacements (mechanical prostheses 20 and bioprostheses 3), 27 aortic root replacements (mechanical conduits 21, aortic allografts five, and biological conduit one), one trans-apical valve implantation and one primary closure of a false aneurysm. The additional procedures were mitral valve repair (N = 5), mitral valve replacement (N = 1), ascending aortic replacement (N = 5), and coronary artery bypass grafting (CABG) (N = 4; in two patients unforeseen). Thirty-day mortality after re-operation occurred in two patients (3.9%). Five patients died during follow-up. The survival after re-operation was 87.1% (SE 5.5%) after 1 year and 79.3% (SE 7.4%) after 9 years. Re-operations after aortic allograft root implantation will be required in a substantial and growing number of patients. These re-operations, although technically demanding, can be performed with satisfying results.
The Journal of thoracic and cardiovascular surgery
To report the results of aortic root reoperations after pulmonary autograft implantation. All con... more To report the results of aortic root reoperations after pulmonary autograft implantation. All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technica...
To report our experience with the Ross operation in patients with predominant aortic stenosis (AS... more To report our experience with the Ross operation in patients with predominant aortic stenosis (AS) using an inclusion cylinder (IC) method. Out of 324 adults undergoing a Ross operation, 204 patients of mean age of 41.3 years (limits 16-62) underwent this procedure for either AS or mixed AS and regurgitation (AS/AR) between October, 1992 and February, 2012, implanting the PA with an IC method. Clinical follow up and serial echo data for this group is 97% complete with late mortality follow up 99% complete. There has been zero (0%) early mortality, and late survival at 15 years is 98% (96%, 100%). Only one re-operation on the aortic valve for progressive aortic regurgitation (AR) has been required with freedom from re-operation on the aortic valve at 15 years being 99% (96%, 100%). The freedom from all re-operations on the aortic and pulmonary valves at 15 years is 97% (94%, 100%). Echo analysis at the most recent study shows that 98% have nil, trivial or mild AR. Aortic root size ha...
The purpose of the study is to report major cardiac and cerebrovascular events after the Ross pro... more The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.
Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve auto... more Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis. 1335 adult patients (mean age:43.5+/-12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09+/-3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root-R) group was associated with a 6x increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P<0.001). SC and Root groups had similar rate of aortic regurgitation (AR) development over time. Root+R patients had no progression of AR, whereas Root-R had 6 times higher AR development compared to Root+R. In SC, R had no remarkable effect on the annual AR progression. The SC technique was associated with lower rates of autograft dilatation at all levels of the aortic root compared to the Root techniques. R did not influence autograft dilatation rates in the Root group. For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure.
Statistical methods in medical research, Jan 9, 2015
Nowadays there is an increased medical interest in personalized medicine and tailoring decision m... more Nowadays there is an increased medical interest in personalized medicine and tailoring decision making to the needs of individual patients. Within this context our developments are motivated from a Dutch study at the Cardio-Thoracic Surgery Department of the Erasmus Medical Center, consisting of patients who received a human tissue valve in aortic position and who were thereafter monitored echocardiographically. Our aim is to utilize the available follow-up measurements of the current patients to produce dynamically updated predictions of both survival and freedom from re-intervention for future patients. In this paper, we propose to jointly model multiple longitudinal measurements combined with competing risk survival outcomes and derive the dynamically updated cumulative incidence functions. Moreover, we investigate whether different features of the longitudinal processes would change significantly the prediction for the events of interest by considering different types of associa...
Current clinical practice guidelines advocate shared decision-making (SDM) in prosthetic valve se... more Current clinical practice guidelines advocate shared decision-making (SDM) in prosthetic valve selection. This study assesses among adult patients accepted for aortic valve replacement (AVR): (1) experience with current clinical decision-making regarding prosthetic valve selection, (2) preferences for SDM and risk presentation and (3) prosthetic valve knowledge and numeracy. In a prospective multicentre cohort study, AVR patients were surveyed preoperatively and 3 months postoperatively. 132 patients (89 males/43 females; mean age 67 years (range 23-86)) responded preoperatively. Decisional conflict was observed in 56% of patients, and in 25% to such an extent that it made them feel unsure about the decision. 68% wanted to be involved in decision-making, whereas 53% agreed that they actually were. 69% were able to answer three basic knowledge questions concerning prosthetic valves correctly. 56% were able to answer three basic numeracy questions correctly. Three months postsurgery, ...
Microsimulation can be used to predict the prognosis of an individual patient based on a virtual ... more Microsimulation can be used to predict the prognosis of an individual patient based on a virtual patient population of copies of that patient. In this study we compare the outcomes of an existing validated microsimulation program that is designed to study valvular heart disease and a newly developed microsimulation program that is designed to study heart diseases in general. We studied in depth the results of both systems to model the prognosis of a 40 year old male patient undergoing allograft surgery. Furthermore we studied the model results in relation to age and sex to provide a general overview of the most important outcome variables including operative mortality, average survival time, average event free time and average time to reoperation. Our results show a good agreement between the two systems regarding all simulations of allograft surgery. We intend to use the newly developed software to explore other disease/event related prognostic models.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, Jan 9, 2015
Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal sol... more Conventional aortic valve replacement (AVR) in young, active patients represents a suboptimal solution in terms of long-term survival, durability and quality of life. The aim of the present work is to present an update on the multicentre experience with the pulmonary autograft procedure in young, adult patients. Between 1990-2013, 1779 adult patients (1339 males; 44.7 ± 11.6 years) underwent the pulmonary autograft procedure in 8 centres. All patients underwent prospective clinical and echocardiographic examinations annually. The mean follow-up was 8.3 ± 5.1 years (range 0-24.3 years) with a total cumulative follow-up of 14 288 years and 662 patients having a follow-up of at least 10 years. The early (30-day) mortality rate was 1.1% (n = 19). Late (>30 day) survival of the adult population was comparable with the age- and gender-matched general population (observed deaths: 101, expected deaths: 91; P = 0.29). Freedom from autograft reoperation at 5, 10 and 15 years was 96.8, 94.7...
The Journal of Thoracic and Cardiovascular Surgery, 2012
Reinterventions after the Ross procedure are a concern for patients and treating physicians. The ... more Reinterventions after the Ross procedure are a concern for patients and treating physicians. The scope of the present report was to provide an update on the reinterventions observed in the large patient population of the German-Dutch Ross Registry. From 1988 to 2011, 2023 patients (age, 39.05 ± 16.5 years; male patients, 1502; adults, 1642) underwent a Ross procedure in 13 centers. The mean follow-up was 7.1 ± 4.6 years (range, 0-22 years; 13,168 patient-years). In the adult population, 120 autograft reinterventions in 113 patients (1.03%/patient-year) and 76 homograft reinterventions in 67 patients (0.65%/patient-year) and, in the pediatric population, 14 autograft reinterventions in 13 patients (0.91%/patient-year) and 42 homograft reinterventions in 31 patients (2.72%/patient-year) were observed. Of the autograft and homograft reinterventions, 17.9% and 21.2% were performed because of endocarditis, respectively. The subcoronary technique in the adult population resulted in significantly superior autograft durability (freedom from autograft reintervention: 97% at 10 years and 91% at 12 years; P < .001). The root replacement technique without root reinforcement (hazard ratio, 2.4; 95% confidence interval, 1.4-4.1) and the presence of pure aortic insufficiency preoperatively (hazard ratio, 2.3; 95% confidence interval, 1.5-3.5) were statistically significant predictors for a shorter time to reoperation. The center volume had a significant influence on the long-term results. The freedom from homograft reoperation for the adults and pediatric population was 97% and 87% at 5 years and 93% and 79% at 12 years, respectively (P < .001), with younger recipient and donor age being significant predictors of a shorter time to homograft reoperation. The autograft principle remains a valid option for young patients requiring aortic valve replacement. The risk of reoperation depends largely on the surgical technique used and the preoperative hemodynamics. Center experience and expertise also influence the long-term results. Adequate endocarditis prophylaxis might further reduce the need for reoperation.
We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated c... more We retrospectively investigated the short and mid-term outcome of non-emergent primary isolated coronary artery bypass graft (CABG) surgery in relation to risk stratification in the fully equipped university location (FE) and the low volume, limited facility location (LVLF) of our department. Between September 1995 and December 1996, 832 patients were referred to our department to undergo a primary isolated CABG operation. The surgical team selected 482 patients (58%) as being at low-risk. These were treated in the LVLF hospital. The other 350 patients with mixed-risk were treated in the FE hospital. The selection consisted primarily of exclusion of patients with moderate or poor left ventricular function, severe COPD or renal impairment, from surgery in the LVLF location. Finally, the prognostic value of the EuroSCORE and the Parsonnet score was tested on our patient population. Overall in-hospital mortality was 1.6% (13 patients). One patient died in the LVLF group (0.2%) and 12 patients (3.4%) in the FE group. LVLF patients experienced less complications during the hospital period compared to the FE patients (5 versus 21%; P=0.0001). The Parsonnet risk model and the EuroSCORE risk model showed both a good relation with in-hospital mortality. After discharge, an increased risk of late mortality was observed up to 1 year postoperative in the FE group compared to the LVLF group (2.7 versus 0.5%; P=0.01). Risk factors for 5-year mortality were pre-operative renal impairment (blood creatinine >150 micromol/l) (hazard ratio (HR): 2.8; 95% confidence interval (CI): 1.4-5.5), diabetes (HR: 2.1; 95% CI: 1.3-3.5), impaired LVEF (HR: 1.9; 95% CI: 1.2-3.0), COPD (HR: 1.9; 95% CI: 1.1-3.5) and older age (HR: 1.07 per year; 95% CI: 1.01-1.10). Lipid-lowering therapy was a predictor of lower mortality at 5-years (HR: 0.5; 95% CI: 0.4-0.9). By careful decision making, selection of low-risk patients for a low volume and limited facility location resulted in excellent in-hospital survival with very low complication rates.
The Journal of thoracic and cardiovascular surgery, 2015
It is hypothesized that by performing radical aortic root manipulation and then autologous suppor... more It is hypothesized that by performing radical aortic root manipulation and then autologous support for the pulmonary autograft in the Ross procedure, this will maintain aortic root size and should, in turn, lead to the demonstrated low incidence of late aortic regurgitation and need for reoperation on the aortic root and valve. Aortic root size was measured echocardiographically both preoperatively and then at second yearly intervals in 322 consecutive patients who underwent a Ross operation between October 1992 and June 2013 with autologous support of the pulmonary autograft root using the patient's own aorta. This technique, a variant of the inclusion cylinder method, has been developed with the aim of minimizing prosthetic materials in the aortic root. Measures to reduce aortic root size included annulus reduction in 201 patients (62.4%) and reduction in aortic sinus or sinotubular junction in 159 patients (49.4%). Maximal aortic root diameter postoperatively at 5, 10, and 15...
The study aims to report results of re-operations after aortic allograft root implantation. All c... more The study aims to report results of re-operations after aortic allograft root implantation. All consecutive patients in our prospective allograft database, who underwent aortic allograft root implantation, were selected for analysis, and additional information for patients who subsequently underwent re-operation was obtained from hospital records. From 1989 to 2009, 262 aortic allograft root implantations were performed. Thirty-day mortality was 5.7%. During follow-up, 69 patients died. The actuarial survival was 77.0% (95% confidence interval (CI) 71-83%) after 10 years, and 65.1% (95% CI 57-74%) after 14 years. A total of 52 patients required re-operation. The actuarial freedom from allograft re-operation was 82.9% (Standard Error (SE) 2.9%) after 10 years and 55.7% (SE 5.7%) after 14 years. The actuarial median time to re-operation was 14.8 years. The indications for re-operation were structural valve dysfunction in 46 patients, endocarditis in two patients and non-structural valve dysfunction in four patients. The re-operations included 23 aortic valve replacements (mechanical prostheses 20 and bioprostheses 3), 27 aortic root replacements (mechanical conduits 21, aortic allografts five, and biological conduit one), one trans-apical valve implantation and one primary closure of a false aneurysm. The additional procedures were mitral valve repair (N = 5), mitral valve replacement (N = 1), ascending aortic replacement (N = 5), and coronary artery bypass grafting (CABG) (N = 4; in two patients unforeseen). Thirty-day mortality after re-operation occurred in two patients (3.9%). Five patients died during follow-up. The survival after re-operation was 87.1% (SE 5.5%) after 1 year and 79.3% (SE 7.4%) after 9 years. Re-operations after aortic allograft root implantation will be required in a substantial and growing number of patients. These re-operations, although technically demanding, can be performed with satisfying results.
The Journal of thoracic and cardiovascular surgery
To report the results of aortic root reoperations after pulmonary autograft implantation. All con... more To report the results of aortic root reoperations after pulmonary autograft implantation. All consecutive patients in our prospective Ross research database were selected for analysis, and additional information for patients requiring reoperation was obtained from the hospital records. From 1988 to 2009, 155 pulmonary autograft operations were performed. During this period, 41 patients required reoperation for aortic root dilatation and/or autograft valve insufficiency, in 8 patients combined with pulmonary allograft dysfunction. The freedom from autograft reoperation rate was 86% (standard error, 3.3%) after 10 years and 52% (standard error, 6.6%) after 15 years. The median interval to reoperation was 15.3 years. During reoperation, 39 patients underwent aortic root replacement (mechanical conduit, 31; stentless root, 2; allograft, 3; and valve sparing, 3), and 2 patients underwent valve replacement. In 8 patients this was combined with pulmonary allograft replacement. The technica...
To report our experience with the Ross operation in patients with predominant aortic stenosis (AS... more To report our experience with the Ross operation in patients with predominant aortic stenosis (AS) using an inclusion cylinder (IC) method. Out of 324 adults undergoing a Ross operation, 204 patients of mean age of 41.3 years (limits 16-62) underwent this procedure for either AS or mixed AS and regurgitation (AS/AR) between October, 1992 and February, 2012, implanting the PA with an IC method. Clinical follow up and serial echo data for this group is 97% complete with late mortality follow up 99% complete. There has been zero (0%) early mortality, and late survival at 15 years is 98% (96%, 100%). Only one re-operation on the aortic valve for progressive aortic regurgitation (AR) has been required with freedom from re-operation on the aortic valve at 15 years being 99% (96%, 100%). The freedom from all re-operations on the aortic and pulmonary valves at 15 years is 97% (94%, 100%). Echo analysis at the most recent study shows that 98% have nil, trivial or mild AR. Aortic root size ha...
The purpose of the study is to report major cardiac and cerebrovascular events after the Ross pro... more The purpose of the study is to report major cardiac and cerebrovascular events after the Ross procedure in the large adult and pediatric population of the German-Dutch Ross registry. These data could provide an additional basis for discussions among physicians and a source of information for patients. One thousand six hundred twenty patients (1420 adults; 1211 male; mean age, 39.2±16.2 years) underwent a Ross procedure between 1988 and 2008. Follow-up was performed on an annual basis (median, 6.2 years; 10 747 patient-years). Early and late mortality were 1.2% (n=19) and 3.6% (n=58; 0.54%/patient-year), respectively. Ninety-three patients underwent 99 reinterventions on the autograft (0.92%/patient-year); 78 reinterventions in 63 patients on the pulmonary conduit were performed (0.73%/patient-year). Freedom from autograft or pulmonary conduit reoperation was 98.2%, 95.1%, and 89% at 1, 5, and 10 years, respectively. Preoperative aortic regurgitation and the root replacement technique without surgical autograft reinforcement were associated with a greater hazard for autograft reoperation. Major internal or external bleeding occurred in 17 (0.15%/patient-year), and a total of 38 patients had composite end point of thrombosis, embolism, or bleeding (0.35%/patient-year). Late endocarditis with medical (n=16) or surgical treatment (n=29) was observed in 38 patients (0.38%/patient-year). Freedom from any valve-related event was 94.9% at 1 year, 90.7% at 5 years, and 82.5% at 10 years. Although longer follow-up of patients who undergo Ross operation is needed, the present series confirms that the autograft procedure is a valid option to treat aortic valve disease in selected patients. The nonreinforced full root technique and preoperative aortic regurgitation are predictors for autograft failure and warrant further consideration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00708409.
Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve auto... more Autograft reinforcement interventions (R) during the Ross procedure are intended to preserve autograft function and improve durability. The aim of this study is to evaluate this hypothesis. 1335 adult patients (mean age:43.5+/-12.0 years) underwent a Ross procedure (subcoronary, SC, n=637; root replacement, Root, n=698). 592 patients received R of the annulus, sinotubular junction, or both. Regular clinical and echocardiographic follow-up was performed (mean:6.09+/-3.97, range:0.01 to 19.2 years). Longitudinal assessment of autograft function with time was performed using multilevel modeling techniques. The Root without R (Root-R) group was associated with a 6x increased reoperation rate compared to Root with R (Root+R), SC with R (SC+R), and without R (SC-R; 12.9% versus 2.3% versus 2.5%.versus 2.6%, respectively; P<0.001). SC and Root groups had similar rate of aortic regurgitation (AR) development over time. Root+R patients had no progression of AR, whereas Root-R had 6 times higher AR development compared to Root+R. In SC, R had no remarkable effect on the annual AR progression. The SC technique was associated with lower rates of autograft dilatation at all levels of the aortic root compared to the Root techniques. R did not influence autograft dilatation rates in the Root group. For the time period of the study surgical autograft stabilization techniques preserve autograft function and result in significantly lower reoperation rates. The nonreinforced Root was associated with significant adverse outcome. Therefore, surgical stabilization of the autograft is advisable to preserve long-term autograft function, especially in the Root Ross procedure.
Statistical methods in medical research, Jan 9, 2015
Nowadays there is an increased medical interest in personalized medicine and tailoring decision m... more Nowadays there is an increased medical interest in personalized medicine and tailoring decision making to the needs of individual patients. Within this context our developments are motivated from a Dutch study at the Cardio-Thoracic Surgery Department of the Erasmus Medical Center, consisting of patients who received a human tissue valve in aortic position and who were thereafter monitored echocardiographically. Our aim is to utilize the available follow-up measurements of the current patients to produce dynamically updated predictions of both survival and freedom from re-intervention for future patients. In this paper, we propose to jointly model multiple longitudinal measurements combined with competing risk survival outcomes and derive the dynamically updated cumulative incidence functions. Moreover, we investigate whether different features of the longitudinal processes would change significantly the prediction for the events of interest by considering different types of associa...
Current clinical practice guidelines advocate shared decision-making (SDM) in prosthetic valve se... more Current clinical practice guidelines advocate shared decision-making (SDM) in prosthetic valve selection. This study assesses among adult patients accepted for aortic valve replacement (AVR): (1) experience with current clinical decision-making regarding prosthetic valve selection, (2) preferences for SDM and risk presentation and (3) prosthetic valve knowledge and numeracy. In a prospective multicentre cohort study, AVR patients were surveyed preoperatively and 3 months postoperatively. 132 patients (89 males/43 females; mean age 67 years (range 23-86)) responded preoperatively. Decisional conflict was observed in 56% of patients, and in 25% to such an extent that it made them feel unsure about the decision. 68% wanted to be involved in decision-making, whereas 53% agreed that they actually were. 69% were able to answer three basic knowledge questions concerning prosthetic valves correctly. 56% were able to answer three basic numeracy questions correctly. Three months postsurgery, ...
Microsimulation can be used to predict the prognosis of an individual patient based on a virtual ... more Microsimulation can be used to predict the prognosis of an individual patient based on a virtual patient population of copies of that patient. In this study we compare the outcomes of an existing validated microsimulation program that is designed to study valvular heart disease and a newly developed microsimulation program that is designed to study heart diseases in general. We studied in depth the results of both systems to model the prognosis of a 40 year old male patient undergoing allograft surgery. Furthermore we studied the model results in relation to age and sex to provide a general overview of the most important outcome variables including operative mortality, average survival time, average event free time and average time to reoperation. Our results show a good agreement between the two systems regarding all simulations of allograft surgery. We intend to use the newly developed software to explore other disease/event related prognostic models.
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Papers by Johanna Takkenberg