30-05-11 Clinical outcome after pre-incision Aim Study - PDF document

30-­‑05-­‑11 ¡ Clinical outcome after pre-incision Aim Study assessment of aortic atherosclerosis by A-View echocardiography in 5,553  To determine the diagnostic effect of the introduction of elective cardiac surgery patients A-View on clinical outcome  Question: A R N O N I E R I C H , W O U T E R J A N S E N K L O M P , L I N D A P E E L E N , G E O R G E B R A N D O N B R A V O B R U I N S M A  A-View  postoperative reduction in 30 Day Mortality? A R N O U D V A N T H O F F ISALA CLINICS, ZWOLLE, NETHERLANDS  Primary endpoint: 30 day mortality UNIVERSITY MEDICAL CENTER UTRECHT, JULIUS CENTER FOR HEALTH SCIENCES AND PRIMARY CARE, DEPARTMENT OF EPIDEMIOLOGY, UTRECHT, NETHERLANDS  Secondary endpoint  clinical neurological event  (CVA = any CT <30 days after surgery)  Combined mortality and CVA Stroke and Encephalopathy After Cardiac Surgery An Update Stroke and Encephalopathy After Cardiac Surgery An Update Guy M. McKhann, et al. Stroke . 2006;37:562-571 Guy M. McKhann, et al. Stroke . 2006;37:562-571 3% ¡ Death ¡ 7% ¡ 12% Stroke ¡ 10% 30% ¡ Delirium ¡ 8% 6% 4% 60% ¡ Cogni;ve ¡dysfunc;on ¡ 2% 0% 50 55 60 65 70 75 80 85 ?? ¡ Stroke Death Reeks2 Reeks1 Demen;a ¡ Age Perioperative Stroke Blind spot by TEE Magdy Selim . N Engl J Med 2007;356:706-13 Meta-analysis of the diagnostic accuracy of  Etiology Aortic Source transesophageal echocardiography for assessment of atherosclerosis in the ascending aorta in patients undergoing cardiac surgery B Van Zaane, et al. Acta Anaesthesiol Scand 2008; 52: 1179– 1187 Visualization of the Distal Ascending Aorta  With A-Mode Transesophageal Echocardiography A. Nierich, et al. Journal of Cardiothoracic and Vascular Anesthesia, Vol 22, No 5 , 2008: pp 766-773  Diagnostic accuracy of modified transoesophageal echocardiography for pre- incision assessment of aortic atherosclerosis in cardiac surgery patients B Van Zaane, et al. BJA June 10, 2010 Imaging of the distal ascending aorta using  modified transesophageal echocardiography in cardiac surgery B Van Zaane PhD dissertation 5 nov 2009 Cost-effectiveness analysis of modified  transoesophageal echocardiography to assess the distal ascending aorta before incision in cardiac surgery patients. Nierich, EACTA 2010. Koffijberg et al. Medical Decision Making submited. 1 ¡

30-­‑05-­‑11 ¡ Baseline Characteristics of patients with and Design & methods without monitoring with A-View  Period Jan 2006- september 2010.  Follow up till march 2011.  Observational study of diagnostic effect  Non-randomized comparative intervention study  No surgical intervention protocol  Complete Case Analysis  Patient cohort total: 5553  - A-View: 707  +A-View: 4846  Analyses (multivariable):  Dependent: Mortality & Combined 30-day endpoint  Independent: A-View  Multivariate correction for confounding by indication (demographics, surgery) Operative Characteristics of patients with Crude Outcomes and without monitoring with A-View 30 day mortality Analysis adjusted for patient + operative characteristics of A-View  Multivariate correction of combined end-point for patient + operative characteristics of A-View A-View Euroscore Euroscore + clinical characteristics  Model 0: A-View OR: 0.96, 95% CI: 0.88 to 1.72  Model 1: Euroscore  Patient characteristics OR: 0.71, 95% CI: 0.43 to 1.18  Model 2: Euroscore + operative characteristics  Operative characteristics  CABG, AVR, ARR, AAR  ECC time OR: 0.61, 95% CI: 0.36 to 1.03  Aortic clamp time  Minimal core temperature 0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 2 2 ¡

30-­‑05-­‑11 ¡ combined endpoint (mortality-CVA) Cause of Mortality 30 day adjusted for patient + operative characteristics of A-View A-View Euroscore Euroscore + clinical characteristics Other Infectious Multiple organ failure OR: 1.23, 95% CI: 0.88 to 1.72 Pulmonary A-View + CVA OR: 0.93, 95% CI: 0.66 to 1.32 A-View - Tamponade Cardiac OR: 0.85, 95% CI: 0.59 to 1.21 Unknown 0% 5% 10% 15% 20% 25% 30% 35% 0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 Conclusions  Now possible to identify patients at high risk before surgery or Trans-Aortic Valve Implantation  Creating awareness by A-View leads to surgical adaptation  A-View monitoring tends to reduce mortality by 40% Current: • A-View 3 trial. MRI study embilization after CABG • Standard care Isala during Cardiac surgery and TAVI • Advanced TEE A-View course by Isala Academy & Patient safety department • Start of new surgical team approach and treatment modalities 3 ¡