BACKGROUND:For suspected acute coronary syndrome (ACS), guidelines recommend using high-sensitivity troponins (hs-cTn) in accelerated diagnostic pathways (ADPs) with 0/1-hour recommended over 0/3-hour ADP. However, implementation of these ADPs, with universal use of hs-cTns, has not been directly compared in randomized trials OBJECTIVES: This study sought to compare the efficiency and safety of the European Society of Cardiology (ESC) 0/1-hour and a 0/3-hour ADP when implemented in real-world clinical practice. METHODS:This pragmatic, randomized, noninferiority implementation trial compared the safety and efficiency of clinician decision making using these 2 pathways. To prevent incorporation bias, an independent hs-cTnI was used for formal adjudication using the fourth universal definition of myocardial infarction (MI). Efficiency was judged by the proportion of patients discharged within 4 hours. The safety endpoint was major adverse cardiac events (MACE) within 30 days (adjudicated index or representation type 1 MI, cardiovascular death, and urgent coronary revascularization) for those who were considered not to have ACS and discharged. The noninferiority margin, for absolute difference in sensitivity, between the ESC 0/1-hour and the 0/3-hour ADP was set at 3%, assessed with a 1-sided 97.5% CI. RESULTS:From December 2021 to July 2024, of 13,983 screened 3,543 individual patients with suspected ACS were recruited and consented from 2 major emergency departments in North-West England, with 100% follow-up achieved for all representations to any national hospital. The median age was 60 years (IQR: 49.5-70.5 years), 53% were men, 6.7%, and 7.6% had adjudicated index type 1 MI and MACE within 30 days, respectively. The turnaround time from sample to result for central laboratory hs-cTnT was 81 minutes (IQR: 69-101 minutes). The proportion of patients discharged within 4 hours was relatively low and did not differ substantially (21.8% vs 19.2%, P = 0.07). In addition, the 0/1-hour pathway was noninferior for safety, in patients discharged, compared with the 0/3-hour pathway, absolute difference in sensitivity was +4.2% (1-sided 97.5% CI: -2.5) in favor of the 0/1-hour pathway. The calculated sensitivities were 93.7% (95% CI: 88.4%-97.1%) vs 89.5% (95% CI: 82.7%-94.3%), respectively. CONCLUSIONS:Implementation of the ESC 0/1-hour pathway failed to discharge significantly more patients within 4 hours of presentation compared with the 0/3-hour ADP. In addition, The ESC 0/1-hour was noninferior to the 0/3-hour hs-cTn pathway for safety of discharge, although safety for both pathways was less than that imputed by observational studies. This trial demonstrates that perceived benefits to emergency department efficiency of a reduced sampling interval are mitigated by central laboratory turnaround times as well as system constraints. (Pragmatic Randomised Trial of the ESC 0/​1 Versus 0/​3 Hour Troponin Pathway [MACROS2]; NCT05322395).

OBJECTIVES:Individuals undergoing cardiac surgery often have obstructive lung disease. This may affect surgical mortality, but a pre-existing diagnosis may not be present in all individuals with obstruction. The objectives of this study were to describe the relationship between obstructive spirometry and cardiothoracic surgery outcomes in those with and without a preoperative diagnosis of respiratory disease. DESIGN:Retrospective, observational, noncontrolled. SETTING:Single-center, tertiary cardiothoracic teaching hospital. PARTICIPANTS:A total of 16,906 consecutive patients undergoing preoperative spirometry between January 2010 and September 2020. INTERVENTIONS:Preoperative spirometry prior to cardiac surgery. MEASUREMENTS AND MAIN RESULTS:The median (interquartile range) age of participants was 69 (61, 75) years, and 28.4% were female. Overall, 3,284 (19.4%) had a documented history of lung disease, and 4,712 (27.9%) demonstrated obstruction on spirometry. Of those without a diagnosis of respiratory disease, 3,672 (21.7%) were found to demonstrate obstructive spirometry and were considered "diagnosis-/obstruction+." Of those with a diagnosis of chronic obstructive pulmonary disease, 568 (39.2%) did not demonstrate a pattern of obstruction on spirometry and were considered "diagnosis+/obstruction-." In-hospital mortality was highest in the diagnosis+/obstruction+ (4.5%) and diagnosis+/obstruction- (3.8%) groups, and lowest in the diagnosis-/obstruction+ (2.6%) and diagnosis-/obstruction- (1.8%) groups. CONCLUSIONS:A significant proportion of patients undergoing cardiac surgery have obstructive spirometry, many of whom have no diagnosis of respiratory disease. Mis- or undiagnosed obstructive disease may impact in-hospital mortality. Preoperative spirometry offers opportunities for case finding, disease reclassification, and treatment optimization.

Measurement of high sensitivity cardiac troponin (hs-cTn) I using cartridge-based systems at the point of care (POC) requires an appropriate quality control system. The optimal strategy for this currently remains unclear. We report the results of our experience with such a system with measurement over 842 days. The Mersey Acute Coronary syndrome Rule Out Study (MACROS-2). MACROS-2 is a two-centre, pragmatic, randomised controlled trial (RCT) comparing the rule out of non ST-elevation myocardial infarction (NSTEMI), using the European Society of Cardiology (ESC) 0/1 or 0/3 hour diagnostic algorithms (ClinicalTrials.gov Identifier: NCT05322395). The inclusion period was 13/4/22-29/07/2024. Upon presentation with symptoms compatible with NSTEMI, the patient had blood drawn at presentation for central laboratory high sensitive cardiac troponin(hs-cTn) T (roche , elecsys [clinical biomarker in use]), but an additional research sample was drawn for immediate analysis in the ED (emergency department) of whole blood (EDTA tube) Quidel TriageTrueTM hs-cTn I test on the Quidel Triage Meterpro device. This process was repeated for any serial samples. The device includes two on-board quality control (QC) checks on the analytical process. Internal liquid QC was performed using manufacturer supplied EDTA plasma-based QC material. Both alow control (target 25 ng/L) and high control (target 500 ng/L) were use by expert laboratory operators with regular checks on a weekly basis. For plasma, the analytical range is 0.1-1000 ng/L, limit of detection (LoD) is 1.5 ng/L, limit of quantitation (LoQ) at 20% coefficient of variation (CV) 2.1 ng/L and at 10% CV 4.6ng/L. 99th percentile overall 20.5 ng/L. All IQC was downloaded to a central repository for analysis. Over 842 days 539triage true POC tests were run on patient samples and 382 QC samples. An invalid test result on first analysis occurred in 56/5391 (1%). On repeat analysis there were 24 analytical failures giving a total failure rate of 24/5291 (0.4%). 328 (165 low, 162 high) QC samples were run. There were 7 lots for the low QC and 9 lots for a high QC over 21 reagent lots. eight expert laboratory operators undertook IQC. For the low control, 4/165 (2.5%) samples exceeded the two standard deviation (SD) limit and none exceeded 3 SD. Mean value was 25.4 ng/L with a mean CV of 9.7%. There was only one analytical failure in the high control with only 2 (1.2% exceeded 2 SD and none 3 SD’s. The mean value was 519 ng/L with a mean CV of 9.5%. Time series regression analysis across reagent batches showed no evidence of significant lot to lot variation or evidence of QC drift across the entire period of the study. Analytical reliability of the system was robust. QC stability with time suggests that following lot verification, QC frequency can be such that only the midpoint and towards the end of a particular batch is measured.

Urologists face a significant challenge when presented with cases in which complete, yet reversible, urinary diversion is desirable. With multidisciplinary collaboration, we have used a novel technique involving the antegrade deployment of distally-ligated covered metal (Allium®) ureteral stents, achieving ureteral occlusion and complete urinary diversion via nephrostomy tubes. We have used this technique, with good early results, in complex cases, including that of a young male patient with complex pelvic injuries after polytrauma and a female patient with a malignant vesicovaginal fistula, neither of whom were candidates for definitive surgical reconstruction or diversion at the time of treatment. We describe our experience, which we believe may be of interest to urologists and interventional radiologists managing similarly challenging cases.

Coronary artery disease (CAD) is a major cause of ill health and death worldwide. Coronary computed tomographic angiography (CCTA) is the first-line investigation to detect CAD in symptomatic patients. This diagnostic approach risks greater second-line heart tests and treatments at a cost to the patient and health system. The National Health Service funded use of an artificial intelligence (AI) diagnostic tool, computed tomography (CT)-derived fractional flow reserve (FFR-CT), in patients with chest pain to improve physician decision-making and reduce downstream tests. This observational cohort study assessed the impact of FFR-CT on cardiovascular outcomes by including all patients investigated with CCTA during the national AI implementation program at 27 hospitals (CCTA n = 90,553 and FFR-CT n = 7,863). FFR-CT was safe, with no difference in all-cause (n = 1,134 (3.2%) versus 1,612 (2.9%), adjusted-hazard ratio (aHR) 1.00 (0.93-1.08), P = 0.97) or cardiovascular mortality (n = 465 (1.3%) versus 617 (1.1%), aHR 0.96 (0.85-1.08), P = 0.48), while reducing invasive coronary angiograms (n = 5,720 (16%) versus 8,183 (14.9%), aHR 0.93 (0.90-0.97), P < 0.001) and noninvasive cardiac tests (189/1,000 patients versus 167/1,000), P < 0.001). Implementation of an AI-diagnostic tool as part of a health intervention program was safe and beneficial to the patient pathway and health system with fewer cardiac tests at 2 years.

OBJECTIVES:Post-cardiac and aortic surgery stroke is often underreported. We detail our single-centre experience the following introduction of comprehensive consultant-led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries. METHODS:This retrospective, single-centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow-up. RESULTS:A total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow-up were 86.0% and 84.0% respectively. Independent risk factors for post-operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p < .001), female sex (OR 1.491, 95% [1.212, 1.827], p < .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p < .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p < .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p < .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001). CONCLUSIONS:Perioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.

OBJECTIVES:The objective of this study is to evaluate the analytical and diagnostic performance of a high-sensitivity point-of-care (POC) cardiac troponin I assay, the Quidel TriageTrue™ (QuidelOrtho Inc, San Diego, USA), compared to central laboratory testing (CLT) in accelerated diagnostic protocols (ADP) in real time in a clinical environment. METHODS:In a nested sub-study of a pragmatic randomised control trial, consecutive patients with suspected acute coronary syndrome (ACS) and chest pain <12 h duration were randomised to the ESC 0/1 and 0/3-h ADP. Subjects underwent sampling for Quidel TriageTrue POC hs-TnI whole blood and plasma, CLT hs-TnT Roche Elecsys and a validated, NICE approved CLT High sensitivity cardiac troponin I (hs-TnI) (Siemens Attellica) at each time point. Assay imprecision was assessed by repeat analysis of whole blood samples at three levels (low, near 10 % CV 5-10 ng/L, medium, approximating 99th percentile 15-25 ng/L and high, 3-5 times the 99th percentile, 60-100 ng/L). Final diagnosis was adjudicated at 6 weeks by Roche hs-TnT using the 4th universal definition of myocardial infarction (MI). RESULTS:A total of 1,157 patients consented and had both investigational POC whole blood and plasma and central lab hs-cTn available. The median age was 59, 47.2 % were female and 15 % had suffered a previous MI. Assay imprecision of whole blood POC TriageTrue revealed 10 % CV at 8.6 ng/L (>50 % lower than 99th percentile [20.5 ng/L]) and a 20 % CV at 1.2 ng/L. Receiver operator characteristics (ROC) curves were computed for each assay against adjudicated index type 1 MI to study clinical performance. At all-time points there were excellent performance for whole blood POC TriageTrue: area under the curve (AUC) 0.97 [95 % CI 0.94-098], 0.98 [95 % CI 0.97-1.00] and 0.95 [95 % CI 0.92-0.98] at time 0, 1 and 3 h respectively. There was statistical equivalence for performance of whole blood and plasma POC TriageTrue hs-TnI and laboratory Siemens Atellica hs-TnI. CONCLUSIONS:The whole blood POC TriageTrue hs-TnI assay demonstrates imprecision levels consistent with high sensitivity characteristics and has a clinical performance equivalent to an established, validated and NICE approved laboratory Siemens Atellica hs-TnI.

INTRODUCTION:Dynamic chest radiography (DCR) is a novel, low-dose, real-time digital imaging system where software identifies moving thoracic structures and can automatically calculate lung areas. In an observational, prospective, non-controlled, single-centre pilot study, we compared it with whole-body plethysmography (WBP) in the measurement of lung volume subdivisions in people with cystic fibrosis (pwCF).METHODS:Lung volume subdivisions were estimated by DCR using projected lung area (PLA) during deep inspiration, tidal breathing and full expiration, and compared with same-day WBP in 20 adult pwCF attending routine review. Linear regression models to predict lung volumes from PLA were developed.RESULTS:Total lung area (PLA at maximum inspiration) correlated with total lung capacity (TLC) (r=0.78, p<0.001), functional residual lung area with functional residual capacity (FRC) (r=0.91, p<0.001), residual lung area with residual volume (RV) (r=0.82, p=0.001) and inspiratory lung area with inspiratory capacity (r=0.72, p=0.001). Despite the small sample size, accurate models were developed for predicting TLC, RV and FRC.CONCLUSION:DCR is a promising new technology that can be used to estimate lung volume subdivisions. Plausible correlations between plethysmographic lung volumes and DCR lung areas were identified. Further studies are needed to build on this exploratory work in both pwCF and individuals without CF.TRIAL REGISTRATION NUMBER:ISRCTN64994816.

BackgroundThoraco Abdominal Aortic Aneurysm (TAAA) is rare, occurring in approximately 6-10 per every 100,000 people.But surgical correction of this pathology possesses serious complications like paraplegia and spinal cord problems.The overall 30-day mortality and paraplegia results are 8.5% and 4.2% respectively. MethodsBetween Jan 2019 & Sept 2021 we have performed about 12 Thoraco Abdominal Aortic Aneurysm cases and our perfusion techniques for this type of surgery provides good clinical practice and prevents the neuro, spinal cord, gut and renal related complications.All the 12 cases are retrospectively analysed in detail for perfusion techniques, neurological outcome, renal function and the post-operative outcome.Operative technique CPB established with cannulation on PA, RA and Descending Aorta or Femoral venous and Descending Aorta.The surgery was performed at 26 °C and Systemic Potassium was administered into the venous reservoir to arrest the heart.Retrograde cerebral perfusion was performed through the Long Femoral venous cannula.Once the Proximal anastomosis is done under RCP, the upper body flow is established by the sidearm of the anteflo graft.The abdominal vessels are perfused by Silicon catheter.The abdominal vessels and renal arteries are anastomosed one after another to the arms of coselli graft.We perfused the renal arteries with renoplegia every 10 min in each renal artery.Once the descending aorta is anastomosed the clamp is removed and rewarmed to 36 °C.Hemostasis secured and came off CPB uneventfully. ResultsThere was no incidence of any neurological deficit in the post-operative period for all the 12 Patients.Two patients required tracheostomy in the post-operative phase.The Sr. Creatinine was in the desirable range and there was no gut ischemia in the post-operative period. ConclusionOur strategic planning of perfusion techniques for the Thoraco Abdominal Aortic Aneurysm cases resulted in yielding favorable outcome.

Background: The aim of this study is to investigate outcomes of pre-operative stent dwell time on infectious complications following ureteroscopy and stone treatment to identify a time cut-off. Material and Methods: Three tertiary referral centres in Europe retrospectively collected outcomes of ureteroscopy and laser fragmentation (URSL) for all patients with pre-operative indwelling ureteric stents over a period of up to 5 years. Data was collected on patient details, stone demographics, stent dwell time, complications and stone free rate (SFR). Matching for age, sex, operative time, stone size and post-operative stent insertion. To examine for a threshold effect, monthly cut-offs were used to compare post-ureteroscopic febrile UTIs. Binomial logistic regression was used (SPSS v.24) with a significance level set at 0.0036. The risk ratio (RR) with a 95% confidence interval (CI) and the number needed to harm (NNH) are reported. Results: There were 467 patients with a pre-operative stent for analysis. These patients (n = 315) were matched to non-stented controls after excluding 152 patients to achieve adequate matching. There was a significant difference in rates of post-ureteroscopic febrile UTI between stented vs non-stented patients (RR = 2.67, 95% CI: 1.10–6.48, p = 0.03). On adjustment, a dwell time of more than two months was associated with an increased risk of post-ureteroscopic febrile UTI (RR = 3.94, 95% CI: 1.30–12.01, p = 0.02), this increased risk rose with longer dwell time. At stent time longer than four months was associated with a significantly increased risk of post-ureteroscopic febrile UTI (5% vs. 15%, RR = 3.09, 95% CI: 1.56–6.10, p = 0.001), with the number needed to harm at 10. Conclusions: Overall infectious complication rates from URSL are low. The risk of post-operative UTI after four months of dwell time is nearly tripled compared to less than four months.

OBJECTIVES:Pre-emptive strategies to manage the aortic complications of Marfan syndrome have resulted in improved life expectancy yet, secondary to the variation of phenotypic expression, anticipating the risk and nature of future aortic events is challenging. We examine rates of new aortic events and reinterventions in a Marfan cohort following initial aortic presentation.METHODS:Retrospective cohort study of Marfan patients with aortic pathology presenting to our institution 1998-2018. Patients were grouped according to index event: aortic dissection or root aneurysm. Patients with aortic dissection were classified according to Debakey criteria. Incidence of new aortic events and frequency of reintervention were analysed.RESULTS:One hundred and twenty-six aortic procedures were performed in 74 Marfan patients with a median follow-up of 7 years. Forty-seven patients had an index event of root aneurysm and 27 had aortic dissection. Following operative intervention in the aneurysm group, 7 patients developed Debakey III dissections raising the overall number of patients who developed dissection within this cohort to 34. Reinterventions were more frequent in the dissection group with full replacement of the native aorta in 5 patients.CONCLUSIONS:After operative intervention on the proximal aorta, a proportion will develop distal pathology. A greater focus on factors contributing to future events, such as mapping genotypes to clinical course, may lead the way for targeted operative techniques and surveillance.

Prostate cancer is a common and increasing malignancy in men. Tissue is generally obtained using prostate biopsy for diagnosis and risk stratification. There are many prostate biopsy techniques. Historically, the transrectal approach has been the most adopted. In many centers, however, there has a been a shift towards transperineal prostate biopsies, increasingly performed under local anesthetic. The transperineal approach has proven advantages, including better sampling of the anterior area of the prostate and lower infection rates. Biopsies are typically performed using a combination of a systematic and targeted approach. Targeting of lesions identified by magnetic resonance imaging can be performed cognitively, assisted by a fused imaging approach with the transrectal ultrasound, or directly within the magnetic resonance imaging scanner. There are several novel developments in the field, which include robotic techniques to guide biopsy needles based on fusion images or directly targeting lesions robotically during in-bore magnetic resonance imaging.

Background: The CFTR modulator elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA) leads to significant improvement in the symptoms and spirometry of people with cystic fibrosis (pwCF), but little evidence exists to understand its effect on respiratory pump function. Dynamic chest radiography (DCR) is a novel cineradiographic tool that identifies and tracks the chest wall and diaphragm throughout the breathing cycle, alongside fluoroscopic images of the chest of diagnostic quality. Methods: In this observational work, we examined the spirometry and DCR of 24 pwCF before and after starting ELX/TEZ/IVA. DCR automatically tracked the hemidiaphragm midpoints and projected lung area (PLA) during tidal and deep breathing manoeuvres. Results: ppFEV 1 (61 +/- 18 to 73 +/- 22, P<0.001) and ppFVC (77 +/- 16 to 88 +/- 15, P< 0.001) improved significantly. DCR demonstrated a significant increase in hemidiaphragm excursion on both the right (18 +/- 11 to 26 +/- 9 mm, P<0.001) and left (21 +/- 11 to 31 +/- 11 mm, P<0.001) sides, as well as maximum hemidiaphragm speed during inspiration (right 22 +/- 14 to 31 +/- 11 mm/s, P=0.03; left 28 +/- 11 to 37 +/- 16 mm/s, P=0.02). PLA at end-expiration was significantly reduced (334 +/- 71 to 290 +/- 72cm(2), P<0.001), with a significant increase in Delta PLA (83 +/- 40 to 117 +/- 36cm2, P<0.001). Conclusions: DCR demonstrated significant improvements in hemidiaphragm excursion and Delta PLA in pwCF started on ELX/TEZ/IVA. These changes likely reflect a reduction in air trapping and improved elastic recoil of the chest, and are consistent with improvements seen in spirometry. The changes seen with DCR are physiologically plausible and correlate well with spirometry. DCR warrants further investigation as a tool for assessing the impact of CFTR-modulating therapies. (c) 2022 The Authors. Published by Elsevier B.V. on behalf of European Cystic Fibrosis Society. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

To investigate the burden of infectious complications following ureteroscopy (URS) for ureteric stones on a national level in England using data from the Hospital Episodes Statistics (HES) data warehouse.

BACKGROUND:The frozen elephant trunk (FET) technique for total arch replacement (TAR) is widely used for repair of aortic arch dissections and aneurysms. Despite its widespread adoption, there are no international or regional guidelines for the sizing of FET prostheses in TAR. We seek to highlight the heterogeneity thereof and pave the way for evidence-based guidelines to advise FET prosthesis sizing in TAR.METHODS:An online questionnaire was sent to 22 specialist aortic surgeons from 13 different countries across North America, Europe, Asia, and Australia, inquiring about each surgeon's approach to FET prosthesis sizing. The results were then pooled for frequency analysis.RESULTS:All 22 surgeons responded to the questionnaire. Zone 2 is preferred implantation zone for AAD, CAD, and TAA (selected by 72.7%, 72.7%, and 68.2% respectively). The maximal diameter of the true lumen in the DTA is the most common index measurement for AAD and CAD (40.9% and 59.1%, respectively). Stent-graft diameters equal to the index measurement is the most common approach for AAD and CAD (77.3% and 45.5%, respectively) while 59.1% of surgeons oversize the index diameter by 10% for TAA; 100 mm is the preferred length for 50.0%, 27.3%, and 40.9% of surgeons in AAD, CAD, and TAA respectively.CONCLUSIONS:There is considerable heterogeneity in sizing practices for FET prostheses internationally, with variable evidence for its impact on clinical outcomes. This issue would be aided by the development of evidence-based guidelines to inform clinical decision making.

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.With recent improvements in clinical practice, outcomes in acute type A aortic dissection (ATAAD) have improved significantly over the last 2 decades, with mortality rates falling significantly.1Hsu M.E. Chou A.H. Cheng Y.T. Lee H.A. Liu K.S. Chen D.Y. et al.Outcomes of acute aortic dissection surgery in octogenarians.J Am Heart Assoc. 2020; 9: e017147https://doi.org/10.1161/JAHA.120.017147Crossref PubMed Scopus (11) Google Scholar Several studies emerged trying to focus on outcomes in the elderly cohort, in particular, octogenarians; however, most of these studies are of small size cohorts with a probability of selection bias.2Kondoh H. Satoh H. Daimon T. Tauchi Y. Yamamoto J. Abe K. et al.Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians.J Thorac Cardiovasc Surg. 2016; 152: 439-446Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar,3Kawahito K. Kimura N. Yamaguchi A. Aizawa K. Misawa Y. Adachi H. Early and late surgical outcomes of acute type A aortic dissection in octogenarians.Ann Thorac Surg. 2018; 105: 137-143Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The recent study by Bojko and colleagues4Bojko M.M. Suhail M. Bavaria J.E. Bueker A. Hu R.W. Harmon J. et al.Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.J Thorac Cardiovasc Surg. 2022; 163: 2-12.e7https://doi.org/10.1016/j.jtcvs.2020.03.157Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar reports on outcomes in 70 octogenarians who underwent surgery for ATAAD over the course of 15 years compared with 165 septuagenarians. The octogenarians underwent a more conservative approach of only 1 total arch replacement (1.4%) compared with 14 patients (8.4%) in the septuagenarians. Although the 30-day mortality rate was greater in octogenarians (28.6% vs 21.2%) this was not statistically significant P = .29).While the authors should be commended on these reported outcomes, careful consideration should be given in selecting patients for surgical intervention among the octogenarian cohorts to achieve satisfactory postoperative outcomes. Furthermore, Bojko and colleagues4Bojko M.M. Suhail M. Bavaria J.E. Bueker A. Hu R.W. Harmon J. et al.Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.J Thorac Cardiovasc Surg. 2022; 163: 2-12.e7https://doi.org/10.1016/j.jtcvs.2020.03.157Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar did not report on the number of patients who were turned down for surgery, which forms a key element in comparing outcomes between both cohorts. Clearly, those who were operated on are those who were deemed fit for surgery and as such, included in the analysis. In our experience, over the course of 13 years, we have reported a 33.3% versus 15.8% mortality rate in octogenarians and septuagenarians who underwent nonelective complex aortic surgeries, respectively.5Harky A. Bailey G. Othman A. Shaw M. Field M. The life in their years versus the years in their life.J Thorac Cardiovasc Surg. 2021; 161: e361-e362https://doi.org/10.1016/j.jtcvs.2020.11.113Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Specifically, between 2018 and 2022, we operated on 115 patients with ATAAD, of whom only 3 patients were octogenarians (Figure 1). In this period, we turned down 23 patients with ATAAD (15 patients >80 years old), as they were deemed not fit for surgery due to either significant medical comorbidities that could halt a satisfactory postoperative recovery or debilitating presentation such as extensive neurologic symptoms (Figure 1).Figure 1Summary of turned-down cases and their causes.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The authors rightfully measured the quality of life of this cohort, yet only 11% of the octogenarians were followed up, which questions the mid-term impact in operating on such an elderly cohort. Furthermore, could a more conservative approach be a relevant contributing factor for this equal improvement in quality of life among septuagenarians and octogenarians, this remains to be clarified.Frailty assessment, medical comorbidities, age, cognitive impairment, and careful patient selection should be given serious consideration before operating on patients who are 80 years old or older. Large aortic centers may consider publishing outcomes for those with ATAAD that are not offered surgery to provide a deeper understanding of outcomes and when deciding not to operate. The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. With recent improvements in clinical practice, outcomes in acute type A aortic dissection (ATAAD) have improved significantly over the last 2 decades, with mortality rates falling significantly.1Hsu M.E. Chou A.H. Cheng Y.T. Lee H.A. Liu K.S. Chen D.Y. et al.Outcomes of acute aortic dissection surgery in octogenarians.J Am Heart Assoc. 2020; 9: e017147https://doi.org/10.1161/JAHA.120.017147Crossref PubMed Scopus (11) Google Scholar Several studies emerged trying to focus on outcomes in the elderly cohort, in particular, octogenarians; however, most of these studies are of small size cohorts with a probability of selection bias.2Kondoh H. Satoh H. Daimon T. Tauchi Y. Yamamoto J. Abe K. et al.Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians.J Thorac Cardiovasc Surg. 2016; 152: 439-446Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar,3Kawahito K. Kimura N. Yamaguchi A. Aizawa K. Misawa Y. Adachi H. Early and late surgical outcomes of acute type A aortic dissection in octogenarians.Ann Thorac Surg. 2018; 105: 137-143Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The recent study by Bojko and colleagues4Bojko M.M. Suhail M. Bavaria J.E. Bueker A. Hu R.W. Harmon J. et al.Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.J Thorac Cardiovasc Surg. 2022; 163: 2-12.e7https://doi.org/10.1016/j.jtcvs.2020.03.157Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar reports on outcomes in 70 octogenarians who underwent surgery for ATAAD over the course of 15 years compared with 165 septuagenarians. The octogenarians underwent a more conservative approach of only 1 total arch replacement (1.4%) compared with 14 patients (8.4%) in the septuagenarians. Although the 30-day mortality rate was greater in octogenarians (28.6% vs 21.2%) this was not statistically significant P = .29). While the authors should be commended on these reported outcomes, careful consideration should be given in selecting patients for surgical intervention among the octogenarian cohorts to achieve satisfactory postoperative outcomes. Furthermore, Bojko and colleagues4Bojko M.M. Suhail M. Bavaria J.E. Bueker A. Hu R.W. Harmon J. et al.Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians.J Thorac Cardiovasc Surg. 2022; 163: 2-12.e7https://doi.org/10.1016/j.jtcvs.2020.03.157Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar did not report on the number of patients who were turned down for surgery, which forms a key element in comparing outcomes between both cohorts. Clearly, those who were operated on are those who were deemed fit for surgery and as such, included in the analysis. In our experience, over the course of 13 years, we have reported a 33.3% versus 15.8% mortality rate in octogenarians and septuagenarians who underwent nonelective complex aortic surgeries, respectively.5Harky A. Bailey G. Othman A. Shaw M. Field M. The life in their years versus the years in their life.J Thorac Cardiovasc Surg. 2021; 161: e361-e362https://doi.org/10.1016/j.jtcvs.2020.11.113Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Specifically, between 2018 and 2022, we operated on 115 patients with ATAAD, of whom only 3 patients were octogenarians (Figure 1). In this period, we turned down 23 patients with ATAAD (15 patients >80 years old), as they were deemed not fit for surgery due to either significant medical comorbidities that could halt a satisfactory postoperative recovery or debilitating presentation such as extensive neurologic symptoms (Figure 1). The authors rightfully measured the quality of life of this cohort, yet only 11% of the octogenarians were followed up, which questions the mid-term impact in operating on such an elderly cohort. Furthermore, could a more conservative approach be a relevant contributing factor for this equal improvement in quality of life among septuagenarians and octogenarians, this remains to be clarified. Frailty assessment, medical comorbidities, age, cognitive impairment, and careful patient selection should be given serious consideration before operating on patients who are 80 years old or older. Large aortic centers may consider publishing outcomes for those with ATAAD that are not offered surgery to provide a deeper understanding of outcomes and when deciding not to operate. Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenariansThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1PreviewThe incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients. Full-Text PDF