ObjectiveSurgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.MethodsAll patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50–59, 60–69, 70–79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.ResultsThe number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60–69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.ConclusionSurgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.
Background There is little known about how payer status impacts clinical outcomes in a universal single-payer system such as the UK National Health Service (NHS). The aim of this study was to evaluate the relationship between payer status (private or public) and clinical outcomes following cardiac surgery from NHS providers in England. Methods The National Adult Cardiac Surgery Audit (NACSA) registry was interrogated for patients who underwent adult cardiac surgery in England from 2009 to 2018. Information on socioeconomic status were provided by linkage with the Iteration of the English Indices of Deprivation (IoD). The primary outcome was in-hospital mortality. Secondary outcomes included incidence of in-hospital postoperative cerebrovascular accident (CVA), renal dialysis, sternal wound infection, and re-exploration. To assess whether payer status was an independent predictor of in-hospital mortality, binomial generalized linear mixed models (GLMM) were fitted along with 17 items forming the EuroSCORE and the IoD domains. Findings The final sample consisted of 280,209 patients who underwent surgery in 31 NHS hospitals in England from 2009 to 2018. Of them, 5,967 (2.1%) and 274,242 (97.9%) were private and NHS payers respectively. Private payer status was associated with a lower risk of in-hospital mortality (OR 0.79; 95%CI 0.65 – 0.97; P = 0.026), CVA (OR 0.77; 95%CI 0.60 – 0.99; P = 0.039), need for re-exploration (OR 0.84; 95%CI 0.72 – 0.97; P = 0.017) and with non-significant lower risk of dialysis (OR 0.84; 95%CI 0.69 – 1.02; P = 0.074). Private payer status was found to be independently associated with lower risk of in-hospital mortality in the elective subgroup (OR 0.76; 95%CI 0.61 – 0.96; P = 0.020) but not in the non-elective subgroup (OR 1.01; 95%CI 0.64 – 1.58; P = 0.976). Interpretation In conclusion, using a national database, we have found evidence of significant beneficial effect of payer status on hospital outcomes following cardiac surgery in favour of private payers regardless their socioeconomic factors.
Objectives We have developed a deep learning model that provides predictions of the COVID-19 related number of cases and mortality in the upcoming 5 weeks and simulates the effect of policy changes targeting COVID-19 spread. Methods We developed a Deep Recurrent Reinforced Learning (DRRL) based model. The data used to train the DRRL model was based on various available datasets that have the potential to influence the trend in the number of COVID-19 cases and mortality. Analyses were performed based on the simulation of policy changes targeting COVID-19 spread, and the geographical representation of these effects. Results Model predictions of the number of cases and mortality of COVID-19 in the upcoming 5 weeks closely matched the actual values. Local lockdown with social distancing (LD_SD) was found to be ineffective compared to national lockdown. The ranking of effectiveness of supplementary measures for LD_SD were found to be consistent across national hotspots and local areas. Measure effectiveness were ranked from most effective to least effective: 1) full lockdown; 2) LD_SD with international travel -50%; 3) LD_SD with 100% quarantine; 4) LD_SD with closing school -50%; 5) LD_SD with closing pubs -50%. There were negligible differences observed between LD_SD, LD_SD with -50% food & Accommodation and LD_SD with -50% Retail. Conclusions The second national lockdown should be followed by measures which are more effective than LD_SD alone. Our model suggests the importance of restrictions on international travel and travel quarantines, thus suggesting that follow-up policies should consist of the combination of LD_SD and a reduction in the number of open airports within close proximity of the hotspot regions. Stricter measures should be placed in terms travel quarantine to increase the impact of this measure. It is also recommended that restrictions should be placed on the number of schools and pubs open.
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