History of Serious Mental Illness Is a Predictor of Morbidity and Mortality in Cardiac Surgery.

BACKGROUND: Serious mental illness (SMI), defined as a mental disorder causing functional impairment, affects 9.8 million Americans. SMI correlates with earlier onset, more extensive cardiac disease, and reduced life expectancy by 25 years. The impact of SMI on patients undergoing cardiac surgery has not been extensively studied. We hypothesized that patients with SMI have worse cardiac surgery outcomes. METHODS: Using our institution's Society of Thoracic Surgeons database of 16,781 cardiac operations (2002-2017), a total of 1445 (8.7%) patients with SMI were identified and stratified into anxiety, mood disorders, and psychosis. The risk-adjusted impact on morbidity and mortality were evaluated using multivariable regression. RESULTS: Patients with SMI were more often female patients, were younger, and had more comorbid disease. SMI patients were more likely to have had previous cardiac surgery and require urgent or emergent procedures (both P < .05). Among specific SMI diagnoses, patients with psychosis had worse outcomes compared with the general population, with higher operative mortality (9.1% vs 4.2%; P = .001), major morbidity (30.4% vs 15.8%; P < .0001), and cost ($50,211 vs $38,820; P < .001). After multivariable risk adjustment, SMI and psychosis remained independently associated with composite mortality and major morbidity (odds ratio, 1.21; P = .012; and odds ratio, 1.68; P = .003, respectively). CONCLUSIONS: SMI is independently associated with morbidity and mortality after cardiac surgery. SMI patients, especially the subset with psychosis, are complicated, high-risk, and resource-consuming. Refined strategies to reduce postoperative complications and improve care coordination are necessary in this population.

Early Versus Delayed Pacemaker for Heart Block After Valve Surgery: A Cost-Effectiveness Analysis.

BACKGROUND: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery. METHODS: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d. RESULTS: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function. CONCLUSIONS: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.

Effect of Cardiac Surgery on One-Year Patient-Reported Outcomes: A Prospective Cohort Study.

BACKGROUND: Current cardiac surgery risk algorithms and quality measures focus on perioperative outcomes. However, delivering high-value, patient-centered cardiac care will require a better understanding of long-term patient-reported quality of life after surgery. Our objective was to prospectively assess the effect of cardiac surgery on long-term patient-reported outcomes. METHODS: Patients undergoing cardiac surgery at an academic medical center (2016 to 2017) were eligible for enrollment. Patient-reported outcomes were measured using the National Institutes of Health Patient-Reported Outcomes Measurement Information System preoperatively and 1 year postoperatively across five domains: mental health, physical health, physical functioning, social satisfaction, and applied cognition. Baseline data and perioperative outcomes were obtained from The Society of Thoracic Surgeons Database. The effect of cardiac surgery on long-term patient-reported quality of life was assessed. RESULTS: Ninety-eight patients were enrolled and underwent cardiac surgery, with 92.9% (91 of 98) successful follow-up. The most common operation was coronary artery bypass graft surgery at 63.3% (62 of 98), with 60.2% (59 of 98) undergoing an elective operation. One-year all-cause mortality was 5.1% (5 of 98). Rate of major morbidity was 11.2% (11 of 98). Cardiac surgery significantly improved patient-reported outcomes at 1 year across four domains: mental health (preoperative 47.3 ± 7.7 vs postoperative 51.1 ± 8.9, P < .001), physical health (41.2 ± 8.2 vs 46.3 ± 9.3, P < .001), physical functioning (39.8 ± 8.6 vs 44.8 ± 8.5, P < .001), and social satisfaction (46.8 ± 10.9 vs 50.7 ± 10.8, P = .023). Hospital discharge to a facility did not affect 1-year patient-reported outcomes. CONCLUSIONS: Cardiac surgery improves long-term patient-reported quality of life. Mental, physical, and social well-being scores were significantly higher 1 year postoperatively. Data collection with the National Institutes of Health Patient-Reported Outcomes Measurement Information System provides meaningful, quantifiable results that may improve delivery of patient-centered care.

Cost-Effectiveness of Postoperative Drug Rehabilitation for Injection Drug Users.

BACKGROUND: With the opioid crisis showing no sign of abating, strategies are needed to facilitate postoperative care for endocarditis related to injection drug use (IDU). The current standard, 6 weeks of intravenous antibiotics, yields frequent reoperation and IDU relapse. We examined the cost-effectiveness of inpatient drug rehabilitation (DR) postoperatively to optimize outcomes and costs. METHODS: Two postoperative strategies were assessed: hospital-only care (HC) vs HC plus inpatient DR. Monte Carlo simulation evaluated effectiveness in quality-adjusted life-years (QALY) and cost per patient calculated over a 20-year time horizon in 100,000 iterations. Willingness to pay was set to $100,000/QALY. To determine probabilities of continued postoperative IDU, recurrent infection, and death, best available evidence was combined with institutional data from IDU patients. Baseline probability of postoperative IDU was set to 35% after DR vs 60% after HC, and the cost of inpatient rehabilitation to $30,000. RESULTS: Addition of inpatient DR to standard HC is the favorable strategy, with incremental per-patient cost of $36,920 and 0.93 QALYs gained over 20 years. Sensitivity analysis demonstrates DR is within our willingness-to-pay of $100,000/QALY if postoperative IDU is reduced by at least 7% (from 60% to 53%). CONCLUSIONS: Addition of postoperative inpatient DR for IDU-related endocarditis is cost-effective even if only a modest reduction in IDU is achieved. Collaboration between hospitals and payors to launch pilot programs that provide postoperative addiction treatment and intravenous antibiotics after cardiac operations could dramatically improve endocarditis care.

Nightly Preoperative Huddle Email Improves Perioperative Efficiency.

BACKGROUND: Our institution created a nightly "Huddle" email for all staff involved in patient care, detailing the next day's cases. This study evaluated the impact of the Huddle email on perioperative efficiency and identified factors associated with operating room delays. METHODS: A total of 1080 first start, open, nonemergent cardiac operations were stratified as Pre-Huddle (January 2013-June 2015) or Huddle (July 2015-January 2017). Scheduled start-to-in-room time (delay time), in-room-to-incision time, and total minutes utilized were analyzed. On-time starts were defined as a delay time of 0 minutes, and long delays were defined as delay time of more than 15 minutes. Long delays were compared with other cases based on preoperative factors. Multivariate regression identified independent predictors of delay time. RESULTS: The analysis included 643 Pre-Huddle and 437 Huddle cases. After Huddle implementation, delay time decreased by 2 minutes (9 minutes Pre-Huddle vs 7 minutes Huddle, P < .001). However, time to incision increased (70 minutes vs 73 minutes, P = .002), as did minutes utilized (373 minutes vs 394 minutes, P = .002) in the Huddle era. On-time entry increased 46% (5.0% to 9.2%, P = .007), and long delay decreased 26% (33.3% vs 24.3%, P = .002). Long delay was associated with urgent cases (58.2% vs 28.6%, P < .001), non-Society of Thoracic Surgeons Predicted Risk of Mortality cases (46.9% vs 34.1%, P < .001), and less surgeon experience (7 years vs 9 years, P < .001). Delay time was independently predicted by urgent status (+10.17 minutes), surgeon experience (-0.15 min/y), lung disease (+5.43 minutes), and non-Society of Thoracic Surgeons Predicted Risk of Mortality (+5.44 minutes) on multivariate regression. CONCLUSIONS: Implementation of the Huddle improved delay time, on-time entry, and long delay. Strategies focused on optimizing perioperative care are beneficial for multidisciplinary teams.

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

OBJECTIVE: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands. METHODS: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric. RESULTS: A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution's overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants. CONCLUSIONS: NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.

Examination of a Proposed 30-day Readmission Risk Score on Discharge Location and Cost.

BACKGROUND: Readmissions cost an estimated $41 billion in the United States each year. To address this, a single institution recently developed a new risk model predictive of 30-day readmission after adult cardiac surgery. The purpose of this study is to validate and refine this new readmission risk model using a statewide database. METHODS: A total of 19,964 patients were analyzed using a statewide Society of Thoracic Surgeons database (2014-2017). The aforementioned multivariate model was replicated (model 1): race, hospital length of stay, chronic lung disease, operation type, and renal failure. Model 2 also included discharge location. Thirty-day readmission risk scores and low-risk (0%-10%), moderate-risk (10%-13%), and high-risk (≥13%) categories were calculated. RESULTS: The overall 30-day readmission rate was 11.1% with both models 1 and 2 predicting readmission (odds ratio, 1.09; 95% confidence interval, 1.08-1.11 vs odds ratio, 1.10; 95% confidence interval, 1.08-1.11). Statistically significant differences were observed across all risk categories in discharge location and total cost. For models 1 and 2, 86% of low-risk patients were discharged to home vs 66.9% and 42.9% of patients in high-risk groups, respectively (P < .001). The largest increases were observed with a hospice discharge location for both model 1 (from $37,930 to $89,285) and model 2 (from $37,930 to $89,230). CONCLUSIONS: Both risk models significantly predicted 30-day readmission in our multiinstitutional dataset, confirming the score is valid and a generalizable quality improvement tool. The addition of discharge location and total cost adds valuable information of the ongoing efforts to identify patients at high risk for readmission.

Porcine Model of Infrarenal Abdominal Aortic Aneurysm.

Large animal models to study abdominal aortic aneurysms are sparse. The purpose of this model is to create reproducible, clinically significant infrarenal abdominal aortic aneurysms (AAA) in swine. To achieve this, we use a combination of balloon angioplasty, elastase and collagenase, and a lysyl oxidase inhibitor, called ß-aminopropionitrile (BAPN), to create clinically significant infrarenal aortic aneurysms, analogous to human disease. Noncastrated male swine are fed BAPN for 7 days prior to surgery to achieve a steady state in the blood. A midline laparotomy is performed and the infrarenal aorta is circumferentially dissected. An initial measurement is recorded prior to aneurysm induction with a combination of balloon angioplasty, elastase (500 units)/collagenase (8000 units) perfusion, and topical elastase application. Swine are fed BAPN daily until terminal procedure on either postoperative day 7, 14, or 28, at which time the aneurysm is measured, and tissue procured. BAPN + surgery pigs are compared to pigs that underwent surgery alone. Swine treated with BAPN and surgery had a mean aortic dilation of 89.9% ± 47.4% at day 7, 105.4% ± 58.1% at day 14, and 113.5% ± 30.2% at day 28. Pigs treated with surgery alone had significantly smaller aneurysms compared to BAPN + surgery animals at day 28 (p < 0.0003). The BAPN + surgery group had macroscopic and immunohistochemical evidence of end stage aneurysmal disease. Clinically significant infrarenal AAA can be induced using balloon angioplasty, elastase/collagenase perfusion and topical application, supplemented with oral BAPN. This model creates large, clinically significant AAA with hallmarks of human disease. This has important implications for the elucidation of AAA pathogenesis and testing of novel therapies and devices for the treatment of AAA. Limitations of the model include variation in BAPN ingested by swine, quality of elastase perfusion, and cost of BAPN.

Septal ablation acutely reduces outflow obstruction after transcatheter mitral valve replacement.

Transcatheter mitral valve replacement (TMVR) is an emerging treatment of mitral valve pathology in patients that are not candidates for conventional surgical approaches. Higher rates of left ventricular outflow tract obstruction (LVOTO) may occur following TMVR and its occurrence is an independent predictor of mortality. We present a case of severe mitral stenosis and annular calcification that was treated with a balloon-expandable Sapien S3 valve in the mitral position delivered through surgical port-access approach, which resulted in postoperative LVOTO. The LVOTO was successfully treated with alcohol septal ablation with immediate reduction in outflow tract gradients and long-term resolution.

Murine Surgical Model of Topical Elastase Induced Descending Thoracic Aortic Aneurysm.

According to the Center for Disease Control, aortic aneurysms (AAs) were considered a leading cause of death in all races and both sexes from 1999-2016. An aneurysm forms as a result of progressive weakening and eventual dilation of the aorta, which can rupture or tear once it reaches a critical diameter. Aneurysms of the descending aorta in the chest, called descending thoracic aortic aneurysms (dTAA), make up a large proportion of aneurysm cases in the United States. Uncontained dTAA rupture is almost universally lethal, and elective repair has a high rate of morbidity and mortality. The purpose of our model is to study dTAA specifically, to elucidate the pathophysiology of dTAA and to search for molecular targets to halt the growth or reduce the size of dTAA. By having a murine model to study thoracic pathology precisely, targeted therapies can be developed to specifically test dTAA. The method is based on the placement of porcine pancreatic elastase (PPE) directly on the outer murine aortic wall after surgical exposure. This creates a destructive and inflammatory reaction, which weakens the aortic wall and allows for aneurysm formation over weeks to months. Though murine models possess limitations, our dTAA model produces robust aneurysms of predictable size. Furthermore, this model can be used to test genetic and pharmaceutical targets which may arrest dTAA growth or prevent rupture. In human patients, interventions such as these could help avoid aneurysm rupture, and difficult surgical intervention.

Preoperative Statin Use Not Associated With Improved Outcomes After Ascending Aortic Repair.

Statins have potent pleiotropic effects that have been correlated with improved perioperative cardiovascular surgery outcomes. We hypothesize that statins may improve morbidity and mortality after ascending aortic surgery. Within a statewide database consisting of 19 centers a total of 1804 patients had ascending aortic repair with or without aortic valve replacement (2004-2016). Patients were stratified by preoperative statin therapy for analysis. To account for baseline differences, patients were propensity matched in a 1:1 fashion by baseline characteristics. Patient characteristics and outcomes were analyzed by paired analysis. Of 1804 patients undergoing ascending aortic repair, 35% took statins preoperatively. After matching, 386 patients in each group were well matched with no statistically significant baseline or operative differences. There was no statistically significant difference in outcomes between patients taking statins preoperatively and those not taking statins, including operative mortality (3.6% vs 3.1%, P = 0.68) and major morbidity (18.4% vs 17.1%, P = 0.62). Postoperative atrial fibrillation (27.2% vs 28.5%, P = 0.71) and acute kidney injury (3.1% vs 4.2%, P = 0.41) also showed no statistically significant difference. Statins have no apparent clinical impact on perioperative outcomes after ascending aortic aneurysm repair. Considering recent evidence suggesting statins may increase perioperative risk of acute kidney injury, there is insufficient evidence to recommend starting preoperative statin before ascending aortic repair.

Review of screening guidelines for non-AIDS-defining malignancies: evolving issues in the era of highly active antiretroviral therapy.

HIV-associated morbidity and mortality have declined dramatically in the era of HAART. Through direct and indirect benefits of HAART, people with HIV/AIDS are living longer, developing less AIDS-defining cancers and more cancers commonly seen in the seronegative population. Herein, we review cancer screening strategies for people living with HIV and compare and contrast them with those of the general population. The most noticeable differences occur in anal and cervical cancer screening. Although anal cancer is uncommon in the general population, it is more prevalent in men who have sex with men and people at high risk for human papillomavirus infection, especially those infected with HIV. To address this, we recommend that a digital rectal exam and a visual inspection be performed annually. In addition, an anal Pap test should be performed soon after the diagnosis of HIV infection, with follow-up testing every six months until two normal tests. Abnormal cytological results are then investigated with high-resolution anoscopy and biopsy of suspicious lesions. In screening for cervical cancer, a Pap test should be performed during the anogenital exam after initial HIV diagnosis, with a second Pap six months later, then annually if the results are normal. A colposcopy should follow an abnormal result. Human papillomavirus testing as a screening method for cervical cancer in women with HIV can also be efficacious. In lung cancer screening, preliminary data suggest that low-dose computerized tomography may play an important role, but further research is needed. Screening for breast and colon cancer should follow guidelines for the general population. Early screening for prostate cancer based on a diagnosis of HIV lacks clear benefit.