The impact of surgeon and hospital procedural volume on outcomes after aortic root replacement in the United States.

OBJECTIVE: Surgeon procedural volume for complex cardiac procedures have become important quality metrics. The objective is to determine the association of surgeon and hospital case volume on patient outcomes after an aortic root replacement for aortic root aneurysms. METHODS: From 2009 to 2014, 4629 Medicare patients underwent an aortic root replacement for a root aneurysm. Procedures were performed by 1276 surgeons at 718 hospitals. Patients with endocarditis, aortic rupture, or Type-A dissection were excluded. Procedural volume was defined as mean number of cases performed each year during the study period. The impact of hospital and surgeon volume on adjusted 30-day mortality was analyzed as a continuous variable using adjusted logistic regression with cubic splines. RESULTS: After an aortic root replacement, we observed a nonlinear reduction in the adjusted odds ratio for 30-day mortality as surgeon and hospital volume increased. Surgeons that performed approximately five cases/year and hospitals that completed approximately five cases/year had the greatest reduction in the odds of perioperative death. Patients treated at high-volume hospitals (≥4.5 cases/year) had a lower risk for 30-day postoperative stroke (hazard ratio [HR] = 0.51, p = .008), myocardial infarction (HR = 0.49, p = .016), hemodialysis (HR = 0.44, p = .005), and reoperation (HR = 0.48, p = .003). Additionally, patients treated with high-volume surgeons (≥9 cases/year) had lower risk for stroke (HR = 0.65, p = .005), hemodialysis (HR = 0.65, p = .03), sepsis (HR = 0.62, p = .03), and reoperation (HR = 0.67, p = .004). CONCLUSION: Among Medicare patients undergoing an aortic root replacement, there is a strong inverse relationship between annualized surgeon and hospital case volume and postoperative outcomes. Procedural volume is an important quality metric for this high-risk procedure.

Risk of Stroke and Major Bleeding With Vitamin K Antagonist Use After Mitral Valve Repair.

BACKGROUND: Guidelines are discordant on the use of a vitamin K antagonist (VKA) after mitral valve repair (MVr) to reduce the risk of cerebral embolic events. We performed an observational study among patients who underwent a MVr, without perioperative atrial fibrillation, to determine the risk of cerebral ischemic and major bleeding events with or without VKA. METHODS: From 2004 to 2016, we included patients who underwent MVr, using a national administrative claims database. Those with preoperative atrial fibrillation and anticoagulant use were excluded. Patients were stratified based on the presence of a VKA. Inverse probability weighting with a Cox proportional hazard model was used. RESULTS: After MVr, 754 patients were discharged on VKA and 1462 on no-VKA. We found no difference in the cumulative incidence for embolic stroke at 180 days (VKA: 2.21% vs no-VKA: 1.50%; hazard ratio, 1.35; P = .38). However, VKA patients had a significantly increased risk for any-cause major bleeding events at 180 days (VKA: 8.58% vs no-VKA: 4.21%; hazard ratio, 2.09; P < .001). VKA patients also had increased need for a pericardiocentesis/pericardial window at 30 days after discharge (VKA: 1.13% vs no-VKA: 0.37%; hazard ratio, 3.88; P = .025). CONCLUSIONS: Our study suggests that VKA after MVr does not reduce the risk of cerebral embolic events but is associated with an increased risk of major bleeding events.

National Adherence to Medical Management of Aortic Aneurysms.

OBJECTIVES: The purpose of this study was to describe levels of adherence to guideline-based medical management in patients with aortic aneurysms, using an analogous population with coronary artery disease as a comparator. Adherence among those with aortic aneurysms has never been studied. METHODS: Adult patients with an aortic aneurysm or coronary artery disease diagnosed between 2004 and 2018 in the Optum Clinformatics deidentified Datamart were queried. Aneurysms were subclassified as thoracic, abdominal, or both. Receipt of an antihypertensive or antihyperlipidemic was determined through pharmacy claims. Adherence was determined as receipt of the indicated pharmacologic(s) after a diagnosis of aneurysm or coronary artery disease. Adherence was compared between those with aneurysms and coronary disease using univariable logistic regression. RESULTS: After exclusions, 194,144 patients with an aortic aneurysm and 3,946,782 with coronary artery disease were identified. Overall adherence was low (45.0%) and differed significantly by aneurysm subtype: highest in isolated thoracic (45.9%) and lowest in isolated abdominal aneurysms (42.6%). Adherence levels declined significantly after 1 year by about 15% in each aneurysm subtype. All subtypes of aneurysm had a significantly lower odds of adherence compared to those with coronary disease with odds ranging from 0.61 in those with isolated abdominal aneurysms to 0.80 with isolated thoracic aneurysms. CONCLUSIONS: Adherence among those with aortic aneurysms is very low, differs by subtype, and declines with time. Levels of adherence in those with aortic aneurysms is significantly lower compared to those with coronary artery disease. This should prove a reasonable target for implementation initiatives.

Patients with Atrial Fibrillation Benefit from SAVR with Surgical Ablation Compared to TAVR Alone.

INTRODUCTION: In patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone. METHODS: Medicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan-Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1. RESULTS: Of 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in all-cause mortality (HR 0.65, 95% CI 0.53-0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44-0.87), bleeding (HR 0.63, 95% CI 0.39-1.00), and rehospitalization for heart failure (HR 0.49 (0.36-0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74-1.54), transient ischemic attack (HR 1.05, 95% CI 0.75-1.47), or rehospitalization for atrial arrhythmia. CONCLUSION: Select patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.

Development of Persistent Opioid Use After Cardiac Surgery.

Importance: The overuse of opioids for acute pain management has led to an epidemic of persistent opioid use. Objective: To determine the proportion of opioid-naive patients who develop persistent opioid use after cardiac surgery and investigate the association between the initial amount of opioids prescribed at discharge and the likelihood of developing new persistent opioid use. Design, Setting, and Participants: This retrospective cohort study used data from a national administrative claims database from January 1, 2004, to December 31, 2016 and included 35 817 patients who underwent coronary artery bypass grafting (CABG) (25 673 [71.7%]) and heart valve (10 144 [28.3%]) procedures. All patients were opioid-naive within 180 days before the index procedure and filled an opioid prescription within 14 days after surgery. Exposures: Opioid medications after cardiac surgery. Main Outcomes and Measures: The proportion of opioid-naive patients who developed new persistent opioid use within 90 to 180 days after surgery was determined. Oral morphine equivalents (OMEs) were calculated for the first opioid prescription filled after discharge. A multivariable logistic regression with cubic splines was used to analyze the association among the OMEs at discharge and likelihood of developing persistent opioid use. Results: Of the 25 673 patients who underwent CABG, the mean (SD) age for those without (n = 23 064) vs with (n = 2609) persistent opioid use was 62.9 (9.8) years vs 61.6 (9.7) years, respectively, and the number who were men were 18 758 (81.3%) vs 1998 (76.6%). Of the 10 144 patients who underwent heart valve surgery, the mean (SD) age for those without (n = 9343) vs with (n = 821) persistent opioid use was 63.2 (12.4) years vs 61.2 (12.5) years, respectively, and the number who were men were 6378 (68.3%) vs 511 (62.2%). Persistent opioid use is a substantial concern after cardiac surgery and occurred in 2609 patients undergoing CABG (10.2%) and 821 valve surgery patients (8.1%; P = .001). The likelihood for developing persistent opioid use was decreased among heart valve surgery recipients (odds ratio [OR], 0.78; P < .001) and increased for patients who were women; younger; with preoperative congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and alcoholism; and those taking preoperative benzodiazepines and muscle relaxants (women: OR, 1.15 [95% CI, 1.03-1.26]; younger age: OR, 1.02 [95% CI, 1.01-1.02]; congestive heart failure: OR, 1.17 [95% CI, 1.06-1.30]; chronic lung disease: OR, 1.32 [95% CI, 1.19-1.45]; diabetes: OR, 1.27 [95% CI, 1.15-1.40]; kidney failure: OR, 1.17 [95% CI, 1.00-1.37]; chronic pain: OR, 2.71 [95% CI, 2.10-3.56]; alcoholism: OR, 1.56 [95% CI, 1.23-2.00]; benzodiazepines: OR, 1.71 [95% CI, 1.52-1.91]; muscle relaxants: OR, 1.74 [95% CI, 1.51-2.02]; all P < .001). Furthermore, we found that when patients were prescribed more than approximately 300 mg of OMEs at discharge, they had a significantly increased risk of new persistent opioid use than with lower opioid prescriptions. Conclusions and Relevance: Opioids are used extensively after cardiothoracic surgery and nearly 1 of 10 patients will continue to use opioids over 90 days after surgery. Furthermore, higher OMEs prescribed at discharge were significantly associated with developing persistent use. Centers must adopt protocols to increase patient education and limit opioid prescriptions after discharge.

Effects of Frailty on Outcomes and 30-day Readmissions After Surgical Mitral Valve Replacement.

BACKGROUND: Frailty is increasingly recognized as an important prognostic marker in surgical populations. The effects of frailty on outcomes after mitral valve replacement (MVR) is less clear given the inherent complexity of this patient population. We evaluated the influences of frailty on outcomes and readmission rates after MVR. METHODS: Adult patients undergoing isolated MVR were queried from the National Readmissions Database from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, a validated instrument developed for use in health administrative data. Multivariable logistic regression was used to determine hospital- and patient-level risk factors for readmission, postoperative complications, and death. RESULTS: Among 50,410 patients who underwent MVR, 7.9% met frailty criteria. Frail patients were more likely to be older, have nonprivate insurance, an index admission from the emergency department, and teaching hospital care (all P < .001). Frail patients had significantly more postoperative complications (77% vs 47%, P < .001), more discharges to a facility (50% vs 21%, P < .001), and higher in-hospital mortality (12% vs 4%, P < .001). Index hospitalization costs were almost doubled in frail patients, and of those who survived to discharge, 30-day readmissions were more frequent (28% vs 20%, P < .001). Frailty independently increased the risk of index hospitalization composite complications (adjusted odds ratio [AOR], 3.28; 95% confidence interval [CI], 2.61-4.12), in-hospital mortality (AOR, 2.35; 95% CI, 1.90-2.92), and 30-day readmission (AOR, 1.47; 95% CI, 1.20-1.78). CONCLUSIONS: Frailty is an independent predictor of morbidity, death, and increased costs after MVR. Frailty metrics should be increasingly understood among patients requiring mitral valve intervention as percutaneous approaches for intervention become increasingly used.

Thoracic Endovascular Aneurysm Repair Trends and Outcomes in Over 27,000 Medicare Patients for Descending Thoracic Aneurysms.

BACKGROUND: Since United States Food and Drug Administration approval in 2005, thoracic endovascular aneurysm repair (TEVAR) has replaced open surgery to become the preferred treatment for descending thoracic aneurysms (DTAs). This study investigated TEVAR trends during the previous 15 years regarding patient and hospital characteristics and their effect on survival. METHODS: Between 2000 and 2014, 27,079 Medicare patients underwent TEVAR for DTA. We analyzed TEVAR trends during this period and stratified hospitals based on the number of cases completed during the previous 5 years: low (0-19 cases), medium (20-99 cases), and high (≥100 cases) volume. Trends over time were calculated using Poisson regression to determine the average annual percentage changes (aAPC). Survival was calculated using a multivariate Cox regression and adjusted logistic regression with a restricted cubic spline. RESULTS: TEVAR volume significantly increased from 81 cases in 2000 to 3478 cases in 2014 (aAPC, 16.2%; P < .001). During the study period, the proportion of cases performed at medium-volume centers increased (aAPC, 5.2%; P < .001). Thirty-day mortality after TEVAR increased in the recent period (2013-2014) to 8.8% as compared with 6.6% in the early years (2004-2006) of TEVAR (P < .001), and a significant contribution was due to increased patient comorbidity score (aAPC, 1.6%; P < .001). Lastly, TEVAR center volume was significantly associated with 30-day survival when fewer than 33 cases were done in the prior 5 years. CONCLUSIONS: From 2000 to 2014, TEVAR volume accelerated, and centers are gaining more experience. TEVAR patients have become more acute, and mortality has increased over this period. Patient selection and procedural experience are critical to improving outcomes.

Predictors of 30-day readmission and resource utilization after thoracic endovascular aortic repair.

OBJECTIVES: The introduction and expansion of thoracic endovascular aortic repair (TEVAR) have revolutionized the treatment of a variety of thoracic aortic diseases. We sought to evaluate the incidence, causes, predictors and costs associated with 30-day readmission after TEVAR in a nationally representative cohort. METHODS: Adult patients undergoing isolated TEVAR were identified in the National Readmissions Database from 2010 to 2014. Hospital costs were estimated by converting individual hospital charge data adjusted to 2014 consumer price indices. Multivariable logistic regression was utilized to determine hospital- and patient-level factors associated with readmissions. RESULTS: A total of 24 983 TEVARs were noted during the study period; the average age of the patients was 65 ± 16 years; 40% were women. The most common indication was an intact thoracic aneurysm (43.5%), followed by aortic dissection (30.5%). The average cost of the index admission was $63 644 ± $52 312; the average hospital stay was 11 ± 14 days; the index mortality rate was 6.7%. Readmissions within 30 days occurred in 17.4% of patients. Indications for readmission were varied; the most common aetiologies were cardiac (17.8%), infectious (16.0%) and pulmonary (12.1%). On multivariable analysis, the strongest predictor of readmission was the diagnosis, with a ruptured thoraco-abdominal aneurysm having the highest readmission burden (adjusted odds ratio 2.23, 1.17-4.24; P = 0.015). Notably, hospital volume did not predict index hospital length of stay, costs or 30-day readmissions (all P > 0.10). CONCLUSIONS: Annual TEVAR volume was not associated with any of the outcomes assessed. Rather, indication for TEVAR was the strongest predictor for many outcomes. As TEVAR becomes increasingly utilized, a focus on cardiac and vascular diseases may reduce readmissions and improve quality of care.

Outcomes after thoracic endovascular aortic repair in patients with chronic kidney disease in the Medicare population.

OBJECTIVE: Thoracic endovascular aortic repair has been increasingly performed in higher-risk patients with renal failure. The objective was to compare Medicare patients with preoperative chronic kidney disease with patients with normal renal function to determine differences in postoperative survival and complications. METHODS: From 2000 to 2014, 27,079 Medicare fee-for service patients underwent thoracic endovascular aortic repair. Patients were stratified by kidney function, and 23,375 patients (86%) had no chronic kidney disease, 2957 patients (11%) had chronic kidney disease stage I/IV, and 747 patients (3%) had end-stage renal disease or hemodialysis. Groups were then compared with determined differences in adjusted all-cause mortality and rates of postoperative complications. RESULTS: Overall survival was significantly worse among patients with chronic kidney disease and end-stage renal disease or hemodialysis compared with patients with no chronic kidney disease (1-year survival no chronic kidney disease: 78%; chronic kidney disease I/II: 77%; chronic kidney disease III: 67%; chronic kidney disease IV: 58%; and end-stage renal disease or hemodialysis: 48%, P < .001). Mortality was significantly increased among patients with chronic kidney disease III (hazard ratio [HR], 1.29; P < .001), chronic kidney disease IV (HR, 1.74; P < .001), and end-stage renal disease or hemodialysis (HR, 2.03; P < .001). No mortality difference was found between patients with no chronic kidney disease and patients with chronic kidney disease stage I/II. At 30 days after thoracic endovascular aortic repair, sepsis was increased for patients with chronic kidney disease stage III/IV (HR, 1.7; P < .001) and end-stage renal disease or hemodialysis (HR, 2.7; P < .001). CONCLUSIONS: In this elderly Medicare population undergoing thoracic endovascular aortic repair, patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis had poor survival and increased morbidity compared with those with normal kidney function. These data may suggest that patients with chronic kidney disease stage III, chronic kidney disease stage IV, or end-stage renal disease/hemodialysis should be more cautiously evaluated for thoracic endovascular aortic repair, weighing the benefits of the procedure against the high expected mortality.

Type A Aortic Dissection in Patients With Bicuspid Aortic Valve Aortopathy.

BACKGROUND: The aim of this study was to evaluate clinical, aortic, and outcome characteristics of type A aortic dissection patients with bicuspid aortic valves (BAVs) and tricuspid aortic valves (TAVs). METHODS: Patient characteristics and radiographic, operative, and outcome data were evaluated and compared between 1068 TAV patients and 72 BAV patients operated on for type A aortic dissection in 2 centers. Predissection aortic diameters were calculated as previously reported for TAV patients. RESULTS: BAV patients were significantly younger (P < .001) and had a lower incidence of cardiovascular risk factors. Although the clinical presentation was similar, the dissection affected the abdominal aorta significantly more often in TAV patients (P = .029). Aortic root replacements were performed significantly more often in BAV patients (P < .001). Postoperative outcome was similar between the 2 groups. BAV patients had a significantly larger maximum postdissection diameter (P < .001) and calculated predissection diameter (P < .001) compared with TAV patients. Predissection ascending aortic diameters were less than 5.5 cm in 96% of all TAV patients and less than 5.0 cm in 76% of all BAV patients. CONCLUSIONS: Acute type A aortic dissection in BAV patients is not associated with worse clinical or long-term outcome but significantly influences the proximal aortic repair. After modeling predissection aortic diameters, less than 5% of all TAV patients and possibly less than 25% of all BAV patients would meet the elective threshold for preventative replacement of the ascending aorta.

Optimal timing for heart transplantation in patients bridged with left ventricular assist devices: Is timing of the essence?

OBJECTIVES: Due to the scarcity of donor hearts to meet recipient demands, more than 40% of heart transplants are performed in patients bridged to transplant (BTT) with a left ventricular assist device (LVAD). The objective of this study was to determine the effect of BTT duration with an LVAD on posttransplant outcomes. METHODS: From 2009 to 2014, we identified 2639 fee-for-service Medicare patients who underwent a primary heart transplants with 1186 (45%) patients BTT with an LVAD. The LVAD patients were stratified as BTT ≤31 days (n = 28 [2.4%]), BTT 31-365 days (n = 748 [63.1%]), and BTT >365 days (n = 409 [34.5%]). Patients went directly to heart transplantation and were not bridged in 1453 cases (55%). LVAD duration was analyzed dichotomously and as a continuous variable with adjusted overall survival as the primary end point. RESULTS: All-cause mortality was significantly worse in patients who were BTT <31 days. Survival at 30 days was 81.5% for BTT <31 days, 94% for BTT 31 to 365 days, 95% for BTT >365 days, and 94% for no BTT. At 1 year, survival was 74% for BTT <31 days, 85% for BTT 31 to 365 days, 88% for BTT >365 days, and 89% for no BTT (P = .018). When LVAD duration was analyzed as a continuous variable, patients BTT with an LVAD <34 days had significantly increased mortality. CONCLUSIONS: Patients who underwent heart transplantation within the first month of BTT with an LVAD had significantly increased mortality. However, there was no survival difference among patients who were BTT with an LVAD longer than 31 days.

Management of Patients With Coronary Artery Malperfusion Secondary to Type A Aortic Dissection.

BACKGROUND: This study reviewed our experience with coronary artery (CA) malperfusion secondary to type A aortic dissection. METHODS: Between 2002 and 2017, 76 patients presented with CA malperfusion, with a dissection flap limited to the aorta in the region of the coronary ostium (type A lesion) in 26 (34%), with a dissection flap involving the CA itself (type B lesion) in 32 (42%), or with complete avulsion of the CA (type C lesion) in 18 (24%). RESULTS: Ostial repair was successfully performed in 23 type A patients (88%), in 20 type B patients (63%), and in no type C patient (0%). CA bypass grafting was performed when antegrade cardioplegia could not be applied in all 18 type C patients (100%) and in 5 type B patients (16%) because of a primary entry at the coronary ostium and in 7 patients (type A: 3 patients [12%], type B: 4 patients [13%]) with evidence of CA disease (p < 0.001). Perioperative mortality in patients with CA malperfusion was high (18 patients [24%]), but there was no difference in short-term (p = 0.153) or long-term survival (log-rank p = 0.542). Also, a landmark analysis showed equal survival of discharged patients with and without CA malperfusion (log-rank p = 0.645). CONCLUSIONS: We recommend CA bypass grafting in patients with type C lesions or in patients with underlying CA disease for optimal delivery of cardioplegia and ostial pledgetted suture repair in patients with type A lesions or type B lesions when the administration of antegrade cardioplegia is successful.