Identifying Variation in Intraoperative Management of Brain-Dead Organ Donors and Opportunities for Improvement: A Multicenter Perioperative Outcomes Group Analysis.

BACKGROUND: Intraoperative events and clinical management of deceased organ donors after brain death are poorly characterized and may consequently vary between hospitals and organ procurement organization (OPO) regions. In a multicenter cohort, we sought to estimate the incidence of hypotension and anesthetic and nonanesthetic medication use during organ recovery procedures. METHODS: We used data from electronic anesthetic records generated during organ recovery procedures from brain-dead adults across a Multicenter Perioperative Outcomes Group (MPOG) cohort of 14 US hospitals and 4 OPO regions (2014-2020). Hypotension, defined as mean arterial pressure or MAP <60 mm Hg for at least 10 cumulative minutes was the primary outcome of interest. The associations between hypotension and age, sex, race, anesthesia time, OPOs, and OPO case volume were examined using multivariable mixed-effects Poisson regression analyses with robust standard error estimates. We calculated intraclass correlation coefficients (ICCs) to describe the variation between-MPOG centers and the OPO regions in the use of medications, time of the operation, and duration of the operation. RESULTS: We examined 1338 brain-dead adult donors, with a mean age of 42± (standard deviation [SD] 15) years; 60% (n = 801) were males and 67% (n = 891) non-Hispanic White. During the entire intraoperative monitoring period, 321 donors (24%, 95% confidence interval [CI], 22%-26%) had hypotension for a median of 13.8% [quartile1-quartile 3: 9.4%-21%] of the monitoring period and a minimum of 10 minutes to a maximum of 96 minutes [(median: 17, quartile1-quartile 3: 12-24]). The probability having hypotension in donors 35 to 64 years and 65 years and older were approximately 30% less than in donors 18 to 34 years of age (adjusted relative risk ratios, aRR, 0.68, 95% CI, 0.55-0.82, aRR, 0.63, 95% CI, 0.42-0.94, respectively). Donors received intravenous heparin (96.4%, n = 1291), neuromuscular blockers (89.5%, n = 1198), vasoactive medications (82.7%, n = 1108), crystalloids (76.2%, n = 1020), halogenated anesthetic gases (63.5%, n = 850), diuretics (43.8%, n = 587), steroids (16.7%, n = 224), and opioids (23.2%, n = 310). The largest practice heterogeneity observed between the MPOG center and OPO regions was steroids (between-center ICCs = 0.65, 95% CI, 0.62-0.75, between-region ICCs = 0.39, 95% CI, 0.27-0.63) and diuretics (between-center ICCs = 0.44, 95% CI, 0.36-0.6, between-region ICCs = 0.30, 95% CI, 0.22-0.49). CONCLUSIONS: Despite guidelines recommending maintenance of MAP >60 mm Hg in adult brain-dead organ donors, hypotension during recovery procedures was common. Future research is needed to clarify the relationship between intraoperative events with donation and transplantation outcomes and to identify best practices for the anesthetic management of brain-dead donors in the operating room.

Identifying quality of life outcome patterns to inform treatment choices in ischemic cardiomyopathy.

BACKGROUND: The Surgical Treatment for Ischemic Heart Failure (STICH) trial found that routine use of coronary artery bypass surgery (CABG) improved mean quality of life (QoL) scores relative to guideline-directed medical therapy (GDMT) in patients with ischemic cardiomyopathy. However, mean differences in QoL scores do not provide what patients want to know when facing a high-risk/high-benefit treatment choice. METHODS: We analyzed Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary scores in CABG and GDMT patients over 36 months using a combination of statistical methods to group QoL data into clinically relevant outcome patterns (phenotype trajectories) and to then identify the main baseline predictors of each phenotype. QoL outcome phenotypes were developed using mixture models to define the dominant phenotype trajectories present in STICH QoL data. Logistic regression models were used to predict each patient's probability of achieving each outcome pattern with each treatment. RESULTS: In STICH, 592 patients underwent CABG and 607 were managed with GDMT. Our analyses identified 3 phenotype trajectory patterns in both treatment groups. Two of the 3 trajectories showed improving patterns, and were classified as "good QoL trajectories," seen in 498 (84.1%) CABG and 449 (73.9%) GDMT patients. Defining a consequential CABG-GDMT treatment difference as a >10% higher absolute predicted probability of belonging to good QoL trajectories, 277 (23.5%) patients were more likely to have good outcome with CABG while 45 (3.8%) patients were more likely to have a good outcome with GDMT. For 644 (54.7%) patients, CABG and GDMT probabilities of a good outcome were within 5% of each other. CONCLUSIONS: The pattern of QoL outcomes after CABG compared with GDMT in STICH followed 3 main phenotypic trajectories, which could be predicted based on individual baseline features. Patient-specific predictions about expected QoL outcomes with different treatment choices provide an intuitive framework for personalizing patient decision making.

Variable definitions and treatment approaches for atrial functional mitral regurgitation: A scoping review of the literature.

OBJECTIVES: Atrial functional mitral regurgitation (AFMR) is a subtype of functional mitral regurgitation due to longstanding atrial fibrillation (AF) or heart failure with preserved ejection fraction. The variation in AFMR' definition and the common mode of treatment described in the literature remain unknown. METHODS: We performed a scoping review of studies that surgically treated AFMR to characterize the existing variability in the definition of AFMR, the type of operations performed for AFMR valvulopathy, and the treatment for the chronic AF. We searched Medline, EMBASE, Cochrane Library, Scopus, and Web of Science since their inceptions for studies of patients affected by AFMR and surgically treated for their valvulopathy. RESULTS: Twelve studies (n = 494 patients) met eligibility criteria. All studies excluded patients with signs of left ventricular (LV) dysfunction, but the way additional parameters were used to define AFMR at a more granular level varied across studies: nine studies (75%) used the presence of AF to define their AFMR cohorts, with five (41.2%) requiring a history of AF of >1 year; additionally, the threshold values for the LV ejection fraction differed (45%-55%). Isolated mitral annuloplasty was performed in 96.2% of patients. Broad variability was detected in the proportion of patients undergoing the Cox-Maze procedure (range, 17.8%-79.5%), pulmonary vein isolation (0.0%-66.7%), and left atrial appendage ligation (0.0%-100.0%). CONCLUSIONS: AFMR remains variably defined in surgical studies, making comparisons across studies difficult. Mitral annuloplasty was most commonly performed. The proportion of AFMR patients undergoing concomitant procedures for AF varied substantially.

Socioeconomic disparities in surveillance and follow-up of patients with thoracic aortic aneurysm.

BACKGROUND: Thoracic aortic aneurysm (TAA) is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status (SES) and surveillance practices in patients with ascending aortic aneurysms. METHODS: We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013 and 2016 with ascending aortic aneurysm ≥4 cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing SES at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death before follow up with a cardiovascular specialist. RESULTS: Lower SES was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest SES had lower hazard of follow-up with a cardiologist or cardiac surgeon before death (hazard ratio: 0.46 [0.34, 0.62], p < .001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs. 23%-38%, p < .001). CONCLUSION: Patients with lower SES receive less timely follow-up imaging and specialist referral for TAAs, resulting in surgical intervention only when alarming symptoms are already present.

Risk factors and mortality associated with permanent pacemaker after surgical or transcatheter aortic valve replacement: Early versus late implantation.

INTRODUCTION: Inflation of transcatheter aortic valve replacement (TAVR) procedures compared to surgical aortic valve replacement (SAVR) has increased the number of patients requiring a postprocedure permanent pacemaker (PPM). We investigate the impact of PPM on mid-term mortality comparing SAVR versus TAVR procedures and risk factors for early and late (>14 days) need of PPM. METHODS: We conducted a retrospective, single-center evaluation of 903 patients that underwent either SAVR or TAVR procedures at the Yale New Haven Hospital from 2012 to 2017. Patients were stratified into PPM and non-PPM groups. We performed Kaplan-Meier and Cox proportional hazard analysis to characterize mid-term mortality. Further subgroup analysis was performed to identify risk factors for early and late PPM implantation in the TAVR cohort. RESULTS: There was no correlation between PPM implantation and mid-term mortality in both SAVR (hazard ratio [HR] = 0.69; confidence interval [CI] = 0.21-2.30; p = .56) and TAVR (HR = 0.70; CI = 0.42-1.17; p = .18) patients. The presence of the right bundle branch block (Odds ratio = 24.07; 95% CI = 2.34-247.64, p = .007) was associated with higher odds of early PPM requirement after TAVR procedures. CONCLUSION: PPM placement after SAVR or TAVR procedures is not associated with increased mid-term mortality. In-depth characterization of risk factors for early and late PPM implantation will require further analysis in the growing TAVR patient population.

Institution representation in publications reporting mitral valve repair durability: A scoping review.

BACKGROUND: Mitral valve repair durability currently plays a key role in operative decision making and in defining optimal surgical practice. However, mitral valve durability outcomes measures are not captured by national registries and limited to centers that publish their outcomes. In this study, we aim to describe the scope of institutions represented by reports describing durability outcomes after mitral valve repair within the contemporary literature. METHODS AND RESULTS: A scoping review of the literature was performed to extract abstracts potentially reporting mitral valve operation outcomes published between 2000-2019. 370 full text articles reporting mitral valve durability outcomes by either reoperation rate or rate of recurrent mitral regurgitation met criteria for analysis. Study characteristics including case volume, country and institution of origin, and surgeon volume were extracted and used to calculate the proportion of total cases in the top 3, 5, and 10 represented countries and institutions by the sum of reported mitral valve repairs described. The top 5 of 21 countries represented 78.9% of the mitral valve repair cases described. The top 3 most represented institutions described 20,120 (37.3%) of all mitral valve repairs in 58 (33.9%) single-center studies. CONCLUSION: Published mitral valve repair durability data must be interpreted with caution when used to derive policies and practice recommendations that govern the cardiovascular community at large.

Long-term risk of arch complications in Loeys Dietz syndrome patients undergoing proximal ascending aortic replacement.

PURPOSE: Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. In LDS patients with normal arch morphology, whether the arch should be prophylactically replaced at the time of proximal aortic replacement remains unknown. We evaluated the risk of long-term arch complications in genetically confirmed LDS patients who underwent proximal ascending aortic replacement. METHODS: We retrospectively reviewed the records of patients with LDS who have been followed at our institution between 1994 and 2020. Patients were only included if whole exome genetic testing confirmed a mutation in an LDS-causing gene (TGFBR1, TGFBR2, SMAD3, TGFB2, or TGFB3). Mutations were categorized as pathogenic, benign, or of unknown significance. We collected demographic information, aortic dimensions, comorbidities, mortality, and operative course from patients' charts. Descriptive statistics and freedom from reoperation plots were generated. RESULTS: Of the 18 patients with a mutation in an LDS-causing gene, 15 had known pathogenic variants, two had mutations of unknown significance, and one had a benign genetic variant. For the 15 patients with confirmed pathogenic variants of LDS the median follow-up duration was 5 years (interquartile range [IQR]: 4-8). Eleven patients underwent ascending aortic replacements (AAR) ± aortic valve replacement. Two patients required an additional operation; one required arch and staged elephant trunk for a dissection 18 years post-AAR and the other patient required an isolated descending aortic replacement for dissection 5 years post-AAR. Among patients who underwent surgery, the median ascending aortic diameter at intervention was 5.0 cm (IQR: 4.3-5.3). There was no surgical or late follow-up mortality observed for any of the 18 patients in the study. CONCLUSION: LDS patients who underwent proximal aortic replacement appeared to have low long-term risk of arch complications. While our study is somewhat limited by its sample size and follow-up duration, it suggests that routine prophylactic total arch replacement may not be warranted in LDS patients with nonaneurysmal aortic arches.

Cardiac surgeons' practices and attitudes toward addiction care for patients with substance use disorders.

INTRODUCTION: Rates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons' practices and attitudes toward patients with IDU-IE due to their integral role treating them. METHODS: This is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons' practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD). RESULTS: A minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8-9.27, p = 0.001). CONCLUSION: Access to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.

Late-onset acute disseminated encephalomyelitis followed by optic neuritis without anti-myelin oligodendrocyte glycoprotein antibodies: a biopsied case report.

BACKGROUND: Acute disseminated encephalomyelitis (ADEM) followed by optic neuritis (ADEM-ON) is characterized by the following features: early onset, monophasic or multiphasic ADEM followed by one or more episodes of ON, and the presence of serum anti-myelin oligodendrocyte glycoprotein (MOG) antibodies. CASE REPORT: We report a case of ADEM-ON without anti-MOG antibodies in a 78-year-old woman. The patient developed acute-onset neurological findings and was diagnosed with ADEM. She was treated with intravenous methylprednisolone (IVMP), and oral corticosteroids. Her clinical symptoms and MRI findings subsequently improved. Left optic neuritis emerged 6 months later, and we made a diagnosis of ADEM-ON. A brain biopsy performed during the acute phase of ADEM showed perivascular infiltration of macrophages with demyelination. CONCLUSION: The majority of the reported ADEM-ON cases are pediatric cases with serum anti-MOG antibodies, but our patient was the elderly, without anti-MOG antibodies. Moreover, the pathological features of our case were similar to those observed in patients with typical ADEM and in patients with anti-MOG antibody-positive ADEM. Although ADEM-ON is related to the presence of anti-MOG antibodies, factors other than anti-MOG antibodies could contribute to the development of ADEM-ON.

Network meta-analysis of treatment strategies in patients with coronary artery disease and low left ventricular ejection fraction.

OBJECTIVE: The optimal treatment strategy in patients with coronary artery disease (CAD) and low left ventricular ejection fraction (LVEF) remains controversial. Herein, we conducted a network meta-analysis comparing coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), and optimal medical therapy (OMT) in patients with CAD and low LVEF. METHODS: MEDLINE and EMBASE were searched through March, 2021 to identify randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing CABG, PCI, and OMT. We extracted hazard ratios (HRs) of the outcomes. RESULTS: A total of three RCTs and 10 PSM trials were identified, yielding a total of 18,855 patients with CAD with low EF who were treated with CABG (n = 9241), PCI (n = 8771), or OMT (n = 1003). All-cause mortality was significantly lower in patients with CABG compared with those with PCI or OMT (HR [95% confidence interval (CI)] = 0.72 [0.62-0.82], p < .001, HR [95% CI] = 0.65 [0.51-0.82], p = .004, respectively), while no difference was observed between PCI and OMT. The rates of MI were significantly lower in patients treated with CABG compared to those treated with PCI or OMT. However, the subgroup analysis by limiting the PCI group to patients who received drug-eluting stent (DES) showed similar all-cause mortality between CABG and PCI, while both CABG and PCI were associated with lower all-cause mortality compared with OMT. CONCLUION: The present study demonstrated that CABG was the appropriate treatment strategy in patients with CAD and low LVEF. Further long-term trials were warranted to investigate outcomes of PCI with DES compared with CABG.

Progression of aortic stenosis in patients with bicuspid aortic valve.

BACKGROUND: Bicuspid aortic valve is the most common congenital heart defect and predisposes patients to developing aortic stenosis more frequently and at a younger age than the general population. However, the influence of bicuspid aortic valve on the rate of progression of aortic stenosis remains unclear. METHODS: In 236 patients (177 tricuspid aortic valve and 59 bicuspid aortic valve) matched by initial severity of mild or moderate aortic stenosis, we retrospectively analyzed baseline echocardiogram at diagnosis with latest available follow-up echocardiogram. Baseline comorbidities, annualized progression rate of hemodynamic parameters, and hazard of aortic valve replacement were compared between valve phenotypes. RESULTS: Median echocardiographic follow-up was 2.6 (interquartile range [IQR] 1.6-4.2) years. Patients with tricuspid aortic stenosis were significantly older with more frequent comorbid hypertension and congestive heart failure. Median annualized progression rate of mean gradient was 2.3 (IQR 0.6-5.0) mmHg/year versus 1.5 (IQR 0.5-4.1) mmHg/year (p = .5), and that of peak velocity was 0.14 (IQR 0-0.31) m/s/year versus 0.10 (IQR 0.04-0.26) m/s/year (p = .7) for tricuspid versus bicuspid aortic valve, respectively. On multivariate analyses, bicuspid aortic valve was not significantly associated with more rapid progression of aortic stenosis. In a stepwise Cox proportional hazards model adjusted for baseline mean gradient, bicuspid aortic valve was associated with increased hazard of aortic valve replacement (hazard ratio: 1.7, 95% confidence interval [1.0-3.0], p = .049). CONCLUSION: Bicuspid aortic valve may not significantly predispose patients to more rapid progression of mild or moderate aortic stenosis. Guidelines for echocardiographic surveillance of aortic stenosis need not be influenced by valve phenotype.

The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis.

BACKGROUND: It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases. METHODS: We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice. RESULTS: The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice. CONCLUSION: High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.

Center-level CABG and valve operative outcomes and volume-outcome relationships in New York State.

BACKGROUND: We analyzed center-level outcome correlations between valve surgery and coronary artery bypass graft (CABG) in New York (NY) State and how volume-outcome effect differ between case types. METHODS: We used the 2014-2016 NY cardiac surgery outcomes report. Center-level observed to-expected (observed-to-expected ratio [O/E]) ratio for operative mortality provided risk-adjusted operative outcomes for isolated CABG and valve operations. Correlation coefficient characterized the concordance in center-level outcomes in CABG and valve. Discordant outcomes were defined as having O/E ratio greater than 2 in one operation type with O/E ratio ≤1 in another. Linearized slope of volume-outcome effect in case types offered insights into centers with discordant performances between procedures. RESULTS: Among 37 NY centers, annual center volumes were 220 ± 120 cases for CABG and 190 ± 178 cases for valve operations. Modest center-level correlation between CABG and valve O/E ratio was shown (R2 = 0.31). Two centers had discordant performance between valve and CABG (O/E ≤ 1 for CABG while O/E > 2 for valve procedures). No centers had CABG O/E ratio greater than 2 while valve O/E ratio ≤1. Linearized slope describing volume-outcome effects showed stronger effect in valve operations compared to CABG: O/E ratio declined 0.1 units per 100 CABG volume increase, while O/E ratio declined 0.33 units per 100 valve volume increase. CONCLUSION: In NY hospitals, favorable valve outcomes may indicate good CABG outcomes but good CABG outcomes may not ensure valve outcomes. Outcome variation in valve operation could be related to stronger volume-outcome effect in valve operations relative to CABG. Valve operations may benefit from regionalization.

Telemedicine in the era of coronavirus 19: Implications for postoperative care in cardiac surgery.

BACKGROUND: The Coronavirus 19 (COVID-19) pandemic forced an unprecedented shift of postoperative care for cardiac surgery patients to telemedicine. How patients and surgeons perceive telemedicine is unknown. We examined patient and provider satisfaction with postoperative telehealth visits following cardiac surgery. METHODS: Between April 2020 and September 2020, patients who underwent open cardiac surgery and had a postoperative appointment via telemedicine were administered a patient satisfaction survey over the phone. Time of survey administration ranged from 1 to 4 weeks following their appointment. Surgeons also completed a satisfaction survey following each telemedicine appointment they conducted. RESULTS: Fifty patients were surveyed. Of these, 36 (72%) had a postoperative appointment over the telephone, and 14 (28%) had a postoperative appointment via video-chat. Overall, patients expressed satisfaction with the care that they received via our two telemedicine modalities (mean Likert scale agreement 4.8, SD 0.5). Despite this, 46% of patients said they would prefer their next postoperative appointment to be via telemedicine even if there was not a stay-at-home order in place. All surgeons surveyed reported (agree/strongly agree) that they would prefer to see their postoperative patients using telemedicine. CONCLUSIONS: These findings highlight acceptability of continuing telemedicine use in the postoperative care of cardiac surgery patients.

The impact of trainees' working hour regulations on outcome in CABG and valve surgery in the State of New York.

BACKGROUND AND AIM: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear. METHODS: We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies. RESULTS: (1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH. CONCLUSION: The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.

Variants of the aortic arch in adult general population and their association with thoracic aortic aneurysm disease.

BACKGROUND: Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies. METHODS: CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm (TAA). RESULTS: Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n = 354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p < .001), non-Caucasian(p < .001), and hypertensive (p < .001). Prevalence of TAA in arch anomalies group was 10.8% (n = 65) compared to 4.1% (n = 844) in the nonarch anomaly cohort (p < .001). The highest prevalence of thoracic aneurysm was associated with right-sided arch combined with aberrant left subclavian configuration (33%), followed by bovine arch (13%), and aberrant right subclavian artery (8.2%). On binary logistic regression, arch anomaly (OR = 2.85 [2.16-3.75]), aortic valve pathology (OR 2.93 [2.31-3.73]), male sex (OR 2.38 [2.01-2.80]), and hypertension (OR 1.47 [1.25-1.73]) were significantly associated with increased risk of thoracic aneurysm disease. CONCLUSIONS: Reported prevalence of aortic arch anomalies by CT imaging in the older adult population is approximately 3%, with high association of TAA (OR = 2.85) incidence in this subgroup. This may warrant a more tailored surveillance strategy for aneurysm disease in this subpopulation.

Relationship of surgeon experience and outcomes of surgery for degenerative mitral valve disease.

OBJECTIVE: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. METHODS: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011 and 2016. Experienced surgeon was defined as performing ≥ 25 mitral valve operations/year. Patient characteristics and outcomes were compared. Competing risk analysis was performed to identify factors associated with mitral regurgitation (MR) recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional hazard method. RESULTS: There were 575 patients treated by 9 surgeons for severe MR caused by degenerative mitral valve disease between 2011 and 2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (p = .001). Experienced surgeons were more likely to attempt repair (p = .024), to succeed in repair (94.7% vs. 87%; p = .001), had shorter cross-clamp times (p = .001), and achieved higher repair rate (81.3% vs. 69.7%; p = .005). Experienced surgeons were more likely to use neochordae (p = .001) and less likely to use chordae transfer (p = .001). Surgeon experience was not associated with recurrence of moderate or higher degree of MR after repair but was an independent risk factor for mortality (HR = 2.64; p = .002). CONCLUSIONS: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

STratification risk analysis in OPerative management (STOP score) for drug-induced endocarditis.

BACKGROUND: The opioid epidemic has seen a drastic increase in the incidence of drug-associated infective endocarditis (IE). No clinical tool exists to predict operative morbidity and mortality in patients undergoing surgery. METHODS: A multi-institutional database was reviewed between 2011 and 2018. Multivariate logistic regression was fitted in an automated stepwise fashion. The STratification risk analysis in OPerative management of drug-associated IE (STOP) score was constructed. Morbidity was defined as reintubation, prolonged ventilation, pneumonia, renal failure, dialysis, stroke, reoperation for bleeding, and a permanent pacemaker. Cross-validation provided an unbiased estimate of out-of-sample performance. RESULTS: A total of 1181 patients underwent surgery for drug-associated IE (median age, 39; interquartile range [IQR], 30-54, 386 women [32.7%], 341 reoperations for prosthetic valve endocarditis [28.9%], 316 patients with multivalve disease [26.8%]). Operative morbidity and mortality were 41.1% and 5.9%, respectively. Predictors of morbidity were dialysis (95% confidence interval [CI], 1.16-2.82), emergent intervention (1.83-4.73), multivalve procedure (1.01-1.98), causative organisms other than Streptococcus (1.09-2.02), and type of valve procedure performed [aortic valve procedure (1.07-2.15), mitral valve replacement (1.03-2.05), tricuspid valve replacement (1.21-2.60)]. Predictors of mortality were dialysis (1.29-5.74), active endocarditis (1.32-83), lung disease (1.25-5.43), emergent intervention (1.69-6.60), prosthetic valve endocarditis (1.24-3.69), aortic valve procedure (1.49-5.92) and multivalve disease (1.00-2.95). Variables maximizing explanatory power were translated into a scoring system. Each point increased odds of morbidity and mortality by 22.0% and 22.4% with an accuracy of 94.0% and 94.1%, respectively. CONCLUSION: Drug-related IE is associated with significant morbidity and mortality. An easily-applied risk stratification score may aid in clinical decision-making.

Transition to Advanced Therapies in Elderly Patients Supported by Extracorporeal Membrane Oxygenation Therapy.

BACKGROUND: Although the use of extracorporeal membrane oxygenation (ECMO) continues to increase, very little is known about how age influences the transition to definitive advanced therapies. METHODS: Using the National Inpatient Sample database from 2008 to 2017, we analyzed patients supported by ECMO for cardiogenic shock and separated patients into 2 age cohorts: < 65 years and ≥ 65 years. Primary outcomes of interest included the proportion of patients undergoing orthotopic cardiac transplantation (OHT) and left ventricular assist device (LVAD) implantation. RESULTS: Over the study period, we identified 16,132 hospitalizations of people with cardiogenic shock requiring ECMO support. Significantly fewer patients in the older group underwent OHT compared to the younger group (0.4% vs 1.2%, P < 0.001). Compared to the younger group, a lower proportion of those ≥ 65 years received an LVAD (3.7% vs 5.8%, P < 0.001). LVAD implantation increased over the study period in both age cohorts, whereas OHT increased only in the < 65 group (P < 0.05, all). After multivariable adjustment, patients in the oldest age group were still less likely to receive an LVAD (odds ratio 0.54; confidence interval: 0.43-0.69, P < 0.001) and continued to have the highest odds of in-hospital mortality (odds ratio 1.53; confidence interval : 1.39-1.69, P < 0.001). CONCLUSIONS: Survival of patients ≥ 65 years requiring ECMO for cardiogenic shock is poor and less commonly includes transition to definitive advanced therapies. Although we must stress that no patient should be denied ECMO based solely on age, we believe our results may be helpful for providers when counseling patients and their families.

Surgical management of thoracic aortic emergency with pre- and postoperative COVID-19 disease.

The nuance of operative decision making for those in need of emergent operation during coronavirus disease 2019 (COVID-19) pandemic is increasingly complex in the absence of robust data or guidelines. We present two cases of thoracic aortic emergencies with COVID-19 disease who survived high-risk operations to highlight the potential for successful outcomes even in situations compounding patient disease, morbid operation, and the added risk associated with virulent disease in the pandemic time.