The impact of academic calendar cycle on coronary artery bypass outcomes: a comparison of teaching and non-teaching hospitals.

BACKGROUND: The commencement of new academic cycle in July is presumed to be associated with poor patient outcomes, although supportive evidence is limited for cardiac surgery patients. We sought to determine if the new academic cycle affected the outcomes of patients undergoing Coronary Artery Bypass Grafting. METHODS: A retrospective analysis was performed on 10-year nationwide in-hospital data from 1998-2007. Only patients who underwent CABG in the first and final academic 3-month calendar quarter were included. Generalized multivariate regression was used to assess indicators of hospital quality of care such as risk-adjusted mortality, total complications and "failure to rescue" (FTOR) - defined as death after a complication. RESULTS: Of the 1,056,865 CABG operations performed in the selected calendar quarters, 698,942 were at teaching hospitals. The risk-adjusted mortality, complications and FTOR were higher in the beginning of the academic year [Odds ratio = 1.14, 1.04 and 1.19 respectively; p < 0.001 for all] irrespective of teaching status. However, teaching status was associated with lower mortality (OR 0.9) despite a higher complication rate (OR 1.02); [p < 0.05 for both]. The July Effect thus contributed to only a 2.4% higher FTOR in teaching hospitals compared to 19% in non teaching hospitals. CONCLUSIONS: The July Effect is reflective of an overall increase in morbidity in all hospitals at the beginning of the academic cycle and it had a pronounced effect in non-teaching hospitals. Teaching hospitals were associated with lower mortality despite higher complication rates in the beginning of the academic cycle compared to non-teaching hospitals. The July effect thus cannot be attributed to presence of trainees alone. ULTRAMINI ABSTRACT: This study compares the July effect in teaching and non-teaching hospitals and demonstrates that this effect is not unique to teaching hospitals for CABG patients. In fact, teaching hospitals have somewhat better outcomes at the beginning of the academic cycle and the July effect is a much broader seasonal variation.

Cirrhosis as a moderator of outcomes in coronary artery bypass grafting and off-pump coronary artery bypass operations: a 12-year population-based study.

BACKGROUND: Cirrhosis substantially affects morbidity and mortality in patients who undergo complex surgical procedures. However, cirrhosis is not included as a parameter in standardized perioperative cardiac risk assessment models. We sought to identify the impact of cirrhosis on coronary artery bypass grafting (CABG) and off-pump CABG (OPCAB) outcomes. METHODS: Using the 1998 to 2009 Nationwide Inpatient Sample databases, we identified 3,046,709 patients who underwent CABG procedures, 744,636 (24.4%) of which were OPCAB; 6,448 (0.3%) had cirrhosis. Using hierarchical multivariable regression models, we analyzed the impact of cirrhosis on in-hospital outcomes: mortality, morbidity, length of stay, hospital charges, and disposition. Severity of liver dysfunction was assessed by the Deyo-Charlson comorbidity index. RESULTS: In the overall CABG group, cirrhosis was independently associated with increased mortality (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI] 2.8 to 17), morbidity (AOR 1.6, 95% CI 1.3 to 2.0), length of stay (+1.2 days; p < 0.001), and hospital charges (+$22,491; p < 0.001). The prevalence of cirrhosis in the OPCAB group was 0.3% (n = 2,246); the OPCAB subgroup analysis revealed that the presence of cirrhosis did not affect mortality or morbidity unless there was severe liver dysfunction (mortality AOR 5.1, 95% CI 3.7 to 6.9; morbidity AOR 2.1, 95% CI 1.6 to 2.4). However, in the on-pump CABG patients, cirrhosis was associated with increased mortality and morbidity regardless of the severity of liver dysfunction. CONCLUSIONS: The impact of cirrhosis on perioperative outcomes and health care costs is significant; CABG should be performed on carefully selected cirrhotic patients and, whenever possible, without the use of cardiopulmonary bypass.

Acute aortic dissection and stroke in multivessel fibromuscular dysplasia.

Fibromuscular dysplasia is a rare, nonatherosclerotic, noninflammatory vascular disease that typically affects women between the ages of 20 and 60 years. Although any artery can be affected, fibromuscular dysplasia most commonly affects the renal and carotid arteries. Fibromuscular dysplasia of the renal arteries usually presents with hypertension, while carotid or vertebral artery disease causes transient ischemic attacks, strokes, or dissection. Fibromuscular dysplasia of the brachial arteries is extremely uncommon. It can induce extremity ischemia, nerve compression, or both-causing coldness, discoloration, pain, ulceration or gangrene of the fingers, paresthesias, or paralysis. We report a rare case of multivessel fibromuscular dysplasia manifested by acute stroke in association with type I aortic dissection, which progressed rapidly to ascending aortic false aneurysmal development that necessitated arch replacement. Outcomes of aortic arch replacement in this setting are currently unknown. Therefore, our case might well offer some insight.

Impact of surgeon demographics and technique on outcomes after esophageal resections: a nationwide study.

BACKGROUND: Thoracic, cardiac, and general surgeons perform esophageal resections in the United States. This article examines the impact of surgeon subspecialty on outcomes after esophagectomy. METHODS: Esophagectomies performed between 1998 and 2008 were identified in the Nationwide Inpatient Sample. Surgeons were classified as thoracic, cardiac, or general surgeons if greater than 65% of their operative case mix was representative of their specialty. Surgeons with less than 65% of a specialty-specific case mix served as controls. Regression equations calculated the independent effect of surgeon specialty, surgeon volume, and operative approach (transhiatal versus transthoracic) on outcomes. RESULTS: Of the 40,589 patients who underwent esophagectomies, surgeon identifiers were available for 23,529 patients. Based on case mix, thoracic, cardiac, and general surgeons performed 3,027 (12.9%), 688 (2.9%), and 4,086 (17.4%) esophagectomies, respectively. Operative technique did not independently affect risk-adjusted outcomes-mortality, morbidity, and failure to rescue (defined as death after a complication). Surgeon volume independently lowered mortality and failure to rescue by 4% (p ≤ 0.002 for both), but not complications (p = 0.6). High-volume hospitals (>12 procedures/year) independently lowered mortality (adjusted odds ratio [AOR], 0.67, 95% confidence interval [CI], 0.46-0.96), and failure to rescue (AOR, 0.64; 95% CI, 0.44-0.94). Esophageal resections performed by general surgeons were associated with higher mortality (AOR, 1.87; 95% CI 1.02-3.45) and failure to rescue (AOR, 1.95; 95% CI, 1.06-3.61) but not complications (AOR, 0.97; 95% CI, 0.64-1.49). CONCLUSIONS: General surgeons perform the major proportion of esophagectomies in the United States. Surgeon subspecialty is not associated with the risk of complications developing but instead is associated with mortality and failure to rescue from complications. Surgeon subspecialty case mix is an important determinant of outcomes for patients undergoing esophagectomy.

Predictors of in-hospital complications after pericardiectomy: a nationwide outcomes study.

OBJECTIVE: Advances in medical care had caused a paradigm shift in the indications for pericardiectomy. We evaluated the current predictors of in-hospital complications for pericardiectomy. METHODS: Patients who underwent pericardiectomy between 1998 and 2008 were identified from the US Nationwide Inpatient Sample. Risk-adjusted logistic regression model was used to analyze the predictors of surgical outcomes. RESULTS: A total of 13,593 patients underwent pericardiectomy during this period. Pericardiectomy was performed for constrictive pericarditis (28%; n = 3851), pericardial calcification (15%; n = 2061), secondary malignancies (3%; n = 456), adhesive pericarditis (2%; n = 318), and other causes (40%; n = 5461). Unadjusted mortality and complication rates were approximately 8% and 48%, respectively. Fourteen percent of patients required blood transfusion. Only 62% were routinely discharged home. After risk adjustment, age, female gender, comorbidity index, and the primary diagnosis independently predicted in-hospital mortality and overall complication rates (P < .05). Calcific pericarditis was the only etiology associated with lower risk-adjusted mortality (odds ratio [OR], 0.48), operative complications (OR, 0.32), overall complications (OR, 0.32), incidence of transfusion (OR, 0.38), and highest routine discharge rates (OR, 1.84); P < .001 for all. Constrictive pericarditis had the highest requirement for cardiopulmonary bypass (OR, 6.41; P < .01) and incidence of bleeding complications (OR, 2.61; P < .01). CONCLUSIONS: Morbidity remains high for pericardiectomy. In addition to age, gender, and comorbidities, attention should be given to etiology during surgical planning or referral. This significantly influences the requirement for cardiopulmonary bypass, chances of bleeding complications, and transfusion requirements.

Robotic-assisted or minithoracotomy incision for left ventricular lead placement: a single-surgeon, single-center experience.

OBJECTIVE: Left ventricular (LV) resynchronization with epicardial lead placement after failed coronary sinus cannulation can be achieved with minimally invasive robotic-assisted (RA) or minithoracotomy (MT) incisions. We evaluated early outcomes and costs after RA and MT epicardial LV lead implantation at our academic center. METHODS: From 2005 to 2010, 24 patients underwent minimally invasive RA or MT epicardial LV lead placement for resynchronization. Patient characteristics, electrophysiologic features, outcomes, and costs were analyzed. RESULTS: Ten patients underwent RA and 14 underwent MT minimally invasive LV lead placement, with no 30-day mortality in either group. Younger patients underwent RA epicardial lead placement (63.8 ± 15.4 vs 75.6 ± 10.0 years; P = 0.03). In addition, although both groups had comparable body surface areas, RA patients had significantly higher body mass index versus MT patients (44.4 ± 17.5 vs 26.9 ± 7.1 kg/m, respectively; P = 0.003). Premorbid risk and cardiovascular profiles were similar across groups. Importantly, pacing threshold, impedance, and postoperative QRS interval were equivalent between groups. Significantly, both operating room and mechanical ventilation durations were higher with RA epicardial placement (P < 0.001). Despite equivalent outcomes, incision-to-closure interval was 48 minutes shorter with MT (P = 0.002). Absolute differences in direct costs between groups were negligible. Despite these differences, resource utilization and lengths of stay were equivalent. CONCLUSIONS: Epicardial LV lead placement is efficacious with either approach. Early outcomes and mortality are equivalent. Greater tactile feedback during operation and equivalent short-term outcomes suggest that MT minimally invasive LV lead placement is the more favorable approach for epicardial resynchronization.

Outcomes of concomitant aortic valve replacement and coronary artery bypass grafting at teaching hospitals versus nonteaching hospitals.

OBJECTIVE: Hospitals with a high volume and academic status produce better patient outcomes than other hospitals after complex surgical procedures. Risk models show that concomitant aortic valve replacement and coronary artery bypass grafting pose a greater risk than isolated coronary artery bypass grafting or aortic valve replacement. We examined the relationship of hospital teaching status and the presence of a thoracic surgery residency program with aortic valve replacement/coronary artery bypass grafting outcomes. METHODS: By using the Nationwide Inpatient Sample database, we identified patients who underwent concomitant aortic valve replacement/coronary artery bypass grafting from 1998 to 2007 at nonteaching hospitals, teaching hospitals without a thoracic surgery residency program, and teaching hospitals with a thoracic surgery residency program. Multivariate analysis was performed to identify intergroup differences. Risk-adjusted multivariable logistic regression analysis was used to assess independent predictors of in-hospital mortality and complication rates. RESULTS: The 3 groups of patients did not differ significantly in their baseline characteristics. Patients who underwent aortic valve replacement/coronary artery bypass grafting had higher overall risk-adjusted complication rates in nonteaching hospitals (odds ratio 1.58; 95% confidence interval, 1.39-1.80; P < .0001) and teaching hospitals without a thoracic surgery residency program (odds ratio 1.42; 95% confidence interval, 1.26-1.60; P < .0001) than in thoracic surgery residency program hospitals. However, no difference was observed in the adjusted mortality rate for nonteaching hospitals (odds ratio 0.95; 95% confidence interval, 0.87-1.04; P = .25) or teaching hospitals without a thoracic surgery residency program (odds ratio 1.00; 95% confidence interval, 0.92-1.08; P = .98) when compared with thoracic surgery residency program hospitals. Robust statistical models were used for analysis, with c-statistics of 0.98 (complications) and 0.82 (mortality). CONCLUSION: Patients who require complex cardiac operations may have better outcomes when treated at teaching hospitals with a thoracic surgery residency program.

Endovascular versus open repair of ruptured descending thoracic aortic aneurysms: a nationwide risk-adjusted study of 923 patients.

OBJECTIVE: Recent studies support the use of endovascular treatment for ruptured abdominal aortic aneurysms, but few studies have examined the use of thoracic endovascular aortic repair (TEVAR) for ruptured descending thoracic aortic aneurysm. We evaluated nationwide data regarding short-term outcomes of TEVAR and open aortic repair (OAR) for ruptured descending thoracic aortic aneurysm. METHODS: From US Nationwide Inpatient Sample data, we identified 923 patients who underwent ruptured descending thoracic aortic aneurysm repair in 2006-2008 and who had no concomitant aortic disorders. Of these patients, 364 (39.4%) underwent TEVAR and 559 (60.6%) underwent OAR. Multivariable regression was used to assess the effect of TEVAR versus OAR after adjusting for potential confounding factors. Outcomes assessed were in-hospital mortality, complications, failure to rescue (defined as the mortality among patients in whom a complication develops), and disposition. Backward stepwise logistic regression was used to identify independent predictors of outcomes for each approach. RESULTS: Patients undergoing TEVAR were older (72 ± 12 years vs 65 ± 15 years; P < .001) and had a higher Deyo comorbidity index (4.19 ± 1.79 vs 3.14 ± 2.05; P < .001) than patients undergoing OAR. Unadjusted mortality was 23.4% (85/364) for TEVAR and 28.6% (160/559) for OAR. After risk adjustment, the odds of mortality, complications, and failure to rescue were similar for TEVAR and OAR (P > .1 for all), but patients undergoing TEVAR had a greater chance of routine discharge (odds ratio [OR] = 3.3; P < .001). An interaction was identified that linked hospital size and operative approach with risk of complications (P < .001). In smaller hospitals, TEVAR was associated with lower complication rates than OAR (OR = 0.21; P < .05). Regression analysis revealed that smaller hospital size predicted significantly higher rates of mortality (OR = 2.4; P < .05), complications (OR = 4.0; P < .005), and failure to rescue (OR = 51.12; P < .001) in those undergoing OAR but not in those undergoing TEVAR. Preexisting renal disorders substantially increased mortality risk (OR = 10.81; P < .001) and failure to rescue (OR = 309.54; P < .001) in patients undergoing TEVAR. CONCLUSIONS: Nationwide data for ruptured descending thoracic aortic aneurysm reveal equivalent mortality, complication rates, and failure to rescue for TEVAR and OAR but more frequent routine discharge with TEVAR. Unlike OAR outcomes, TEVAR outcomes were not poorer in smaller hospitals, where TEVAR produced fewer complications than OAR. Therefore, TEVAR may be an ideal alternative to OAR for ruptured descending thoracic aortic aneurysm, particularly in small hospitals where expertise in OAR may be lacking and immediate transfer to a higher echelon of care may not be feasible.

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.

Staged versus synchronous carotid endarterectomy and coronary artery bypass grafting: analysis of 10-year nationwide outcomes.

BACKGROUND: The timing of operative interventions for patients with concurrent carotid and coronary artery disease is controversial. We evaluated nationwide data regarding staged or synchronous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) and compared the two approaches' outcome profiles. METHODS: From Nationwide Inpatient Sample database 1998 to 2007, we identified 6,153 (28.9%) patients who underwent CEA before or after CABG during the same hospital admission but not on the same day (STAGED) and 16,639 patients who underwent both procedures on the same day (SYNC). Hierarchic multivariable regression was used to assess the independent effect of operative strategy on mortality, neurologic and overall complications, and charges. RESULTS: Mean age (69.5±9.0 years) and Charlson-Deyo score (4.6±1.5) were similar for both groups. Mortality (4.2% vs 4.5%) or neurologic complications (3.5% vs 3.9%) were similar between the STAGED and SYNC groups (p>0.7 for both). The STAGED patients had higher morbidity (48.4% vs 42.6%; odds ratio [OR] 1.8; 95% confidence interval [CI], 1.5 to 2.2; p<0.001) and more cardiac (OR, 1.5; 95% CI, 1.4 to 1.7; p<0.001), wound (OR, 2.1; 95% CI, 1.8 to 2.4; p<0.001), respiratory (OR, 1.2; 95% CI, 1.1 to 1.3; p=0.001), and renal complications (OR, 1.2; 95% CI, 1.03 to 1.3; p<0.001). In SYNC patients, on-pump CABG increased stroke rates (OR, 1.6; 95% CI, 1.3 to 1.9; p<0.001). The STAGED procedures were independently associated with higher hospital charges by $23,328 (p<0.001). CONCLUSIONS: We identified no significant difference in mortality or neurologic complications between STAGED and SYNC approaches. Staged procedures were associated with a greater risk of overall complications and higher hospital charges than SYNC. On-pump CABG was associated with higher stroke rates in SYNC patients.

Superior nationwide outcomes of endovascular versus open repair for isolated descending thoracic aortic aneurysm in 11,669 patients.

OBJECTIVES: Thoracic endovascular aneurysm repair (TEVAR) was introduced in 2005 to treat descending thoracic aortic aneurysms. Little is known about TEVAR's nationwide effect on patient outcomes. We evaluated nationwide data regarding the short-term outcomes of TEVAR and open aortic repair (OAR) procedures performed in the United States during a 2-year period. METHODS: From the Nationwide Inpatient Sample data, we identified patients who had undergone surgery for an isolated descending thoracic aortic aneurysm from 2006 to 2007. Patients with aneurysm rupture, aortic dissection, vasculitis, connective tissue disorders, or concomitant aneurysms in other aortic segments were excluded. Of the remaining 11,669 patients, 9106 had undergone conventional OAR and 2563 had undergone TEVAR. Hierarchic regression analysis was used to assess the effect of TEVAR versus OAR after adjusting for confounding factors. The primary outcomes were mortality and the hospital length of stay (LOS). The secondary outcomes were the discharge status, morbidity, and hospital charges. RESULTS: The patients who had undergone TEVAR were older (69.5 ± 12.7 vs 60.2 ± 14.2 years; P < .001) and had higher Deyo comorbidity scores (4.6 ± 1.8 vs 3.3 ± 1.8; P < .001). The unadjusted LOS was shorter for the TEVAR patients (7.7 ± 11 vs 8.8 ± 7.9 days), but the unadjusted mortality was similar (TEVAR 2.3% vs OAR 2.3%; P = 1.0). The proportion of nonelective interventions was similar between the 2 groups (TEVAR 15.9% vs OAR 15.8%; P = .9). The TEVAR and OAR techniques produced similar risk-adjusted mortality rates; however, the TEVAR patients had 60% fewer complications overall (odds ratio, 0.39; P < .001) and a shorter LOS (by 1.3 days). The TEVAR patients' hospital charges were greater by $6713 (95% confidence interval $1869 to $11,556; P < .001). However, the TEVAR patients were 4 times more likely to have a routine discharge to home. CONCLUSIONS: The nationwide data on TEVAR for descending thoracic aortic aneurysms have associated this procedure with better in-hospital outcomes than OAR, even though TEVAR was selectively performed in patients who were almost 1 decade older than the OAR patients. Compared with OAR, TEVAR was associated with a shorter hospital LOS and fewer complications but significantly greater hospital charges.

Intracorporeal knot-tying for the thoracoscopic surgeon: a novel and simplified technique.

Thoracoscopic surgery has usually been limited by 2-dimensional vision and the limited space between ribs--problems that have been only partially overcome by the use of robotics. One of the technical challenges of any minimally invasive surgical approach is tying an intracorporeal knot. For the thoracoscopic surgeon, we describe an easier technique of knot-tying that involves using a right-angled dissector. The technique enables ambidextrous performance and is particularly useful for ligating major pulmonary vessels that might be too small to be stapled or too confined for the admission and maneuvering of a stapling device. Rotating the thumb-dials accordingly enables one to vary the configuration of the knots to create slip or reef knots.The technique is easy to learn and does not require any complicated devices. It is easily adapted to create even more complex constructs, such as a double surgeon's knot. This technique has special advantages in areas of limited domain and in situations that require very narrow angles of instrument manipulation, particularly in thoracoscopic-assisted procedures.

Impact of ACGME work-hour restrictions on the outcomes of coronary artery bypass grafting in a cohort of 600,000 patients.

BACKGROUND: Since the resident physician 80-h/wk restriction was implemented on July 1, 2003, little has been learned about the impact of this reform on patient outcomes after coronary artery bypass grafting (CABG). METHODS: Using the Nationwide Inpatient Sample database, we identified 614,177 patients who underwent isolated CABG from 1998 through 2007. Of the 374,947 patients who underwent CABG at a teaching hospital, 133,285 (36%) belonged to the post-reform group. Hierarchic logistic and multivariable regression models were used to assess the independent effect of the reform after adjusting for potential confounding factors. Outcomes assessed were operative morbidity and mortality, and length of stay. Outcomes of CABG patients at non-teaching hospitals were used to control for time bias. RESULTS: In teaching hospitals, after risk adjustment, the post-reform era was associated with lower mortality risk (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.56-0.63; P < 0.001) but greater operative morbidity (OR, 1.5; 95% CI, 1.43-1.58; P < 0.001). Although the implementation of work-hour reforms was correlated with shorter lengths of stay, there were fewer routine home discharges (OR, 0.73; 95% CI, 0.73-0.76; P < 0.001). Outcomes at non-teaching hospitals were similar, except that operative morbidity rates were lower during the post-reform era. CONCLUSIONS: The implementation of the resident work-hour reform in teaching hospitals did not affect mortality rates in CABG patients but was associated with increased morbidity. Further studies are needed to identify the reasons for the post-reform increase in postoperative complications at teaching hospitals.

Aortic valve replacement: mortality predictions of surgeons versus risk model.

BACKGROUND: We compared the abilities of surgeons and of an established risk model to predict operative mortality after aortic valve replacement (AVR), and we investigated scenarios that give rise to discrepancies between these predictions. MATERIALS AND METHODS: We reviewed all AVR procedures performed at a Veterans Affairs institution between 1993 and 2008 (n = 317). The abilities of the Continuous Improvement in Cardiac Surgery Program (CICSP) risk model and of the surgeons to predict operative mortality were assessed by computing the area under the receiver operating characteristic curve (AUC). We investigated cases in which there was a significant discrepancy (2-fold or greater) between the surgeons' and the CICSP model's predictions. RESULTS: The predictive abilities of both the surgeons and the CICSP risk model were good-AUC values were 0.73 and 0.75, respectively (P = 0.84)-but the surgeons' mean estimate of mortality risk (8.3% +/- 8.3%) exceeded both the CICSP model's estimate (6.6% +/- 8.3%) (P < 0.0001) and the actual mortality rate (5.4%). There was significant discrepancy between the two sources of prediction in 38% (122/317) of cases. In this subset of cases, the CICSP did not adjust for factors that influenced risk stratification by the surgeon in 33% (40/122) of cases; the most common of these factors were anticipation of a more extensive procedure, severe pulmonary disease other than chronic obstructive pulmonary disease, hepatic disease, and pulmonary hypertension. CONCLUSIONS: Both surgeons and the CICSP model performed well in risk-stratifying AVR patients, but the surgeons tended to overestimate the risk. The CICSP model did not capture some disease entities considered relevant in estimating mortality by surgeons.

Autonomic cardiovascular dysregulation as a potential mechanism underlying depression and coronary artery bypass grafting surgery outcomes.

BACKGROUND: Coronary artery bypass grafting (CABG) is often used to treat patients with significant coronary heart disease (CHD). To date, multiple longitudinal and cross-sectional studies have examined the association between depression and CABG outcomes. Although this relationship is well established, the mechanism underlying this relationship remains unclear. The purpose of this study was twofold. First, we compared three markers of autonomic nervous system (ANS) function in four groups of patients: 1) Patients with coronary heart disease and depression (CHD/Dep), 2) Patients without CHD but with depression (NonCHD/Dep), 3) Patients with CHD but without depression (CHD/NonDep), and 4) Patients without CHD and depression (NonCHD/NonDep). Second, we investigated the impact of depression and autonomic nervous system activity on CABG outcomes. METHODS: Patients were screened to determine whether they met some of the study's inclusion or exclusion criteria. ANS function (i.e., heart rate, heart rate variability, and plasma norepinephrine levels) were measured. Chi-square and one-way analysis of variance were performed to evaluate group differences across demographic, medical variables, and indicators of ANS function. Logistic regression and multiple regression analyses were used to assess impact of depression and autonomic nervous system activity on CABG outcomes. RESULTS: The results of the study provide some support to suggest that depressed patients with CHD have greater ANS dysregulation compared to those with only CHD or depression. Furthermore, independent predictors of in-hospital length of stay and non-routine discharge included having a diagnosis of depression and CHD, elevated heart rate, and low heart rate variability. CONCLUSIONS: The current study presents evidence to support the hypothesis that ANS dysregulation might be one of the underlying mechanisms that links depression to cardiovascular CABG surgery outcomes. Thus, future studies should focus on developing and testing interventions that targets modifying ANS dysregulation, which may lead to improved patient outcomes.

Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) is becoming increasingly popular for lung resection in some centers. However, the issue of whether VATS or open thoracotomy is better remains controversial. We compared outcomes of open and VATS lobectomy in a national database. METHODS: Using the 2004 and 2006 Nationwide Inpatient Sample database, we identified 13,619 discharge records of patients who underwent pulmonary lobectomy by means of thoracotomy (n = 12,860) or VATS (n = 759). Student's t and chi(2) tests were used to compare the two groups. Multivariable analysis was used to identify independent predictors of outcome measures. RESULTS: The two groups of patients had similar demographics and preoperative comorbidities. They also had similar in-hospital mortality rates (3.1% versus 3.4%; p = 0.67); lengths of stay (9.3 +/- 0.1 versus 9.2 +/- 0.4 days; p = 0.84); hospitalization costs ($23,862 +/- $206 versus $25,125 +/- $1,093; p = 0.16); and rates of wound infection (0.8% versus 1.3%; p = 0.15), pulmonary complications (32.2% versus 31.2%; p = 0.55), and cardiovascular complications (3.4% versus 3.9%; p = 0.43). However, multivariable analysis showed that the VATS group had a significantly higher incidence of intraoperative complications than the thoracotomy group (odds ratio, 1.6; 95% confidence interval, 1.0 to 2.4; p = 0.04). A higher percentage of patients with annual income greater than $59,000 underwent VATS lobectomy than patients with income less than $59,000 (35.7% versus 25.4%; p < 0.0001). CONCLUSIONS: Patients who underwent VATS lobectomy were 1.6 times more likely to have intraoperative complications than patients who underwent open lobectomy. However, short-term mortality, lengths of stay, and hospitalization costs were similar between the two groups of patients. There seems to be a socioeconomic disparity between VATS and open thoracotomy patients.

Clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder as risk factors for in-hospital mortality after coronary artery bypass grafting surgery.

OBJECTIVE: The goal of this study was to examine the effect of clinical depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder on in-hospital mortality after a coronary artery bypass grafting surgery. It is hypothesized that depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder will independently contribute to an increased risk for in-hospital mortality rates after coronary artery bypass grafting surgery. METHODS: We performed a retrospective analysis of the 2006 Nationwide Inpatient Sample database. The Nationwide Inpatient Sample database provides information on approximately 8 million US inpatient stays from about 1000 hospitals. We performed chi(2) and unpaired t tests to evaluate potential confounding group demographic and medical variables. Hierarchic logistic regression was used with forced order entry of depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder. RESULTS: Deceased patients were more likely to have had depression (alive, 24.8%; deceased, 60.3%; P < .001), posttraumatic stress disorder (alive, 13.4%; deceased, 56.1%; P < .001), and cormorbid depression and posttraumatic stress disorder (alive, 7.8%; deceased, 48.5%; P < .001). After adjusting for potential confounding factors, patients with depression (odds ratio, 1.24; 95% confidence interval, 1.02-1.50), posttraumatic stress disorder (odds ratio, 2.09; 95% confidence interval, 1.65-2.64), and comorbid depression and posttraumatic stress disorder (odds ratio, 4.66; 95% confidence interval, 3.46-6.26) had an increased likelihood of in-hospital mortality compared with that seen in patients who were alive. CONCLUSIONS: Two findings were noteworthy. First, depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder are prevalent in patients undergoing coronary artery bypass grafting procedures. Second, depression, posttraumatic stress disorder, and comorbid depression and posttraumatic stress disorder increase the risk of death by magnitudes comparable with well-established physical health risk factors after coronary artery bypass grafting surgery. The implications for clinical practice and future directions are discussed.

Severe aortic stenosis in a veteran population: treatment considerations and survival.

BACKGROUND: We examined factors affecting the choice of surgical versus medical treatment of severe aortic stenosis and evaluated associated patient survival. METHODS: We retrospectively reviewed data from all patients diagnosed with severe aortic stenosis at a Veterans Affairs medical facility between January 1997 and April 2008. RESULTS: Of 345 patients with severe aortic stenosis, 260 (75%) underwent surgical evaluation, and 205 (59%) underwent aortic valve replacement (AVR). The patient's decision to decline surgical referral or AVR (n = 47) and severe comorbidities (n = 34) were the top two reasons for medical treatment rather than AVR. The AVR group was younger (69.5 +/- 9.6 years versus 75.7 +/- 8.6 years; p < 0.001) and had a higher prevalence of symptoms (96% versus 71%; p < 0.001) than the medical group. The medical group had a lower cardiac ejection fraction (0.42 +/- 0.15 versus 0.50 +/- 0.12; p < 0.001) and was less likely to be independent in activities of daily living (64% versus 74%). The AVR group had higher survival rates than the medical patients at 1 year (92% versus 65%), 3 years (85% versus 29%), and 5 years (73% versus 16%; log-rank test p < 0.0001). Valve replacement was independently associated with decreased mortality (hazard ratio, 0.17; 95% confidence interval, 0.10 to 0.27; p < 0.0001). CONCLUSIONS: The management of severe aortic stenosis in veterans is sometimes limited to medical evaluation and treatment. Surgeons should be involved in the complex process of risk assessment, to select patients with severe aortic stenosis who would benefit from the survival advantage associated with AVR.

Predictors of surgical mortality and discharge status after coronary artery bypass grafting in patients 80 years and older.

BACKGROUND: Little is known about the outcomes and predictors of discharge status (DCS) in elderly patients after coronary artery bypass grafting (CABG). METHODS: By using the 2004 Nationwide Inpatient Sample database, we identified 5,731 patients aged 80 years and older who underwent primary isolated CABG. Multivariate logistic regression analyses were used to identify independent predictors of surgical mortality and DCS. RESULTS: The mean patient age was 82.8 +/- 2.5 years. The surgical mortality rate was 7%. Only 21% of patients had a routine hospital discharge; the rest used home health care (27%) or were transferred to a rehabilitation unit or another care facility (45%). Older age, female sex, a higher comorbidity index, and referral from the emergency room were independent predictors of surgical mortality and a nonroutine DCS (P < .05 for all). In addition, DCS was associated with the patients' level of income and the expected payer. CONCLUSIONS: Although patients aged 80 years and older have acceptable CABG-related mortality risk, many of these patients require further specialized care at discharge.