Outcomes After Left Atrial Appendage Clip Placement During Cardiac Surgery: A Nationwide Analysis.

This study evaluated the nationwide associations between concomitant left atrial appendage clip (LAAC) placement during cardiac surgery and postoperative outcomes. We identified 1,260,999 patients who underwent coronary artery bypass grafting, valve, and aortic surgeries in the 2016 to 2020 Nationwide Readmissions Database and stratified by concomitant LAAC versus no LAAC placement. Patients who underwent surgical ablation were excluded. Mortality and complications were compared during index admissions and for patients readmitted within 30 and 90 days of the index discharge date for unmatched and propensity score-matched groups. Overall, 6.7% (84,293) of patients underwent cardiac surgery and concomitant LAAC placement without surgical ablation. After propensity score matching, the index admission mortality and overall complications were not different in patients with LAAC versus patients without LAAC. LAAC placement was associated with increased any-cause 30-day readmissions (15% vs 13%, p <0.01). In patients with LAAC, within 30 days, there were no differences in mortality (3.9% vs 3.8%, p = 0.60) or overall complications (64% vs 63%, p = 0.20), whereas stroke was lower (5.3% vs 6.5%, p <0.01) and heart failure was higher (35% vs 30%, p <0.01). For patients readmitted within 90 days, similar findings were observed for any-cause readmissions, mortality, overall complications, stroke, and heart failure. In conclusion, concomitant LAAC placement during cardiac surgery was associated with lower early postdischarge incidence of stroke and a favorable overall risk-benefit profile. Given these short-term findings in a real-world population of all patients who underwent cardiac surgery, longer-term studies with more granular data are needed to evaluate the potential benefit of this practice.

Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery.

OBJECTIVE: An increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. METHODS: From January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non-long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan-Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. RESULTS: Of 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non-long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan-Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. CONCLUSIONS: Patients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.

Trends in surgical ablation at the time of cardiac surgery among patients with atrial fibrillation.

Background: The 2017 American Association for Thoracic Surgery (AATS) guidelines support surgical ablation in patients undergoing cardiac surgery with preoperative atrial fibrillation (AF) owing to a reduction in early mortality and improved overall safety. We explored practice patterns changes and outcomes in patients undergoing concomitant surgical ablation following the guideline change. Methods: We identified 19,246 patients with preoperative AF who underwent cardiac surgery between 2016 and 2019 from the Florida and Maryland State Inpatient Databases. Rates of surgical ablation by procedure type were temporally trended across years. Secondary outcomes included complications, inpatient mortality, and hospital readmissions. Using multivariable logistic regression, we identified patient variables associated with concomitant surgical ablation. Results: A total of 2738 patients (14.3%) with AF underwent a concomitant surgical ablation. The rate of surgical ablation increased from 2.1% to 17.4% (P < .001) from 2016 to 2017 but remained unchanged thereafter. Postoperative mortality was lower in the surgical ablation cohort (2.7% vs 3.7%; P = .006), although with a higher rate of pacemaker insertion (11.8% vs 7.2%; P < .0001). Patients with a high-risk Elixhauser score (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.73-0.95), lower income (OR, 0.66; 95% CI, 0.57-0.75), or African American or Hispanic race/ethnicity (OR, 0.80; 95% CI, 0.67-0.96 and OR, 0.82; 95% CI, 0.71-0.96, respectively) had lower odds of undergoing concomitant surgical ablation. Conclusions: Despite a class I-2a recommendation by the AATS, surgical ablation continues to be underutilized in clinical practice, especially in patients with high-risk comorbidities, with lower incomes, or from minority populations. Surgeons should be mindful of guideline-directed AF management in these vulnerable populations.

Weight Bias: Examining Achalasia Therapy in the Obese Patient.

We hypothesize that obesity is a common diagnosis in those with achalasia at our institution but time to diagnosis and treatment is longer compared to normal weight counterparts due to implicit bias. We retrospectively reviewed all adult patients between 1/1/2013 and 6/31/2020 with a diagnosis of achalasia. Demographics, comorbidities, Eckardt scores, interventions, complications, time to consult, duration of symptoms, and follow-up were evaluated. More than half of the patients were seen in the most recent 2 years following POEM introduction and 138 had available BMI data. 46 were obese (33%) and 92 were non-obese (67%). Obese patients reported a shorter duration of symptoms prior to seeking treatment 12 versus 24 months. There was no difference in time to intervention or procedure offered. There was a non-significant trend toward higher leak (11 vs 5%) and overall complication rate (19 vs 17%) in obese patients. In follow-up 98 patients had BMI data. There was a a significant difference in mean BMI change -1.2 +/- 4.2 kg/m2 in obese patients and +0.1 +/- 2.1 kg/m2 in normal weight patients. One year follow-up was available in 16 (47%) obese and 25 (33%) non-obese patients and showed a non-significant trend toward greater weight gain in the normal/overweight group (+3.2 +/- 1.1 kg/m2) compared to obese (+2.0 +/- 3.5 kg/m2). Obese patients with achalasia have unique considerations. Duration of symptoms may be shorter in the obese patient with esophageal dysphagia. We noted trends toward greater weight gain following interventions in non-obese patients with equivalent complication rates.

Elevated plasma endothelin-1 is associated with reduced weight loss post vertical sleeve gastrectomy.

BACKGROUND: Obesity and insulin resistance are positively correlated with plasma endothelin-1 (ET-1) levels; however, the mechanisms leading to increased ET-1 are not understood. Similarly, the full physiological complexity of ET-1 has yet to be described, especially in obesity. To date, one of the best treatments available for morbid obesity is bariatric surgery to quickly reduce body fat and the factors associated with obesity-related disease; however, the effects of vertical sleeve gastrectomy (SG) on plasma ET-1 have not been described. OBJECTIVES: To determine if SG will reduce plasma ET-1 levels and to determine if plasma ET-1 concentration is associated with weight loss after surgery. SETTING: The studies were undertaken at a University Hospital. METHODS: This was tested by measuring plasma ET-1 levels from 12 obese patients before and after SG. All data were collected from clinic visits before SG, 6 weeks after SG, and 6 months after surgery. RESULTS: At 6 weeks after SG, plasma ET-1 levels increased by 24%; however, after 6 months, there was a 27% decrease compared with presurgery. Average weight loss in this cohort was 11.3% ± 2.4% body weight after 6 weeks and 21.4% ± 5.7% body weight after 6 months. Interestingly, we observed an inverse relationship between baseline plasma ET-1 and percent body weight loss (R2 = .49, P = .01) and change in body mass index 6 months (R2 = .45, P = .011) post bariatric surgery. CONCLUSIONS: Our results indicate that SG reduces plasma ET-1 levels, a possible mechanism for improved metabolic risk in these patients. These data also suggest that ET-1 may serve as a predictor of weight loss after bariatric surgery.