Coronary Endarterectomy: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

BACKGROUND: Coronary endarterectomy (CE) is an uncommon and often unplanned technique used to approach difficult targets during coronary artery bypass grafting (CABG). We evaluated the outcomes of CABG with CE (CE-CABG) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. METHODS: All isolated, first-time, elective or urgent CABG cases from July 2011 to September 2019 in the Adult Cardiac Surgery Database were retrospectively reviewed. Because of a higher risk profile in the patients undergoing CE-CABG, we performed propensity score matching. Primary outcomes included operative mortality and postoperative myocardial infarction. For patients ≥65 years, long-term mortality and rehospitalization were evaluated using linked data from Centers for Medicare and Medicaid Services. RESULTS: Of the total 1 111 792 patients included, 32 164 (2.9%) had CE-CABG and 1 079 628 (97.1%) underwent CABG alone. The majority of CE-CABG involved a single-vessel endarterectomy (86.9%; n = 27 945); the left anterior descending was most common (40.9%; n = 13 161). Compared with propensity score-matched CABG, CE-CABG had increased operative mortality (3.2% vs 1.7%; P < .0001; odds ratio, 1.81; 95% CI, 1.63-2.01) and postoperative myocardial infarction (6.8% vs 3.9%; P < .0001; odds ratio, 1.80; 95% CI, 1.68-1.93). CE-CABG had higher risk of mortality in the first year and rehospitalization for myocardial infarction in the first 3 years but was comparable to CABG alone thereafter. Subgroup analysis showed no difference between CE-CABG of the left anterior descending compared with CE-CABG of other coronary arteries. CONCLUSIONS: This analysis demonstrates that CE-CABG has acceptable long-term outcomes and serves as a benchmark for what can be expected when this rare procedure is used.

Populational Perceptions Regarding Decision to Visit the Emergency Room with Chest Pain During COVID-19.

INTRODUCTION: A significant decrease in emergency presentations of acute cardiac conditions has been observed during the COVID-19 pandemic. We aimed to understand perceptions that influence people's decisions whether to present to the emergency department (ED) with symptoms related to acute cardiovascular events to inform necessary medical communication. METHODS: We recruited users of Amazon Mechanical Turk (Seattle, WA) to participate in a survey to elucidate perceptions of COVID-19 risk associated with a visit to the ED. A conjoint analysis was designed based on commonly reported factors associated with people's decisions to present to the ED during the pandemic to calculate preference utilities. RESULTS: After exclusions, 1003 participants completed the survey between 12/5/2020 and 12/6/2020. Participants ranked the perceived risk of contracting COVID-19 at the ED as one of the highest, only second to that at bars and restaurants. Only 68% (685/1003) were willing to present to the ED immediately with severe chest pain. Fear of further transmitting the virus to loved ones was the most frequently cited reason for not presenting. Conjoint analysis demonstrated severe chest pain to be the dominant factor in the decision to present to the ED. CONCLUSIONS: The risk of contracting COVID-19 while presenting to the ED for a life-threatening cardiovascular symptom is overestimated and is strongly affected by social factors.

Volume of frail patients predicts outcome in frail patients after cardiac surgery.

OBJECTIVE: Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery. METHODS: We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. RESULTS: In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. CONCLUSIONS: In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.

Nationwide Analysis of 30-Day Readmissions After Esophagectomy: Causes, Costs, and Risk Factors.

BACKGROUND: Postsurgical readmissions are an increasingly scrutinized marker of health care quality. We sought to estimate the rate, risk factors, causes, and costs associated with readmissions after esophagectomy in a large, nationally representative cohort. METHODS: We studied patients from the Nationwide Readmissions Database undergoing esophagectomy from 2010 to 2014. Data were collected on the prevalence and indications for readmission within 30 days as well as the hospital-, procedure-, and patient-level risk factors as determined by multivariable logistic regression. RESULTS: Among 13,282 cases, the rate of 30-day readmission was 19.4%, with the most common indications for readmission being pulmonary (20.6%) and gastrointestinal complications (20%). Median cost of readmission was $9660 (interquartile range, $5392 to $20,447), and pulmonary complications accounted for the greatest total cost burden at 25.8% of all readmission-related costs. Independent risk factors for readmission on multivariable analysis included perioperative blood transfusion (adjusted odds ratio [AOR] 1.33; 95% confidence interval [CI], 1.08 to 1.65; P = .008), discharge to a nursing facility (AOR 1.83; 95% CI, 1.41 to 2.39; P < .001), high illness severity based on All Patients Refined Diagnosis-Related Groups scoring (AOR 1.49; 95% CI, 1.21 to 1.84; P < .001), chronic renal failure (AOR 1.61; 95% CI, 1.13 to 2.29; P = .009), and comorbid drug abuse (AOR 2.19; 95% CI, 1.08 to 4.41; P = .029). CONCLUSIONS: Nearly 1 in 5 patients undergoing esophagectomy are readmitted within 30 days of discharge, at a median cost of $9660 per readmission. Pulmonary complications account for the greatest number of readmissions and the greatest total cost burden. Targeting the causes of readmission, especially pulmonary causes, may help significantly reduce the total morbidity and health care costs associated with esophagectomy.

Causes, Risk Factors, and Costs of 30-Day Readmissions After Mitral Valve Repair and Replacement.

BACKGROUND: Postsurgical readmissions are an increasingly scrutinized marker of health care quality. We sought to estimate the risk factors and costs associated with readmissions after mitral valve (MV) surgery in a large, nationally representative cohort. METHODS: Adult patients undergoing MV repair or replacement were queried from the National Readmissions Database from 2010 to 2014. Data were collected on the prevalence and indications for readmission within 30 days as well as the hospital-, procedure, and patient-level risk factors as determined by multivariable logistic regression. RESULTS: Among 76,342 patients undergoing MV surgery, the rate of 30-day readmission was 17.0%. Those undergoing replacement procedures had significantly higher readmission rates (20.7% vs 13.1%; P < .001) compared with repair. Significant independent predictors of readmission after both MV repair and replacement included length of stay ≥8 days, chronic lung disease, chronic renal disease, and low hospital procedural volume for MV surgery. Readmissions to nonindex hospitals accounted for 26.6% of all readmissions. The most common indications for readmission were heart failure (21.4%), arrhythmia (17.0%) and respiratory diagnoses (15.0%), and infections (10.2%). The mean cost per readmission was $15,397, and among readmitted patients, the cost of readmission accounted for 17.8% of the total cost of the episode of care. CONCLUSIONS: Nearly 1 in 5 patients undergoing MV surgery are readmitted within 30 days. Treatment at a low-volume center was strongly associated with readmission, and much of the readmission burden falls on nonindex hospitals. Further characterization of readmissions may improve the quality of care associated with MV surgery.

Recipient working status is independently associated with outcomes in heart and lung transplantation.

Employment status may capture elements of patients' physical strength, mental resilience, and socioeconomic status to better prognosticate transplant outcomes. This study characterized the effect of working status on thoracic transplant outcomes by evaluating the United Network for Organ Sharing registry for adult lung or heart transplants from 2005 to 2016. Kaplan-Meier estimates illustrated 5-year and 10-year survival by working status at transplant, while multivariable Cox proportional hazards regressions controlled for baseline differences, including functional and socioeconomic status. Of 17 778 lung transplant recipients, 1700 (9.6%) worked at transplant and experienced significantly lower 5-year mortality than nonworking recipients (38.6% vs 45.5%, P < 0.001). Of 21 394 heart transplant recipients, 1289 (6.0%) were employed and experienced significantly lower 10-year mortality than nonworking recipients (34.1% vs 40.2%, P < 0.001). Adjusted Cox regressions demonstrated that employment significantly reduced mortality independent of functional status for both lung (HR: 0.86 [0.78-0.95], P = 0.003) and heart (HR: 0.84 [0.72-0.97], P = 0.023) recipients. After accounting for insurance status, the effect of working status persisted only in lung transplantation (HR: 0.89 [0.81-0.98], P = 0.023). Since heart and lung transplant candidates employed at transplant face lower long-term mortality, working status must encompass a broad set of physical, psychological, and socioeconomic variables that may prognosticate post-transplant outcomes.

Assessment of Differential Pressures in Chest Drainage Systems: Is What You See What You Get?

BACKGROUND: Dry-suction chest drainage systems are used to achieve proper drainage of the pleural space after cardiothoracic operations. Data on the actual intrapleural pressure during the use of these systems is lacking. The present study was performed to evaluate pressure differences across the circuit using an ex vivo model. METHODS: An ex vivo apparatus coupled to a hospital-grade pleural drainage system was devised to provide calibrated levels of suction and air leak. Simultaneous pressure measurements were obtained at the system outlet and the simulated patient entry site. Trials were conducted with increasing levels of water between the patient and drainage modules at various levels of suction and leak pressures. Signals were recorded at 100 Hz and analyzed using two-way ANOVA. RESULTS: With no obstruction, the drainage system provided precise levels of negative pressure at the patient level (10-40 cm H2O). Addition of fluid in the drainage tubing caused significant differences in transmitted suction (P < 0.001). With increasing air leakage and fluid volume, the pressure differential between the system and patient increased significantly (1.14 to 36.69 cm H2O, P < 0.001). In the off-suction setting, increasing levels of obstruction to 22 cm of water led to development of positive intrapleural pressures (2.6 to 11.1 cm H2O, P < 0.001). CONCLUSIONS: While commercially available chest drainage systems are able to provide predictable levels of suction at the device, intrapleural pressures can be highly variable and depend on complete patency of connecting tubes. Systems capable of modulating the level of suction based on actual intrapleural pressures may enhance recovery after procedures requiring tube thoracotomy.

Lung transplantation in the Lung Allocation Score era: Medium-term analysis from a single center.

In 2005, the Lung Allocation Score (LAS) was implemented as the allocation system for lungs in the US. We sought to compare 5-year lung transplant outcomes before and after the institution of the LAS. Between 2000 and 2011, 501 adult patients were identified, with 132 from January 2000 to April 2005 (Pre-LAS era) and 369 from May 2005 to December 2011 (Post-LAS era). Kruskal-Wallis or chi-squared test was used to determine significance between groups. Survival was censored at 5 years. Overall, the post-LAS era was associated with more restrictive lung disease, higher LAS scores, shorter wait-list times, more preoperative immunosuppression, and more single lung transplantation. In addition, post-LAS patients had higher O2 requirements with greater preoperative pulmonary impairment. Postoperatively, 30-day mortality improved in post-LAS era (1.6% vs 5.3%, P = .048). During the pre- and post-LAS eras, 5-year survival was 52.3% and 55.3%, respectively (P = .414). The adjusted risk of mortality was not different in the post-LAS era (P = .139). Freedom from chronic lung allograft dysfunction was significantly higher in the post-LAS era (P = .002). In this single-center report, implementation of the LAS score has led to allocation to sicker patients without decrement in short- or medium-term outcomes. Freedom from CLAD at 5 years is improving after LAS implementation.

The In-Hospital Cost of Ventricular Assist Device Therapy: Implications for Patient Selection.

Ventricular assist device (VAD) therapy is increasingly utilized to support patients in end-stage heart failure. However, VAD programs are resource intensive and demand active monitoring to ensure long-term sustainability. The purpose of this study was to analyze total cost trends of the VAD program at our academic medical center. Retrospective analysis of University of California - Los Angeles's VAD program between 2013 and 2014 was performed. Total in-hospital costs from the date of VAD surgery admission were queried and normalized to a z score. Multivariable linear regression analysis with step-wise elimination was used to model total costs. Overall, 42 patients received a VAD during the study period, with 19 (45%) receiving biventricular support. On univariate analysis, high body mass index, biventricular support, time between VAD implantation and discharge, and total length of hospital stay were correlated with higher costs (all p < 0.02). On multivariable analysis, time between VAD implantation and discharge and biventricular support remained significantly related to total costs (overall R = 0.831, p < 0.001). The time between VAD implantation and discharge and the use of biventricular support were the most predictive factors of total cost in our VAD population. Reducing hospital stay post-VAD implantation is important in minimizing the cost of VAD care.