Race and Socioeconomic Disparities in Proximal Aortic Surgery.

BACKGROUND: Substantial socioeconomics-based disparities exist in cardiac surgery. Although there are robust data for revascularization and valve procedures, the effect of race and socioeconomic status on proximal aortic surgery is not well studied. This study analyzed the impact of race and socioeconomic status on in-hospital outcomes after proximal aortic surgery. METHODS: All adult patients who underwent proximal aortic surgery for aortic dissection or thoracic aneurysm from the 2016 to 2018 National Inpatient Sample were included. Primary outcomes included in-hospital mortality and in-hospital composite morbidity (stroke, pulmonary embolus, major bleeding, acute kidney injury, or permanent pacemaker insertion). Adjusted outcomes were assessed with multivariable analysis. RESULTS: A weighted total of 32,895 patients were included; 25,461 (77.4%) classified as White, 3224 (9.8%) Black, 2039 (6.2%) Hispanic, and 2171 (6.6%) other. Black and Hispanic patients had significantly lower median household income, higher proportion of self-pay insurance status, younger age, higher comorbidity burden, and a higher proportion of urgent or emergency procedures compared with White patients. There was no significant difference in observed in-hospital mortality by patient race, but non-White patients had significantly higher composite morbidity. On adjusted analysis, there was no difference in in-hospital mortality, but non-White race was an independent predictor of in-hospital morbidity (adjusted odds ratio, 1.6; 95% CI, 1.4-1.8; P < .001). CONCLUSIONS: Patients of non-White race who undergo proximal aortic surgery have less insurance coverage, more urgent procedures, and a higher comorbidity burden than White patients, disparities that translate to significantly higher morbidity in non-White. A greater focus on nonfatal outcome differentials and improving access to care likely will improve aortic surgery disparities.

Incidence, characteristics, and outcomes of reintervention after mitral transcatheter edge-to-edge repair.

OBJECTIVE: The use of transcatheter edge-to-edge repair (TEER) is growing substantially, and reintervention after TEER by way of repeat TEER or mitral valve surgery (MVS) is increasing as a result. In this nationally representative study we examined the incidence, characteristics, and outcomes of reintervention after index TEER. METHODS: Between July 2013 and November 2017, we reviewed 11,396 patients who underwent index TEER using Medicare beneficiary data. These patients were prospectively tracked and identified as having repeat TEER or MVS. Primary outcomes included 30-day mortality, 30-day readmission, 30-day composite morbidity, and cumulative survival. RESULTS: Among 11,396 patients who underwent TEER, 548 patients (4.8%) required reintervention after a median time interval of 4.5 months. Overall 30-day mortality was 8.6%, 30-day readmission was 20.9%, and 30-day composite morbidity was 48.2%. According to reintervention type, 294 (53.7%) patients underwent repeat TEER, and 254 (46.3%) underwent MVS. Patients who underwent MVS were more likely to be younger and female, but had a similar comorbidity burden compared with the repeat TEER cohort. After adjustment, there were no differences in 30-day mortality (adjusted odds ratio [AOR], 1.26 [95% CI, 0.65-2.45]) or 30-day readmission (AOR, 1.14 [95% CI, 0.72-1.81]). MVS was associated with higher 30-day morbidity (AOR, 4.76 [95% CI, 3.17-7.14]) compared with repeat TEER. Requirement for reintervention was an independent risk factor for long-term mortality in a Cox proportional hazard model (hazard ratio, 3.26 [95% CI, 2.53-4.20]). CONCLUSIONS: Reintervention after index TEER is a high-risk procedure that carries a significant mortality burden. This highlights the importance of ensuring procedural success for index TEER to avoid the morbidity of reintervention altogether.

Benchmarking Outcomes of Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valves.

BACKGROUND: The relative roles for transcatheter and surgical aortic valve replacement (SAVR) for bicuspid aortic valve (AV) stenosis are debated. This study analyzes the 5-year longitudinal outcomes of isolated SAVR in bicuspid vs tricuspid AV patients, particularly in low-risk patients. METHODS: All patients undergoing isolated index SAVR at 1146 United States hospitals in The Society of Thoracic Surgeons (STS) Adult Cardiac database between July 1, 2011, and December 31, 2018, with linkage to Medicare claims, were analyzed. RESULTS: A total of 65,687 patients were analyzed, including of 9131 bicuspid patients (13.9%). Compared with tricuspid patients, bicuspid patients were significantly younger (median 70 vs 74 years, P < .001) with lower Society of Thoracic Surgeons predicted risk of mortality scores (mean 1.6% vs 2.3%, P < .001) and lower risk profile. Risk-adjusted 30-day mortality and major morbidity were similar, but risk-adjusted 5-year mortality was significantly lower in the bicuspid patients (adjusted hazard ratio, 0.72; 95% CI, 0.66-0.77), specifically in low-risk patients (adjusted hazard ratio, 0.69; 95% CI, 0.64-0.76). Additionally, the bicuspid cohort had a lower 5-year readmission risk of heart failure, stroke, bleeding, or other cardiovascular causes (all P < .05). CONCLUSIONS: In this nationally representative study, 30-day mortality was similar, but risk-adjusted 5-year mortality was significantly lower in bicuspid patients undergoing isolated SAVR compared with tricuspid patients, specifically low-risk and normal left ventricular ejection fraction patients. This analysis provides a much-needed 5-year longitudinal national-level benchmark to better inform the discussion of transcatheter vs SAVR in bicuspid patients.

Contemporary socioeconomic-based disparities in cardiac surgery: Are we closing the disparities gap?

OBJECTIVE: Female sex and lower income residence location are associated with worse health care outcomes. In this study we analyzed the national, contemporary status of socioeconomic disparities in cardiac surgery. METHODS: Adult patients within the Nationwide Readmissions Database who underwent coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), mitral valve (MV) replacement, MV repair, or ascending aorta surgery from 2016 to 2018 were included. Sex and median household income quartile (MHIQ) were compared within each surgery group. Primary outcome was 30-day mortality. Multivariable analysis was adjusted for patient characteristics and hospital-level factors. RESULTS: A weighted total of 358,762 patients were included. Fewer women underwent CABG (22.3%), SAVR (32.2%), MV repair (37.5%), and ascending aorta surgery (29.7%). In adjusted analysis, female sex was independently associated with higher 30-day mortality rates after CABG (adjusted odds ratio [aOR], 1.6), SAVR (aOR, 1.4), MV repair (aOR, 1.8), and ascending aorta surgery (aOR, 1.2; all P < .03). The lowest MHIQ was independently associated with higher 30-day mortality rates after CABG (aOR, 1.4), SAVR (aOR, 1.5), MV replacement (aOR, 1.3), and ascending aorta surgery (aOR, 1.8; all P < .004) compared with the highest quartile. Women were less likely to receive care at urban and academic hospitals for CABG compared with men. Patients of lower MHIQ received less care at urban and academic institutions for all surgeries. CONCLUSIONS: Despite advances in the techniques and safety, women and patients of lower socioeconomic status continue to have worse outcomes after cardiac surgery. These persistent disparities warrant the need for root cause analysis.

Nationally Representative Repeat Transcatheter Aortic Valve Replacement Outcomes: Report From the Centers for Medicare and Medicaid Services.

OBJECTIVES: The aim of this study was to examine real-world experience with repeat transcatheter aortic valve replacement (TAVR) in a population-based national database. BACKGROUND: Repeat TAVR is a growing option in patients requiring reintervention for TAVR. However, large-scale studies with longitudinal follow-up are limited. METHODS: All Medicare beneficiaries who underwent TAVR from 2012 to 2017 were included. Outcomes included 30-day and longitudinal mortality and major adverse cardiovascular events, defined as death, stroke, pacemaker insertion, major bleeding, acute kidney injury, or cardiac arrest. Outcomes of repeat TAVR were compared with surgical explantation after TAVR (TAVR explantation) in a matched analysis. RESULTS: Of 133,250 patients who underwent TAVR, 617 (0.46%) underwent subsequent repeat TAVR at a median interval of 154 days (interquartile range: 58-537 days). Mortality at 30 days and 1 year was 6.0% and 22.0%, respectively. Rates of 30-day stroke and pacemaker insertion were 1.8% and 4.2%. Mortality at 30 days was lower in those who underwent their first TAVR during the later era (2015-2017) compared with earlier years (2012-2014) (4.6% vs 8.7%; P = 0.049). Repeat TAVR was associated with lower 30-day mortality compared with a matched group undergoing TAVR explantation (6.2% vs 12.3%; P = 0.05), although 1-year mortality was similar (21.0% vs 20.8%; P = 1.000). The incidence of 30-day major adverse cardiovascular events was higher with TAVR explantation compared with repeat TAVR (risk ratio: 2.92; 95% CI: 1.88-4.99; P ≤ 0.001). CONCLUSIONS: Repeat TAVR was performed with acceptable 30-day mortality in this high-risk population. Short-term outcomes were superior to surgical explantation, but 1-year outcomes were similar. Repeat TAVR will likely be an important option for aortic valve reintervention after TAVR.

Association of the hospital readmission reduction program with readmission and mortality outcomes after coronary artery bypass graft surgery.

The Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP) to reduce payments to hospitals with excessive readmissions in an effort to link payment to the quality of hospital care. Prior studies demonstrating an association of HRRP implementation with increased mortality after heart failure discharges have prompted concern for potential unintended adverse consequences of the HRRP. We examined the impact of these policies on coronary artery bypass graft (CABG) surgery outcomes using the Nationwide Readmissions Database and found that, in line with previously observed readmission trends for CABG, readmission rates continued to decline in the era of the HRRP, but that this did not come at the expense of increased mortality. These results suggest that inclusion of surgical procedures, such as CABG in the HRRP might be an effective cost-reducing measure that does not adversely affect quality of hospital care.