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.

Social media forensics applied to assessment of post-critical incident social reaction: The case of the 2017 Manchester Arena terrorist attack.

Forensic science is constantly evolving and transforming, reflecting the numerous technological innovations of recent decades. There are, however, continuing issues with the use of digital data, such as the difficulty of handling large-scale collections of text data. As one way of dealing with this problem, we used machine-learning techniques, particularly natural language processing and Latent Dirichlet Allocation (LDA) topic modeling, to create an unsupervised text reduction method that was then used to study social reactions in the aftermath of the 2017 Manchester Arena bombing. Our database was a set of millions of messages posted on Twitter in the first 24 h after the attack. The findings show that our method improves on the tools presently used by law enforcement and other agencies to monitor social media, particularly following an event that is likely to create widespread social reaction. For example, it makes it possible to track different types of social reactions over time and to identify subevents that have a significant impact on public perceptions.

Distressed communities are associated with worse outcomes after coronary artery bypass surgery.

OBJECTIVES: Although low socioeconomic status has been associated with increased risk of complications after cardiac surgery, analyses have typically focused on insurance status, race, or median income. We sought to determine if the Distressed Communities Index, a composite socioeconomic metric, could predict operative mortality after coronary artery bypass grafting. METHODS: All patients who underwent isolated coronary artery bypass grafting (2011-2018) in the National Society of Thoracic Surgeons adult cardiac surgery database were analyzed. Clinical data were paired with the Distressed Communities Index, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies by ZIP code. Developed by the Economic Innovation Group, Distressed Communities Index scores range from 0 (no distress) to 100 (severe distress). A distressed community was defined as one having a Distressed Communities Index of 75 or greater for univariate analyses. RESULTS: Of the 575,900 patients undergoing coronary artery bypass grafting with a Distressed Communities Index score, the median age was 65 years. The operative mortality rate was 2.0%, and the composite morbidity or mortality rate was 11.5%. Distressed communities were associated with increased Society of Thoracic Surgeons predicted risk of mortality (1.97% vs 1.85%, P < .0001) and risk of composite morbidity or mortality (12.8% vs 11.7%, P < .0001). After adjusting for Society of Thoracic Surgeons risk model, the Distressed Communities Index remained significantly associated with mortality (odds ratio, 1.12; P < .0001) and composite morbidity and mortality (odds ratio, 1.03; P = .002). CONCLUSIONS: Patients from distressed communities are at increased risk for adverse events and death after coronary artery bypass grafting. The Distressed Communities Index is a useful, holistic measure of socioeconomic status that may help identify high-risk patients for quality improvement and should be considered when building risk models or comparing hospitals.

Assessment of erythrocyte damage and in-line pressure changes associated with simulated transfusion of canine blood through microaggregate filters.

OBJECTIVE: To determine whether passage of whole blood through a microaggregate filter by use of a syringe pump would damage canine erythrocytes. SAMPLE: Blood samples obtained from 8 healthy client-owned dogs. PROCEDURES: Whole blood was passed through a standard microaggregate filter by use of a syringe pump at 3 standard administration rates (12.5, 25, and 50 mL/h). Prefilter and postfilter blood samples were collected at the beginning and end of a simulated transfusion. Variables measured at each time point included erythrocyte osmotic fragility, mean corpuscular fragility, RBC count, hemoglobin concentration, RBC distribution width, and RBC morphology. In-line pressure when blood passed through the microaggregate filter was measured continuously throughout the simulated transfusion. After the simulated transfusion was completed, filters were visually analyzed by use of scanning electron microscopy. RESULTS: Regardless of administration rate, there was no significant difference in mean corpuscular fragility, RBC count, hemoglobin concentration, or RBC distribution width between prefilter and postfilter samples. Additionally, there were no differences in in-line pressure during the simulated transfusion among administration rates. Echinocytes were the erythrocyte morphological abnormality most commonly observed at the end of the transfusion at administration rates of 12.5 and 25 mL/h. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggested that regardless of the administration rate, the microaggregate filter did not alter fragility of canine RBCs, but may have altered the morphology. It appeared that the microaggregate filter would not contribute to substantial RBC damage for transfusions performed with a syringe pump.

Geographically Derived Socioeconomic Factors to Improve Risk Prediction in Patients Having Aortic Valve Replacement.

Socioeconomic status (SES) has been associated with adverse outcomes after cardiac surgery, but is not included in commonly applied risk adjustment models. This study evaluates whether inclusion of SES improves aortic valve replacement (AVR) risk prediction models, as this is the most common elective operation performed at our institution during the study period. All patients who underwent AVR at a single institution from 2005 to 2015 were evaluated. SES measures included unemployment, poverty, household income, home value, educational attainment, housing density, and a validated SES index score. The risk scores for mortality, complications, and increased length of stay were generated using models published by the Society for Thoracic Surgeons. Univariate models were fitted for each SES covariate and multivariable models for mortality, any complication, and prolonged length of stay (PLOS). A total of 1,386 patients underwent AVR with a 2.7% mortality, 15.1% complication rate, and 9.7% PLOS. In univariate models, higher education was associated with decreased mortality (odds ratio [OR] 0.96, p = 0.04) and complications (OR 0.97, p <0.01). Poverty was associated with increased length of stay (OR 1.02, p = 0.02). In the multivariable models, the inclusion of SES covariates increased the area under the curve for mortality (0.735 to 0.750, p = 0.14), for any complications (0.663 to 0.680, p <0.01), and for PLOS (0.749 to 0.751, p = 0.12). The inclusion of census-tract-level socioeconomic factors into the the Society of Thoracic Surgeons risk predication models is new and shows potential to improve risk prediction for outcomes after cardiac surgery. With the possibility of reimbursement and institutional ranking based on these outcomes, this study represents an improvement in risk prediction model.

Insurance status is associated with acuity of presentation and outcomes for thoracic aortic operations.

BACKGROUND: Nonelective procedure status is the greatest risk factor for postoperative morbidity and mortality in patients undergoing thoracic aortic operations. We hypothesized that uninsured patients were more likely to require nonelective thoracic aortic operation due to decreased access to preventative care and elective surgical services. METHODS AND RESULTS: An observational study of the Society of Thoracic Surgeons Database identified 51 282 patients who underwent thoracic aortic surgery between 2007 and 2011 at 940 North American centers. Patients were stratified by insurance status (private insurance, Medicare, Medicaid, other insurance, or uninsured) as well as age <65 or ≥65 years to account for differences in Medicare eligibility. The need for nonelective thoracic aortic operation was highest for uninsured patients (71.7%) and lowest for privately insured patients (36.6%). The adjusted risks of nonelective operation were increased for uninsured patients (adjusted risk ratio, 1.77; 95% confidence interval, 1.70-1.83 for age <65 years; adjusted risk ratio, 1.46; 95% confidence interval, 1.29-1.62 for age ≥65 years) as well as Medicaid patients aged <65 years (adjusted risk ratio, 1.18; 95% confidence interval, 1.10-1.26) when compared with patients with private insurance. The adjusted risks of major morbidity or mortality were further increased for all patients aged <65 years without private insurance (adjusted risk ratios between 1.13 and 1.27). CONCLUSIONS: Insurance status was associated with acuity of presentation and major morbidity and mortality for thoracic aortic operations. Efforts to reduce insurance-based disparities in the care of patients with thoracic aortic disease seem warranted and may reduce the incidence of aortic emergencies and improve outcomes after thoracic aortic surgery.