Effect of Hospital Volume on Outcome of Extracorporeal Membrane Oxygenation Support　- Nationwide Population-Based Cohort Study in Taiwan.

BACKGROUND: In modern critical care, extracorporeal membrane oxygenation (ECMO) is crucial in the management of severe respiratory and cardiac failure. Nationwide studies of the relationship between hospital volume and outcomes of ECMO use are unavailable.Methods and Results: Using Taiwan's National Health Insurance Research Database, we identified 11,734 adult patients who received ECMO support in 101 hospitals between January 1, 2001, and December 31, 2017. Outcomes included in-hospital mortality, 1-year mortality, and ECMO-related complications. Cox proportional hazards model, locally estimated scatterplot smoothing, and restricted cubic spline regression were used to analyze the volume-outcome relationship. The overall in-hospital mortality rate was 65.5%, and the 1-year mortality rate was 70.6% in this database. The 101 hospitals were divided into 4 groups based on annual volume. The in-hospital and 1-year mortality rates were significantly lower in the high-volume group (annual volume >40) than in the low-volume group (annual volume <10). CONCLUSIONS: For critical care, high-volume hospitals have superior short-term and mid-term outcomes. To make the medical system equitable and reasonable, establishing a rapid and efficient nationwide referral system should be considered.

Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience.

BACKGROUND: Repair of acute type A aortic dissection (ATAAD) is a complex and emergent cardiovascular surgery that is associated with high perioperative morbidity and mortality. Each cannulation strategy has different benefits and drawbacks during cardiopulmonary bypass. Using a retrospective study design, we aimed to clarify the safety and efficacy of right axillary artery cannulation in combination with femoral artery cannulation compared to single arterial cannulation for ATAAD repair. METHODS: From January 2007 to July 2017, 476 adult patients underwent ATAAD repair at a single institution. Patients were classified into groups according to their cannulation strategy: the double arterial cannulation (DAC) group (n = 377; 79.2%) or single arterial cannulation (SAC) group (n = 99; 20.8%). Preoperative demographics, surgical information, and postoperative recovery were compared between both groups. Survival and freedom from reoperation rates were analyzed using the Kaplan-Meier actuarial method. RESULTS: Demographics, comorbidities, and surgical procedures were generally homogenous between the two groups, except for sex, age, and rate of extensive aortic repair. Patients who underwent DAC had lower in-hospital mortality (13.5% vs. 25.3%; P = 0.005) and lower incidence of malperfusion-related complications (18.8% vs. 30.3%; P = 0.011) than those who underwent SAC. During multivariate analysis, SAC was identified as an in-hospital mortality predictor (odds ratio, 2.81; 95% confidence interval, 1.52-5.17; P = 0.001), as were preoperative ventilator support, intraoperative extracorporeal membrane oxygenation installation, and postoperative malperfusion-related complications. Three-year cumulative survival and freedom from reoperation rates were 74.8% and 85.3% for the DAC group and 62.6% and 81.1% for the SAC group, respectively (P = 0.010 and 0.430, respectively). CONCLUSIONS: With acceptable short- and mid-term outcomes, DAC is effective and safe for establishing cardiopulmonary bypass during ATAAD repair.

The Prognostic Scoring System Establishment and Validation for Chronic Atrial Fibrillation Patients Receiving Modified Cox-Maze IV and Concomitant Cardiac Surgery.

OBJECTIVES: Traditional Cox maze III is the gold standard for treatment of atrial fibrillation (AF). Because of its invasiveness, it has been replaced by a simplified procedure involving radiofrequency ablation of modified Cox maze IV. Although the modified Cox maze IV has the advantages of simplicity and less morbidity, a lower rate of sinus rhythm conversion has been reported. We try to establish a scoring system to predict the outcome of this procedure. METHODS AND RESULTS: The derivation group consisted of 287 patients with structural heart disease and chronic AF who underwent cardiac surgery and modified Cox-maze IV procedure between August 2005 and March 2013. Demographics, clinical and laboratory variables were retrospectively collected as sinus conversional predictors. Overall sinus conversion rate was 75.8%. The parameters of the Soft Markers Scoring system included AF duration, preoperative left atrial (LA) size, rheumatic pathology and postoperative LA remodeling. We compared 80 patients from another hospital between January 2004 and December 2011 as a validation group to evaluate the power of the scoring system. Soft Markers Score indicated a good discriminative power by using the areas under the receiver operating characteristic curve (AUROC: 0.759 ± 0.032). The score was further divided into three groups: low (0-2), intermediate (3-5), and high (6-10), with predicted sinus conversion rates of 92.4%, 74.2%, and 47.8%, respectively. CONCLUSIONS: In patients with chronic AF receiving modified Cox-maze IV procedure, the Soft Markers Score demonstrated good discriminative power of predicting sinus recovery in our patients and applied well to the other validation populations.

Prognosis of patients with acute respiratory distress syndrome on extracorporeal membrane oxygenation: the impact of urine output on mortality.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, including life-threatening respiratory failure and postcardiotomy cardiogenic shock. This study analyzed the outcomes of patients with acute respiratory distress syndrome (ARDS) treated by ECMO and identified the relationship between prognosis and urine output (UO) obtained on the first day of ECMO support. METHODS: This study reviewed the medical records of 81 ARDS patients after ECMO support on a specialized cardiovascular surgery intensive care unit of a tertiary care university hospital between May 2006 and December 2011. Demographic, clinical, and laboratory variables were retrospectively collected as survival predictors. RESULTS: The overall mortality rate was 55.5%. A multiple logistic regression analysis indicated that the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, mean arterial pressure, platelet count, and UO on day 1 of ECMO support were independent risk factors for hospital mortality. By using the areas under the receiver operating characteristic (AUROC) curve, UO obtained on the first day of ECMO support demonstrated good discriminative power (AUROC 0.754 ± 0.056, p < 0.001). Urine output had the best discriminative power, the best Youden index, and the highest overall correctness of prediction. Cumulative survival rates at the 6-month follow-up differed significantly (p < 0.001) for UO 1,432 mL or greater on day 1 of ECMO support versus those with UO less than 1,432 mL on day 1 of ECMO support. CONCLUSIONS: In ARDS patients receiving ECMO support, UO obtained on the first day of ECMO support showed good prognostic ability in predicting hospital mortality.