Coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention: Meds Matter: Impact of Adherence to Medical Therapy on Comparative Outcomes.

BACKGROUND: Multiple studies have compared coronary artery bypass graft (CABG) with percutaneous coronary interventions (PCI) for coronary revascularization. There is considerable evidence that adherence to medical therapy can affect the outcomes of therapeutic interventions. However, the long-term influence of compliance with recommended medical therapy on the comparative outcomes of CABG versus PCI remains to be defined. METHODS: All non-ST-segment-elevation myocardial infarction patients undergoing coronary revascularization in an 8-hospital network were followed for up to 8 years to determine medication history and major adverse cardiac events: all-cause mortality, nonfatal myocardial infarction, and reintervention. All mortalities were checked against the Social Security Death Index. Survival curves were derived with Kaplan-Meier methods; hazard ratios were calculated with the Cox proportional hazard model; and propensity score matching was used to account for differences in patient selection. RESULTS: Among the 973 CABG and 2255 PCI patients, Kaplan-Meier major adverse cardiac event-free survival curves demonstrated a significant benefit for antiplatelet, lipid-lowering, and ß-blocker therapy in both the CABG and PCI groups (P=0.001 for all 3 medications). Cox regression identified compliance with optimal medical therapy as a more powerful predictor of major adverse cardiac event-free survival than choice of therapy (hazard ratio for noncompliance=2.79; 95% confidence limits, 2.19-3.54; P<0.001; hazard ratio for PCI versus CABG=1.68, 95% confidence limits, 138-2.04; P<0.001). In propensity-matched patients, CABG outcomes were superior to PCI outcomes in patients nonadherent to optimal medical therapy (P=0.001) but were not different in patients adherent to optimal medical therapy (P=0.574). CONCLUSIONS: Regardless of coronary revascularization strategy, medication adherence has a dramatic effect on long-term outcome. Among comparable patients who adhere to optimal medical therapy, outcomes of PCI and CABG may not differ; however, among nonadherent patients, CABG affords better major adverse cardiac event-free survival. Therefore, patient compliance with medical therapy may inform clinical decision making and should be incorporated into all future comparative studies of comparative coronary revascularization strategies.

Influence of surgical volume on outcomes in low-risk patients undergoing isolated surgical aortic valve replacement.

BACKGROUND: Intermediate- and high-risk patients undergoing isolated surgical aortic valve replacement have superior outcomes at higher-volume compared with lower-volume hospitals. This study examines the impact of hospital volume on outcomes in low-risk patients undergoing aortic valve replacement. METHODS: Using data from our 29 North Texas hospital collaborative, we examined 2066 low-risk cases (Society of Thoracic Surgeons Predicted Risk of Mortality of ≤3%) undergoing aortic valve replacement surgery between January 1, 2012, and December 31, 2017. Cases from 3 high-volume hospitals (≥200 aortic valve replacement cases total) and 26 low-volume hospitals (<200 cases total) were examined. RESULTS: Some 53.5% of the cases were at high-volume hospitals. No statistical differences were seen in the Predicted Risk of Mortality or pertinent demographics between the high-volume and low-volume hospitals. Significant differences in outcomes were seen between the 2 groups in operative mortality (2.28% vs 1.19%, P = .007), renal failure (2.14% vs 1.00%, P = .003), and readmission within 30 days (9.72% vs 6.25%, P < .001) when comparing low-volume with high-volume hospitals. In patients undergoing aortic valve replacement, undergoing the procedure in a low-volume hospital was an independent predictor for operative mortality (odds ratio, 1.95; 95% confidence interval, 1.20-3.20; P = .008) and renal failure (odds ratio, 2.25; 95% confidence interval, 1.33-3.81; P = .003). CONCLUSIONS: Operative mortality in low-risk patients undergoing aortic valve replacement is higher in low-volume compared with high-volume hospitals. The probability of a major complication, such as renal failure, is also greater in low-volume hospitals. The relationship between volume and outcomes in low-risk patients will require more research to understand the causes and design appropriate interventions.

Mitral valve surgery: comparison of outcomes in matched sternotomy and port access groups.

BACKGROUND AND AIM OF THE STUDY: The 30-day outcomes were compared between matched groups of patients undergoing mitral valve procedures through Port Access (femoral cannulation, percutaneous retrograde cardioplegia and aortic occlusion), and through a sternotomy. METHODS: By using a Society of Thoracic Surgeons (STS)-certified, audited database, a total of 1108 patients was identified who were operated on between January 1996 and November 2008. A total of 608 mitral valve repair (MV-Rpr) patients (including 241 with Port Access procedures) and 500 mitral valve replacement (MVR) patients (including 45 with Port Access procedures) was included. Matching groups were created for 177 MV-Rpr patients (matched on preoperative cerebrovascular accident (CVA), previous coronary artery bypass grafting (CABG) and valve procedures, urgent operative status, mitral stenosis, heart failure, NYHA class IV, and age) and for MVR patients with 43 matches (matched for previous CABG surgery, operative status, NYHA class IV, and mitral insufficiency). RESULTS: Patients with Port Access procedures for MV-Rpr had a shorter length of hospital stay (5.4 +/- 2.8 versus 7.3 +/- 5.8 days), less postoperative ventilator usage (8.4 +/- 36.0 versus 24.8 +/- 81.6 h) and a shorter intensive care unit (ICU) stay (34.0 +/- 40.5 versus 81.7 +/- 133.8 h) when compared to sternotomy cases. Port Access also resulted in fewer patients requiring postoperative ventilation (50.3% versus 76.9%; p < 0.001) or reoperation for bleeding (2.3% versus 6.8%; p = 0.048). In MVR patients, Port Access use led to reductions in mortality (11.6% versus 0%; p = 0.021), ventilation time (13.8 +/- 40.3 versus 38.1 +/- 83.0 h), ICU stay (51.9 +/- 83.4 versus 152.4 +/- 125.0 h) and postoperative hospital stay (8.2 +/- 8.0 versus 11.0 +/- 8.6 days). In both groups, the cross-clamp time was longer with Port Access (107.7 +/- 26.8 versus 92.8 +/- 35.2 min for MV-Rpr; 130.2 +/- 44.2 versus 102.7 +/- 64.6 min for MVR). CONCLUSION: The performance of mitral valve surgery through a Port Access approach led to a reduction in ICU time, ventilator time, and hospital stay when compared to sternotomy. No increase in morbidity was observed with Port Access compared to sternotomy.

Coronary bypass versus percutaneous intervention: sex matters. The impact of gender on long-term outcomes of coronary revascularization.

Objectives: Women have a higher mortality than men following coronary artery bypass grafting (CABG). The influence of patient sex on outcomes of percutaneous coronary interventions (PCI) is controversial. Since patient selection for randomized clinical trials may not reflect clinical practice, we investigated the impact of sex on outcomes of CABG versus PCI in a comprehensive registry of coronary revascularization (CR). Methods: All patients undergoing CR in a network of eight community hospitals were enrolled. Follow-up was obtained after 5 years (median, 79.7 months). ST-elevation myocardial infarction (MI) patients were excluded. Propensity-score matching accounted for differences between groups. Results: There were 2162 men (673 CABG, 1489 PCI) and 991 women (294 CABG, 697 PCI). Survival free from major adverse cardiac events (MACE)-all cause mortality, nonfatal MI, re-intervention at 5 years for PCI versus CABG was 77.1 +/- 1.1 vs. 83.1 +/- 1.5, hazard ratio (HR) 0.588 (95% confidence interval [CI]: 0.491-0.704; P < 0.001) for men, but 75.0 +/- 1.6 vs. 74.5 ± 2.5, HR 0.869 (95% CI: 0.687-1.100; P = 0.24) for women. After matching, MACE-free survival for men remained significantly different, 69.5 +/- 2.2 vs. 79.5 +/- 2.0, HR 0.548 (95% CI: 0.424-0.682; P < 0.001) but not for women, 68.1 +/- 3.4 vs. 69.4 +/- 3.4, HR 0.752 (95% CI: 0.540-1.049; P = 0.093). Conclusions: In a 'real world' unselected cohort of CR patients, men enjoy improved survival and reduced MACE with CABG versus PCI. Outcomes for women are worse than for men and are equivalent with either procedure, emphasizing importance of accounting for sex in assessing outcomes of comparative CR procedures.

Establishing a Dedicated General Thoracic Surgery Subspecialty Program Improves Lung Cancer Outcomes.

BACKGROUND: Various factors may influence outcomes after lobectomy for lung cancer. Postgraduate subspecialty training in general thoracic surgery with a focus on minimally invasive surgery (MIS) and thoracic oncology was completed by an established cardiothoracic surgeon on the hospital staff in July 2007, and principles emphasized in that training were incorporated into practice through formation of a subspecialty program. We hypothesized that establishing a dedicated general thoracic surgeon-lead subspecialty program, with focus on MIS and thoracic oncology, would improve short-term and long-term outcomes. METHODS: Patients entered into the hospital cancer registry have survival status updated annually through correspondence with patients, physicians, and searches of the Social Security Death Index and obituaries. The registry was queried for all patients undergoing lobectomy for lung cancer, 2002 to 2013, and divided into two groups for comparison, before and after, based on operation date relative to January 2008. Patients (n = 279) who had lobectomy for lung cancer were identified in the registry. Data included surgical approach (percent of video-assisted thoracoscopy [VATS]), pathologic stage, number of lymph nodes and stations sampled, hospital length of stay (LOS), and survival. χ2 statistics were used for proportions, t tests for continuous variables, and a nonparametric test for LOS. A Cox proportional hazard model was created, and survival curves were constructed using time between operation and death or last follow-up. RESULTS: Patients having lobectomy in the after group had substantially more VATS procedures (53.9% versus 9.5%), decreased LOS (median 3.5 versus 7.0 days), greater mean total lymph nodes (9.0 versus 6.3), and nodal stations (4.2 versus 2.8) sampled per patient. Thirty-day, 90-day, and 1-year survival were similar in both groups. Overall survival was better in the after group (hazard ratio [HR] 0.41, 95% confidence interval: 0.25 to 0.68), and this survival benefit remained statistically significant when comparing groups stratified by lung cancer stage (stage I: HR 0.46, stage II: HR 0.32, combined stage III to IV: HR 0.19). CONCLUSIONS: Establishing a dedicated general thoracic surgeon-lead subspecialty program, with focus on MIS and thoracic oncology, can substantially improve short-term outcomes with increased VATS utilization, decreased LOS, and increased lymph node sampling. Long-term survival was also significantly improved.

Impact of Accurate 30-Day Status on Operative Mortality: Wanted Dead or Alive, Not Unknown.

BACKGROUND: Risk-adjusted operative mortality is the most important quality metric in cardiac surgery for determining The Society of Thoracic Surgeons (STS) Composite Score for star ratings. Accurate 30-day status is required to determine STS operative mortality. The goal of this study was to determine the effect of unknown or missing 30-day status on risk-adjusted operative mortality in a regional STS Adult Cardiac Surgery Database cooperative and demonstrate the ability to correct these deficiencies by matching with an administrative database. METHODS: STS Adult Cardiac Surgery Database data were submitted by 27 hospitals from five hospital systems to the Texas Quality Initiative (TQI), a regional quality collaborative. TQI data were matched with a regional hospital claims database to resolve unknown 30-day status. The risk-adjusted operative mortality observed-to-expected (O/E) ratio was determined before and after matching to determine the effect of unknown status on the operative mortality O/E. RESULTS: TQI found an excessive (22%) unknown 30-day status for STS isolated coronary artery bypass grafting cases. Matching the TQI data to the administrative claims database reduced the unknowns to 7%. The STS process of imputing unknown 30-day status as alive underestimates the true operative mortality O/E (1.27 before vs 1.30 after match), while excluding unknowns overestimates the operative mortality O/E (1.57 before vs 1.37 after match) for isolated coronary artery bypass grafting. CONCLUSIONS: The current STS algorithm of imputing unknown 30-day status as alive and a strategy of excluding cases with unknown 30-day status both result in erroneous calculation of operative mortality and operative mortality O/E. However, external validation by matching with an administrative database can improve the accuracy of clinical databases such as the STS Adult Cardiac Surgery Database.

Comparison of Outcomes of Operative Therapy for Acute Type A Aortic Dissections Provided at High-Volume Versus Low-Volume Medical Centers in North Texas.

Immediate surgery is standard therapy for acute type A aortic dissections (TAAD). Because of its low incidence, many smaller cardiac surgery programs do not routinely perform this procedure because it may negatively affect outcomes. Many high-risk, low-volume (LV) surgical procedures are now preferentially performed in reference centers. We compared the outcomes of surgery for TAAD in high-volume (HV) and LV centers in a single metropolitan area to determine the optimal setting for treatment. Thirty-five of the 37 cardiac surgery programs in the Dallas Ft. Worth metropolitan area participate in a regional consortium to measure outcomes collected in the Society of Thoracic Surgeons Adult Cardiac Database. From January 01, 2008, to December 31, 2014, 29 programs had treated TAAD. Those programs performing at least 100 operations for TAAD were considered HV centers and the others LV. Surgery for TAAD was performed in 672 patients over the 7-year study period with HV centers performing 469 of 672 (70%) of the operations. Despite similar preoperative characteristics, operative mortality was significantly lower in HV versus LV centers (14.1% vs 24.1%; p = 0.001). There was no significant difference in postoperative paralysis rates (2.6% vs 4.5%; p = 0.196), stroke rates (10.7% vs 9.4%; p = 0.623), or 30-day readmission rates (12.1% vs 15.5%; p = 0.292). An improved survival rate in HV centers was maintained over a 5-year follow-up period. Surgery for TAAD in a single large metropolitan area was most commonly performed in HV centers. In conclusion, the treatment of acute thoracic aortic dissection is recommended to be performed in reference centers because of lower early and midterm mortality.

The occurrence of postoperative pulmonary homograft stenosis in adult patients undergoing the Ross procedure.

BACKGROUND AND AIM OF THE STUDY: The Ross procedure employs an autologous pulmonary valve to replace the aortic valve, but requires pulmonary homograft replacement. Concerns regarding long-term homograft function may limit the adoption of this technique. Herein, the incidence of, and factors leading to, stenosis of the homograft were examined. METHODS: Data were collected from 131 patients (32 females, 99 males) who underwent a Ross procedure between July 1994 and December 2003. Complete follow up data were collected from 113 of 125 (90.4%) living patients. Donor valve information, including storage time, was supplied by the graft manufacturers. Data were analyzed using chi-square tests, t-test and logistic regression. RESULTS: The mean patient follow up was 703 +/- 574 days (median 599 days; range: 2 to 2,408 days). Echocardiographic stenosis had occurred in 14 patients (12.4%). Four patients (3.2%) required homograft replacement, and two required balloon valvuloplasty. There was no significant difference in graft vendor, recipient, donor age or blood type match between stenotic and non-stenotic recipients. Donor valve size was appropriate for the recipients, and greater than predicted by recipient body surface area (BSA). Donor valves that developed stenosis had a shorter storage time after processing (160 +/- 100 versus 249 +/- 223 days; p = 0.03). Male donor valves became stenotic in 9.9% (7/71) of male recipients, but in none of 20 females. Female donor valves became stenotic in 27.3% (3/11) of male recipients, and in 28.6% (2/7) females. Logistic regression showed donor gender to be a significant predictor for stenosis (p = 0.007; odds ratio 14.1 for female/male donors; 95% CI 2.1-96.4). CONCLUSION: Donor valves which developed stenosis had a shorter mean cryopreservation time than those that did not develop stenosis. In addition, female donor homografts appeared to develop stenosis at a greater rate, independent of patient age, graft size to BSA match, and blood type.

Excess short-term mortality in women after isolated coronary artery bypass graft surgery.

OBJECTIVE: Female sex is considered a risk factor for adverse outcomes following isolated coronary artery bypass graft (CABG) surgery. We assessed the association between sex and short-term mortality following isolated CABG, and estimated the 'excess' deaths occurring in women. METHODS: Short-term mortality was investigated in 13 327 consecutive isolated CABG patients in North Texas between January 2008 and December 2012. The association between sex and CABG short-term mortality, and the excess deaths among women were assessed via a propensity-adjusted (by Society of Thoracic Surgeons-recognised risk factors) generalised estimating equations model approach. RESULTS: Short-term mortality was significantly higher in women than men (adjusted OR=1.39; 95% CI 1.04 to 1.86; p=0.027). This significantly greater risk translates into 35 'excess' deaths among women included in this study (>10% of the total 343 deaths in the study cohort) and into 392 'excess' deaths among the ∼40 000 women undergoing isolated CABG in the USA each year. CONCLUSIONS: The higher risk associated with female sex lead to 35 'excess' deaths in women in this study cohort (over 10% of the total deaths) and to 392 'excess' deaths among women undergoing isolated CABG in the USA each year. Further research is needed to assess the causal mechanisms underlying this sex-related difference. Results of such work could inform the development and implementation of sex-specific treatment and management strategies to reduce women's mortality following CABG. Based on our results, if such work brought women's short-term mortality into line with men's, total short-term mortality could be reduced by up to 10%.

Does reporting of coronary artery bypass grafting from administrative databases accurately reflect actual clinical outcomes?

OBJECTIVES: Quality assessment of coronary artery bypass grafting has traditionally been performed with data from clinical databases. Administrative databases that rely primarily on information collected for billing purposes increasingly have been used as tools for public reporting of outcomes quality. The correlation of administrative data with clinical data for clinical quality assessment has not been confirmed. METHODS: With data from a clinical database, we analyzed the outcomes of all patients who underwent coronary artery bypass grafting surgery in 1 hospital between 1999 and 2001. This information was collected before, during, and after the surgery and hospitalization by designated clinical individuals involved with the patient's care and then entered into an audited clinical database (The Society of Thoracic Surgeons National Cardiac Database). These data were then compared with administrative data collected on the same cohort of patients for the number of procedures performed and mortality rate as reported by the federal government (Medical Provider Analysis and Review), state government (Texas Health Care Information Council), hospital system (HCA, Inc, Casemix Database), and an internet Web site (healthgrades.com). Data were analyzed on the basis of the population reported, definitions used, risk assessment algorithms, and case volumes. RESULTS: By using the audited The Society of Thoracic Surgeons database as the standard and aggregating the reporting of case volumes by the inclusion criteria of various sources of administrative data, we found variances in the reported procedure volumes and mortality. Case volumes were overreported by as much as 21% in all patients and underreported by up to 16% or more in Medicare patients. Mortality in administrative data exceeded that reported in clinical data by 21%. Reasons for variances included time period reported (calendar vs fiscal year), population reported (all patients, Medicare patients, Medicare patients aged >/= 65 years), date used for the patient record captured (date of surgery, discharge), and the definition of mortality. Different proprietary risk-adjusting algorithms used magnified variances with risk-adjusted mortality exceeding the Society of Thoracic Surgeons data by as much as 61%. CONCLUSIONS: Substantial variability of reported outcomes is seen in administrative data sets compared with an audited clinical database in the end points of the number of procedures performed and mortality. This variability makes it challenging for the nonclinician unfamiliar with outcomes analysis to make an informed decision.

Mitral valve surgery using the classical 'heartport' technique.

BACKGROUND AND AIM OF THE STUDY: Mitral surgery in selected patients using femoral cannulation, percutaneous retrograde cardioplegia and endoballoon aortic occlusion with a 4-5 cm thoracotomy is felt to carry a higher operative risk than sternotomy with conventional cannulation. Herein, the authors compared their experience of the first 117 'Heartport' (HP) patients with a computer-matched group of sternotomy approach surgical patients (SP) to assess operative risk and 30-day outcome. METHODS: Data were extracted from the authors' STS certified, audited database on 117 patients based on an intention to treat. Between December 1997 and December 2004, a total of 92 isolated mitral valve (MV) repair (HP-MVRpr) and 25 isolated MV replacement (HP-MVR) procedures was conducted using Heartport. The patients were matched 1:1 (by age +/-7 years, cerebrovascular disease, inotrope use, and ejection fraction +/- 5%) to a control SP group. Operative and 30-day outcomes were measured. RESULTS: No parameter showed any significant difference in 30-day outcome between the HP and SP groups, except for an increase in cross-clamp and perfusion times. Two patients in the HP-MVRpr group required conversion to sternotomy for repair of coronary sinus perforation, and one patient was repaired without conversion. Surgery in one HP-MVRpr patient was aborted due to limited aortic dissection, but successful repair was carried out later with a conventional approach. No patient required conversion to sternotomy for improved exposure of the operative site. CONCLUSION: Despite a longer cross-clamp time, 'classical' HP MV surgery can be performed with no increased risk compared to conventional MV surgery. Catheter and endoballoon complications were rare even in the early experience, and conversion to sternotomy was unusual and safely performed with this approach.

Improved long-term survival for diabetic patients with surgical versus interventional revascularization.

BACKGROUND: Diabetes is increasing at an alarming rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in diabetics. However, randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) many not accurately reflect current clinical practice. We therefore undertook a prospective registry of coronary revascularization (CR) in diabetic patients with CABG, on-pump and off-pump, and PCI with bare-metal and drug-eluting stents to determine long-term clinical outcomes. METHODS: All patients undergoing isolated CR in 8 community hospitals were enrolled. Follow-up was obtained after 5 to 8 years; all mortalities were checked against the Social Security Death Index. The ST-elevation myocardial infarction and salvage patients were excluded. Propensity matching was used to account for differences between PCI and CABG groups. Survival curves were derived using Kaplan-Meier methods, whereas hazard ratios and cumulative hazards were calculated using the Cox proportional hazard model. RESULTS: Of the 3,156 patients in the registry, there were 1,082 diabetics; 334 CABG and 748 PCI. Due to the differences in baseline characteristics between the 2 groups, propensity score matching was used to achieve clinically comparable groups of 240 patients each. In matched patient groups mortality was more common in the PCI group with an odds ratio (OR) of 0.60 (95% confidence interval [CI] 0.39% to 0.93%; p = 0.023). Similarly, occurrence of any major cardiac adverse event (MACE) (mortality, non-fatal myocardial infarction, or revascularization) was more frequent in the PCI group with an OR of 0.57 (95% CI 0.31% to 0.70%, p < 0.001). Kaplan-Meier event-free survival of matched groups was significantly improved in the CABG versus PCI group (p = 0.001). CONCLUSIONS: In the current era of on-pump and off-pump CABG surgery and bare-metal and drug-eluting stents, this registry which unselectively records all non-ST elevation myocardial infarction patients undergoing coronary revascularization, diabetic patients benefit from improved long-term survival and reduced MACE with CABG versus PCI. These findings corroborate recent evidence from prospective randomized trials and thus provide clinically relevant validation of their broad applicability to diabetics with extensive coronary artery disease in need of revascularization.

Improved outcomes in coronary artery bypass grafting with beating-heart techniques.

OBJECTIVE: Although improved outcomes for selected patients by elimination of cardiopulmonary bypass have been demonstrated, a benefit for all patients undergoing coronary artery bypass grafting by all surgeons has yet to be definitively proved. METHODS: We reviewed our experience with beating-heart surgery from its inception in January 1995 through December 2000. A total of 12,540 patients underwent isolated coronary artery bypass grafting, including 1915 procedures (15%) performed without cardiopulmonary bypass. Groups were compared by univariate analysis for preoperative risk factors and postoperative complications, and predicted risk was determined by the Society of Thoracic Surgeons risk algorithm. RESULTS: There was a gradual increase in the percentage of coronary operations performed off pump, from 1.2% in 1995 to 34.1% in 2000. Individual surgeon adoption rates ranged from 1% to 96% by 2000. There was a decrease in mortality to 3.22%, compared with an overall observed mortality rate of 4.0% in the 5 years before beating-heart surgery (P =.0482). There was a significant difference in observed mortality between the off-pump and on-pump groups (1.9% vs 3.5%, P <.001), despite a higher mean predicted risk among the patients in the off-pump group (3.13% vs 2.8%, P <.004). Additionally, decreased morbidity in the off-pump group was evidenced by reduced needs for blood products (28.45% vs 54.65%, P =.0001), prolonged ventilation (5.83% vs 10.93%, P =.001), and reoperation for bleeding (2.41% vs 3.65%, P =.0237), and by shorter hospital stay (5.98 vs 7.32 days, P =.001). CONCLUSIONS: Beating-heart surgery can be safely assimilated into a cardiac surgical practice, although adoption rates vary significantly among individual surgeons. Gradual integration can lead to improved outcomes in the total coronary artery bypass surgery population.

Thoracoscopic sympathectomy for hyperhidrosis: indications and results.

BACKGROUND: Hyperhidrosis can cause significant professional and social handicaps. Although treatments such as oral medication, botox, and iontophoresis are available, surgical sympathectomy is being increasingly utilized. METHODS: Between January 1997 and December 2002, 180 patients with palmar, axillary, facial, or plantar hyperhidrosis underwent a thoracoscopic sympathectomy. Surgical technique evolved during our study period and included excision of the sympathetic ganglia at T(2), T(3), or T(4) depending on the location of the sweating using monopolar cautery. RESULTS: Patient demographics included 33% males (59/180) and 67% females (121/180), with a mean age of 29.2 years old (range 12 to 76 years old). Ethnic origin was 67% white (122/180), 19% Asian (34/180), 8% Black (14/180), and 6% Hispanic (10/180). Positive family history of hyperhidrosis was noted in 57%. Preoperatively, 49% patients (86/180) had palmar sweating only, 7% patients (12/180) axillary only, 24% patients (43/180) palmar and axillary, 16% patients (28/180) face/scalp only, and 7% patients (11/180) all of the above; additionally 69% patients (125/180) had plantar hyperhidrosis. All procedures were performed through 3-mm and 5-mm ports, and 98% (177/180) were completed as an outpatient procedure. Complications included a mild temporary Horner's Syndrome (n = 1; 0.5%), air leak requiring chest drainage (n = 9; 5%), and bleeding (n = 3; 1.6%) requiring thoracoscopic reexploration (n = 1) and chest drainage (n = 2). Success rates were palmar 100% (109/109), axillary 98% (48/49), and face/scalp 93% (26/28). Plantar hyperhidrosis responded with improvement in 82% (72/88) of all patients. Seventy-eight percent patients (96/123) experienced compensatory hyperhidrosis, usually affecting the stomach, chest, back, and neck. Overall satisfaction was 94% (139/148). CONCLUSIONS: Thoracoscopic sympathectomy is a safe and effective outpatient method for managing hyperhidrosis. Although overall satisfaction is high, patients should be fully informed about the potential for compensatory sweating.

Safety and efficacy of minimally invasive atrial septal defect closure.

BACKGROUND: Atrial septal defects (ASDs) have been surgically closed with low mortality utilizing the conventional sternotomy approach (CSA). The technical ease of ASD closure has triggered interest in minimally invasive closure (MIC) to obviate the morbidity associated with sternotomy. Our study assesses the safety and efficacy of minimally invasive ASD closure. METHODS: Preoperative, intraoperative, and postoperative data were collected on 68 patients (39 CSA, 29 MIC) who underwent ASD closure from January 1997 to August 2002. Using univariate analysis of 17 preoperative risk factors there was no statistically significant difference between the two groups. RESULTS: MIC resulted in equivalent success rates in ASD closures, with similar morbidity, no mortality, and a significant difference in postoperative length of stay (3.93 +/- 1.6 days versus 5.36 +/- 2.51 days, p = 0.006). CONCLUSIONS: In experienced hands, MIC is an excellent alternative to CSA in ASD closure.

Are unaudited records from an outcomes registry database accurate?

BACKGROUND: Data from outcomes registry databases are being increasingly used for peer review and public reporting. However, administrative and clinical databases are mostly unaudited; thus, their accuracy has not been verified. METHODS: Outcomes data from all coronary artery bypass operations from a single cardiac surgery practice were entered into The Society of Thoracic Surgeons (STS) National Cardiac Database. From our practice of 18 surgeons, we audited 247 (10%) of the clinical records of patients undergoing surgery in 2001 and correlated them with all 315 elements of the STS National Cardiac Database for verification of accuracy. Inaccuracies were defined as a disagreement with a nominal or categorical variable or, for continuous variables, as the value not being within a predetermined window. When discrepancies existed, the hospital clinical record was assumed to be accurate. Outcomes discrepancies were then analyzed by four major categories: components of the preoperative risk algorithm, operative mortality, major complications, and other outcomes. RESULTS: Discrepancies were noted in 5% (16) or fewer of the audited fields for 98.8% of the records. Of the 32 variables in the mortality risk algorithms, discrepancies were present in fewer than 10% of the audits on 30 of the 32 variables. More than 95% of the audited charts had zero or one discrepancy in the seven most important variables in the mortality risk models. Operative mortality was determined to be completely accurate with no discrepancies between the database and the audited clinical record. Among major complications, the error rate was less than 1% for all complications except prolonged ventilation (4.0%). A higher rate of discrepancies did exist in some of the other variables, including discharge medications (14.1%) and ventilator time (36.4%). CONCLUSIONS: A detailed audit of a clinical outcomes registry database demonstrated that the major fields within this specific database including operative mortality, major complications, and the significant factors in the risk algorithm were highly accurate. Process improvement factors were identified to further increase the accuracy of data collection.

Conversion in off-pump coronary artery bypass grafting: an analysis of predictors and outcomes.

BACKGROUND: The incidence, predictive factors, and outcomes related to conversion from off-pump coronary artery bypass (OPCAB) to on-pump coronary artery bypass grafting (ONCAB) have not been well defined. We sought to determine the incidence of conversion, predictive factors, and any associated adverse consequences. METHODS: From January 2000 through June 2002, 1,644 patients underwent nonemergent OPCAB with 61 patients requiring conversion from OPCAB to ONCAB. These groups were retrospectively compared by univariate and multivariate regression analysis. The converted group was then computer matched 1:3, to a cohort of ONCAB patients to determine differences in outcomes. RESULTS: The overall conversion rate was 3.71%. Converted patients compared with a computer-matched ONCAB patients had a higher incidence of operative mortality (18.0% versus 2.7%, p < 0.001). Urgently converted patients had a higher incidence of postoperative cardiac arrest (25% versus 1.1%, p < 0.001), multisystem organ failure (10.7% versus 0.6%, p < 0.001), vascular complications (7.1% versus 1.1%, p = 0.03), and perioperative myocardial infarction (10.7% versus 1.1%, p = 0.02). Predictive factors for conversion were surgeon early in OPCAB experience (odds ratio [OR] 4.4), previous CABG (OR 2.8), and congestive heart failure (OR 2.0). The need for urgent-emergent conversion was highly predictive for operative mortality (OR 7.3) compared with elective conversion. CONCLUSIONS: Patients undergoing urgent-emergent but not elective conversion from OPCAB to ONCAB had a significantly higher risk of mortality and morbidity compared with patients whose procedure was initially ONCAB. Variables predictive of conversion included previous CABG, congestive heart failure, and surgeons early in OPCAB experience.

First-year outcomes of beating heart coronary artery bypass grafting using proximal mechanical connectors.

BACKGROUND: To determine the extended results of mechanical connectors we compared the 1-year outcomes of patients having beating heart coronary artery bypass surgery with at least one sutured or mechanically connected proximal vein graft anastomosis. METHODS: From May 2001 to December 2001, 166 patients were identified as having undergone off-pump bypass grafting utilizing at least one St. Jude symmetry aortic connector (St Jude Medical Anastomotic Technology Group, St. Paul, MN). Follow-up for major adverse cardiac events (MACEs), which is defined as cardiac mortality, myocardial infarction, or revascularization of a previous target vessel, was obtained on 162 patients (97.6%). A control group of 159 patients was identified from a cohort of patients having beating heart surgery with one or more sutured proximal vein graft anastomosis in the preceding year. The MACE follow-ups were obtained in 136 patients (85.6%) by direct telephone contact. RESULTS: Patients with connectors showed an accelerated number of MACEs beginning approximately 180 days from the time of surgery and stabilizing at approximately 300 days. Logistic regression analysis identified the presence of diabetes as a significant preoperative risk factor predisposing patients to earlier onset of MACEs (p = 0.03) with an odds ratio of 2.9 (95% confidence interval, 1.1 to 7.6). Insulin dependent diabetics showed no differences between connector and control patients in the frequency or timing of MACEs. Connector patients using oral hypoglycemic agents demonstrated a significant deviation (p = 0.01) from a similar control population in the prevalence and timing of MACEs. CONCLUSIONS: Connector patients showed an increased incidence of early MACEs. These events were characterized by an increased requirement for early target vessel revascularization and were predominantly in noninsulin-dependent diabetics.

Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients.

BACKGROUND: Coronary artery bypass graft (CABG) surgery performed without cardiopulmonary bypass (CPB) is currently increasing in clinical practice. Decreased morbidity associated with off-pump (OP) CABG in selected risk groups examined in relatively small, single institution groups has been the focus of most recent studies. The purpose of this study was to determine the independent impact of CPB on early survival in all isolated multivessel CABG patients undergoing surgery in two large institutions with established experience in OPCABG techniques. METHODS: A review of two large databases employed by multiple surgeons in the hospitals of two institutions identified 8,758 multivessel CABG procedures performed from January 1998 through July 2000. In all, 8,449 procedures were included in a multivariate logistic regression analysis to determine the relative impact of CPB on mortality independent of known risk factors for mortality. Procedures were also divided into two treatment groups based on the use of CPB: 6,466 had CABG with CPB (CABG-CPB), 1,983 had CABG without CPB (OPCABG). Disparities between groups were identified by univariate analysis of 17 preoperative risk factors and treatment groups were compared by Parsonnet's risk stratification model. Finally, computer-matched groups based on propensity score for institution selection for OPCABG were combined and analyzed by a logistic regression model predicting risk for mortality. RESULTS: CABG-CPB was associated with increased mortality compared with OPCABG by univariate analysis, 3.5% versus 1.8%, despite a lower predicted risk in the CABG-CPB group. CPB was associated with increased mortality by multiple logistic regression analysis with an odds ratio of 1.79 (95% confidence interval = 1.24 to 2.67). An increased risk of mortality associated with CPB was also determined by logistic regression analysis of the combined computer-matched groups based on OPCABG-selection propensity scores with an odds ratio of 1.9 (95% confidence interval = 1.2 to 3.1). CONCLUSIONS: Elimination of CPB improves early survival in multivessel CABG patients. Rigorous attempts to statistically account for selection bias maintained a clear association between CPB and increased mortality. Larger multiinstitutional studies are needed to confirm these findings and determine the most appropriate application of OPCABG.

Video-assisted thymectomy for myasthenia gravis: an update of a single institution experience.

OBJECTIVE: Video-assisted thymectomy was introduced in 1992 as a minimally invasive alternative for the treatment of myasthenia gravis. As experience with this technique is limited and follow-up short, we present this expanded and updated experience for purposes of validation of the technique. METHODS: Thirty-eight video-assisted thymectomies for myasthenia gravis were performed in our institution between March 1992 and March 2002. Two patients were lost to follow-up. We analyzed clinical results of 36 patients (14 males and 22 females) with a mean age of 41.2 years. Preoperative clinical staging was assessed by the newly recommended Myasthenia Gravis Foundation of America Clinical Classification. Clinical status at follow-up was assessed by the Myasthenia Gravis Foundation of America Postintervention Status classification. RESULTS: There was no perioperative mortality or long-term morbidity. One of 38 (2.6%) patients required conversion to limited thoracotomy for bleeding. The mean length of hospital stay was 1.64 days (range 0-8 days) with a median stay of 1 day. The mean length of follow-up is 53.24 months (range 4-126 months). Overall clinical improvement at follow-up was observed in 30 of 36 (83.0%) patients, with five of 36 (14.0%) patients in complete stable remission. CONCLUSIONS: Video-assisted thymectomy for myasthenia gravis provides acceptable clinical long-term results by a minimally invasive approach comparable to standard surgical approaches to the disease. The presented data is reported in accordance with the new guidelines by Myasthenia Gravis Foundation of America Task Force for valid comparison with future studies.