Outcomes in orthotopic heart transplantation following pacemaker implantation.

BACKGROUND: Bradyarrhythmias including sinus node dysfunction (SND) and atrioventricular block (AVB) can necessitate pacemaker (PPM) implantation in orthotopic heart transplant (OHT) recipients. Prior studies have shown conflicting findings regarding the effect of PPM implantation on survival. We evaluated the effect of PPM indication on long-term re-transplant-free survival in OHT patients. METHODS: We conducted a retrospective cohort study of OHT patients at UCLA Medical Center from 1985 to 2018. Indication for PPM (SND, AVB) was identified. Cox proportional hazards model with pacemaker implantation as a time-varying covariate was used to evaluate its effect on the primary endpoint of retransplant or death. We included 1609 OHTs in 1511 adult patients with median follow-up of 12 years. RESULTS: At transplant, patients were aged 53 ± 13 years and 1125 (74.5%) were male. Pacemakers were implanted in 109 (7.2%) patients; 65 for SND (4.3%) and 43 for AVB (2.8%). Repeat OHT was performed in 103 (6.4%) cases and 798 (52.8%) patients died during the follow-up period. The risk of the primary endpoint was significantly higher in patients requiring PPM for AVB (HR 3.0, 95% CI 2.1-4.2, p < .01) after controlling for age at OHT, gender, hypertension, diabetes, renal disease, history of repeat OHT, acute rejection, transplant coronary vasculopathy, and atrial fibrillation, but not PPM for SND (HR 1.0, 95% CI 0.70-1.4, p = 1.0). CONCLUSIONS: Patients who required PPM for AVB, but not SND, were at significantly higher risk of death or retransplant compared to patients who did not require PPM.

Outcomes and Resource Utilization in Robotic Mitral Valve Repair: Beyond the Learning Curve.

BACKGROUND: After the initial learning curve associated with mastering a robotic procedure, there is a plateau where operative time and complication rates stabilize. Our objective was to evaluate one surgeon's experience with robotic mitral valve repairs (MVRep) beyond the learning curve and to compare its effectiveness against the traditional open approach. METHODS: Data from Ronald Reagan University of California, Los Angeles Medical Center was prospectively collected from January 2008 to March 2016 to identify adult patients undergoing robotic MVRep. Operative times, complication rates, and cost for robotic versus open MVRep were compared using multivariate regressions, adjusting for comorbidities and previous cardiac surgeries. RESULTS: During the study period, 175 robotic (41%) and 259 open (59%) MVRep cases were performed at our institution. As the surgeon performed more robotic operations, there was a decrease in room time (554-410 min, P < 0.001), surgery time (405-271 min, P < 0.001), and cross-clamp times (179-93 min, P < 0.001). After application of a multivariate regression model, robotic MVRep was associated with lower odds of complications (odds ratio = 0.42, P = 0.001), shorter length of stay (ß = -2.51, P < 0.001), and a reduction of 11% in direct (P = 0.003) and 24% in room costs (P < 0.001), but a 51% increase in surgery cost (P < 0.001). CONCLUSIONS: As the surgeon gained experience with robotic MVRep, operative times decreased in a steady manner. Robotic MVRep had comparable outcomes to open MVRep and lower overall cost. The observed difference in costs is likely related to shorter length of stay and lower room cost with the robotic approach.

Impact of New-Onset Postoperative Depression on Readmission Outcomes After Surgical Coronary Revascularization.

BACKGROUND: Depression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onset depression beyond acute follow-up remain ill-defined. The present study aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery. METHODS: A retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2 wk but within 90 d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression. RESULTS: During the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90 d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (P = 0.014). Depression was associated with lower odds of mortality (OR = 0.56, P = 0.02). CONCLUSIONS: New-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

Short-Term Readmissions After Open, Thoracoscopic, and Robotic Lobectomy for Lung Cancer Based on the Nationwide Readmissions Database.

BACKGROUND: Readmission after surgery is an established surrogate indicator of quality of care. We aimed to compare short-term readmission rates and patient outcomes between open, video-assisted thoracoscopic (VATS), and robotic lobectomies in the Nationwide Readmissions Database (NRD). METHODS: Adults who underwent open, VATS, or robotic lobectomy for lung cancer from 2010 to 2014 were evaluated. Propensity-matched analysis was used to assess differences in readmission characteristics, GDP-adjusted cost, and mortality. RESULTS: Of the 129,539 lobectomies for lung cancer, 74,493 (57.5%) were open, 48,185 (37.2%) VATS, and 6861 (5.3%) robotic. Open surgery was associated with significantly higher readmission rate (10.5 vs 9.3%, p < 0.001), mortality (2 vs 1.2%, p < 0.001), index hospitalization cost [$21,846 (16,158-31,034) vs $20,779 (15,619-27,920), p < 0.001], and length of stay [6 (5-9) vs 4 (3-7) days, p < 0.001] compared to minimally invasive surgery. The robotic approach had similar mortality, readmission rate, and length of stay compared to VATS, but higher index cost [$23,870 (18,372-31,300) vs $20,279 (15,275-27,375), p < 0.001] and incidence of pulmonary complication (35.9 vs 31.6%, p < 0.001). The robotic approach was associated with greater direct discharges to home. CONCLUSIONS: Analysis of the NRD revealed significantly reduced readmission rates, better clinical outcomes, and lower cost in the minimally invasive approach compared to open surgery. Although VATS and robotic surgery had similar readmission and mortality rates, VATS is associated with significantly reduced risk of short-term complications and lower cost.

National trends in volume-outcome relationships for extracorporeal membrane oxygenation.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) has emerged as a common therapy for severe cardiopulmonary dysfunction. We aimed to describe the relationship of institutional volume with patient outcomes and examine transfer status to tertiary ECMO centers. MATERIALS AND METHODS: Using the National Inpatient Sample, we identified adult patients who received ECMO from 2008 to 2014. Individual hospital volume was calculated as tertiles of total institutional discharges for each year independently. RESULTS: Of the total 18,684 adult patients placed on ECMO, 2548 (13.6%), 5278 (28.2%), and 10,858 (58.1%) patients were admitted to low-, medium-, and high-volume centers, respectively. Unadjusted mortality at low-volume hospitals was less than that of medium- (43.7% versus 50.3%, P = 0.03) and high-volume hospitals (43.7% versus 55.6%, P < 0.001). Length of stay and cost were reduced at low-volume hospitals compared to both medium- and large-volume institutions (all P < 0.001). In high-volume institutions, transferred patients had greater postpropensity-matched mortality (58.5% versus 53.7%, P = 0.05) and cost ($190,299 versus $168,970, P = 0.009) compared to direct admissions. On exclusion of transferred patients from propensity analysis, mortality remained greater in high-volume compared to low-volume centers (50.2% versus 42.8%, P = 0.04). Predictors of mortality included treatment at high-volume centers, respiratory failure, and cardiogenic shock (all P < 0.001). CONCLUSIONS: Our findings show increased in-hospital mortality in high-volume institutions and in patients transferred to tertiary centers. Whether this phenomenon represents selection bias or transfer from another facility deserves further investigation and will aid with the identification of surrogate markers for quality of high-risk interventions.

Predictors of cardiogenic shock in cardiac surgery patients receiving intra-aortic balloon pumps.

BACKGROUND: Cardiogenic shock after cardiac surgery leads to severely increased mortality. Intra-aortic balloon pumps may be used during the preoperative period to increase coronary perfusion. The purpose of this study was to characterize predictors of postoperative cardiogenic shock in cardiac surgery patients with and without intra-aortic balloon pumps support. METHODS: We performed a retrospective analysis of our institutional database of the Society of Thoracic Surgeons for patients operated between January 2008 to July 2015. Multivariable logistic regression was used to model postoperative cardiogenic shock in both the intra-aortic balloon pumps and matched control cohorts. RESULTS: Overall, 4,741 cardiac surgery patients were identified during the study period, of whom 192 (4%) received a preoperative intra-aortic balloon pump. Intra-aortic balloon pumps patients had a greater prevalence of diabetes, previous cardiac surgery, congestive heart failure, and an urgent/emergent status (P < .001). Intra-aortic balloon pumps patients also had greater 30-day mortality and more postoperative cardiogenic shock (9% vs 3%, P < .001). On multivariable analysis of the matched control cohort, postoperative cardiogenic shock remained multifactorial. Among the intra-aortic balloon pumps cohort, only sex, previous percutaneous coronary intervention and preoperative arrhythmia remained significant on multivariable analysis (all P < .05). CONCLUSION: Factors associated with cardiogenic shock among postcardiac surgery patients differ between those patients receiving intra-aortic balloon pumps and those who do not. Further analysis of the effects of prophylactic intra-aortic balloon pumps support is warranted. (Surgery 2017;160:XXX-XXX.).

A nationwide study of treatment modalities for thoracic aortic injury.

BACKGROUND: Thoracic aortic injuries have traditionally been associated with high morbidity and mortality. Thoracic endovascular aortic repair has emerged as a suitable alternative to open repair, but its impact at a national level remains ill defined. This study aimed to analyze the national trends of patient characteristics, outcomes, and resource utilization in the treatment of thoracic aortic injuries. METHODS: Patients admitted with thoracic aortic injuries from 2005-2014 were identified in the National Inpatient Sample. Patients were identified as undergoing thoracic endovascular aortic repair, open surgery, or nonoperative management. The primary outcome was in-hospital mortality, while secondary outcomes included complications and costs. Multivariate regressions accounting for characteristics of the patients and injury characteristics were used to determine predictors of mortality and changes in cost. RESULTS: Of the 11,257 patients admitted for thoracic aortic injuries, 33% received thoracic endovascular aortic repair, 8% open surgery, and 59% nonoperative management. Thoracic endovascular aortic repair had the great largest growth in case volume (P < .001). Compared to open surgery, thoracic endovascular aortic repair patients had greater rates of concomitant brain (17 vs 26%, P = .01), pulmonary (21 vs 33%, P < .001), and splenic injuries (2 vs 4%, P = .031). In-hospital mortality was greater for open surgery (odds ratio = 3.06, P = .003) and nonoperative management (odds ratio = 4.33, P < .001) than thoracic endovascular aortic repair. Over time, mortality rates for thoracic endovascular aortic repair decreased (P = .002), but increased for open surgery (P = .04). Interestingly, total costs with thoracic endovascular aortic repair increased (P = .004), while they decreased for open surgery (P = .031). CONCLUSION: Our findings indicate the rapid adoption of thoracic endovascular aortic repair over open surgery for management of thoracic aortic injuries. Thoracic endovascular aortic repair is associated with lower mortality rates, but it has greater costs not otherwise explained by other patient factors.

Racial Disparities in the Incidence of Pulmonary Embolism after Colectomy.

Disparities in the incidence of pulmonary embolism (PE) based on racial and socioeconomic factors remain ill-defined. The present study evaluated the impact of race and hospital characteristics on rates of PE for all adult colectomy patients in the 2005 to 2014 Nationwide Inpatient Sample. Hospitals were designated as high-burden hospitals (HBHs) or low-burden hospitals of underinsured payers. Chi-squared tests of trend and multivariable regression adjusting for patient and hospital characteristics were performed. Of the 2,737,977 adult patients who underwent colectomy in the study period, 79 per cent were White, 10 per cent Black, and 7 per cent Hispanic. The annual rate of PE increased from 0.6 per cent in 2005 to 0.95 per cent in 2014 (P < 0.0001). Black patients had significantly higher incidence of PE than Whites (1.5% vs 0.9%, P < 0.001) and Hispanics (1.5% vs 0.8%, P < 0.001). Colectomy at HBHs was also associated with significantly higher rates of PE (1% vs 0.86%, P < 0.001). After adjusting for baseline differences, colectomy at HBHs (odds ratio 1.14, 95% confidence interval 1.02-1.27, P = 0.02) and Black race (odds ratio 1.4, 95% confidence interval 1.26-1.66, P < 0.001) were independent predictors of PE. In this national study of colectomy patients, Black patients experienced a disproportionate burden of postoperative PE. Further investigation into the causes and prevention of PE in vulnerable populations may identify targets for surgical quality improvement.