The Impact of Silent Liver Disease on Hospital Length of Stay Following Isolated Coronary Artery Bypass Grafting Surgery.

Objectives: Risk assessment models for cardiac surgery do not distinguish between degrees of liver dysfunction. We have previously shown that preoperative liver stiffness is associated with hospital length of stay following cardiac surgery. The authors hypothesized that a liver stiffness measurement (LSM) ≥ 9.5 kPa would rule out a short hospital length of stay (LOS < 6 days) following isolated coronary artery bypass grafting (CABG) surgery. Methods: A prospective observational study of one hundred sixty-four adult patients undergoing non-emergent isolated CABG surgery at a single university hospital center. Preoperative liver stiffness measured by ultrasound elastography was obtained for each participant. Multivariate logistic regression models were used to assess the adjusted relationship between LSM and a short hospital stay. Results: We performed multivariate logistic regression models using short hospital LOS (<6 days) as the dependent variable. Independent variables included LSM (< 9.5 kPa, ≥ 9.5 kPa), age, sex, STS predicted morbidity and mortality, and baseline hemoglobin. After adjusting for included variables, LSM ≥ 9.5 kPa was associated with lower odds of early discharge as compared to LSM < 9.5 kPa (OR: 0.22, 95% CI: 0.06-0.84, p = 0.03). The ROC curve and resulting AUC of 0.76 (95% CI: 0.68-0.83) suggest the final multivariate model provides good discriminatory performance when predicting early discharge. Conclusions: A preoperative LSM ≥ 9.5 kPa ruled out a short length of stay in nearly 80% of patients when compared to patients with a LSM < 9.5 kPa. Preoperative liver stiffness may be a useful metric to incorporate into preoperative risk stratification.

Use of veno-venous extracorporeal membrane oxygenation for stabilization prior to redo sternotomy for aortic pseudoaneurysm repair.

Background: Aortic pseudoaneurysms are particularly dangerous because of the risk of rupture and compression of mediastinal structures, including the trachea, and resultant respiratory distress. If respiratory distress progresses to respiratory failure, extracorporeal membrane oxygenation may be used to provide oxygenation prior to or during pseudoaneurysm repair. Case presentation: A 62-year-old male with a history of emergent aortic ascending and arch replacement for Stanford Type A dissection 10 months prior presented to his primary care physician with dyspnea. Chest radiography revealed a widened mediastinum, and subsequent computed tomography angiogram revealed a pseudoaneurysm at the distal suture line of the aortic arch replacement. Due to the location of the pseudoaneurysm, the patient's trachea was compressed, and he was emergently placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) following unsuccessful intubation for respiratory distress. Two days later, the patient underwent a redo sternotomy and repair of a 2-3 mm defect in the anterior aspect of the distal suture line of the prior aortic arch replacement. The patient progressed well and was discharged on postoperative day 13. What we learned: Using a combination of peripheral bypass, hypothermic circulatory arrest, delayed closure, and respiratory support, this case demonstrates how even complex patients can be successfully treated with multiple strategies.

Reoperative CABG in a patient with prior concomitant lung transplantation and two-vessel CABG.

BACKGROUND: Lung transplants (LTx) are being offered to increasingly older patients, and as a result, more concomitant coronary artery disease is being encountered in LTx candidates. While concurrent coronary artery bypass grafting (CABG) and LTx have become more common, the long-term considerations of reoperative CABG in patients following CABG with concomitant LTx are not fully understood. CASE PRESENTATION: A 75-year-old man with a history of bilateral LTx and concomitant CABG X 2 15 years prior presented to the emergency room with tachycardia and chest discomfort radiating to the left upper extremity. Emergent coronary angiography revealed severe three-vessel coronary artery disease with two occluded saphenous vein grafts, severe distal obtuse marginal (OM) and left circumflex disease, a collateralized chronic total occlusion of the mid LAD, and tortuosity of the proximal right innominate artery. The patient underwent a complex redo sternotomy and CABG X 2 due to dense adhesions in the mediastinum and pleura bilaterally. The postoperative course was complicated by left leg SVG harvest site cellulitis treated with IV antibiotics and hypervolemia treated with diuresis. The patient was discharged postoperatively on day 13. DISCUSSION: To our knowledge, this is the first reported successful reoperative CABG in a patient with a history of concomitant LTx and CABG. This case demonstrates feasibility, though additional caution is required due to the technical complexity and risk of immunosuppression in such complex patients.

Costs and Readmissions Associated with Type A Aortic Dissections at High- and Low-Volume Centers.

BACKGROUND: Costs and readmissions associated with type A aortic dissection repairs are not well understood. We investigated statewide readmissions, costs, and outcomes associated with the surgical management of type A aortic dissection repairs at low- and high-volume centers. METHODS: We identified all adult type A aortic dissection patients who underwent operative repair in the Maryland Health Services Cost Review Commission's database (2012-2020). Hospitals were stratified into high- (top quartile of total repairs) or low-volume centers. RESULTS: Of the 249 patients included, 193 (77.5%) were treated at a high-volume center. Patients treated at high- and low-volume centers had no differences in age, sex, race, primary payer, or severity (all p > 0.5). High- compared to low-volume centers had a greater proportion of patients transferred in (71.5% vs. 17.9%, p < 0.001). High-volume centers also had longer lengths of stay (12 vs. 8 days, p < 0.001), similar inpatient mortality (13.0% vs. 16.1%, p = 0.6), and similar proportion of patients readmitted (54.9% vs. 51.8%, p = 0.7). High-volume centers had greater index admission costs ($114,859 vs. $72,090, p < 0.001) and similar readmission costs ($48,367 vs. $42,204, p = 0.5). At high-volume centers, transferred patients compared to direct admissions had greater severity of illness (p = 0.05), similar mortality (p = 0.53), and greater lengths of stay (p = 0.05). CONCLUSIONS: High-volume centers had a greater number of patients transferred from other institutions compared to low-volume centers. High-volume centers were associated with increased index admission resource utilization, with transfer patients having higher illness severity and greater resource utilization, yet similar mortality, compared to direct admission patients.