The Impact of COVID-19 on Racial and Ethnic Disparities in Cardiac Procedural Care.

OBJECTIVE: The primary objective of this study was to evaluate whether the COVID-19 pandemic altered the racial and ethnic composition of patients receiving cardiac procedural care. DESIGN: This was a retrospective observational study. SETTING: This study was conducted at a single tertiary-care university hospital. PARTICIPANTS: A total of 1,704 adult patients undergoing transcatheter aortic valve replacement (TAVR) (n = 413), coronary artery bypass grafting (CABG) (n = 506), or atrial fibrillation (AF) ablation (n = 785) from March 2019 through March 2022 were included in this study. INTERVENTIONS: No interventions were performed as this was a retrospective observational study. MEASUREMENTS AND MAIN RESULTS: Patients were grouped based on the date of their procedure: pre-COVID (March 2019 to February 2020), COVID Year 1 (March 2020 to February 2021), and COVID Year 2 (March 2021 to March 2022). Population-adjusted procedural incidence rates during each period were examined and stratified based on race and ethnicity. The procedural incidence rate was higher for White patients versus Black, and non-Hispanic patients versus Hispanic patients for every procedure and every period. For TAVR, the difference in procedural rates between White patients versus Black patients decreased between the pre-COVID and COVID Year 1 (12.05-6.34 per 1,000,000 persons). For CABG, the difference in procedural rates between White patients versus Black, and non-Hispanic patients versus Hispanic patients did not change significantly. For AF ablations, the difference in procedural rates between White patients versus Black patients increased over time (13.06 to 21.55 to 29.64 per 1,000,000 persons in the pre-COVID, COVID Year 1, and COVID Year 2, respectively). CONCLUSION: Racial and ethnic disparities in access to cardiac procedural care were present throughout all study time periods at the authors' institution. Their findings reinforce the continuing need for initiatives to reduce racial and ethnic disparities in healthcare. Further studies are needed to fully elucidate the effects of the COVID-19 pandemic on healthcare access and delivery.

Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease.

Importance: For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown. Objective: To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis. Design, Setting, and Participants: Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018. Exposures: One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure. Main Outcomes and Measures: The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model. Results: Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction). Conclusions and Relevance: Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.

Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel.

Diagnostic point-of-care ultrasound (PoCUS) has emerged as a powerful tool to help anesthesiologists guide patient care in both the perioperative setting and the subspecialty arenas. Although anesthesiologists can turn to guideline statements pertaining to other aspects of ultrasound use, to date there remains little in the way of published guidance regarding diagnostic PoCUS. To this end, in 2018, the American Society of Anesthesiologists chartered an ad hoc committee consisting of 23 American Society of Anesthesiologists members to provide recommendations on this topic. The ad hoc committee convened and developed a committee work product. This work product was updated in 2021 by an expert panel of the ad hoc committee to produce the document presented herein. The document, which represents the consensus opinion of a group of practicing anesthesiologists with established expertise in diagnostic ultrasound, addresses the following issues: (1) affirms the practice of diagnostic PoCUS by adequately trained anesthesiologists, (2) identifies the scope of practice of diagnostic PoCUS relevant to anesthesiologists, (3) suggests the minimum level of training needed to achieve competence, (4) provides recommendations for how diagnostic PoCUS can be used safely and ethically, and (5) provides broad guidance about diagnostic ultrasound billing.

Accuracy of administrative database estimates of national surgical volume: Solid organ transplantation in the National Inpatient Sample.

BACKGROUND: Little is known about the accuracy of procedural coding in the National Inpatient Sample, in part because it is challenging to validate population-level estimates. METHODS: We evaluated the accuracy of the National Inpatient Sample by comparing estimates of solid organ transplantation to known national transplant volumes from the Organ Procurement and Transplant Network. RESULTS: The mean deviation of National Inpatient Sample point estimates from true transplant volume for the study period was 17.5 ± 20.8%. The mean deviation of point estimates from 2005 to 2011 was 26.4 ± 22.8% compared to 4.9 ± 6.3% from 2012 to 2016 (P < .001). CONCLUSIONS: Although future National Inpatient Sample transplantation research may be limited by the inability to subgroup procedures by donor type, surgical procedure coding of solid organ transplantation within the National Inpatient Sample appears to be accurate and reliable for generating national estimates, particularly after the National Inpatient Sample redesign in 2012.

Intraoperative diastolic function assessed by TEE does not agree with preoperative diastolic function grade in CABG patients.

OBJECTIVE: To compare the agreement of the 2016 ASE/EACVI guidelines for grading diastolic dysfunction (DD) with the most commonly used intraoperative transesophageal echocardiography (TEE)-based diastolic function grading algorithm in cardiac surgical patients, and to describe the contribution of the echocardiographic variables used in the algorithms to any observed differences. DESIGN: Retrospective data analysis. SETTING: University tertiary medical center. PARTICIPANTS: Hundred and one patients undergoing coronary artery bypass grafting (CABG) at a single institution from June 2017 to February 2019. INTERVENTIONS: Preoperative transthoracic echocardiography (TTE) diastolic function grade determined by the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines was compared to intraoperative diastolic function grade obtained by TEE. MEASUREMENTS AND MAIN RESULTS: Incidence of DD on preoperative TTE was only 19.8%, while 62.3% of patients were graded as having DD on the intraoperative TEE exam. There was grade agreement between TTE and TEE in only 47/101 patients (46.5%). The McNemar test showed poor agreement between the two algorithms (OR for disagreement = 15.33, CI = 4.77-49.30; p < 0.0001). Despite the low incidence of DD on preoperative TTE, mean lateral e' values were significantly lower on TTE compared to TEE (7.7 cm/s vs 9.5 cm/s; p = < 0.0001). CONCLUSIONS: There is strong disagreement between TTE and TEE-based DD grading algorithms. Due to the different echocardiographic variables used in each and the unique clinical settings in which they are applied, they produce fundamentally different results.

A Population-Based Analysis of Intraoperative Cardiac Arrest in the United States.

BACKGROUND: A new billable code for intraoperative cardiac arrest was introduced with the International Classification of Diseases, Tenth Revision, classification system. Using a national administrative database, we performed a retrospective analysis of intraoperative cardiac arrest in the United States. METHODS: Hospital admissions involving patients ≥18 years of age who underwent operating room procedures in 2016 were identified using the National Inpatient Sample. The primary outcome was the incidence of intraoperative cardiac arrest. Secondary outcomes included total cost of admission, in-hospital mortality, length of stay, and identification of risk factors associated with intraoperative cardiac arrest. Clinical risk factors were evaluated with multivariable logistic regression models using sampling weights and adjustment for clustering by strata. RESULTS: Of 35,675,421 admissions in 2016 in the United States, 9,244,861 admissions were identified in patients ≥18 years of age who underwent at least one operating room procedure. An estimated 5230 hospital admissions involved intraoperative cardiac arrest, yielding an estimated incidence of 5.7 (95% confidence interval [CI], 5.3-6.0) per 10,000 hospital admissions. Admissions involving an intraoperative cardiac arrest had a 35.7% in-hospital mortality, compared with 1.3% for admissions without intraoperative cardiac arrest. Intraoperative cardiac arrest was associated with a 15.44-fold (95% CI, 12.74-18.70; P < .001) increase in the risk-adjusted odds of in-hospital mortality and an additional $13,184 (95% CI, 9600-16,769; P < .001) of total admission costs. Selected factors independently associated with increased risk-adjusted odds of intraoperative cardiac arrest included: black or missing race; cardiac, thoracic, or vascular surgery; congestive heart failure; pulmonary circulation disorders; peripheral vascular disease; end-stage renal disease; and fluid and electrolyte disorders. CONCLUSIONS: In this population-based study of intraoperative cardiac arrest in the United States, admissions involving an intraoperative cardiac arrest were rare but were associated with high in-hospital mortality.

Impact of the Addition of Examples to the American Society of Anesthesiologists Physical Status Classification System.

Examples of comorbidities for the widely used American Society of Anesthesiologists physical status (ASA-PS) classification system were developed and approved in 2014. We conducted a retrospective cohort study of patients with 4 comorbidities included in the examples as warranting a specific minimum ASA-PS class. For each comorbidity subgroup, we used interrupted time-series models to compare ASA-PS underclassification for the periods before (2011-2014) and after (2015-2017) the introduction of examples. Rates of underclassification ranged from 4.8% to 38.7%. We observed no evidence of a significant impact on ASA-PS classification with the introduction of examples in 2014.

Does A Low 6-Minute Walk Distance Predict Elevated Postoperative Troponin?

Our study of 100 major vascular and renal transplant patients evaluated the 6-minute walk test (6MWT) as an indicator of perioperative myocardial injury, using troponin as a marker. Using logistic regression and the area under the receiving operator characteristic curve, we compared the 6MWT to the Revised Cardiac Risk Index and metabolic equivalents. Only the 6MWT was associated with elevated postoperative troponins (95% CI, 0.98-0.99). However, the 6MWT area under the receiving operator characteristic curve (0.71 [95% CI, 0.57-0.85]) was not different from the Revised Cardiac Risk Index (P = .23) or metabolic equivalents (P = .14). The 6MWT may have a role in cardiac risk stratification in the perioperative setting.