For your consideration: Benefits of listing as willing to consider heart offers from donors with hepatitis C.

BACKGROUND: Despite excellent outcomes of heart transplants from hepatitis C virus (HCV)-positive donors (D+), many candidates are not listed to even consider HCV D+ offers. METHODS: Using the Scientific Registry of Transplant Recipients, we identified adult (age ≥18 years) heart transplant candidates prevalent on the waitlist between 2018 and March 2023. We compared the likelihood of waitlist mortality or heart transplant by candidate willingness to consider HCV D+ offers using competing risk regression. RESULTS: We identified 19,415 heart transplant candidates, 68.9% of whom were willing to consider HCV D+ offers. Candidates willing to consider HCV D+ offers had a 37% lower risk of waitlist mortality (subhazard ratio [SHR], 0.63; 95% confidence interval [CI], 0.56-0.70; P < .001) than candidates not willing to consider HCV D+ offers, after adjustment for covariates and center-level clustering. Over the same period, heart transplant candidates willing to consider HCV D+ offers had a 21% higher likelihood of receiving a transplant (SHR, 1.21; 95% CI, 1.7-1.26; P < .001). As a result, among candidates willing to consider HCV D+ offers, 74.9% received a transplant and 6.1% died/deteriorated after 3 years, compared to 68.3% and 9.1%, respectively, of candidates not willing to consider HCV D+ offers. Lower waitlist mortality also was observed on subgroup analyses of candidates on temporary and durable mechanical circulatory support. CONCLUSIONS: Willingness to consider HCV D+ heart offers was associated with a 37% lower risk of waitlist mortality and a 21% higher likelihood of receiving a transplant. We urge providers to encourage candidates to list as being willing to consider offers from donors with hepatitis C to optimize their waitlist outcomes and access to transplantation.

The Safety and Efficacy of Tracheostomy in Patients Diagnosed With COVID-19: An Analysis of 143 Patients at a Major NYC Medical Center.

OBJECTIVE: To determine the optimal surgical strategy for performing tracheostomy in COVID-19 patients. BACKGROUND: Many ventilated COVID-19 patients require prolonged ventilation. We do not know if tracheostomy will improve their care. Given the paucity of data on this topic, the optimal surgical approach has yet to be elucidated. METHODS: This is a cohort study of 143 ventilator dependent COVID-19 patients undergoing tracheostomy at an academic medical center from April 15th to May 15th, 2020, with follow up until June 1, 2020. We included adult patients admitted to a NYC medical center with COVID-19 who required invasive mechanical ventilation for greater than 2 weeks who were unable to be extubated and determined to have reasonable chance of recovery and fit defined tracheostomy candidate criteria. Patients underwent either a percutaneous tracheostomy (PT) or open surgical tracheostomy (ST) performed by 1 of 3 surgical services. RESULTS: One hundred forty-three patients underwent tracheostomy, 58 (41%) via a ST, and 85 (59%) via a PT. There were no significant differences in patient characteristics between the 2 groups, except that more patients who had a history of extracorporeal membrane oxygenation underwent PT (11% vs 2%, P = 0.049). There were no statistical differences observed between the PT and ST groups with regard to bleeding complications (3.5%vs 10.3%, P = 0.099), tracheostomy related complications (5.9% vs 8.6%, P = 0.528), inpatient death (12% vs 5%, P = 0.178), discharge from hospital (39% vs 36%, P = 0.751) or surgeon illness (0% vs 0%, P = 1). CONCLUSION AND RELEVANCE: The rapid formation of a multi-disciplinary team allows for the efficient evaluation and performance of a large volume of tracheostomies in a resource-limited setting. Bedside tracheostomy in COVID-19 does not cause additional harm to patients if performed after 2 weeks from intubation. It also seems to be safe for proceduralists to perform in this timeframe. The manner of tracheostomy does not change outcomes significantly if it is performed safely and efficiently.

Massive ductal aneurysm in an asymptomatic child with Loeys-Dietz syndrome.

An asymptomatic 3-year-old with Loeys-Dietz Syndrome (LDS) followed for a small patent ductus arteriosus and dilated aorta was found to have a massive ductal aneurysm on routine surveillance cardiac magnetic resonance. The aneurysm was successfully resected. Serial advanced imaging tools are useful in surveillance, diagnosis, and management in patients with LDS.

Increased hospital volume is associated with reduced mortality after thoracoabdominal aortic aneurysm repair.

OBJECTIVE: Contemporary data on outcomes in open thoracoabdominal aortic aneurysm (TAAA) repair are limited to reports from major aortic referral centers showing excellent outcomes. This study aimed to characterize the national experience of open TAAA repair using national outcomes data, with a primary focus on the association of hospital volume with mortality and morbidity. METHODS: The Nationwide Inpatient Sample was queried from 1998 to 2011, and all patients with a diagnosis of TAAA who underwent open operative repair were included. These patients were further stratified into tertiles based on the operative volume of the institution that performed the operation: low volume (LV), <3 cases/y; medium volume (MV), 3 to 11 cases/y; and high volume (HV), ≥12 cases/y. Baseline demographics as well as perioperative outcomes were compared between these groups. Multivariable logistic regression was performed to determine predictors of operative mortality and morbidity. Subgroup analyses were performed for patients presenting for elective surgery and for those presenting for urgent and emergent surgery. RESULTS: Overall operative mortality was 21% for the entire cohort. Operative mortality was higher at LV (26%) and MV (21%) centers compared with HV centers (15%; P < .001). This difference was similar in both elective surgery (LV, 18%; MV, 14%; HV, 12%; P < .001) and urgent and emergent surgery (LV, 34%; MV, 30%; HV, 19%; P < .001). Furthermore, rates of blood transfusion and acute renal failure were significantly lower in the HV group. Multivariable analysis revealed that compared with the HV group, patients operated on at LV centers (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.7-2.1; P < .001) and MV centers (OR, 1.5; 95% CI, 1.4-1.7; P < .001) had at least 1.5 times the odds of in-hospital mortality. The HV group also had significantly lower odds of dying in the subgroup analyses of both elective surgery and urgent and emergent surgery. Increasing TAAA volume was associated with increased use of distal aortic perfusion (OR, 1.03; 95% CI, 1.02-1.03; P < .001). CONCLUSIONS: Patients with TAAA in the United States operated on at HV centers have significantly lower mortality and morbidity compared with patients operated on at lower volume centers. Consideration of referral to HV centers may be warranted, but further research is required to justify this conclusion.

Higher Institutional Volume Reduces Mortality in Reoperative Proximal Thoracic Aortic Surgery.

OBJECTIVE: This study aims to determine the impact of institutional volume on mortality in reoperative proximal thoracic aortic surgery patients using national outcomes data. METHODS: The Nationwide Inpatient Sample was queried from 1998 to 2011 for patients with diagnoses of thoracic aneurysm and/or dissection who underwent open mediastinal repair. A total of 103,860 patients were identified. A total of 1,430 patients had prior cardiac surgery. Patients were further stratified into groups by institutional aortic volume: low (<12 cases/year), medium (12-39 cases/year), and high (40+ cases/year) volume. Multivariable risk-adjusted analysis accounting for emergent status and aortic dissection among other factors was performed to determine the impact of institutional volume on mortality. RESULTS: Overall mortality was 12% in the reoperative population. When the redo cohort was divided into tertiles, high-volume group had a 5% operative mortality compared with 9 and 15% for the medium- and low-volume groups, respectively. Multivariable analysis revealed that patients operated on at low- (odds ratio [OR] = 5.0, 95% confidence interval [CI]: 2.6-9.6, p < 0.001) and medium-volume centers (OR = 2.1, 95% CI: 1.1-4.2, p = 0.03) had higher odds of mortality when compared with patients operated on at high-volume centers. CONCLUSIONS: High-volume aortic centers can significantly reduce mortality for reoperative aortic surgery, compared with lower volume institutions.

Importance of surgical expertise in septal myectomy for obstructive hypertrophic cardiomyopathy.

OBJECTIVE: In 2011, a multidisciplinary hypertrophic cardiomyopathy (HCM) program with a dedicated myectomy surgeon was implemented at our institution. We hypothesized that a dedicated approach allows better identification and management of mitral regurgitation (MR) during septal myectomy (SM) for obstructive HCM with significant mitral regurgitation. METHODS: Between 2006 and 2018, 181 patients had SM at our institution. This study consists of 53 patients with preoperative moderate or greater MR associated with systolic anterior motion who underwent isolated SM with or without mitral intervention. Patients were divided into those who underwent SM by a dedicated myectomy surgeon (group D, n = 31) or by a non-dedicated surgeon (group ND, n = 22). Primary outcome of interest was rate of mitral valve replacement (MVR) at SM. Secondary outcomes include in-hospital mortality, need for permanent pacemaker, mitral valve reoperation, and residual MR and left ventricular outflow tract gradient on postoperative echocardiography. RESULTS: 12 patients (55%) had a concomitant MVR during septal myectomy in group ND compared to 2 patients (6%) in group D (p < 0.01). Among patients who did not undergo MVR, patients in group D less commonly had residual MR than patients in ND after SM (p < 0.01). Group D had 100% survival with NYHA class I in 94% patients at follow-up visit (p = 0.01). Reoperation for MVR was required in four patients in group ND vs. none in group D (p < 0.01). CONCLUSIONS: A dedicated surgeon is able to spare the mitral valve in patients undergoing SM. This study emphasizes the importance of surgical expertise in this cohort.

Impact of Septal Myectomy Volume on Mitral-Valve Replacement Rate in Hypertrophic Cardiomyopathy Patients.

OBJECTIVE: Mitral regurgitation (MR) induced by systolic anterior motion in patients with hypertrophic cardiomyopathy (HCM) can frequently be abolished with a proficient septal myectomy (SM) without the need for mitral-valve replacement (MVR). ACC guidelines stress the importance of volume in improving outcomes after SM, but there is a lack of data measuring the impact of volume on the need for MVR during SM. This study was designed to assess the impact of institutional volume on MVR rates using national outcomes data. METHODS: The Nationwide Inpatient Sample was queried from 1998 to 2011 and a total of 6,207 patients had a diagnosis of HCM and a procedure code for SM. Outcomes were compared between patients who underwent SM (group I) and SM and MVR (group II). Furthermore, patients were stratified into 3 groups based on the number of SMs at the performing institution: low experience (1-24 cumulative SMs), medium experience (25-49 SMs), and high experience (>50 SMs). These patients underwent multivariable analysis to determine the impact of institutional volume on MVR rate. RESULTS: The total MVR rate was 26%. Perioperative outcomes were worse, i.e., there were higher rates of mortality, kidney injury, and urinary complications, in group II than in group I. Only 37.6% of patients were operated on at institutions meeting the guideline criteria of >50 cumulative SMs. When compared to patients in the high-experience group, patients in the low- (OR 2.7, 95% CI 2.3-3.2, p < 0.05) and medium-experience (OR 3.0, 95% CI 2.5-3.6, p < 0.05) groups were more likely to undergo MVR. CONCLUSION: Compared to reports from SM reference centers, national data suggest that MVR rates are quite high at SM. Patients undergoing SM at centers that do not meet the guideline standard have >2.5× the odds of undergoing MVR compared to those operated on at guideline-endorsed centers.

Improving Outcomes of Iatrogenic Type A Aortic Dissection during Cardiac Surgery.

BACKGROUND: Iatrogenic Type A aortic dissection (IAD) is a rare but devastating complication of cardiac and aortic surgery with reported operative mortality of 30 to 50%. In this study, we report our experience with IAD and propose a standardized approach to management. METHODS: From January 1, 2000 through December 31, 2016, 23,275 patients underwent cardiac surgery at our institution. We identified 15 patients who developed IAD. Our approach to management included (1) immediate repair, (2) involvement of a second attending surgeon, (3) aggressive monitoring of malperfusion, (4) securing true lumen arterial perfusion access and systemic cooling, and (5) performance of hemiarch or total arch replacement based on the presence of suspected brain malperfusion. The index operation was also completed at the same time. Patient preoperative characteristics, operative sequence and technique, complications, and outcomes were analyzed with chart review. RESULTS: The incidence of IAD at our institution was 0.06% (n = 15). A disproportionate percentage of patients had aneurysmal ascending aortas (33.3%). The index surgery consisted of aortic surgery in five patients (33.3%), coronary bypass in three patients, valve surgery in five patients, and transplantation in one patient. The mechanism of dissection was aortic cannulation in 66.7% and aortic root vent site cannulation in 13.3%. In 46.7% of patients, the IAD was first recognized based on clinical evidence such as aortic hematoma, pericardial bleeding, or abnormal perfusion line pressures. In 40.0%, the diagnosis was made with intraoperative echocardiography without any clinical manifestations. The timing of the diagnosis was at the initiation of cardiopulmonary bypass initiation in 60.0%, while in 40.0% it was recognized after discontinuation of bypass. Hemiarch was done in 73.3% and total arch replacement performed in 13.3%. Isolated ascending repairs were done in two patients. Bypass and cross-clamp times were 229.5 ± 212.7 minutes and 130.5 ± 109.5 minutes, respectively. In-hospital mortality in our cohort was 6.7%. While stroke occurred in one patient, no visceral organ malperfusion was recognized. CONCLUSIONS: Incidence of IAD is low with cannulation of an aneurysmal aorta being a risk factor. A standardized approach may result in reduced operative mortality.

Institutional Marfan syndrome surgical volume influences mitral valve surgical strategy in patients with Marfan syndrome.

BACKGROUND/AIM: The goal of this study was to evaluate trends in mitral valve (MV) operations performed on patients with Marfan syndrome (MfS) and determine the influence of an institution's MfS and MV surgical volume on MV surgical strategy in the US. METHODS: The Nationwide Inpatient Sample was queried from 1998 to 2011 and a total of 1126 patients with MfS were identified who underwent MV operations meeting our inclusion criteria. Linear regression was performed to assess trends of MV repair (MVr) rates over time. Patients were stratified into tertiles depending on the institution's annual MfS and MV surgical volumes. Multivariate analysis was used to determine the impact of institutional MV and MfS surgical volume on whether a patient received an MV replacement (MVR). RESULTS: The MVR rate was 60% for the entire cohort. There was a decreasing trend of MVR rates during the study period (82% in 1998-99 vs 49% in 2010-2011, P < .05). Multivariate analysis revealed that patients operated on at high (odds ratio [OR], 0.65; P < .05) and medium (OR, 0.66; P < .05) volume MfS centers were less likely to undergo MVR when compared to lower-volume MfS centers. In contrast, MV volume was not a significant predictor of surgical strategy in this cohort. CONCLUSION: The national MVR rate in the MfS population is higher than published reports. Data from this study suggest that MfS patients with indications for MV surgery should be referred to high-volume MfS surgical centers to have the best opportunity for MVr.

Use Side Branch of the Aortic Graft to Facilitate Coronary Reconstruction During Complex Aortic Surgery.

The interposition graft could be used for difficult coronary reconstruction during aortic root replacement. We introduced a new technique that utilizes side branch of an aortic graft to facilitate coronary reconstruction. The present study describes this technique and its outcomes. We retrospectively reviewed 234 patient charts of those who underwent aortic root replacement between January 2013 and November 2017. Within this group, 6 patients required coronary reconstruction with branches of aortic graft and were included in this study. All patients were reoperative cases, 3 of which were for acute type A aortic dissection. The mean cardiopulmonary and aortic cross clamp times were 317.2 ± 35.1 minutes and 153.3 ± 75.4 minutes, respectively. All patients survived to discharge with a median hospital stay of 20.5 days (interquartile range: 13.75-27.75). During a median follow-up of 221 days (interquartile range: 197.78-1208), no patients experienced major adverse cardiovascular events. Four patients underwent radiographic follow-up, which confirmed patent interposition grafts (5/5). The use of branches from the aortic graft for coronary reconstruction is feasible with satisfactory outcomes.

Concomitant repair for mild aortic insufficiency and continuous-flow left ventricular assist devices.

OBJECTIVES: Aortic insufficiency (AI) after continuous-flow left ventricular assist device (CF-LVAD) implantation has become a highly relevant subject. However, management of pre-existing mild AI is unknown. We examined the fate of pre-existing mild AI during CF-LVAD support. METHODS: From March 2004 to October 2015, 446 consecutive patients received CF-LVAD. Of these, 56 (12.6%) patients with pre-existing mild AI were identified. Outcomes were compared between patients who underwent repair [n = 41 (73.2%); Group A] and those who did not [n = 15 (26.8%); Group B]. RESULTS: Group A patients were more likely to have destination therapy intent at device insertion than Group B. Otherwise both groups displayed similar clinical/echocardiographic findings at baseline. There was no difference with respect to the occurrence of postoperative adverse events between groups. Kaplan-Meier analyses revealed the estimated 2-year on-device survival to be 63.3 ± 10.7 and 84.0 ± 10.6% (P = 0.41) and freedom from AI ≥moderate at 2 years to be 81.8 ± 9.7 and 45.0 ± 21.1% (P = 0.031) in Groups A and B, respectively. Furthermore, 83.3% (5 of 6) of Group B patients with large (>1.94 cm/m2; 75th percentile) body surface area-indexed aortic diameter developed ≥moderate AI, while none of the Group B individuals with smaller aortic root (0 of 9) did. In contrast, Group A patients with large indexed aortic root (n = 7) have all been free of AI at 2 years. CONCLUSIONS: AI progression among CF-LVAD-supported patients with baseline mild AI is highly prevalent. Baseline aortic root diameter may help identify patients with 'borderline' AI lesion needing repair at device insertion.

Prolonged continuous-flow left ventricular assist device support and posttransplantation outcomes: A new challenge.

OBJECTIVE: To assess outcomes after cardiac transplantation in patients receiving long-term continuous-flow left ventricular assist device (CF-LVAD) support. METHODS: The United Network of Organ Sharing Database was used to identify 7808 heart transplant recipients between January 2011 and March 2014, 2456 (31.5%) of whom were bridged with CF-LVAD. Recipients were stratified by CF-LVAD duration: group 1, <1 year (n = 1590; 64.7%); group 2, 1 to 2 years (n = 599; 24.4%); and group 3, >2 years (n = 267; 10.9%). RESULTS: Compared with patients in groups 1 and 2, patients in group 3 spent more time as status 1A, had a greater body mass index and higher serum creatinine level, more often received blood transfusions and antibiotics, and more often developed device-related infection and life-threatening arrhythmia before transplantation. Kaplan-Meier analysis revealed statistically significant lower survival rates in group 3 compared with groups 1 and 2, at both 30 days (92.9% vs 96.4% vs 95.5%; group 1 vs group 3, P = .009) and 2 years (78.9% vs 88.2% vs 86.3%; group 1 vs group 3, P = .001) posttransplantation. Multivariable analyses identified duration of CF-LVAD support as a significant factor for 2-year posttransplantation mortality (hazard ratio, 1.16; 95% confidence interval, 1.01-1.34; P = .040). CONCLUSIONS: A bridge-to-transplant (BTT) strategy with a CF-LVAD has become standard care for patients with advanced heart failure. Duration of CF-LVAD support is associated with increased midterm mortality, warranting early transplantation in the modern BTT era.

Concomitant aortic valve repair with continuous-flow left ventricular assist devices: Results and implications.

OBJECTIVES: Aortic insufficiency (AI) after continuous-flow left ventricular assist device implantation can affect patient outcomes. Central aortic valve closure (CAVC) is a strategy commonly practiced; however, its efficacy has not been extensively investigated. METHODS: From March 2004 to May 2014, a total of 340 patients received a continuous-flow left ventricular assist device (89; 26.2%) as destination therapy (DT). Outcomes were compared between patients with CAVC (n = 57 [16.8%]; group A) versus without repair (n = 283 [83.2%]; group B). RESULTS: Patients in group A were older, were more likely to be having DT, had a greater cardiopulmonary bypass and aortic crossclamp time, and more often received intraoperative transfusions than did patients in group B. Twenty-three (40.4%) patients in group A had significant pre-existing AI, defined as >mild AI, whereas none did in group B. Kaplan-Meier analysis revealed that freedom from significant AI was 66.7% and 59.9% at 2 years (P = .77) in groups A and B, respectively. In the DT cohort, freedom from significant AI was 78.1% and 41.8% at 2 years (P = .077). A generalized mixed-effects model demonstrated a 57% and 69% decrease in the odds of significant AI progression among repaired patients in the entire and DT cohort, respectively, after adjusting for time effect and degree of baseline pre-existing AI. CONCLUSIONS: Despite pre-existing AI, the prevalence of significant AI in patients with CAVC was comparable to the AI in those without pre-existing AI/CAVC. The efficacy of this technique was more evident in DT patients. Thus, CAVC may be an effective and durable strategy, especially in patients who require lengthy device support.

Changing prevalence, profile, and outcomes of patients with HIV undergoing cardiac surgery in the United States.

OBJECTIVES: Little is known about the prevalence, risk profile, and outcomes of patients with HIV undergoing cardiac surgery. This study was designed to evaluate clinical outcomes and national trends in this population in the United States. METHODS: Using data from the Nationwide Inpatient Sample from January 1, 2000, to December 31, 2010, prevalence, risk factors and clinical outcomes after cardiac surgery were quantified for patients with HIV. Cox proportional hazards models were used to evaluate the impact of HIV status on postoperative mortality, and weights used to estimate national trends. RESULTS: The prevalence of HIV in cardiac surgery patients doubled from 0.1% to 0.2% (P < .001), with 1,239 cases recorded out of a total of 810,940 over the study period. The proportion of HIV-positive patients undergoing cardiac surgery for endocarditis decreased from 31.8% to 8.2% (P = .016). Operative mortality in patients with HIV decreased from 5.6% to 0.87% (P < .001) over the study period. HIV was not found to be an independent predictor of operative mortality in multivariate analysis (adjusted OR 0.88, 95% CI 0.64-1.2, P = .436), whereas earlier year of operation (adjusted OR 0.72, 95% CI 0.60-0.87, P < .001) and the presence of disease conditions related to HIV status (OR 2.4, 95% CI 1.5-3.8, P = .01) were independent predictors of operative mortality in patients with HIV. CONCLUSIONS: In contemporary practice HIV does not appear to be associated with incremental operative mortality, except in patients with clinical disorders related to their HIV status.

Evaluating the obtunded patient after cardiac surgery: the role of continuous electroencephalography.

PURPOSE: This prospective study was designed to evaluate the role of continuous electroencephalography (EEG) in the management of adult patients with neurological dysfunction early after cardiac surgery. MATERIALS AND METHODS: Seven hundred twenty-three patients undergoing cardiac surgery between December 2010 and June 2011 were divided into 2 groups based on the presence or absence of post-operative neurological dysfunction. All patients with neurological dysfunction underwent continuous EEG. RESULTS: Neurological dysfunction was diagnosed in 12 patients (1.7%), of whom 5 (42%) did not regain consciousness after surgery, 4 (33%) had a clinical event suspicious for seizure and 3 (25%) had neurological deficits. Continuous EEG showed that 2 of the 5 patients who failed to regain consciousness, without clinical signs of seizures, were in electrographic non-convulsive focal status epilepticus. Periodic discharges were present in the continuous EEGs of 3 patients. Three additional patients (25%) had abnormal movements that continuous EEG demonstrated was not due to seizure activity. CONCLUSIONS: Non-convulsive status epilepticus may be an under-recognized cause of obtundation early after cardiac surgery. Continuous EEG monitoring is a non-invasive test that can identify patients that may benefit from anti-epileptic medication. Larger comparative studies are required to establish whether this leads to significant improvements in patient outcomes.

Earlier versus later tracheostomy in patients with respiratory failure after cardiac surgery in the United States.

OBJECTIVES: The objective of this study was to evaluate the impact of timing of tracheostomy on outcomes of patients with respiratory failure after cardiac surgery. DESIGN: Retrospective analysis of national database. SETTING: United States hospitals. PARTICIPANTS: A weighted estimate of 2,063,227 patients (475,773 case records) undergoing cardiac surgery identified from the Nationwide Inpatient Sample between 2002-2010 INTERVENTIONS: Early versus late tracheostomy. MEASUREMENTS AND MAIN RESULTS: The incidence of postoperative respiratory failure was 7.8%. The strongest independent predictors of respiratory failure included female gender (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.28-1.31), age (OR 1.13 for each decade, 95% CI 1.12-1.13), chronic obstructive airways disease (OR 2.16, 95% CI 2.13-2.19), chronic renal insufficiency (OR 2.28, 95% CI 2.25-2.31), and valve surgery (OR 1.62, 95% CI 1.6-1.64). Tracheostomy was performed in 22.9% of patients with respiratory failure; 13.6% of tracheostomies were performed within 5 days of surgery (or within 5 days of intubation in patients who underwent reintubation), and 20.5% were performed on postoperative day 21 or later. Compared with tracheostomy performed within 5 days of intubation, there was a near-stepwise increase in risk of mortality with delayed tracheostomy performed between days 11-15 (OR 1.29, 95% CI 1.16-1.43), days 16-20 (OR 1.25, 95% CI 1.11-1.41), and day 21 or later (OR 1.53, 95% CI 1.37-1.71). CONCLUSIONS: In this analysis of outcomes of patients with respiratory failure after cardiac surgery in the United States, deferring tracheostomy did not appear to improve patient outcomes after cardiac surgery.

Safety of outpatient laparoscopic cholecystectomy in the elderly: analysis of 15,248 patients using the NSQIP database.

BACKGROUND: Studies have shown that laparoscopic cholecystectomy (LC) in an ambulatory setting is a safe alternative to the traditional overnight hospital stay. However, there are limited data on the morbidity and mortality of outpatient LC in elderly patients. We evaluated the safety of ambulatory LC in the elderly and identified risk factors that predict inpatient admission. STUDY DESIGN: A retrospective analysis was performed using the American College of Surgeon's NSQIP database between 2007 and 2010. The database was searched for patients older than 65 years of age who underwent elective LC at all participating hospitals in the United States. Data from 15,248 patients were collected and we compared patients who underwent ambulatory procedures with those patients who were admitted for an inpatient stay. RESULTS: Seven thousand four hundred and ninety-nine (48.9%) patients were ambulatory and 7,799 (51.1%) were nonambulatory. Postoperative complications included mortality (0.2% vs 1.5%; p < 0.001), stroke (0.1% vs 0.3%; p < 0.001), myocardial infarction (0.1% vs 0.6%; p < 0.001), pulmonary embolism (0.1% vs 0.3%; p = 0.005), and sepsis (0.2% vs 0.7%; p < 0.001) for ambulatory and nonambulatory cases, respectively. We identified significant independent predictors of inpatient admission and mortality, including congestive heart failure, American Society of Anesthesiologists class 4, bleeding disorder, and renal failure requiring dialysis. CONCLUSIONS: We believe ambulatory LCs are safe in elderly patients as demonstrated by low complication rates. We identified multiple risk factors that might warrant inpatient hospital admission.