Outcomes of Transcatheter Aortic Valve Implantation in Patients with and without Diabetes Mellitus.

INTRODUCTION: Diabetes mellitus (DM) in patients undergoing cardiac transcatheter or surgical interventions usually is correlated with poor outcomes. Transcatheter aortic valve implantation (TAVI) has been developed as a therapy choice for inoperable, high-, or intermediate-risk surgical patients with severe aortic stenosis (AS). OBJECTIVE: To evaluate the impact of DM and hemoglobin A1c (HbA1c) on outcomes and survival after TAVI. METHODS: Five hundred and fifty-two symptomatic severe AS patients who underwent TAVI, of whom 164 (29.7%) had DM, were included in this retrospective study. Follow-up was performed after 30 days, six months, and annually. RESULTS: The device success and risks of procedural-related complications were similar between patients with and without DM, except for acute kidney injury, which was more frequent in the DM group (2.4% vs. 0%, P=0.021). In-hospital and first-year mortality were similar between the groups (4.9% vs. 3.6%, P=0.490 and 15.0% vs. 11.2%, P=0.282, respectively). There was a statistical difference between HbA1c ≥ 6.5 and HbA1c ≤ 6.49 groups in total mortality (34.4% vs. 15.8%, P<0.001, respectively). The only independent predictors were Society of Thoracic Surgeons score (hazard ratio [HR] 1.28, 95% confidence interval [CI] 1.09-1.51; P=0.003) and HbA1c level ≥ 6.5 (HR 10.78, 95% CI 2.58-21.50; P=0.003) in multivariable logistic regression analysis. CONCLUSION: In this study, we conclude that DM was not correlated with an increased mortality risk or complication rates after TAVI. Also, it was shown that mortality was higher in patients with HbA1c ≥ 6.5, and it was an independent predictor for long-term mortality.

Lymphocyte Levels and Morbidity and Mortality in Cardiovascular Surgery With Cardiopulmonary Bypass.

INTRODUCTION: A year ago, in a sample of 113 patients, our research group found that a high number of lymphocytes in the immediate postoperative period was correlated to a poor prognosis in cardiovascular surgeries. This study is an expansion of the initial study in order to confirm this finding. METHODS: We analyzed the data of 338 consecutive patients submitted to cardiovascular surgeries with cardiopulmonary bypass performed at Hospital Universitário Ciências Médicas (Belo Horizonte/Brazil) from 2015 to 2017. We analyzed 39 variables with the outcomes death, hospital stay, and intensive care unit stay. RESULTS: The value of lymphocytes in the immediate postoperative period > 2175.0/mm³ was an indicator of poor prognosis in this sample (P<0.001). The variables female sex, age, high level of European System for Cardiac Operative Risk Evaluation II, increased stay in the intensive care unit and in the ward, elevation of creatinine in the preoperative period and at intensive care unit discharge, elevation of the percentage of immediate postoperative period segmented neutrophils, high immediate postoperative period neutrophil/lymphocyte ratio, fasting hyperglycemia, preoperative critical condition, reintubation, mild or transient acute renal failure, surgical infection, cardiopulmonary bypass, and aortic cross-clamping and mechanical ventilation durations also had an impact on the mortality outcome. CONCLUSION: The value of lymphocytes in the immediate postoperative period > 2175.0/mm3 was an indicator of poor prognosis in cardiovascular surgery with cardiopulmonary bypass.

Postoperative intensive care allocation and mortality in high-risk surgical patients: evidence from a low- and middle-income country cohort.

BACKGROUND: The escalation of surgeries for high-risk patients in Low- and Middle-Income Countries (LMICs) lacks evidence on the positive impact of Intensive Care Unit (ICU) admission and lacks universal criteria for allocation. This study explores the link between postoperative ICU allocation and mortality in high-risk patients within a LMIC. Additionally, it assesses the Ex-Care risk model's utility in guiding postoperative allocation decisions. METHODS: A secondary analysis was conducted in a cohort of high-risk surgical patients from a 800-bed university-affiliated teaching hospital in Southern Brazil (July 2017 to January 2020). Inclusion criteria encompassed 1431 inpatients with Ex-Care Model-assessed all-cause postoperative 30-day mortality risk exceeding 5%. The study compared 30-day mortality outcomes between those allocated to the ICU and the Postanesthetic Care Unit (PACU). Outcomes were also assessed based on Ex-Care risk model classes. RESULTS: Among 1431 high-risk patients, 250 (17.47%) were directed to the ICU, resulting in 28% in-hospital 30-day mortality, compared to 8.9% in the PACU. However, ICU allocation showed no independent effect on mortality (RR = 0.91; 95% CI 0.68‒1.20). Patients in the highest Ex-Care risk class (Class IV) exhibited a substantial association with mortality (RR = 2.11; 95% CI 1.54-2.90) and were more frequently admitted to the ICU (23.3% vs. 13.1%). CONCLUSION: Patients in the highest Ex-Care risk class and those with complications faced elevated mortality risk, irrespective of allocation. Addressing the unmet need for adaptable postoperative care for high-risk patients outside the ICU is crucial in LMICs. Further research is essential to refine criteria and elucidate the utility of risk assessment tools like the Ex-Care model in assisting allocation decisions.

Addition of High-Sensitivity Troponin to Perioperative Risk Assessment Improves the Predictive Ability of Death in Non-Cardiac Surgery Patients. / Adição da Troponina Ultrassensível à Avaliação de Risco Perioperatório Melhora a Capacidade Preditiva de Morte em Pacientes Submetidos à Cirurgia Não Cardíaca.

BACKGROUND: Risk stratification is an important step in perioperative evaluation. However, the main risk scores do not incorporate biomarkers in their set of variables. OBJECTIVE: Evaluate the incremental power of troponin to the usual risk stratification. METHODS: A total of 2,230 patients admitted to the intensive care unit after non-cardiac surgery were classified according to three types of risk: cardiovascular risk (CVR), Revised Cardiac Risk Index (RCRI); and inherent risk of surgery (IRS). The main outcome was all-cause mortality. Cox regression was used as well as c-statistics before and after addition of high-sensitivity troponin (at least one measurement up to three days after surgery). Finally, net reclassification index and integrated discrimination improvement were used to assess the incremental power of troponin for risk stratification. Significance level was set at 0.05. RESULTS: Mean age of patients was 63.8 years and 55.6% were women. The prevalence of myocardial injury after non-cardiac surgery (MINS) was 9.4%. High CVR-patients had a higher occurrence of MINS (40.1 x 24.8%, p<0.001), as well as high IRS-patients (21.3 x 13.9%, p=0.004) and those with a RCRI≥3 (3.0 x 0.7%, p=0.009). Patients without MINS, regardless of the assessed risk, had similar mortality rate. The addition of troponin to the risk assessment improved the predictive ability of death at 30 days and at 1 year in all risk assessments. CONCLUSION: The prevalence of MINS is higher in the high-risk population. However, its prevalence in lower-risk population is not negligible and causes a higher risk of death. The addition of high-sensitivity troponin increased the predictive ability of risk assessment in all groups.

FUNDAMENTO: A estratificação ode risco é uma importante etapa na avaliação perioperatória. No entanto, os principais escores de risco não incorporam biomarcadores em seus conjuntos de variáveis. OBJETIVO: Avaliar o poder incremental da troponina à estratificação de risco tradicional. MÉTODOS: Um total de 2230 pacientes admitidos na unidade de terapia intensiva após cirurgia não cardíaca foram classificados de acordo com três tipos de risco: Risco Cardiovascular (RCV), Índice de Risco Cardíaco Revisado (IRCR), e Risco Inerente da Cirurgia (RIC). O principal desfecho foi mortalidade por todas as causas. A regressão de Cox foi usada, assim como a estatística C antes e após a adição de troponina ultrassensível (pelo menos uma medida até três dias após a cirurgia). Finalmente, o índice de reclassificação líquida e a melhoria de discriminação integrada foram usadas para avaliar o poder incremental da troponina para a estratificação de risco. O nível de significância usado foi de 0,05. RESULTADOS: A idade média dos pacientes foi 63,8 anos e 55,6% eram do sexo feminino. A prevalência de lesão miocárdica após cirurgia não cardíaca (MINS) foi 9,4%. Pacientes com um RCV elevado apresentaram uma maior ocorrência de MINS (40,1% x 24,8%, p<0,001), bem como pacientes com alto RIC (21,3 x 13,9%, p=0,004) e aqueles com IRCR≥3 (3,0 x 0,7%, p=0,009). Pacientes sem MINS, independentemente do risco avaliado, apresentaram taxa de mortalidade similar. A adição de troponina à avaliação de risco melhorou a capacidade preditiva de mortalidade em 30 dias e de mortalidade em um ano em todas as avaliações de risco. CONCLUSÃO: A prevalência de MINS é mais alta na população de alto risco. No entanto, sua prevalência na população de risco mais baixo não é desprezível e causa um maior risco de morte. A adição da troponina ultrassensível melhorou a capacidade preditiva da avaliação de risco em todos os grupos.

The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair.

OBJECTIVE: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS: We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Evaluation of the RAPID score as a predictor of postoperative morbidity and mortality in patients undergoing pulmonary decortication for stage III pleural empyema.

OBJECTIVE: This study aims to correlate the RAPID score with the 3-month survival and surgical results of patients undergoing lung decortication with stage III pleural empyema. METHODS: This was a retrospective study with the population of patients with pleural empyema who underwent pulmonary decortication between January 2019 and June 2022. Data were collected from the institution's database, and patients were classified as low, medium, and high risk according to the RAPID score. The primary outcome was 3-month mortality. Secondary outcomes were the length of hospital stay, readmission rate, and the need for pleural re-intervention. RESULTS: Of the 34 patients with pleural empyema, according to the RAPID score, patients were stratified into low risk (23.5 %), medium risk (47.1 %), and high risk (29.4 %). The high-risk group had a 3-month mortality of 40 %, while the moderate-risk group had a 6.25 % and the low-risk group had no deaths within 90 days, confirming a good correlation with the RAPID score (p < 0.05). Sensitivity and specificity for the primary outcome in the high-risk score were 80.0 % and 79.3 %, respectively. The secondary outcomes did not reach statistical significance. CONCLUSIONS: In this retrospective series, the RAPID score had a good correlation with 3-month mortality in patients undergoing lung decortication. The morbidity indicators did not reach statistical significance. The present data justifies further studies to explore the capacity of the RAPID score to be used as a selection tool for treatment modality in patients with stage III pleural empyema.

The influence of preoperative e intraoperative factors in predicting postoperative morbidity and mortality in perforated diverticulitis: a systematic review and meta-analysis.

To determine if preoperative-intraoperative factors such as age, comorbidities, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and severity of peritonitis affect the rate of morbidity and mortality in patients undergoing a primary anastomosis (PA) or Hartmann Procedure (HP) for perforated diverticulitis. This is a systematic review and meta-analysis, conducted according to PRISMA, with an electronic search of the PubMed, Medline, Cochrane Library, and Google Scholar databases. The search retrieved 614 studies, of which 11 were included. Preoperative-Intraoperative factors including age, ASA classification, BMI, severity of peritonitis, and comorbidities were collected. Primary endpoints were mortality and postoperative complications including sepsis, surgical site infection, wound dehiscence, hemorrhage, postoperative ileus, stoma complications, anastomotic leak, and stump leakage. 133,304 patients were included, of whom 126,504 (94.9%) underwent a HP and 6800 (5.1%) underwent a PA. There was no difference between the groups with regards to comorbidities (p = 0.32), BMI (p = 0.28), or severity of peritonitis (p = 0.09). There was no difference in mortality [RR 0.76 (0.44-1.33); p = 0.33]; [RR 0.66 (0.33-1.35); p = 0.25]. More non-surgical postoperative complications occurred in the HP group (p = 0.02). There was a significant association in the HP group between the severity of peritonitis and mortality (p = 0.01), and surgical site infection (p = 0.01). In patients with perforated diverticulitis, PA can be chosen. Age, comorbidities, and BMI do not influence postoperative outcomes. The severity of peritonitis should be taken into account as a predictor of postoperative morbidity and mortality.

Neurosurgery Morbidity and Mortality: A Prospective Surgical and Medical Analysis.

OBJECTIVE: The analysis of morbidity and mortality is fundamental for improving the quality of patient care. The objective of this study was to evaluate the combined medical and surgical morbidity and mortality of neurosurgical patients. METHODS: We performed a daily prospective compilation of morbidities and mortalities during a consecutive 4-month period in all the patients who were 18 years of age or older and had been admitted to the neurosurgery service at the Puerto Rico Medical Center. For each patient, any surgical or medical complication, adverse event, or death within 30 days was included. The patients' comorbidities were analyzed for their influence on mortality. RESULTS: Fifty-seven percent of the patients presented at least 1 complication. The most frequent complications were hypertensive episodes, mechanical ventilation for more than 48 hours, sodium disturbances, and bronchopneumonia. Twenty-one patients died, for an overall 30-day mortality of 8.2%. Mechanical ventilation for more than 48 hours, sodium disturbances, bronchopneumonia, unplanned intubation, acute kidney injury, blood transfusion, shock, urinary tract infection, cardiac arrest, arrhythmia, bacteremia, ventriculitis, sepsis, elevated intracranial pressure, vasospasm, stroke, and hydrocephalus were significant factors for mortality. None of the analyzed patients' comorbidities were significant for mortality or longer length of stay. The type of surgical procedure did not influence the length of stay. CONCLUSION: The mortality and morbidity analysis provided valuable neurosurgical information that may influence future treatment management and corrective recommendations. Indication and judgment errors were significantly associated with mortality. In our study, the patients' comorbidities were not significant for mortality or increased length of stay.

Hospital volume, postoperative mortality, and costs after gastrectomy for gastric cancer in colombia: is there any association? / Volume hospitalar, mortalidade pós-operatória e custos após gastrectomia por câncer gástrico na colômbia: existe associação?

ABSTRACT BACKGROUND: There are no information in the literature associating the volume of gastrectomies with survival and costs for the health system in the treatment of patients with gastric cancer in Colombia. AIMS: The aim of this study was to analyze how gastrectomy for gastric cancer is associated with hospital volume, 30-day and 180-day postoperative mortality, and healthcare costs in Bogotá, Colombia. METHODS: A retrospective cohort study based on hospital data of all adult patients with gastric cancer who underwent gastrectomy between 2014 and 2016 using a paired propensity score. The surgical volume was identified as the average annual number of gastrectomies performed by the hospital. RESULTS: A total of 743 patients were included in the study. Hospital mortality at 30 and 180 days postoperatively was 36 (4.85%) and 127 (17.09%) patients, respectively. The average health care cost was USD 3,200. A total of 26 or more surgeries were determined to be the high surgical volume cutoff. Patients operated on in hospitals with a high surgical volume had lower 6-month mortality (HR 0.44; 95%CI 0.27-0.71; p=0.001), and no differences were found in health costs (mean difference 398.38; 95%CI-418.93-1,215.69; p=0.339). CONCLUSIONS: This study concluded that in Bogotá (Colombia), surgery in a high-volume hospital is associated with better 6-month survival and no additional costs to the health system.

RESUMO RACIONAL: Não há informações na literatura relacionando o volume de gastrectomias bem como a sobrevida e os custos para o sistema de saúde, no tratamento de pacientes com câncer gástrico na Colômbia. OBJETIVOS: analisar como a gastrectomia para câncer gástrico está associada ao volume hospitalar, mortalidade pós-operatória de 30 e 180 dias e custos de saúde em Bogotá, Colômbia. MÉTODOS: Estudo de coorte retrospectivo baseado em dados hospitalares de todos os pacientes adultos com câncer gástrico submetidos à gastrectomia entre 2014 e 2016, utilizando um escore de propensão pareado. O volume cirúrgico foi identificado como o número médio anual de gastrectomias realizadas pelo hospital. RESULTADOS: Foram incluídos no estudo 743 pacientes. A mortalidade hospitalar aos 30 e 180 dias de pós-operatório, foram respectivamente, 36 (4,85%) e 127 (17,09%) pacientes. O custo médio de saúde foi de US$ 3.200. Vinte e seis ou mais cirurgias foram determinadas como ponto de corte de alto volume cirúrgico. Pacientes operados em hospitais de alto volume cirúrgico tiveram menor mortalidade em seis meses (HR 0,44; IC95% 0,27-0,71; p=0,001) e não foram encontradas diferenças nos custos com saúde (diferença média 398,38; IC95% −418,93-1215,69; p=0,339). CONCLUSÕES: Este estudo concluiu que em Bogotá (Colômbia), a cirurgia em um hospital com alto volume cirúrgico está associada a uma melhor sobrevida de seis meses e não há custos adicionais para o sistema de saúde.

Factors affecting post-operative complications and mortality in surgical patients with and without COVID-19.

OBJECTIVE: The objective of the study was to evaluate the effect of COVID-19 on the outcomes of surgical patients and the factors associated with postoperative complications and mortality. METHODS: The study included hospitalized patients with similar demographic and clinical features, who underwent similar surgical operations with a positive polymerase chain reaction test for SARS CoV-2 before or within days following the surgery (COVID-19 group) and a control group was formed of patients who tested negative for COVID-19. The two groups were compared in terms of demographic, clinical, and laboratory data, the presence of pneumonia, complications, and 30-day post-operative mortality. RESULTS: The diagnosis for COVID-19 increased the risk of complications and mortality. Age, CRP, D-dimer, ASA Grade 3-4, > 2 comorbidities, and pneumonia were determined to be factors increasing the risk of complications. Age, CRP, > 2 comorbidities, emergency operations, and pneumonia were determined to increase the risk of mortality. CONCLUSION: As patients with peri/post-operative COVID-19 positivity might be at increased risk of postoperative complications and mortality, emergency surgery in infected cases should be delayed in appropriate cases.

OBJETIVO: Nos propusimos evaluar el efecto de la COVID-19 en los resultados de los pacientes quirúrgicos y los factores relacionados con las complicaciones postoperatorias y la mortalidad. MÉTODOS: Se incluyeron los pacientes hospitalizados sometidos a operaciones quirúrgicas similares con características demográficas y clínicas similares con una prueba de reacción en cadena de la polimerasa positiva para el CoV-2 del SARS antes/en los días siguientes a la cirugía (grupo COVID-19) y los controles negativos. Los dos grupos se compararon en términos demográficos, clínicos y de laboratorio de la presencia de neumonía, las complicaciones y la mortalidad a los 30 días del postoperatorio. RESULTADOS: El diagnóstico de COVID-19 aumentó el riesgo de complicaciones y mortalidad. La edad, la CRP, el Dímero D, el grado 3-4 de la ASA, tener más de 2 comorbilidades y neumonía se relacionaron con un mayor riesgo de complicaciones. Mientras que la edad, la PCR, tener más de dos comorbilidades, las operaciones de urgencia y la neumonía se relacionaron con un mayor riesgo de mortalidad. CONCLUSIONES: Los pacientes con COVID-19 pre/postoperatorio podrían tener un mayor riesgo de complicaciones postoperatorias y de mortalidad, por lo que las cirugías de urgencia en casos infectados podrían retrasarse en los casos adecuados.

Membrana de circulación extracorpórea veno-arterial para ablación de tormenta eléctrica en shock cardiogénico: caso clínico / Veno-arterial extracorporeal membrane oxygenation (ECMO) used for support during ablation of ventricular electrical storm: case report

RESUMEN: Se presenta el caso clínico de un paciente que presenta un infarto del miocardio con trombolisis no exitosa y posterior implantación de 2 stents coronarios quien desarrolla, algunos días después, una tormenta eléctrica ventricular. Una ablación de la taquicardia se realizó bajo ECMO, con buen resultado. Se detalla la descripción del caso, revisa y discute el tema.

ABSTRAC: A patient with a myocardial infarction whom, following a failed thrombolisis and implantion of 2 stents developed a ventricular electrical storm and hemodynamic instability. A successful ablation of the tachycardia with the use of ECMO was performed. A full description is included, along with a discussion of the subject.

Risk factors for in-hospital mortality after coronary artery bypass grafting in Colombia.

BACKGROUND: The aim of this study was to determine the factors associated with in-hospital mortality after a coronary artery bypass (CABG) in a high-complexity clinic in the city of Santiago de Cali, Colombia. METHODS: A retrospective case-control analytical study was performed. Cases were defined as adult patients that had undergone CABG and died within 30 days of the surgery. Patients aged ≥18 years that had undergone isolated surgeries were included, i.e. procedures without other interventions combined. Patients were excluded from this study if: 1) they had missing data in their medical records; 2) they had previously been in a state of coma; or 3) they had previously undergone cardiac surgery other than a bypass procedure. Exposure variables were measured at three stages: preoperative, intraoperative, and postoperative. RESULTS: The study included 77 cases and 308 controls. The most common cause of death was cardiogenic shock (53.2%), followed by sepsis (27.3%). The multinomial logistic regression model revealed an association of in-hospital mortality with preoperative variables of age >75 years (odds ratio [OR] 2.5, 95% confidence interval [95% CI]: 1.1-5.8, P=0.032), low socioeconomic status (OR=2.3, 95% CI: 1.1-5.2, P=0.034), heart failure (HF) (OR=3.2, 95% CI: 1.5-7.0, P=0.002), unstable angina (OR=4.2, 95% CI: 1.9-9.0, P=0.000), acute myocardial infarction (AMI)≤7 days (OR=3.9, 95% CI: 1.1-13.7, P=0.037), chronic kidney insufficiency (CKI) (OR=2.9, 95% CI: 1.2-7.0, P=0.018), peripheral vascular disease (PVD) (OR=2.8, 95% CI: 1.2-6.8, P=0.019), and urgent/emergent surgery (OR=8.2, 95% CI: 2.0-34.5, P=0.004). Of the intraoperative variables, the model showed an association between the use of inotropic agents (OR=2.8, 95% CI: 1.3-6.4, P=0.011) and cardiogenic shock (OR=50.6, 95% CI: 7.5-339, P=0.000). CONCLUSIONS: This study identifies the factors during preoperative and intraoperative periods that are associated with in-hospital mortality in patients that have undergone CABG.

Volume of frail patients predicts outcome in frail patients after cardiac surgery.

OBJECTIVE: Recent data from major noncardiac surgery suggest that outcomes in frail patients are better predicted by a hospital's volume of frail patients specifically, rather than overall surgical volume. We sought to evaluate this "frailty volume-frailty outcome relationship" in patients undergoing cardiac surgery. METHODS: We studied 72,818 frail patients undergoing coronary artery bypass grafting or valve replacement surgery from 2010 to 2014 using the Nationwide Readmissions Database. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator. Multilevel logistic regression was used to assess the independent effect of frailty volume by quartile on mortality, surgical complications, failure to rescue, nonhome discharge, 30-day readmissions, length of stay, and hospital costs in frail patients. RESULTS: In comparing the highest volume quartiles with the lowest, both overall cardiac surgical volume and volume for frail patients were significantly associated with shorter length of stay and reduced costs. However, frailty volume was also independently associated with significantly reduced in-hospital mortality (odds ratio, 0.79; 95% confidence interval, 0.67-0.94; P = .006) and failure to rescue (odds ratio, 0.83; 95% confidence interval, 0.70-0.98; P = .03), whereas no such association was seen between overall volume and either mortality (odds ratio, 0.94; 95% confidence interval, 0.74-1.10; P = .43) or failure to rescue (odds ratio, 0.98; 95% confidence interval, 0.83-1.17; P = .85). Neither frailty volume nor overall volume showed any significant relationship with the rate of 30-day readmissions. CONCLUSIONS: In frail patients undergoing cardiac surgery, surgical volume of frail patients was a significant independent of predictor of in-hospital mortality and failure to rescue, whereas overall surgical volume was not. Thus, the "frailty volume-outcome relationship" superseded the traditional "volume-outcome relationship" in frail patients with cardiac disease.

The impact of the incorporation of a feasible postoperative mortality model at the Post-Anaesthestic Care Unit (PACU) on postoperative clinical deterioration: A pragmatic trial with 5,353 patients.

BACKGROUND: Practical use of risk predictive tools and the assessment of their impact on outcome reduction is still a challenge. This pragmatic study of quality improvement (QI) describes the preoperative adoption of a customised postoperative death probability model (SAMPE model) and the evaluation of the impact of a Postoperative Anaesthetic Care Unit (PACU) pathway on the clinical deterioration of high-risk surgical patients. METHODS: A prospective cohort of 2,533 surgical patients compared with 2,820 historical controls after the adoption of a quality improvement (QI) intervention. We carried out quick postoperative high-risk pathways at PACU when the probability of postoperative death exceeded 5%. As outcome measures, we used the number of rapid response team (RRT) calls within 7 and 30 postoperative days, in-hospital mortality, and non-planned Intensive Care Unit (ICU) admission. RESULTS: Not only did the QI succeed in the implementation of a customised risk stratification model, but it also diminished the postoperative deterioration evaluated by RRT calls on very high-risk patients within 30 postoperative days (from 23% before to 14% after the intervention, p = 0.05). We achieved no survival benefits or reduction of non-planned ICU. The small group of high-risk patients (13% of the total) accounted for the highest proportion of RRT calls and postoperative death. CONCLUSION: Employing a risk predictive tool to guide immediate postoperative care may influence postoperative deterioration. It encouraged the design of pragmatic trials focused on feasible, low-technology, and long-term interventions that can be adapted to diverse health systems, especially those that demand more accurate decision making and ask for full engagement in the control of postoperative morbi-mortality.

Selected Vancouver B2 periprosthetic femoral fractures around cemented polished femoral components can be safely treated with osteosynthesis.

AIMS: We aimed to compare the implant survival, complications, readmissions, and mortality of Vancouver B2 periprosthetic femoral fractures (PFFs) treated with internal fixation with that of B1 PFFs treated with internal fixation and B2 fractures treated with revision arthroplasty. METHODS: We retrospectively reviewed the data of 112 PFFs, of which 47 (42%) B1 and 27 (24%) B2 PFFs were treated with internal fixation, whereas 38 (34%) B2 fractures underwent revision arthroplasty. Decision to perform internal fixation for B2 PFFs was based on specific radiological (polished femoral components, intact bone-cement interface) and clinical criteria (low-demand patient). Median follow-up was 36.4 months (24 to 60). Implant survival and mortality over time were estimated with the Kaplan-Meier method. Adverse events (measured with a modified Dindo-Clavien classification) and 90-day readmissions were additionally compared between groups. RESULTS: In all, nine (8.01%) surgical failures were detected. All failures occurred within the first 24 months following surgery. The 24-month implant survival was 95.4% (95% confidence interval (CI) 89.13 to 100) for B1 fractures treated with internal fixation, 90% (95% CI 76.86 to 100) for B2 PFFs treated with osteosynthesis-only, and 85.8% (95% CI 74.24 to 97.36) for B2 fractures treated with revision THA, without significant differences between groups (p = 0.296). Readmissions and major adverse events including mortality were overall high, but similar between groups (p > 0.05). The two-year patient survival rate was 87.1% (95% CI 77.49 to 95.76), 66.7% (95% CI 48.86 to 84.53), and 84.2% (95% CI 72.63 to 95.76), for the B1 group, B2 osteosynthesis group, and B2 revision group, respectively (p = 0.102). CONCLUSION: Implant survival in Vancouver B2 PFFs treated with internal fixation was similar to that of B1 fractures treated with the same method and to B2 PFFs treated with revision arthroplasty. Low-demand, elderly patients with B2 fractures around well-cemented polished femoral components with an intact bone-cement interface can be safely treated with internal fixation. Cite this article: Bone Joint J 2021;103-B(7):1222-1230.

The Full Spectrum of COVID-19 Development and Recovery Among Kidney Transplant Recipients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) fatality rate is high among kidney transplant recipients. Among survivors, kidney outcomes, seroconversion, and persistence of viral shedding are unexplored. METHODS: Single-center prospective cohort study including data from kidney transplant recipients with confirmed COVID-19 between March 20, 2020 and July 31, 2020. Outcomes were adjudicated until August 31, 2020 or the date of death. RESULTS: There were 491 patients with COVID-19 among the 11 875 recipients in follow-up. The majority were middle aged with ≥1 comorbidities. Thirty-one percent were treated at home, and 69% required hospitalization. Among the hospitalized, 61% needed intensive care, 75% presented allograft dysfunction, and 46% needed dialysis. The overall 28-day fatality rate was 22% and among hospitalized patients it was 41%. Age (odds ratio, 3.08; 95% confidence interval, 1.86-5.09), diabetes mellitus (odds ratio, 1.69; 95% confidence interval, 1.06-2.72), and cardiac disease (odds ratio, 2.00; 95% confidence interval, 1.09-3.68) were independent factors for death. Among the 351 survivors, 19% sustained renal graft dysfunction, and there were 13 (4%) graft losses. Biopsy (n = 20) findings were diverse but decisive to guide treatment and estimate prognosis. Seroconversion was observed in 79% of the survivors and was associated with disease severity. Persistence of viral shedding was observed in 21% of the patients without detectable clinical implications. CONCLUSIONS: This prospective cohort analysis confirms the high 28-day fatality rate of COVID-19, associated primarily with age and comorbidities. The high incidence of allograft dysfunction was associated with a wide range of specific histologic lesions and high rates of sequelae and graft loss. Seroconversion was high and the persistence of viral shedding deserves further studies.

Aortic Neck IFU Violations During EVAR for Ruptured Infrarenal Aortic Aneurysms are Associated with Increased In-Hospital Mortality.

OBJECTIVE: Vascular surgeons treating patients with ruptured abdominal aortic aneurysm must make rapid treatment decisions and sometimes lack immediate access to endovascular devices meeting the anatomic specifications of the patient at hand. We hypothesized that endovascular treatment of ruptured abdominal aortic aneurysm (rEVAR) outside manufacturer instructions-for-use (IFU) guidelines would have similar in-hospital mortality compared to patients treated on-IFU or with an infrarenal clamp during open repair (ruptured open aortic aneurysm repair [rOAR]). METHODS: Vascular Quality Initiative datasets for endovascular and open aortic repair were queried for patients presenting with ruptured infrarenal AAA between 2013-2018. Graft-specific IFU criteria were correlated with case-specific proximal neck dimension data to classify rEVAR cases as on- or off-IFU. Univariate comparisons between the on- and off-IFU groups were performed for demographic, operative and in-hospital outcome variables. To investigate mortality differences between rEVAR and rOAR approaches, coarsened exact matching was used to match patients receiving off-IFU rEVAR with those receiving complex rEVAR (requiring at least one visceral stent or scallop) or rOAR with infrarenal, suprarenal or supraceliac clamps. A multivariable logistic regression was used to identify factors independently associated with in-hospital mortality. RESULTS: 621 patients were treated with rEVAR, with 65% classified as on-IFU and 35% off-IFU. The off-IFU group was more frequently female (25% vs. 18%, P = 0.05) and had larger aneurysms (76 vs. 72 mm, P= 0.01) but otherwise was not statistically different from the on-IFU cohort. In-hospital mortality was significantly higher in patients treated off-IFU vs. on-IFU (22% vs. 14%, P= 0.02). Off-IFU rEVAR was associated with longer operative times (135 min vs. 120 min, P= 0.004) and increased intraoperative blood product utilization (2 units vs. 1 unit, P= 0.002). When off-IFU patients were matched to complex rEVAR and rOAR patients, no baseline differences were found between the groups. Overall in-hospital complications associated with off-IFU were reduced compared to more complex strategies (43% vs. 60-81%, P< 0.001) and in-hospital mortality was significantly lower for off-IFU rEVAR patients compared to the supraceliac clamp group (18% vs. 38%, P= 0.006). However, there was no significantly increased mortality associated with complex rEVAR, infrarenal rOAR or suprarenal rOAR compared to off-IFU rEVAR (all P> 0.05). This finding persisted in a multivariate logistic regression. CONCLUSIONS: Off-IFU rEVAR yields inferior in-hospital survival compared to on-IFU rEVAR but remains associated with reduced in-hospital complications when compared with more complex repair strategies. When compared with matched patients undergoing rOAR with an infrarenal or suprarenal clamp, survival was no different from off-IFU rEVAR. Taken together with the growing available evidence suggesting reduced long-term durability of off-IFU EVAR, these data suggest that a patient's comorbidity burden should be key in making the decision to pursue off-IFU rEVAR over a more complex repair when proximal neck violations are anticipated preoperatively.

Patterns and timing of perioperative blood transfusion and association with outcomes after radical cystectomy.

BACKGROUND: Perioperative blood transfusion (PBT) has been associated with worse outcomes across tumor types, including bladder cancer. We report our institutional experience with PBT utilization in the setting of radical cystectomy (RC) for patients with bladder cancer, exploring whether timing of PBT receipt influences perioperative and oncologic outcomes. METHODS: Consecutive patients with bladder cancer treated with RC were identified. PBT was defined as red blood cell transfusion during RC or the postoperative admission. Clinicopathologic and peri and/or postoperative parameters were extracted and compared between patients who did and did not receive PBT using Mann Whitney U Test, chi-square, and log-rank test. Overall (OS) and recurrence-free survival (RFS) were estimated with the Kaplan Meier method. Univariate/multivariate logistic and Cox proportional hazards regression were used to identify variables associated with postoperative and oncologic outcomes, respectively. RESULTS: The cohort consisted of 747 patients (77% men; median age 67 years). Median follow-up was 61.5 months (95% CI 55.8-67.2) At least one postoperative complication (90-day morbidity) occurred in 394 (53%) patients. Median OS and RFS were 91.8 months (95% CI: 76.0-107.6) and 66.0 months (95% CI: 48.3-83.7), respectively. On multivariate analysis, intraoperative, but not postoperative, BT was independently associated with shorter OS (HR: 1.74, 95% CI: 1.32-2.29) and RFS (HR: 1.55, 95%CI: 1.20-2.01), after adjusting for relevant clinicopathologic variables. PBT (intra- or post- operative) was significantly associated with prolonged postoperative hospitalization ≥10 days. CONCLUSIONS: Intraoperative BT was associated with inferior OS and RFS, and PBT overall was associated with prolonged hospitalization following RC. Further studies are needed to validate this finding and explore potential causes for this observation.

Opioid Use Disorder is Associated With Complications and Increased Length of Stay After Major Abdominal Surgery.

OBJECTIVE: The objective of this study was to determine the impact of opioid use disorder (OUD) on perioperative outcomes after major upper abdominal surgeries. SUMMARY OF BACKGROUND DATA: OUD, defined as dependence/abuse, is a national health epidemic. Its impact on outcomes after major abdominal surgery has not been well characterized. METHODS: Patients who underwent elective esophagectomy, total/partial gastrectomy, major hepatectomy, and pancreatectomy were identified using the National Inpatient Sample (2003-2015). Propensity score matching by baseline characteristics was performed for patients with and without OUD. Outcomes measured were in-hospital complications, mortality, length of stay (LOS), and discharge disposition. RESULTS: Of 376,467 patients, 1096 (0.3%) had OUD. Patients with OUD were younger (mean 53 vs 61 years, P < 0.001) and more often male (55.1% vs 53.2%, P < 0.001), black (15.0% vs 7.6%, P < 0.001), Medicaid beneficiaries (22.0% vs 6.4%, P < 0.001), and in the lowest income quartile (32.6% vs 21.3%, P < 0.001). They also had a higher rate of alcohol (17.2% vs 2.8%, P < 0.001) and nonopioid drug (2.2% vs 0.2%, P = 0.023) dependence/abuse. After matching (N = 1077 OUD, N = 2164 no OUD), OUD was associated with a higher complication rate (52.9% vs 37.3%, P < 0.001), including increased pain [odds ratio (OR) 3.5, P < 0.001], delirium (OR 3.0, P = 0.004), and pulmonary complications (OR 2.0, P = 0.006). Additionally, OUD was associated with increased LOS (mean 12.4 vs 10.6 days, P = 0.015) and nonroutine discharge (OR 1.6, P < 0.001). In-hospital mortality did not differ (OR 2.4, P = 0.10). CONCLUSION: Patients with OUD more frequently experienced complications and increased LOS. Close postoperative monitoring may mitigate adverse outcomes.

A Multi-Interventional Nutrition Program for Newborns with Congenital Heart Disease.

OBJECTIVE: To evaluate how outcomes changed in newborns undergoing surgery for congenital heart disease after implementation of a standardized preoperative and postoperative nutrition program. STUDY DESIGN: We performed a single-center cohort study of newborns who underwent cardiac surgery between September 2008 and July 2015. We evaluated growth and feeding outcomes in the 2 years of preprogram time (phase 0), in the 2 years after initiation of a postoperative feeding algorithm (phase 1), and in the 2 years following introduction of a preoperative feeding program (phase 2) using traditional statistics and quality improvement methods. RESULTS: The study included 570 newborns with congenital heart disease. Weight-for-age z-score change from birth to hospital discharge significantly improved from phase 0 (-1.02 [IQR, -1.45 to -0.63]) to phase 1 (-0.83 [IQR, -1.25 to -0.54]; P = .006), with this improvement maintained in phase 2 (-0.89 [IQR, -1.30 to -0.56]; P = .017 across phases). Gastrostomy tube use decreased significantly (25% in phase 0 vs 12% and 14% in phases 1 and 2; P < .001) and preoperative enteral feeding increased significantly (47% and 46% in phases 0 and 1 vs 76% in phase 2; P < .001) without increases in necrotizing enterocolitis, hospital stay, or mortality. CONCLUSIONS: Introduction of a multi-interventional nutrition program was associated with improved weight gain, fewer gastrostomy tubes at hospital discharge, and increased preoperative enteral feeding without increases in necrotizing enterocolitis, hospital stay, or mortality.