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1.
J Card Surg ; 36(10): 3599-3606, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34363420

RESUMO

BACKGROUND: Time of day for surgical procedures has been a topic of considerable controversy, with some suggesting that later operating times are associated with worse outcomes. METHODS: All patients who underwent open cardiac surgery from 2011 to 2018 were included. Patients that had ventricular assist devices, heart transplant, transcatheter aortic valves, aortic dissections, and emergent operations were excluded. Primary outcomes included postoperative mortality and survival; secondary outcomes included postoperative complications and readmission. RESULTS: The initial patient population consisted of 7883 patients who underwent index cardiac surgery. Following propensity matching (3:1), there were 2569 patients in the a.m. cohort (7-11 a.m.) and 860 patients in the p.m. cohort (3-11 p.m.). All baseline characteristics were matched to equivalent proportions. Total intensive care unit time following surgery was longer for the a.m. cohort (46.5 vs. 40.0 h; p<.001). Otherwise, there was no significant difference between cohorts including operative mortality (1.83% vs 2.21%; p= .48). On multivariable analysis, p.m. surgery was not significantly associated with 30 days mortality (hazard ratio [HR]: 0.96 [0.60, 1.53]; p= .86] or mortality over the study follow-up (HR: 0.87 [0.73, 1.03]; p= .10]. For propensity-matched cohorts, Kaplan-Meier survival at 30 days (97.9% vs. 97.4%; p= .44), 1 (93.4% vs 93.9%; p= .51), and 5 years (80.9% vs. 80.2%; p= .84) was not significantly different between cohorts. CONCLUSION: Short- and long-term mortality, hospital readmission, and postoperative complications were not significantly different between patients that underwent cardiac surgery starting in the a.m. versus patients who had cases that started in the afternoon.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Mortalidade Hospitalar , Humanos , Morbidade , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
2.
Artigo em Inglês | MEDLINE | ID: mdl-34420792

RESUMO

OBJECTIVE: This study sought to report outcomes of hemiarch replacement with hypothermic circulatory arrest and retrograde cerebral perfusion, and secondarily, to report outcomes of this operative approach by type of underlying aortic disease. METHODS: This was an observational study of aortic surgeries from 2010 to 2018. All patients who underwent hemiarch replacement with retrograde cerebral perfusion were included, whereas patients undergoing partial or total arch replacement or concomitant elephant trunk procedures were excluded. Patients were dichotomized into 2 groups by underlying aortic disease; that is, acute aortic dissection (AAD) or aneurysmal degeneration of the aorta. These groups were analyzed for differences in short-term postoperative outcomes, including stroke and operative mortality (Society of Thoracic Surgeons definition). Multivariable Cox analysis was performed to identify variables associated with long-term survival after hemiarch replacement. RESULTS: A total of 500 patients undergoing hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion were identified, of whom 53.0% had aneurysmal disease and 47.0% had AAD. For the entire cohort, operative mortality was 6.4%, whereas stroke occurred in 4.6% of patients. Comparing AAD with aneurysm, operative mortality and stroke rates were similar across each group. Five-year survival was 84.4% ± 0.02% for the entire hemiarch cohort, whereas 5-year survival was 88.0% ± 0.02% for the aneurysm subgroup and was 80.5% ± 0.03% for the AAD subgroup. On multivariable analysis, AAD was not associated with an increased hazard of death, compared with aneurysm (P = .790). CONCLUSIONS: Morbidity and mortality after hemiarch replacement with hypothermic circulatory arrest plus retrograde cerebral perfusion are acceptably low, and this operative approach may be as advantageous for AAD as it is for aneurysm.

3.
J Card Surg ; 36(10): 3631-3638, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34242433

RESUMO

INTRODUCTION: Coronary artery bypass grafting (CABG) continues to be the most commonly performed cardiac surgical procedure in the world. The use of multiarterial grafting may confer a long-term survival benefit over the use of vein grafts. However, there is a paucity of data comparing the use of in situ versus free right internal mammary artery (RIMA) in isolated CABG. METHODS: Patients that underwent isolated CABG between 2010 and 2018 where RIMA was used in addition to a left internal mammary artery graft. Patients with prior cardiac surgery or percutaneous coronary intervention were excluded. Propensity matching was used for subanalysis. Mortality and major adverse cardiac and cerebrovascular events (MACCE) were analyzed with Kaplan-Meier survival curves and Cox multivariable regression. Heart failure-specific readmissions were assessed with cumulative incidence curves with Fine and Gray competing risk regression. RESULTS: A total of 667 patients underwent isolated CABG. Of those, 422 had free RIMA and 245 had in situ RIMA utilized. Mortality was similar between cohorts (p = 0.199) with 5-year mortality rates of 6.6% (free) and 4.1% (in situ). MACCE was similar between cohorts, with 5-year event rates of 33.6% and 33.9% (p = 0.99). RIMA style was not a significant predictor of any outcome. CONCLUSION: There was no difference in long-term mortality, complications, MACCE, or heart failure readmissions when comparing a contemporary cohort of patients undergoing isolated CABG utilizing RIMA as a conduit. These data may allow surgeons to consider using RIMA either as an in situ or a free conduit.


Assuntos
Doença da Artéria Coronariana , Artéria Torácica Interna , Intervenção Coronária Percutânea , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Humanos , Anastomose de Artéria Torácica Interna-Coronária , Estudos Retrospectivos , Resultado do Tratamento
4.
Artigo em Inglês | MEDLINE | ID: mdl-34272071

RESUMO

OBJECTIVE: Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses. METHODS: All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes. RESULTS: The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52). CONCLUSIONS: Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.

6.
Ann Med Surg (Lond) ; 65: 102285, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33948166

RESUMO

Background: Coronavirus disease 2019 (COVID-19) has had a widespread impact on graduate medical education. This survey aims to assess how general surgery residency programs adapted to the initial wave of the COVID-19 pandemic in the United States (US). Materials and methods: General surgery program directors (PDs) in the US were invited to partake in a 16-question survey between April 17 and May 1, 2020. The survey included questions about basic program information, clinical practice changes, changes to education structure, surgery resident clinical duties, and perceived impact on resident operative experience and future career choices. Results: Forty-eight PDs completed the survey in the designated two-week period. Almost all (44/48, 91.7%) programs changed their didactic education to an online video conference-based format. Thirteen programs (27.1%) decreased the amount/frequency of formal education, and 13 (27.1%) reported canceling didactic education for some period of time. The majority of PDs (26/48, 54.2%) felt these changes had no impact on resident didactic participation, 14 (29.2%) reported an increase in participation, and 8 (16.7%) reported decreased participation. Ten programs (20.8%) redeployed residents to non-surgical services at the time of this survey, 30 (62.5%) have not redeployed residents but plan to if needed, and 8 (16.7%) did not have any plans to redeploy residents. Conclusions: The outbreak of COVID-19 has required general surgery residency PDs to change numerous aspects of resident education and clinical roles. Future inquiry is needed to assess if these changes lead to appreciable differences in resident preparedness and career selection.

7.
Ann Thorac Surg ; 2021 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-33882294

RESUMO

BACKGROUND: Combining clinical and research excellence has become an increasingly difficult endeavor for thoracic surgeons, with typical success rates for the National Heart, Lung and Blood Institute and the National Cancer Institute being 25.1% and 11.3%, respectively. The Thoracic Surgery Foundation (TSF), which is an arm of The Society of Thoracic Surgeons, provides research awards and grants aimed at early career faculty to assist in securing federal peer-reviewed funding. The aim of this study was to assess the impact of these awards. METHODS: Faculty awardees of the TSF research awards from 1995 to 2019 were included in the study. The scholarly work of awardees was assessed by using Scopus , MEDLINE, and Google Scholar for publications, citations, and h-index. The National Institutes of Health (NIH) RePorter and the Federal RePorter were used to search for any grants awarded to these individuals. For publications and citations associated with a TSF grant, a 4-year window from the time of the research award was used. RESULTS: Fifty-two research awards were given to early career faculty during this study period, and 8 (15%) were awarded to MD PhDs. Six (12%) of awardees were female. Cardiac faculty members were awarded 27 (52%) awards, and general thoracic faculty members were awarded 25 (48%); of the cardiac faculty, 4 (17.4%) were congenital cardiac faculty. In the 4-year period after the TSF grant award, the mean number of published articles per awardee was 23 (interquartile range [IQR], 12 to 36), with a median citation count of 147 (IQR, 32 to 327). The current median h-index was 26 (IQR, 15 to 36), with 2323 (IQR, 1173 to 4568) median citations. Forty-eight percent of all awardees received at least 1 subsequent grant; 40.4% of these awardees received grants from the NIH, and 25% had 2 or more NIH grants. Comparing academic position at the time of the award with current position, 54% of awardees had an advancement in their professional rank. On analyzing leadership positions, 42% of awardees were division chiefs, 21% were associate clinical directors, and 28% were clinical directors. CONCLUSIONS: Being a recipient of the TSF award may position an individual to excel in academic medicine, with a large portion of awardees improving their academic standing with time. The rate of successful NIH grant funding after being a TSF awardee is higher than typical institutional success rates.

9.
Artif Organs ; 45(9): E335-E348, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33908657

RESUMO

Despite the increasing incidence of heart failure, advancements in mechanical circulatory support have become minimal. A new type of mechanical circulatory support, direct cardiac compression, is a novel support paradigm that involves a soft deformable cup around the ventricles, compressing it during systole. No group has yet investigated the biomechanical consequences of such an approach. This article uses a multiscale cardiac simulation software to create a patient-specific beating heart dilated cardiomyopathy model. Left and right ventricle (LV and RV) forces are applied parametrically, to a maximum of 2.9 and 0.46 kPa on each ventricle, respectively. Compression increased the ejection fraction in the left and right ventricles from 15.3% and 27.4% to 24.8% and 38.7%, respectively. During applied compression, the LV freewall thickening increased while the RV decreased; this was found to be due to a change in the balance of the preload and afterload in the freewalls. Principal strain renderings demonstrated strain concentrations on the anterior and posterior LV freewall. Strains in these regions were found to exponentially increase after 0.75 normalized LV force was applied. Component analysis of these strains illuminated a shift in the dominating strain from transmural to cross fiber once 0.75 normalized LV force is exceeded. An optimization plot was created by nondimensionalizing the stroke volume and maximum principal strain for each compression profile, selecting five potential compression schemes. This work demonstrates not only the importance of a computational approach to direct cardiac compression but a framework for tailoring compression profiles to patients.

10.
Artigo em Inglês | MEDLINE | ID: mdl-33838909

RESUMO

OBJECTIVE: To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products. METHODS: All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival. RESULTS: A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001). CONCLUSIONS: In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.

11.
Artigo em Inglês | MEDLINE | ID: mdl-33642109

RESUMO

OBJECTIVE: Pulmonary artery catheterization provides continuous monitoring of hemodynamic parameters that may aid in the perioperative management of patients undergoing cardiac surgery. However, prior data suggest that pulmonary artery catheterization has limited benefit in intensive care and surgical settings. Thus, this study sought to determine the impact of pulmonary artery catheter insertion on short-term postoperative outcomes in a large, contemporaneous cohort of patients undergoing open cardiac surgery compared with standard central venous pressure monitoring. METHODS: This was an observational study of open cardiac surgeries from 2010 to 2018. Patients with pulmonary artery catheter insertion were identified and matched against patients without pulmonary artery catheter insertion via 1:1 nearest neighbor propensity matching. Multivariable analysis was performed to assess the impact of pulmonary artery catheterization on operative mortality in the overall cohort, as well as recent heart failure, mitral valve disease, and tricuspid insufficiency subgroups. RESULTS: Of the 11,820 patients undergoing (Society of Thoracic Surgeons indexed) coronary or valvular surgery, 4605 (39.0%) had pulmonary artery catheter insertion. Propensity score matching yielded 3519 evenly balanced pairs. Compared with central venous pressure monitoring, pulmonary artery catheter use was not associated with improved operative mortality in the overall cohort or in the recent heart failure, mitral valve disease, or tricuspid insufficiency subgroups. Intensive care unit length of stay was longer (P < .001), and there were more packed red blood cell transfusions in the pulmonary artery catheterization group (P < .001); however, postoperative outcomes were otherwise similar, including stroke, sepsis, and new renal failure (P > .05). CONCLUSIONS: These findings suggest that pulmonary artery catheterization may have limited benefit in cardiac surgery.

12.
Artigo em Inglês | MEDLINE | ID: mdl-33600994

RESUMO

The aim of the current study was to assess the impact of hospital readmissions within 30-days of discharge, on long-term postoperative outcomes. All patients who underwent cardiac surgery from 2011 - 2018 were included. Patients who had transcatheter procedures, VAD, and transplant were excluded. Inverse probability of treatment weighting (IPTW) propensity scoring was used for population risk adjustment. Multivariable analysis was performed to identify association with long-term mortality and readmission. The total risk adjusted (propensity scoring with IPTW) patient population consisted of 14,538 patients divided into those who were not readmitted in 30-days (nonreadmitted) (n = 12,627) and patients who were readmitted within 30-days (30-day readmitted) (n = 1911). Following IPTW, all baseline characteristics and postoperative complications were equivalent between cohorts (SMD <0.10). Patients who required intraoperative [OR 1.178 (1.05, 1.32); P = 0.006] and postoperative [1.32 (1.18, 1.48); P < 0.001] blood transfusions were at greater risk for 30-day readmission. Median follow-up period was 4.19 years (2.45 - 6.10). The 30-day readmission cohort had a significantly higher mortality risk during early (6 months) follow-up [HR 2.49 (2.01-3.10); P < 0.001] and late (60 months) follow-up [HR 1.30 (1.16-1.47); P < 0.001]. After risk adjustment, the 30-day readmission cohort was significantly associated with increased mortality over the study follow-up period [HR 1.62 (1.48, 1.78); P < 0.001]. 30-day readmissions were an independent predictor of subsequent long-term hospital readmission [HR 1.61 (1.50, 1.73); P < 0.001]. Patients who require 30-day readmissions following cardiac surgery are at increased risk of long-term mortality and repeat readmissions. Early postoperative hospital readmission may be a marker for worse long-term outcomes in cardiac surgery.

13.
Artigo em Inglês | MEDLINE | ID: mdl-33609669

RESUMO

Prior thoracic radiation has been associated with worse outcomes after cardiac surgery. This study sought to report long-term outcomes in patients undergoing surgery for radiation-associated heart disease. This was an observational study of open cardiac surgeries from 2011 and 2018. Patients with a history of malignancy that required thoracic radiation were identified, and this cohort was matched against a non-irradiated comparison group via Mahalanobis distance matching. Kaplan-Meier survival estimation and multivariable Cox regression analysis was performed to assess the long-term impact of thoracic radiation in patients undergoing cardiac surgery. Of the 15,284 patients receiving cardiac surgery in this time-frame, 269 were identified with a history of thoracic radiation for prior malignancy. Patients with prior radiation had increased 1-year and 5-year mortality (P < 0.001), despite no difference for 30-day mortality (P = 0.719), compared to non-irradiated patients. Mahalanobis distance matching yielded 269 equitably matched pairs. On multivariable analysis, patients with prior radiation demonstrated significantly increased hazard of death, as compared to the non-irradiated group (hazard ratio 1.40, 95% confidence interval: 1.02, 1.94, P = 0.038). Patients with radiation for breast cancer demonstrated a non-significant trend toward reduced hazard of death, as compared to patients with more extensive radiation exposure. There was an increase in long-term mortality in patients with prior radiation undergoing cardiac surgery, however open cardiac surgery can safely be performed in these patients with similar operative mortality. These findings may serve as a useful adjunct in shared decision-making for patients and surgeons alike.

15.
Semin Thorac Cardiovasc Surg ; 33(2): 368-377, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32712423

RESUMO

As percutaneous coronary intervention (PCI) continues to evolve, comparative outcomes for PCI vs coronary artery bypass grafting (CABG) remain relevant in diabetic patients. All revascularization procedures in patients with coronary artery disease and diabetes mellitus from 2010 to 2018 were included. Propensity matching was used to identify equivalent cohorts to compare revascularization strategies. Primary outcomes included 30-day, 1-year, and 5-year mortality. Multivariable analysis was used to define factors associated with major adverse cardiovascular and cerebrovascular events (MACCE). A total of 2869 patients with diabetes were divided into PCI (n = 653) and CABG (n = 2216) cohorts. Propensity matching yielded a 1:1 match consisting of 552 patients in each cohort (CABG vs PCI). Total median follow-up was 3.28 years (range: 1.83-5.00). Following propensity matching in patients with no prior PCI (1:1; n = 279), mortality remained significantly higher in the PCI cohort at 1 year (13.98% vs 7.53%; P = 0.014) and 5 years (26.88% vs 16.85%; P < 0.004). Hospital readmissions were higher for PCI patients at 1 year (16.49% vs 9.32%; P < 0.0122) and 5 years (19.71% vs 11.83%; P = 0.011). MACCE occurred more frequently in the PCI cohort (32.97% vs 21.51%; P = 0.002). Need for subsequent revascularization (6.45% vs 2.51%; P = 0.024) were significantly higher in the PCI cohort, and time interval to revascularization was significantly longer in the CABG cohort (3.48 [2.11-5.17] vs 2.62 [1.33-4.25] years; P < 0.001). The current study reports improved survival, fewer long-term hospital readmissions, and reduced MACCE and need for repeat revascularization in the CABG cohort. Given these data, patients with diabetes mellitus and coronary artery disease may fare better with surgical revascularization, compared to PCI.

16.
Ann Thorac Surg ; 111(5): 1520-1528, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32980326

RESUMO

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has emerged as the preferred alternative to surgical aortic valve replacement in elderly patients. However, the long-term outcomes of nonagenarians undergoing TAVR are unknown. METHODS: Octogenarian and nonagenarian patients undergoing TAVR from 2011 to 2018 were identified from a prospectively maintained institutional database. Cox proportional hazards regression was used for baseline-adjusted outcome comparison and risk prediction. Survival was compared with age and gender-matched population from the Social Security Actuarial Life Table. RESULTS: A total of 649 (54.4%) octogenarians and 157 (13.2%) nonagenarians underwent TAVR. Nonagenarians had a lower body mass index (P < .001), smaller BSA (P < .001), and a lower prevalence of chronic obstructive pulmonary disease (P = .023) but a higher Society of Thoracic Surgeons score (P < .001). The majority of nonagenarians and octogenarians were treated using self-expandable valves (60.3% vs 60.9%; P = .888) via transfemoral access (86.0% vs 81.0%; P = .148). At 30 days, 1 year, and 4 years, there was no difference in survival (95.5%, 80.3%, and 51.2% vs 96.9%, 87.4, and 57.6%, respectively) (adjusted hazard ratio [HR], 0.8; P = .205) and hospital readmissions for cardiac causes (7.9%, 25.7%, and 53.7% vs 10.3%, 27.9%, and 52.0%, respectively) (adjusted HR, 0.9; P = .488). Further, nonagenarians had a survival comparable to an age-matched and sex-matched U.S. population (P = .540). Post-TAVR paravalvular leak (HRs: 3.23 [P = .042] vs 2.66 [P = .032]) and anemia (HRs: 0.64 [P = .002] vs 0.80 [P = .004]) were associated with worse outcomes at 1 year. CONCLUSIONS: TAVR can be performed safely in nonagenarians, with comparable outcomes to younger patients approximating natural life expectancy. This age paradox should strengthen the role of TAVR in well selected nonagenarians by the heart team.


Assuntos
Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter , Fatores Etários , Idoso de 80 Anos ou mais , Feminino , Humanos , Estudos Longitudinais , Masculino , Estudos Prospectivos , Resultado do Tratamento
17.
Ann Thorac Surg ; 111(1): 150-158, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32512000

RESUMO

BACKGROUND: Reoperative coronary artery bypass grafting (CABG) surgery has an established increased operative risk with worse perioperative morbidity and mortality. However, contemporary propensity-matched outcomes are limited in the existing literature. METHODS: All patients who underwent CABG from 2011 to 2017 at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania were included. Propensity matching yielded risk-adjusted patient populations. Cox regression analysis was performed to identify independent predictors of 30-day, 1-year, and 5-year mortality and readmission. RESULTS: The total population consisted of 7615 patients who underwent CABG; 7265 of these patients had first-time CABG, and 350 patients had reoperative CABG. After propensity score matching, blood product transfusion (45.5% vs 56.4%; P = .002) and delayed sternal closure (0.2% vs 2.5%; P < .001) remained significantly higher for reoperative CABG. There was no difference in 30-day (5.3% vs 7.5%; P = .19) or 1-year (12.1% vs 14.8%; P = .23) mortality for first-time vs reoperative CABG. Five-year mortality was significantly higher for the reoperative cohort (28.5% vs 38.3%; P = .03). There was no difference in 30-day, 1-year, or 5-year hospital readmissions. On Cox multivariable regression analysis, reoperative CABG was not a predictor of mortality or readmission at 30 days, 1 year, or 5 years. CONCLUSIONS: After propensity score matching, there was no difference in postoperative mortality or readmission for reoperative CABG up to 1-year. This trend continued for 5-year readmissions; however, 5-year mortality was higher for the reoperative cohort. Risk adjustment did not identify reoperative CABG as a risk factor for long-term mortality.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Reoperação , Adulto , Feminino , Humanos , Masculino , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
18.
Semin Thorac Cardiovasc Surg ; 33(1): 121-127, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32569649

RESUMO

The purpose of the Thoracic Surgery Director's Association In-Training Exam (ITE) is to gauge competency and progression of thoracic surgery residents and to prepare residents for the American Board of Thoracic Surgery (ABTS) examinations. We sought to identify the relationship between traditional resident ITE scores and success at passing the written or oral portion of the ABTS examinations. ITE and ABTS examination records from 2003 to 2019 were examined for all 2-year traditional cardiothoracic surgery residents at a single institution. Paired t tests were carried out between residents on their first- and second-year ITE. Bivariate logistic regression was performed on each of the second ITE component with written or oral board passing rate as the outcome of interest. Sixty residents completed training and took both written and oral boards. First attempt board pass rates were 90% for written and 75% for oral board examination. There was a significant improvement in test scores for each resident between the first the second ITE (P< 0.001 for all scores). Both increasing overall raw (odds ratio 1.26, P = 0.022) and scaled (odds ratio 1.08, P = 0.006) ITE scores were associated with passing the written boards on first attempt. There were no associations identified for oral board passing rates. Traditional residents improved ITE scores from first to second attempt. Increasing ITE scores were associated with improved written but not oral ABTS component pass rates. The ITE serves prepare residents for the ABTS qualifying (written) exam and assists programs with gauging resident readiness for taking this exam.


Assuntos
Internato e Residência , Cirurgia Torácica , Procedimentos Cirúrgicos Torácicos , Competência Clínica , Avaliação Educacional , Humanos , Estados Unidos
19.
J Thorac Cardiovasc Surg ; 161(6): 2056-2064.e4, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31952832

RESUMO

OBJECTIVE: Coronary artery bypass grafting is often delayed after acute myocardial infarction to avoid an increase in postoperative morbidity and mortality. We hypothesized that the timing of coronary artery bypass grafting after acute myocardial infarction may not be consistently associated with postoperative outcomes. METHODS: All patients who underwent isolated coronary artery bypass grafting at the University of Pittsburgh Medical Center from 2011 to 2017 after an acute myocardial infarction were reviewed. A comparative analysis for time from myocardial infarction presentation to coronary artery bypass grafting was performed with primary outcomes including all-cause mortality and readmission. RESULTS: A total of 7048 patients underwent isolated coronary artery bypass grafting. Of these, 2058 patients had acute myocardial infarction with all relevant variables available for analysis. The study population was divided into 2 coronary artery bypass grafting timing cohorts, including less than 24 hours (n = 292) and 24 hours or more (n = 1766). Previous percutaneous coronary intervention, cardiogenic shock, and intra-aortic balloon pump were more prevalent in the less than 24 hours group. Operative mortality was significantly higher in the less than 24 hours cohort (7.19% vs 3.79%; P = .01). Diabetes mellitus, peripheral vascular disease, serum creatinine, age, chronic obstructive pulmonary disease, and immunosuppression were significant predictors (P < .05) of mortality. After risk adjustment with propensity scoring, there was no difference between time cohorts for operative mortality (4.15% vs 4.58%; P = .62). New-onset atrial fibrillation occurred more frequently in the 24 hours or more cohort. There was no difference between groups for the occurrence of major adverse cardiovascular and cerebrovascular event readmissions. CONCLUSIONS: After adjusting for baseline patient characteristics, there was no statistically significant difference between timing cohorts for mortality or major adverse cardiovascular and cerebrovascular event readmissions.

20.
J Card Surg ; 36(1): 206-215, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33225474

RESUMO

BACKGROUND: The wide availability of transcatheter aortic valve replacement (TAVR) and broadening of its indications to most patients with aortic stenosis may increase its utilization in the urgent setting. However, a comparison of long-term outcomes of patients undergoing urgent TAVR when compared to elective TAVR have not been well studied. METHODS: All patients that underwent TAVR from 2011 to 2018 were included. Primary outcomes included operative (30-day), 1-, and 5-year survival and readmissions. RESULTS: The total patient population undergoing TAVR was divided into urgent (n = 247) and elective (n = 946) cohorts. Thirty days mortality (6.5% vs. 2.3%; p = .001), acute kidney injury (2.8% vs. 0.6%; p = .003), and length of stay (12 vs. 3 days; p < .001) were higher for the urgent cohort. There was no significant difference between cohorts for 30-day all-cause (14.6% vs. 10.8%; p = .097) readmissions. Freedom from readmission for heart failure at 1-year (73.6% vs. 83.4%; p < .001) was lower for the urgent cohort. One- (79.0% vs. 87.1%; p < .001) and five-year (39.6% vs. 43.5%; p = .005) survival was lower for the urgent cohort. This difference was eliminated after risk adjustment (hazard ratio [HR]: 1.3; p = .158 and HR: 1.1; p = .639, respectively). CONCLUSION: Unadjusted survival was significantly worse for the urgent cohort up to 1 year. This trend continued for 5-year survival, however, after risk adjustment there was no significant difference in survival between cohorts. Although urgent TAVR is associated with increased periprocedural risk due to more comorbid disease, outcomes and long-term survival are encouraging and support the consideration of urgent TAVR as a viable alternative for this patient population.


Assuntos
Estenose da Valva Aórtica , Implante de Prótese de Valva Cardíaca , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Eletivos , Humanos , Fatores de Risco , Resultado do Tratamento
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