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1.
Ann Thorac Surg ; 2021 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-34785247

RESUMO

BACKGROUND: The relationship between institutional volume and operative mortality following SAVR remains unclear. METHODS: From 1/2013 to 6/2018, 234,556 patients underwent isolated SAVR (n=144,177) or SAVR+CABG (n=90,379) within the STS ACSD. The association between annualized SAVR volume [Group 1 (1-25 SAVR), Group 2 (26-50 SAVR), Group 3 (51-100 SAVR), and Group 4 (>100 SAVR)] and operative mortality and composite major morbidity/mortality was assessed. Random effects models were used to evaluate whether historic (2013-2015) SAVR volume or risk-adjusted outcomes explained future (2016-2018) risk-adjusted outcomes. RESULTS: The annualized median number of SAVRs per site was 35 [IQR: 22-59, isolated AVR: 20, AVR+CABG: 13]. Among isolated SAVR cases, the mean operative mortality and composite morbidity/mortality were 1.5% and 9.7%, respectively, at the highest volume sites (Group 4); with significantly higher rates among progressively lower volume groups (p-trend<0.001). After adjustment, lower volume centers experienced increased odds of operative mortality [Group 1 vs. 4 (Ref): AOR (SAVR), 2.24 (1.91-2.64); AOR (SAVR+CABG), 1.96 (1.67-2.30)] and major morbidity/mortality [AOR (SAVR), 1.53 (1.39-1.69); AOR (SAVR+CABG), 1.46 (1.32-1.61)] compared to the highest volume institutions. Substantial variation in outcomes was observed across hospitals within each volume category and prior outcomes explained a greater proportion of hospital operative outcomes than prior volume. CONCLUSIONS: Operative outcomes following SAVR±CABG is inversely associated with institutional procedure volumes; however, prior outcomes are more predictive than prior volume of future outcomes. Given excellent outcomes observed at many lower volume hospitals, procedural outcomes may be preferable to procedural volumes as a quality metric.

2.
Urol Int ; : 1-8, 2021 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-34802009

RESUMO

INTRODUCTION: The study aimed to construct and validate a risk prediction model for incidence of postoperative renal failure (PORF) following radical nephrectomy and nephroureterectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2005-2014 were used for the derivation cohort. A stepwise multivariate logistic regression analysis was conducted, and the final model was validated with an independent cohort from the ACS-NSQIP database years 2015-2017. RESULTS: In cohort of 14,519 patients, 296 (2.0%) developed PORF. The final 9-factor model included age, gender, diabetes, hypertension, BMI, preoperative creatinine, hematocrit, platelet count, and surgical approach. Model receiver-operator curve analysis provided a C-statistic of 0.79 (0.77, 0.82; p < 0.001), and overall calibration testing R2 was 0.99. Model performance in the validation cohort provided a C-statistic of 0.79 (0.76, 0.81; p < 0.001). CONCLUSION: PORF is a known risk factor for chronic kidney disease and cardiovascular morbidity, and is a common occurrence after unilateral kidney removal. The authors propose a robust and validated risk prediction model to aid in identification of high-risk patients and optimization of perioperative care.

3.
Ann Thorac Surg ; 2021 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-34678286

RESUMO

BACKGROUND: On June 3, 2021, Medtronic, Inc. announced discontinuation of the HVADTM left ventricular assist device. The purpose of this analysis is to provide summary data on surgical risks of HVAD to HeartMate 3TM exchange and compare survival following HVAD to HeartMate 3 exchange to survival following primary HVAD implantation. METHODS: Three cohorts within The Society of Thoracic Surgeons Intermacs database were identified: 1) primary HVAD implant cohort (1/2017-3/2021, n=3,797); 2) HVAD to HeartMate 3 exchange cohort (n=45, 12/2017-3/2021); and 3) HVAD to HVAD exchange cohort (1/2017-3/2021, n=234). Mortality following HVAD to HeartMate 3 exchange was modeled and compared to the constant hazard phase for risk of mortality while on continued HVAD support. As a secondary analysis, outcomes and survival were compared between patients who underwent HVAD to HeartMate 3 and HVAD to HVAD exchange. RESULTS: HVAD to HeartMate 3 exchange was associated with significantly reduced survival compared to survival while remaining on HVAD support (6 months following exchange 73.8% (68.6-77.8; 70% CI) versus 79.0% (78.3-79; 70% CI) for continued HVAD support). Compared to HVAD to HVAD exchange, survival was higher following replacement with HeartMate 3 (1-year: 85.9% (79.5-90.5%) versus 66.6% (63.0-70.0%), 70% CI, p = 0.009). CONCLUSIONS: Compared to continued support on HVAD, an exchange to HeartMate 3 is associated with a significant increase in mortality. For patients who required pump exchange on HVAD support, exchange to HeartMate 3 demonstrated superior survival. Currently, there is insufficient evidence to support elective exchange from an HVAD to HeartMate 3.

4.
J Am Heart Assoc ; 10(22): e019697, 2021 Nov 16.
Artigo em Inglês | MEDLINE | ID: mdl-34658259

RESUMO

Background This study evaluated the role of supplementing Society of Thoracic Surgeons (STS) risk models for surgical aortic valve replacement with machine learning (ML). Methods and Results Adults undergoing isolated surgical aortic valve replacement in the STS National Database between 2007 and 2017 were included. ML models for operative mortality and major morbidity were previously developed using extreme gradient boosting. Concordance and discordance in predicted risk between ML and STS models were defined using equal-size tertile-based thresholds of risk. Calibration metrics and discriminatory capability were compared between concordant and discordant patients. A total of 243 142 patients were included. Nearly all calibration metrics were improved in cases of concordance. Similarly, concordance indices improved substantially in cases of concordance for all models with the exception of deep sternal wound infection. The greatest improvements in concordant versus discordant cases were in renal failure: ML model (concordance index, 0.660 [95% CI, 0.632-0.687] discordant versus 0.808 [95% CI, 0.794-0.822] concordant) and STS model (concordance index, 0.573 [95% CI, 0.549-0.576] discordant versus 0.797 [95% CI, 0.782-0.811] concordant) (each P<0.001). Excluding deep sternal wound infection, the concordance indices ranged from 0.549 to 0.660 for discordant cases and 0.674 to 0.808 for concordant cases. Conclusions Supplementing ML models with existing STS models for surgical aortic valve replacement may have an important role in risk prediction and should be explored further. In particular, for the roughly 25% to 50% of patients demonstrating discordance in estimated risk between ML and STS, there appears to be a substantial decline in predictive performance suggesting vulnerability of the existing models in these patient subsets.

5.
Int J Mol Sci ; 22(17)2021 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-34502076

RESUMO

The transcription factor CEBPA is a master regulator of liver homeostasis, myeloid cell differentiation and is downregulated in several oncogenic diseases. MTL-CEBPA is a small activating RNA drug which upregulates gene expression of CEBPA for treatment of hepatocellular carcinoma (HCC). We investigate whether MTL-CEBPA has immune modulatory effects by combining MTL-CEBPA with an anti-PD-1 checkpoint inhibitor (CPI) and/or radiofrequency ablation (RFA) in two preclinical models. First, mice with two flanks of HCC tumors (BNL) were treated with combinations of RFA (right flank), anti-PD-1 or MTL-CEBPA. The reduction of the left flank tumors was most pronounced in the group treated with RFA+anti-PD1+MTL-CEBPA and 7/8 animals responded. This was the only group with a significant increase in CD8+ and CD49b+/CD45+ tumor infiltrating lymphocytes (TIL). Second, a combination of anti-PD-1+MTL-CEBPA was tested in a CT26 colon cancer model and this treatment significantly reduced tumor size, modulated the tumor immune microenvironment and increased TILs. These data suggest a clinical role for combination treatment with CPIs, RFA and MTL-CEBPA through synergistic priming of the immune tumor response, enabling RFA and CPIs to have a pronounced anti-tumor effect including activity in non-treated tumors in the case of RFA.


Assuntos
Proteínas Estimuladoras de Ligação a CCAAT/genética , Carcinoma Hepatocelular/tratamento farmacológico , Neoplasias do Colo/tratamento farmacológico , Inibidores de Checkpoint Imunológico/uso terapêutico , Neoplasias Hepáticas/tratamento farmacológico , Linfócitos do Interstício Tumoral/efeitos dos fármacos , RNA de Cadeia Dupla/uso terapêutico , Animais , Proteínas Estimuladoras de Ligação a CCAAT/metabolismo , Carcinoma Hepatocelular/cirurgia , Linhagem Celular Tumoral , Células Cultivadas , Neoplasias do Colo/cirurgia , Neoplasias Hepáticas/imunologia , Neoplasias Hepáticas/radioterapia , Linfócitos do Interstício Tumoral/imunologia , Camundongos , Camundongos Endogâmicos BALB C , Ablação por Radiofrequência , Microambiente Tumoral/efeitos dos fármacos , Microambiente Tumoral/imunologia
6.
Ann Thorac Surg ; 2021 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-34536378

RESUMO

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement.

7.
Ann Thorac Surg ; 2021 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-34343473

RESUMO

BACKGROUND: COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on regional and national levels. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from January 1, 2018, to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020, to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze risk-adjustable mortality. RESULTS: The study analyzed 717 103 adult cardiac surgery patients and more than 20 million COVID-19 patients. Nationally, there was a 52.7% reduction in adult cardiac surgery volume and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes did not return to baseline, indicating a COVID-19-associated deficit of cardiac surgery patients. CONCLUSIONS: This large analysis of COVID-19-related impact on adult cardiac surgery volume, trends, and outcomes found that during the pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first COVID-19 surge, with a concurrent increase in observed-to-expected 30-day mortality.

8.
Clin Cancer Res ; 27(21): 5961-5978, 2021 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-34407972

RESUMO

PURPOSE: To evaluate the mechanisms of how therapeutic upregulation of the transcription factor, CCAAT/enhancer-binding protein alpha (C/EBPα), prevents tumor progression in patients with advanced hepatocellular carcinoma (HCC) and in different mouse tumor models. EXPERIMENTAL DESIGN: We conducted a phase I trial in 36 patients with HCC (NCT02716012) who received sorafenib as part of their standard care, and were given therapeutic C/EBPα small activating RNA (saRNA; MTL-CEBPA) as either neoadjuvant or adjuvant treatment. In the preclinical setting, the effects of MTL-CEBPA were assessed in several mouse models, including BNL-1ME liver cancer, Lewis lung carcinoma (LLC), and colon adenocarcinoma (MC38). RESULTS: MTL-CEBPA treatment caused radiologic regression of tumors in 26.7% of HCC patients with an underlying viral etiology with 3 complete responders. MTL-CEBPA treatment in those patients caused a marked decrease in peripheral blood monocytic myeloid-derived suppressor cell (M-MDSC) numbers and an overall reduction in the numbers of protumoral M2 tumor-associated macrophages (TAM). Gene and protein analysis of patient leukocytes following treatment showed CEBPA activation affected regulation of factors involved in immune-suppressive activity. To corroborate this observation, treatment of all the mouse tumor models with MTL-CEBPA led to a reversal in the suppressive activity of M-MDSCs and TAMs, but not polymorphonuclear MDSCs (PMN-MDSC). The antitumor effects of MTL-CEBPA in these tumor models showed dependency on T cells. This was accentuated when MTL-CEBPA was combined with checkpoint inhibitors or with PMN-MDSC-targeted immunotherapy. CONCLUSIONS: This report demonstrates that therapeutic upregulation of the transcription factor C/EBPα causes inactivation of immune-suppressive myeloid cells with potent antitumor responses across different tumor models and in cancer patients. MTL-CEBPA is currently being investigated in combination with pembrolizumab in a phase I/Ib multicenter clinical study (NCT04105335).

9.
Ann Thorac Surg ; 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34153294

RESUMO

BACKGROUND: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the largest cardiac surgical database in the world. Linked data from STS ACSD and the Centers for Medicare and Medicaid Services (CMS) database were used to determine contemporary completeness, penetration, and representativeness of STS ACSD. METHODS: Variables common to both STS and CMS databases were used to link STS procedures to CMS data for all CMS coronary artery bypass grafting surgery (CABG) discharges between 2000 and 2018, inclusive. For each CMS CABG hospitalization, it was determined whether a matching STS record existed. RESULTS: Center-level penetration (number of CMS sites with at least 1 matched STS participant divided by total number of CMS CABG sites) increased from 45% in 2000 to 95% in 2018. In 2018, 949 of 1004 CMS CABG sites (95%) were linked to an STS site. Patient-level penetration (number of CMS CABG hospitalizations at STS sites divided by total number of CMS CABG hospitalizations) increased from 51% in 2000 to 97% in 2018. In 2018, 68,584 of 70,818 CMS CABG hospitalizations (97%) occurred at an STS site. Completeness of case inclusion at STS sites (number of CMS CABG cases at STS sites linked to STS records divided by total number of CMS CABG cases at STS sites) increased from 88% in 2000 to 98% in 2018. In 2018, 66,673 of 68,108 CMS CABG hospitalizations at STS sites (98%) were linked to an STS record. CONCLUSIONS: Linkage of the STS and CMS databases demonstrates high and increasing penetration and completeness of STS ACSD. STS ACSD now includes 97% of CABG in the United States.

10.
Ann Thorac Surg ; 2021 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-34087236

RESUMO

BACKGROUND: The Society of Thoracic Surgeons (STS) Intermacs Registry represents a real-world data source of durable, left ventricular assist devices that can address knowledge gaps not informed through randomized clinical trials. We sought to compare survival with contemporary left ventricular assist device technologies using multiple analytic approaches to assess concordance of treatment effects and to validate prior STS Intermacs observations. METHODS: Patients (≥19 years of age) enrolled into STS Intermacs between August 2017 and June 2019 were stratified by device type (continuous flow, centrifugal left ventricular assist device with hybrid levitation [CF-HL] or full magnetic levitation [CF-FML]). The primary outcome was 1-year survival assessed by 3 statistical methodologies (multivariable regression, propensity score matching, and instrumental variable analysis). RESULTS: Of 4448 patients, 2012 (45.2%) received the CF-HL and 2436 (54.8%) received the CF-FML. One-year survival for the CF-FML was 88% vs 79% for the CF-HL (overall P < .001), with a hazard ratio for mortality of 3.18 for the CF-HL (P < .0001) after risk adjustment. With propensity score matching (n = 1400 each cohort), 1-year survival was 87% for the CF-FML vs 80% for the CF-HL, with a hazard ratio of 3.20 for mortality with the CF-HL (P < .0001) after risk adjustment. With an instrumental variable analysis, the probability of receiving the CF-HL was associated with a hazard ratio of 3.11 (P < .0001). CONCLUSIONS: Statistical methodology using propensity score matching and instrumental variable analysis increased the robustness of observations derived from real-world data and demonstrates the feasibility of performing comparative effectiveness research using STS Intermacs. These analyses provide additional evidence supporting a survival benefit of the CF-FML vs CF-HL.

11.
J Am Coll Cardiol ; 78(1): 1-9, 2021 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-33945832

RESUMO

BACKGROUND: Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative outcomes are ill defined. OBJECTIVES: This study evaluated national outcomes of mitral surgery after TEER. METHODS: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality. RESULTS: In the study cohort of 463 patients, the median age was 76 years (interquartile range [IQR]: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval [CI]: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio [OR]: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease. CONCLUSIONS: This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.


Assuntos
Cateterismo Cardíaco , Implante de Prótese de Valva Cardíaca , Anuloplastia da Valva Mitral/efeitos adversos , Insuficiência da Valva Mitral , Valva Mitral , Complicações Pós-Operatórias , Reoperação , Fatores Etários , Idoso , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/métodos , Feminino , Doenças das Valvas Cardíacas/patologia , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Mortalidade Hospitalar , Humanos , Masculino , Valva Mitral/diagnóstico por imagem , Valva Mitral/patologia , Valva Mitral/cirurgia , Anuloplastia da Valva Mitral/métodos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/mortalidade , Insuficiência da Valva Mitral/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/cirurgia , Prognóstico , Recidiva , Reoperação/efeitos adversos , Reoperação/métodos , Reoperação/estatística & dados numéricos , Fatores de Risco , Estados Unidos
12.
J Clin Endocrinol Metab ; 106(9): e3644-e3654, 2021 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-33954783

RESUMO

CONTEXT: Guidelines for the dosage of vitamin D supplementation vary widely globally. OBJECTIVE: To investigate the impact of 2 vitamin D doses, bracketed between the IOM recommended dietary allowance (RDA) and the upper tolerable limit, on vitamin D nutritional status in elderly individuals. METHODS: This post hoc analysis of data collected from a 12-month, double-blind, randomized control trial included 221 ambulatory participants (≥ 65 years) with a mean BMI of 30.2 kg/m2 and a mean baseline serum 25-hydroxyvitamin D [25(OH)D] level of 20.4 ±â€…7.4 ng/mL, who were recruited from 3 outpatient centers in Lebanon. All participants received 1000 mg of elemental calcium daily from calcium citrate plus the daily equivalent of either 600 IU or 3750 IU of vitamin D3. RESULTS: Mean 25(OH)D level at 12 months was 26.0 ng/mL with low dose and 36.0 ng/mL with high dose vitamin D3. The proportion of participants reaching a value ≥ 20 ng/mL was 86% in the low dose, and 99% in the high dose arms, with no gender differences. The increment of 25(OH)D per 100 IU/day was 1 ng/mL with the low dose, and 0.41 ng/mL with the high dose. Serum 25(OH)D levels at 1 year were highly variable in both treatment arms. Baseline 25(OH)D level and vitamin D dose-but not age, BMI, gender, or season-were significant predictors of serum 25(OH)D level post-intervention. CONCLUSION: The IOM Recommended Dietary Allowance (RDA) of 600 IU/day does not bring 97.5% of ambulatory elderly individuals above the desirable threshold of 20 ng/mL. Country-specific RDAs are best derived taking into account the observed variability and predictors of achieved 25(OH)D levels.


Assuntos
Colecalciferol/administração & dosagem , Colecalciferol/uso terapêutico , Obesidade/tratamento farmacológico , Sobrepeso/tratamento farmacológico , Deficiência de Vitamina D/tratamento farmacológico , Vitamina D/análogos & derivados , Vitaminas/administração & dosagem , Vitaminas/uso terapêutico , Idoso , Envelhecimento , Índice de Massa Corporal , Citrato de Cálcio/uso terapêutico , Suplementos Nutricionais , Método Duplo-Cego , Feminino , Humanos , Masculino , Obesidade/complicações , Sobrepeso/complicações , Recomendações Nutricionais , Estações do Ano , Fatores Sexuais , Vitamina D/sangue , Deficiência de Vitamina D/complicações
13.
J Thorac Cardiovasc Surg ; 162(6): 1838-1847.e4, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33640137

RESUMO

OBJECTIVE: We hypothesized that infants with fetal growth restrictions have increased mortality and morbidity after congenital heart disease surgery. METHODS: The study included patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2016) who underwent cardiac surgery at a corrected gestational age of ≤44 weeks. Patients were classified as severely (birth weight Z-score -4 to -2), moderately (Z-score -2 to -1), and mildly growth restricted (Z-score -1.0 to -0.5) and compared with a reference population (Z-score 0-0.5). Multivariable logistic regression clustering on center was used to evaluate the association of birth weight Z-score with operative mortality and postoperative complications and its interaction with gestational age was assessed. RESULTS: In 25,244 patients, operative mortality was 8.6% and major complications occurred in 19.4%. Compared with the reference group, the adjusted odds ratio (AOR) of mortality was increased in infants with severe (AOR, 2.4; 95% confidence interval [CI], 2.0-3.0), moderate (AOR, 1.7; 95% CI, 1.4-2.0), and mild growth restriction (AOR, 1.4; 95% CI, 1.2-1.6). The AOR for major postoperative complications was increased for severe (AOR, 1.4; 95% CI, 1.2-1.7) and moderate growth restriction (AOR, 1.2; 95% CI, 1.1-1.4). There was significant interaction between birth weight Z-score and gestational age (P = .007). CONCLUSIONS: Even birth weight Z-scores slightly below average are independent risk factors for mortality and morbidity in infants who undergo cardiac surgery. The strongest association between poor fetal growth and operative mortality exists in early-term infants. These novel findings might account for some of the previously unexplained variation in cardiac surgical outcomes.

14.
Heart Lung Circ ; 30(7): 1091-1099, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33516659

RESUMO

BACKGROUND: While reduced left ventricular ejection fraction (LVEF) is a known risk factor for complications after coronary artery bypass grafting (CABG), the relevance of higher LVEF values has not been established. Currently, most risk stratification tools consider LVEF values above a certain point as normal. However, since this does not account for insufficient ventricular filling or increased adrenergic tone, higher values may have clinical significance. To improve our understanding of this situation, we investigated the relationship of preoperative LVEF values with short- and long-term outcomes after CABG using a strategy that allowed for the identification of nonlinear relationships. We hypothesised that both higher and lower values are independently associated with increased postoperative complications and death in this population. METHODS: We performed a single-centre retrospective cohort study of patients undergoing isolated CABG surgery. All patients had a preoperative measurement of their LVEF. Surgery involving mitral valve repair was excluded in order to eliminate the impact of mitral regurgitation. The primary outcome was long-term mortality; secondary outcomes included atrial fibrillation, operative mortality, and a composite outcome including any postoperative adverse event. Fractional polynomial equations were used to model the relationship between LVEF and outcomes so we could account for nonlinear relationships if present. Adjustments for confounders were made using multivariable logistic regression and Cox models. RESULTS: A total of 7,932 subjects were included in the study. After adjusting for patient and surgical characteristics, LVEF remained associated with the primary outcome as well as the composite outcome of any postoperative adverse event. Both these relationships were best described by a J-shaped curve given that higher LVEF values were associated with increased risk, albeit not as high has lower values. Regarding long-term mortality, individuals with a preoperative LVEF of 60% demonstrated the longest survival. A statistically significant relationship was not found between LVEF and operative mortality or atrial fibrillation after adjustment for confounders. CONCLUSIONS: Higher preoperative LVEF values may be associated with increased risk for patients undergoing CABG surgery. Future studies are needed to better characterise this phenotype.


Assuntos
Insuficiência da Valva Mitral , Disfunção Ventricular Esquerda , Ponte de Artéria Coronária , Humanos , Estudos Retrospectivos , Volume Sistólico , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia , Função Ventricular Esquerda
15.
Ann Thorac Surg ; 111(3): 778-792, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33465365

RESUMO

The Society of Thoracic Surgeons (STS)-Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) 2020 Annual Report reviews outcomes on 25,551 patients undergoing primary isolated continuous-flow left ventricular assist device (LVAD) implantation between 2010 and 2019. In 2019, 3198 primary LVADs were implanted, which is the highest annual volume in Intermacs history. Compared with the previous era (2010-2014), patients who received an LVAD in the most recent era (2015-2019) were more likely to be African American (26.8% vs 22.9%, P < .0001) and more likely to be bridged to durable LVAD with temporary mechanical support devices (36.8% vs 26.0%, P < .0001). In 2019, 50% of patients were INTERMACS Profile 1 or 2 before durable LVAD, and 73% received an LVAD as destination therapy. Magnetic levitation technology has become the predominant design, accounting for 77% of devices in 2019. The 1- and 2-year survival in the most recent era has improved compared with 2010 to 2014 (82.3% and 73.1% vs 80.5% and 69.1%, respectively; P < .0001). Major bleeding and infection continue to be the leading adverse events. Incident stroke has declined in the current era to 12.7% at 1 year. STS-Intermacs research publications are highlighted, and the new quality initiatives are introduced.


Assuntos
Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Sistema de Registros , Sociedades Médicas , Cirurgiões , Cirurgia Torácica , Humanos , Estados Unidos
17.
Ann Thorac Surg ; 111(6): 1827-1833, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33031776

RESUMO

BACKGROUND: The longitudinal cost of treating patients with non-small cell lung cancer (NSCLC) undergoing surgical resection has not been evaluated. We describe initial and 4-year resource use and cost for NSCLC patients aged 65 years of age or greater who were treated surgically between 2008 and 2013. METHODS: Using clinical data for NSCLC resections from The Society of Thoracic Surgeons General Thoracic Surgery Database linked to Medicare claims, resource use and cost of preoperative staging, surgery, and subsequent care through 4 years were examined ($2017). Cost of hospital-based care was estimated using cost-to-charge ratios; professional services and care in other settings were valued using reimbursements. Inverse probability weighting was used to account for administrative censoring. Outcomes were stratified by pathologic stage and by surgical approach for stage I lobectomy patients. RESULTS: Resection hospitalizations averaged 6 days and cost $31,900. In the first 90 days, costs increased with stage ($12,430 for stage I to $26,350 for stage IV). Costs then declined toward quarterly means more similar among stages. Cumulative costs ranged from $131,032 (stage I) to $205,368 (stage IV). In the stage I lobectomy cohort, patients selected for minimally invasive procedures had lower 4-year costs than did thoracotomy patients ($120,346 versus $136,250). CONCLUSIONS: The 4-year cost of surgical resection for NSCLC was substantial and increased with pathologic stage. Among stage I lobectomy patients, those selected for minimally invasive surgery had lower costs, particularly through 90 days. Potential avenues for improving the value of surgical resection include judicious use of postoperative intensive care and earlier detection and treatment of disease.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/economia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Custos de Cuidados de Saúde , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/cirurgia , Pneumonectomia/economia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino
18.
Ann Thorac Surg ; 111(2): 600-606, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32599046

RESUMO

BACKGROUND: Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. METHODS: Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching. RESULTS: We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories. CONCLUSIONS: The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Artéria Torácica Interna/cirurgia , Esterno/cirurgia , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade
19.
Ann Thorac Surg ; 111(6): 1781-1790, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33188754

RESUMO

BACKGROUND: Costs related to care of patients who undergo lobectomy for lung cancer may vary depending on patient, disease, and treating facility characteristics. We aimed to identify underlying case mix factors that contribute to variability of 90-day costs of lobectomy for early-stage lung cancer. METHODS: The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for lobectomy for clinical stage I lung cancer (2008-2013). Demographics, clinical outcomes, and 90-day episode-of-care costs across all care settings were analyzed for patients successfully linked to Medicare data. Hospital costs were estimated from charges using cost-to-charge ratios. Comprehensive regression models were created to identify impact of preoperative patient factors and hospital characteristics on costs, and to delineate additive costs due to perioperative outcomes and complications. RESULTS: The mean 90-day cost for lobectomy was $45,080 ± $38,239. Variables associated with significant additive costs were age greater than or equal to 75 years, American Society of Anesthesiologists classification III or IV, forced expiratory volume in 1 second less than 80% predicted, body mass index less than 18.5 or greater than 35, current or past smoker, cerebrovascular disease, chronic kidney disease, impaired functional status, open thoracotomy, prolonged operative time, government hospitals, metropolitan setting, and geographic location. Patients with 1 or more postoperative complication resulted in an overall mean added cost of $27,259. Added costs increased with the number of complications; isolated recurrent laryngeal nerve paresis ($3,911) and respiratory failure ($35,011) were associated with the least and most additive cost, respectively. CONCLUSIONS: Lobectomy is associated with substantial variability of episode-of-care costs. Variability is driven by patient demographic and clinical factors, hospital characteristics, and the occurrence and severity of complications.


Assuntos
Custos de Cuidados de Saúde , Neoplasias Pulmonares/economia , Neoplasias Pulmonares/cirurgia , Pneumonectomia/economia , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Masculino , Medicare , Sociedades Médicas , Cirurgia Torácica , Estados Unidos
20.
J Cardiothorac Vasc Anesth ; 35(1): 22-34, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33008722

RESUMO

The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.


Assuntos
Anestesia , Anestesiologia , Procedimentos Cirúrgicos Cardíacos , Cirurgia Torácica , Adulto , Humanos , Sociedades Médicas
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