Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 25
Filtrar
1.
Ann Thorac Surg ; 2021 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-34678289
2.
Ann Thorac Surg ; 2021 Jun 29.
Artigo em Inglês | MEDLINE | ID: mdl-34214548

RESUMO

BACKGROUND: Methods to assess competency in cardiothoracic training are essential. Here, we report a system that allows us to better assess competency from the perspective of both the trainee and educator. We hypothesized that postprocedural cognitive burden measurement (by the trainee) with immediate feedback (from the educator) could aid in identifying barriers to the acquisition of skills and knowledge so that training curricula can be individualized. METHODS: The National Aeronautics and Space Administration Task Load Index (NASA-TLX), a validated instrument to measure cognitive load, was administered with an online platform after bronchoscopy, esophagogastroduodenoscopy, and video-assisted thoracoscopic surgery for 11 residents. Immediate postprocedure feedback and standardized debriefing occurred for each procedure. RESULTS: Mean NASA-TLX scores were highest (indicating greater cognitive load) for esophagogastroduodenoscopy and video-assisted thoracoscopic surgery (P < .001). When comparing subscale measures, mental demand was significantly higher for video-assisted thoracoscopic surgery (P = .026) compared with the other procedures, whereas physical demand was highest for esophagogastroduodenoscopy (P = .018). Self-reported frustration was similar for all case types (P = .247). Cognitive burden decreased with a greater number of procedures for bronchoscopy (P = .027). Significant improvement was noted by the trainee at the end of the rotation in self-assessed procedural competency and preparedness for thoracic board topics (all P < .05). Postprocedure feedback by the attending surgeon correlated with more frequent completion of self-evaluations by the residents. CONCLUSIONS: Longitudinal assessment of cognitive load in combination with postprocedural feedback identified barriers to skill acquisition for both residents and educators. This information allows for individualized rotation development as a step toward a competency-based curriculum.

3.
Ann Thorac Surg ; 2021 May 27.
Artigo em Inglês | MEDLINE | ID: mdl-34090668

RESUMO

BACKGROUND: Worse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era. METHODS: The Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex. RESULTS: Women constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes. CONCLUSIONS: In-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.

4.
J Thorac Dis ; 13(5): 2874-2884, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-34164179

RESUMO

Background: This study evaluates anticoagulation management and its impact on longitudinal clinical outcomes in patients undergoing mechanical valve replacement. Methods: Patients undergoing mechanical mitral valve replacement (MVR) or aortic valve replacement (AVR) from 2010-2018 at a single center were included. Patients were stratified into therapeutic and non-therapeutic anticoagulation groups based on the median percentage of international normalized ratio (INR) values within the reference range (2.0-3.0 for AVR, 2.5-3.5 for MVR) during the first post-operative year. Using Cox regression analysis, comorbidity-adjusted survival and freedom from adverse events were compared. Results: Six hundred and fifty-one patients underwent mechanical valve replacement (166 MVR, 485 AVR). Comorbidity-adjusted survival was similar in the MVR and AVR cohorts (P=0.23). There was a median of 27 [interquartile range (IQR): 14-42] INRs drawn per patient in the first post-operative year. The median percentage of INRs within the reference values during the first post-operative year was 42.85% (IQR: 30.77-53.95%), with the majority of non-therapeutic INRs being subtherapeutic (34.51%; n=6,864). There were no significant differences in adjusted survival between the therapeutic and non-therapeutic groups [hazard ratio (HR): 1.12, P=0.73]. Within the first post-operative year, there were no significant differences in stroke, major bleeding, peripheral non-stroke arterial thromboembolism, and readmission for intravenous heparin in the therapeutic and non-therapeutic groups. Conclusions: Taking into account relevant comorbidities and valve type, patients with a larger proportion of non-therapeutic INRs during the first post-operative year demonstrated no difference in longitudinal clinical outcomes. Further research into more standardized INR monitoring and potentially expanded INR target ranges for patients undergoing mechanical valve replacement is warranted.

5.
Transplantation ; 105(12): 2639-2645, 2021 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-33988340

RESUMO

BACKGROUND: The use of hepatitis C virus-positive (HCV+) donors has expanded the donor pool for orthotopic heart transplantation (OHT). This study evaluated center-level trends and utilization of HCV+ donors for OHT. METHODS: Data were extracted from the Scientific Registry of Transplant Recipients on adults (≥18 y) undergoing OHT between January 1, 2016 and December 31, 2019. Centers performing <10 OHTs during the study period were excluded. Donor utilization rates were evaluated at the center level. Center-level characteristics were compared between centers performing HCV+ donor hepatitis C virus-negative (HCV-) recipient OHTs and those not utilizing HCV+ donors for HCV- recipients. RESULTS: A total of 10 134 patients underwent OHT, including 613 (6.05%) HCV+ donors transplanted into HCV- recipients. The number of HCV+ OHTs increased from 15 of 2512 (0.60%) in 2016 to 285 of 2490 (11.45%) in 2019 (P < 0.001). In 2016, among 105 centers performing OHTs, 7 (6.67%) utilized HCV+ donors compared to 2019 during which 55 (52.89%) of 104 centers utilized HCV+ donors (P < 0.001). In total, 57 of 107 (53.27%) centers utilized HCV+ donors during the study period. Centers utilizing HCV+ donors had higher overall donor utilization rates (7376/24 378 [30.26%] versus 3463/15 335 [22.58%], P < 0.001) and were higher volume as compared to nonutilizing centers (mean annual OHT volume 30.72 ± 1.21 versus 16.2 ± 1.40, P < 0.001). CONCLUSIONS: Although the use of HCV+ donors for OHT is rapidly expanding in the United States, almost half of transplant centers remain nonutilizers. Broader education and implementation of HCV+ donor protocols may be important in expanding OHT to more patients with end-stage heart failure.

6.
Transplantation ; 105(9): 2097-2103, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33988350

RESUMO

BACKGROUND: The 2018 heart allocation change has resulted in greater frequency of high-risk bridging to orthotopic heart transplantation (OHT). Although survival has been studied in these patients, functional status outcomes are less established. This study evaluated changes in functional status of OHT survivors based on bridging strategy. METHODS: Adults (≥18 y) undergoing OHT between January 2015 and March 2020 were stratified by bridging modality: no bridging, inotropes only, intra-aortic balloon pump (IABP), temporary ventricular assist device (VAD), durable VAD, and extracorporeal membrane oxygenation (ECMO). Using paired analysis, the Karnofsky performance scale (0-100) was utilized to compare differences in function at listing, transplant, and follow-up. RESULTS: In total, 13 142 patients underwent OHT. At the time of both listing and transplant, patients requiring IABP, temporary VAD, and ECMO displayed the lowest functional status (each median 20) compared with other groups (P < 0.001). Among survivors, the median performance status at follow-up was ≥80 for all groups, indicating total functional independence with no assistance required. Substantial improvement in Karnofsky score occurred from transplant to follow-up in survivors bridged with IABP (40), temporary VADs (60), and ECMO (50) (each P < 0.001). Among survivors with at least 90-day follow-up, the median Karnofsky score was 90 regardless of bridging modality. CONCLUSIONS: Despite a higher mortality risk, critically ill patients who survive OHT after bridging with high-risk modalities experience acceptable functional status outcomes. These findings are important to place in the context of the impact that the 2018 allocation change has had on the landscape of OHT in the United States.


Assuntos
Cardiotônicos/uso terapêutico , Oxigenação por Membrana Extracorpórea , Estado Funcional , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Balão Intra-Aórtico , Implantação de Prótese , Adulto , Cardiotônicos/efeitos adversos , Estado Terminal , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Transplante de Coração/efeitos adversos , Transplante de Coração/mortalidade , Coração Auxiliar , Humanos , Balão Intra-Aórtico/efeitos adversos , Balão Intra-Aórtico/mortalidade , Masculino , Pessoa de Meia-Idade , Implantação de Prótese/efeitos adversos , Implantação de Prótese/instrumentação , Implantação de Prótese/mortalidade , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
7.
Ann Thorac Surg ; 2021 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-33930354

RESUMO

BACKGROUND: Percutaneous coronary intervention (PCI) is being performed more frequently for left main coronary artery disease (LMCAD). This study evaluated a real-world propensity-matched analysis of surgical vs percutaneous revascularization for LMCAD. METHODS: Adults (≥18 years of age) at a single academic institution undergoing coronary artery bypass grafting (CABG) or PCI for left main stenosis greater than or equal to 50% between 2010 and 2018 were examined. Greedy propensity-matching techniques were used to generate well-matched cohorts, and Kaplan-Meier analysis was used to compare survival. Multivariable Cox models were created for 5-year mortality and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: A total of 1091 patients with LMCAD were identified (898 CABG, 193 PCI). Patients undergoing PCI were significantly older (77 years of age vs 68 years of age; P < .001), more likely to have heart failure (26.94% vs 13.14%; P < .001), and less likely to have 3-vessel disease (42.49% vs 65.59%; P < .001). Propensity matching yielded 215 CABG and 134 PCI well-matched patients. In the matched analysis, 1-year (77.61% vs 88.37%) and 5-year (48.77% vs 75.62%) survival were lower with PCI. Rates of MACCE at 5 years were also higher with PCI (64.93% vs 32.56%; P < .001). Rates of both myocardial infarction (19.40% vs 7.44%; P = .001) and repeat revascularization (26.12% vs 7.91%; P < .001) were higher with PCI. After risk adjustment, CABG remained associated with reduced risk of mortality (hazard ratio, 0.40; 95% confidence interval, 0.29-0.54; P < .001) and MACCE (hazard ratio, 0.37; 95% confidence interval, 0.28-0.48; P < .001) at 5 years. CONCLUSIONS: This real-world, propensity-matched analysis demonstrates substantial advantages in survival and MACCE with CABG for LMCAD, supporting surgical revascularization in this clinical setting in appropriate operative candidates.

8.
Am J Cardiol ; 145: 91-96, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33454338

RESUMO

This study explored center-level variations in maximum recipient body mass index (BMI) and the associated impact of morbid obesity on outcomes of orthotopic heart transplantation (OHT). Using the United Network for Organ Sharing (UNOS) database, we examined adults (≥18 years) who underwent OHT between 2010 and 2018. Centers performing <10 OHTs per year were excluded. Recipients were stratified by BMI: <35, 35-38, 38 to 40, >40 kg/m2. Kaplan-Meier analysis was utilized to model survival and Cox regression analysis was utilized for adjusted analysis of 1-year mortality. A total of 17,821 candidates underwent OHT with 1,330 having a BMI >35kg/m2. Among 84 centers, a mean of 92.06% of recipients per center had a BMI<35 with 5.87%, 1.01%, and 1.06% of recipients having BMIs of 35 to 38, 38 to 40, and >40 at each center, respectively. A total of 5, 54, 17, and 8 centers had maximum recipient BMIs of <35, 35 to 38, 38 to 40, and >40 kg/m2, respectively. Centers performing OHT on recipients with higher BMIs displayed higher overall OHT volume (p = 0.002). Rates of post-transplant dialysis (p <0.001) and stroke (p = 0.008) were higher with increased BMI and length of stay was significantly longer (p <0.001). Following risk-adjustment, BMI 35 to 38 (HR 1.19) was not associated with increased risk of 1-year mortality although BMI 38 to 40 (HR 1.80, p = 0.007) and >40 (HR 2.85, p <0.001) were associated. In conclusion, most centers in the United States have a maximum recipient BMI of 35 to 38 for OHT, which appears justified as the risk of 1-year mortality increases with BMI >38.


Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração/métodos , Hospitais/estatística & dados numéricos , Mortalidade , Obesidade Mórbida/epidemiologia , Seleção de Pacientes , Adulto , Idoso , Índice de Massa Corporal , Feminino , Insuficiência Cardíaca/epidemiologia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco , Índice de Gravidade de Doença
9.
J Card Surg ; 36(4): 1270-1276, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33484206

RESUMO

BACKGROUND: This study explored trends in utilization of marginal donors for orthotopic heart transplantation (OHT) in the United States. METHODS: Using the United Network for Organ Sharing database, adults (≥18 years) undergoing OHT between 2009 and 2019 were identified. Marginal donors were defined as having ≥2 of the following: age ≥50 years, ejection fraction less than 50%, ischemic time greater than 240 min, donor-to-recipient body mass index ratio less than 0.8, or donor inotrope use. Kaplan-Meier analysis was utilized to model survival with multivariable Cox regression analysis used for risk-adjustment. RESULTS: A total of 23,580 recipients underwent OHT with 4896 (20.76%) receiving organs from marginal donors. The use of marginal donors decreased from 25.6% in 2009 to 16.0% in 2017 but accounted for 24.7% of OHTs in 2019. This recent increase in marginal donor use was largely attributable to increased use of donors with ischemic time greater than 240 min, whereas other marginal donor criteria remained stable. Among 140 centers, median marginal donor use was 20.07% (interquartile range, 14.17%-26.51%). An increasing proportion of marginal donors was not associated with increased center-level OHT volume (R2 < 0.001, p = .833). Marginal donor use was associated with reduced 1- (88.75% vs. 91.87%) and 5-year survival (76.73% vs. 80.08%, p < .001). Following adjustment, marginal donor use remained a significant predictor of post-OHT mortality (hazard ratio, 1.17; p < .001). CONCLUSION: Marginal donors account for approximately 20% of OHTs performed in the United States. Despite a reduction in utilization over the past decade, the 2018 allocation change has resulted in a significant increase in use, largely attributable to longer ischemic times.


Assuntos
Transplante de Coração , Doadores de Tecidos , Transplantes , Adulto , Definição da Elegibilidade , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Estados Unidos/epidemiologia
10.
J Surg Res ; 261: 58-66, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33418322

RESUMO

BACKGROUND: Surgical risk calculators (SRCs) have been developed for estimation of postoperative complications but do not directly inform decision-making. Decision curve analysis (DCA) is a method for evaluating prediction models, measuring their utility in guiding decisions. We aimed to analyze the utility of SRCs to guide both preoperative and postoperative management of patients undergoing hepatopancreaticobiliary surgery by using DCA. METHODS: A single-institution, retrospective review of patients undergoing hepatopancreaticobiliary operations between 2015 and 2017 was performed. Estimation of postoperative complications was conducted using the American College of Surgeons SRC [ACS-SRC] and the Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) calculator; risks were compared with observed outcomes. DCA was used to model optimal patient selection for risk prevention strategies and to compare the relative performance of the ACS-SRC and POTTER calculators. RESULTS: A total of 994 patients were included in the analysis. C-statistics for the ACS-SRC prediction of 12 postoperative complications ranged from 0.546 to 0.782. DCA revealed that an ACS-SRC-guided readmission prevention intervention, when compared with an all-or-none approach, yielded a superior net benefit for patients with estimated risk between 5% and 20%. Comparison of SRCs for venous thromboembolism intervention demonstrated superiority of the ACS-SRC for thresholds for intervention between 2% and 4% with the POTTER calculator performing superiorly between 4% and 8% estimated risk. CONCLUSIONS: SRCs can be used not only to predict complication risk but also to guide risk prevention strategies. This methodology should be incorporated into external validations of future risk calculators and can be applied for institution-specific quality improvement initiatives to improve patient outcomes.


Assuntos
Técnicas de Apoio para a Decisão , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco
11.
Ann Thorac Surg ; 112(2): 582-588, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33127404

RESUMO

BACKGROUND: This study evaluated our institutional experience in forming a surgeon-based committee to discuss and provide consensus opinion on high-risk cardiac surgical cases. METHODS: The committee consisted of 4 surgeons with at least 1 senior surgeon at any given time with a rotating schedule. Patients with a Society of Thoracic Surgeons predicted risk of mortality above specified thresholds were mandated for referral to the committee in addition to patients referred at the discretion of the surgeon. Kaplan-Meier analysis was used to model survival. RESULTS: A total of 110 consecutive patients were reviewed by the committee. The most common procedure types for referral were isolated coronary artery bypass grafting (47.3%; n = 52) and coronary artery bypass grafting with concomitant aortic valve replacement (19.1%; n = 21). The overall median Society of Thoracic Surgeons predicted risk of mortality for referred patients was 5.35% (interquartile range, 4.07%-7.89%). After group discussion, a total of 62 patients were recommended to proceed with surgery (56.4%). Reasons for declining surgery included consensus that an intervention was not indicated (39.6%; n = 19), that an alternative, nonsurgical procedure was recommended (29.2%; n = 14), that there was continued medical management and reevaluation (18.8%; n = 9), and that the patient was deemed at too high a risk for surgery (12.5%; n = 6). Operative mortality in patients proceeding with surgery was 4.6% (n = 2), with an observed-to-expected mortality of 0.86. The 6-month survival after surgery was 92.2%. CONCLUSIONS: Implementation of a surgeon-based committee to discuss high-risk cases provided a unified voice to referring physicians and facilitated consensus decision-making with acceptable clinical outcomes in a challenging patient cohort.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Competência Clínica , Tomada de Decisão Clínica , Cardiopatias/cirurgia , Medição de Risco/métodos , Cirurgiões/normas , Idoso , Feminino , Cardiopatias/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Masculino , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do Tratamento , Estados Unidos/epidemiologia
12.
Ann Thorac Surg ; 112(2): 481-486, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33275933

RESUMO

BACKGROUND: This study evaluated the impact of severe chronic lung disease on outcomes of index adult cardiac operations. METHODS: A single-center, retrospective study of adult patients with severe chronic lung disease (as defined by The Society of Thoracic Surgeons) undergoing index cardiac operations between 2010 and 2018 was performed. Multivariable Cox regression and Kaplan-Meier analyses were used to evaluate survival. RESULTS: Three hundred fifty-four patients (median age, 69 years; 32.77% women) were identified. Current smokers comprised 42.66% of the population, and 34.65% of patients required home oxygen. Median preoperative forced expiratory volume in 1 second was 48% of predicted (interquartile range, 41%-56%), and median diffusing capacity of the lungs for carbon monoxide was 78% of predicted (interquartile range, 55%-101%). Most patients underwent isolated coronary artery bypass (57.06%) or isolated aortic valve replacement (19.49%). Overall, 33 patients (9.07%) required a tracheostomy (median of 10 days from surgery) for a median of 49 days (interquartile range, 25-114) until decannulation. Preoperative home oxygen use was an independent predictor of 30-day (hazard ratio, 2.91; P = .030) and 1-year (hazard ratio, 2.12; P = .009) mortality. One-year and 5-year postoperative survival were 83.62% and 58.34%, respectively. CONCLUSIONS: Although severe chronic lung disease is a predictor of mortality and morbidity after index cardiac operations, only 9% of patients required a tracheostomy, and most were alive at 5 years after surgery. Home oxygen use may serve as a further stratification tool in this higher risk subset; however the presence of severe chronic lung disease alone should not deter from surgery in otherwise reasonable surgical candidates.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Volume Expiratório Forçado/fisiologia , Cardiopatias/complicações , Pneumopatias/complicações , Pulmão/fisiopatologia , Idoso , Doença Crônica , Feminino , Cardiopatias/cirurgia , Humanos , Pneumopatias/diagnóstico , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Testes de Função Respiratória , Estudos Retrospectivos , Índice de Gravidade de Doença
13.
J Surg Res ; 259: 14-23, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33278793

RESUMO

BACKGROUND: This study explores the use of induction therapy in orthotopic heart transplantation as it relates to preoperative renal function and evaluates the impact of its utilization on post-transplant outcomes. METHODS: We conducted a retrospective analysis using the United Network for Organ Sharing database from 2000 to 2018 evaluating the initiation of de novo dialysis after transplantation. We examined the relationship between induction immunosuppression and pre-transplant estimated glomerular filtration rate with post-transplant outcomes, accounting for inter-center variability through a mixed-effects logistic regression model. RESULTS: In total, 16,201 patients were included with a median age of 57 y (interquartile range 47, 63); 26% were women (n = 4222) and 28% (n = 4552) had a history of diabetes mellitus. The median estimated glomerular filtration rate (eGFR) was 67.5 mL/min (interquartile range 53.1, 86.7); 51.2% (n = 3068) of the recipients with eGFR < 60 received induction therapy compared to 42.5% (n = 4336) within the eGFR ≥ 60 group (P < 0.001). Adjusted multivariable analysis found that induction therapy was associated with de novo dialysis (odds ratio 1.25, 95% confidence interval 1.10-1.43, P < 0.001), with the most significant effect on patients with eGFR ≥ 60. Although significant, there was a weak correlation between center-level induction utilization and mean eGFR (r = -0.2, P < 0.001). CONCLUSION: In this analysis, the use of induction immunosuppression in orthotopic heart transplantation varied widely between centers and did not correlate strongly with pre-transplant eGFR. In addition, its utilization did not mitigate the risk of renal replacement therapy after transplantation and in fact was associated with increased risk even after adjusting for confounders most notably in patients with eGFR ≥ 60.


Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração/efeitos adversos , Imunossupressão/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Insuficiência Renal/epidemiologia , Adulto , Idoso , Fatores de Confusão Epidemiológicos , Feminino , Taxa de Filtração Glomerular/fisiologia , Rejeição de Enxerto/imunologia , Rejeição de Enxerto/prevenção & controle , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Humanos , Imunossupressão/métodos , Imunossupressão/normas , Imunossupressão/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Período Pré-Operatório , Diálise Renal/estatística & dados numéricos , Insuficiência Renal/etiologia , Insuficiência Renal/fisiopatologia , Insuficiência Renal/terapia , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
14.
J Card Surg ; 36(2): 449-456, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33284503

RESUMO

BACKGROUND: We sought to derive a risk score for 1-year mortality following orthotopic heart transplantation (OHT) in patients bridged with a contemporary centrifugal left ventricular assist device (LVAD). METHODS: Adult patients (≥18 years) in the United Network for Organ Sharing database undergoing OHT between 2010 and 2019 who were bridged with a HeartWare or HeartMate III device were included. Derivation and validation cohorts were randomly assigned with a 2:1 ratio. Threshold analysis and multivariable logistic regression were utilized to obtain adjusted odds ratios for 1-year post-OHT mortality. A risk score was generated using these adjusted odds ratios in the derivation cohort and the predictive performance of the composite index was evaluated in the validation set. RESULTS: A total of 3434 patients were identified. In the derivation cohort, the mean age was 53.5 ± 12.1 years and 1758 (76.8%) were male; 1789 (78.1%) were bridged with a HeartWare device. Multivariable logistic regression revealed that recipient age ≥50 years, bilirubin level ≥2.4 mg/dl, ischemic time ≥4 h, and preoperative hemodialysis predicted 1-year post-transplant mortality. Stratification into risk groups in the validation cohort revealed significant differences in postoperative renal failure, stroke, and short-term mortality. One-year post-transplant mortality was 5%, 6.7%, and 14.8% in the low-, moderate-, and high-risk categories, respectively (p < .001). CONCLUSIONS: Among patients bridged to OHT with newer generation centrifugal LVADs, older age, increasing bilirubin, longer ischemic time, and pre-OHT dialysis independently predicted post-transplant mortality. The composite risk score based on these factors may assist in patient selection and prognostication in those supported with contemporary LVADs.


Assuntos
Insuficiência Cardíaca , Transplante de Coração , Coração Auxiliar , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
15.
Ann Surg ; 2020 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-32773624

RESUMO

OBJECTIVE: The aim of the study was to quantify the risk of incarceration of incisional hernias. BACKGROUND: Operative repair is the definitive treatment for incisional ventral hernias but is often deferred if the perceived risk of elective operation is elevated secondary to comorbid conditions. The risk of incarceration during nonoperative management (NOM) factors into shared decision making by patient and surgeon; however, the incidence of acute incarceration remains largely unknown. METHODS: A retrospective analysis of adult patients with an International Classification of Diseases, Ninth Revision or Tenth Revision diagnosis of incisional hernia was conducted from 2010 to 2017 in 15 hospitals of a single healthcare system. The primary outcome was incarceration necessitating emergent operation. The secondary outcome was 30-, 90-, and 365-day mortality. Univariate and multivariate analyses were used to determine independent predictors of incarceration. RESULTS: Among 30,998 patients with an incisional hernia (mean age 58.1 ±â€Š15.9 years; 52.7% female), 23,022 (78.1%) underwent NOM of whom 540 (2.3%) experienced incarceration, yielding a 1- and 5-year cumulative incidence of 1.24% and 2.59%, respectively. Independent variables associated with incarceration included: age older than 40 years, female sex, current smoker, body mass index 30 or greater, and a hernia-related inpatient admission. All-cause mortality rates at 30, 90, and 365 days were significantly higher in the incarceration group at 7.2%, 10%, and 14% versus 1.1%, 2.3%, and 5.3% in patients undergoing successful NOM, respectively. CONCLUSIONS: Incarceration is an uncommon complication of NOM but is associated with a significant risk of death. Tailored decision making for elective repair and considering the aforementioned risk factors for incarceration provides an initial step toward mitigating the excess morbidity and mortality of an incarceration event.

16.
Circ Heart Fail ; 13(8): e006971, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32757643

RESUMO

BACKGROUND: This study evaluates the impact of the 2018 allocation policy change on outcomes of orthotopic heart transplantation (OHT) in patients bridged with intra-aortic balloon pumps (IABPs). METHODS: Adult (≥18 years) patients undergoing OHT between 2013 and 2019 who were bridged with an IABP were stratified based on temporal relation to the policy change. Univariate analysis was used to compare baseline characteristics and postoperative outcomes. Multivariate Cox regression analysis was used to estimate risk-adjusted predictors of post-transplant mortality. RESULTS: A total of 1342 (8.6%) OHT patients were bridged with an IABP during the study period. Rates of bridging with IABP to OHT increased significantly after the policy change (7.0% versus 24.9%, P<0.001). The mean recipient age was 54.1±12.1 years with 981 (73.1%) patients being male. Baseline characteristics were similar between the 2 groups whereas post-policy change patients spent fewer days on the waitlist (15 versus 35 days, P<0.001), had longer ischemic times (3.5 versus 3.0 hours, P<0.001), and received organs from a greater distance (301 versus 105 miles, P<0.001). By multivariable analysis, days on the waitlist (for every 30 days; odds ratio, 1.01 [95% CI, 1.00-1.02], P=0.031) and diabetes mellitus (odds ratio, 1.87 [95% CI, 1.16-3.02], P=0.011) emerged as significant predictors of post-transplant mortality. After the policy change, waitlisted patients requiring IABP support were more likely to survive to transplant (76.4 versus 89.8%, P<0.001). CONCLUSIONS: IABP utilization has increased over 3-fold since the 2018 policy change with improved waitlist outcomes and comparable post-OHT survival. Thus, bridging patients to OHT with IABPs appears to be an effective strategy in the current era.


Assuntos
Transplante de Coração , Coração Auxiliar , Balão Intra-Aórtico , Política Organizacional , Listas de Espera , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Retrospectivos
17.
J Card Surg ; 35(10): 2725-2733, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32840925

RESUMO

INTRODUCTION: This study evaluated surgical outcomes of infective endocarditis (IE), with particular attention to the impact of intravenous drug use (IVDU). METHODS: Adult patients undergoing surgery for IE between 2011 and 2018 at a single center were included and stratified by IVDU. The primary outcome was overall survival. Secondary outcomes included postoperative complications and hospital readmissions. Kaplan-Meier and multivariable Cox regression were utilized for unadjusted and risk-adjusted survival analyses, respectively. Cumulative incidence function curves were compared for hospital readmissions. RESULTS: A total of 831 patients (mean age 55 years, 34.4% female) were operated on for IE, including 318 (38.3%) with IVDU. Cultures were most commonly positive for streptococcus (25.2%), methicillin-sensitive Staphylococcus aureus (17.7%), enterococcus (14.3%), or methicillin-resistant Staphylococcus aureus (8.4%). The most common procedures included isolated aortic valve repair/replacement (18.8%), aortic root replacement (15.9%), mitral valve repair/replacement (26.7%), aortic and mitral valve replacement (8.4%), and tricuspid valve repair/replacement (7.6%). Mean follow-up was 3.4 ± 2.4 years. Overall 5-year survival was 64% and was similar between IVDU and non-IVDU. Multivariable analysis demonstrated that IVDU was not associated with mortality risk. IVDU patients displayed higher rates of all-cause readmission (61.6% vs 53.9%; P = .03), drug-use readmission (15.4% vs 1.4%; P < .001), and recurrent endocarditis readmission (33.0% vs 13.0%; P < .001). CONCLUSIONS: The majority of patients undergoing surgical treatment of IE are alive at 5-years although readmission rates are high. IVDU is not a risk factor for longitudinal mortality although patients with IVDU are at higher overall readmission risk, driven largely by greater readmissions for drug-use and recurrent endocarditis.


Assuntos
Endocardite/cirurgia , Adulto , Idoso , Aorta/cirurgia , Implante de Prótese Vascular , Anuloplastia da Valva Cardíaca , Endocardite/microbiologia , Endocardite/mortalidade , Feminino , Implante de Prótese de Valva Cardíaca , Valvas Cardíacas/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Abuso de Substâncias por Via Intravenosa , Taxa de Sobrevida , Resultado do Tratamento
18.
J Am Coll Surg ; 231(5): 536-545.e4, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32822886

RESUMO

BACKGROUND: Incisional hernia develops in up to 20% of patients undergoing abdominal operations. We sought to identify characteristics associated with poor outcomes after acute incisional hernia incarceration. STUDY DESIGN: We performed a retrospective cohort study of adult patients with incisional hernias undergoing elective repair or with acute incarceration between 2010 and 2017. The primary end point was 30-day mortality. Logistic regression was used to determine adjusted odds associated with 30-day mortality. The American College of Surgeons Surgical Risk Calculator was used to estimate outcomes had these patients undergone elective repair. RESULTS: A total of 483 patients experienced acute incarceration; 30-day mortality was 9.52%. Increasing age (adjusted odds ratio 1.05; 95% CI, 1.02 to 1.08) and bowel resection (adjusted odds ratio 3.18; 95% CI, 1.45 to 6.95) were associated with mortality. Among those with acute incarceration, 231 patients (47.9%) had no documentation of an earlier surgical evaluation and 252 (52.2%) had been evaluated but had not undergone elective repair. Among patients 80 years and older, 30-day mortality after emergent repair was high (22.9%) compared with estimated 30-day mortality for elective repair (0.73%), based on the American College of Surgeons Surgical Risk Calculator. Estimated mortality was comparable with observed elective repair mortality (0.82%) in an age-matched cohort. Similar mortality trends were noted for patients younger than 60 years and aged 60 to 79 years. CONCLUSIONS: Comparison of predicted elective repair and observed emergent repair mortality in patients with acute incarceration suggests that acceptable outcomes could have been achieved with elective repair. Almost one-half of acute incarceration patients had no earlier surgical evaluation, therefore, targeted interventions to address surgical referral can potentially result in fewer incarceration-related deaths.


Assuntos
Abdome/cirurgia , Herniorrafia , Hérnia Incisional/mortalidade , Hérnia Incisional/cirurgia , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/cirurgia , Doença Aguda , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
19.
J Card Surg ; 35(10): 2589-2597, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32652638

RESUMO

BACKGROUND: Societal guidelines suggest that aortic valve replacement (AVR) in patients age 50 to 70 years can be performed with either bioprosthetic or mechanical valves. This study reviewed outcomes between these valve types among patients aged 50 to 70 years undergoing AVR. METHODS: We examined adult patients 50 to 70 years undergoing isolated AVR with a mechanical or bioprosthetic valve at a single institution between 2010 and 2018. Kaplan-Meier analysis was used to evaluate longitudinal survival and multivariable Cox regression analysis was used for risk adjustment. A propensity-matched analysis was performed as well. RESULTS: A total of 723 patients underwent isolated AVR with 467 (64.6%) receiving a bioprosthetic valve. At baseline, patients undergoing bioprosthetic AVR were older (median 65 vs 60 years; P < .001). One-year survival was comparable, however, survival at 5 years was significantly higher among patients undergoing mechanical AVR (95.5% vs 82.6%; P = .010). Among the 196 matched pairs, bioprosthetic AVR was associated with an increased adjusted hazard for death (hazards ratio, 3.29; P < .001). Additionally, 5-year freedom from stroke and bleeding were similar following matching, though mechanical AVR was associated with a greater freedom from repeat valve intervention (97.5% vs 92.9%; P = .020). CONCLUSION: In patients age 50 to 70, mechanical AVR is associated with improved long-term survival and freedom from repeat aortic valve intervention. Further large cohort studies should be performed to explore the potential benefits of mechanical valve replacement in this age range.


Assuntos
Valva Aórtica/cirurgia , Bioprótese , Implante de Prótese de Valva Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Fatores Etários , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do Tratamento
20.
J Card Surg ; 35(6): 1195-1201, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32362025

RESUMO

BACKGROUND: The optimal revascularization approach for patients with multivessel coronary artery disease (MVCAD) is controversial. We sought to investigate outcomes in patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for non-ST elevation myocardial infarction (NSTEMI). METHODS: Adult patients with MVCAD and NSTEMI undergoing either CABG or PCI at a single institution between 2011 and 2018 were included. Multivariable analysis was utilized to determine independent predictors of death, major adverse cardiac and cerebrovascular events (MACCE), and readmissions. A subanalysis examined patients undergoing complete revascularization. RESULTS: A total of 2001 patients were included, of whom 1480 (74.0%) underwent CABG. CABG was associated with a lower risk-adjusted hazard for death (hazard ratio, 0.59, P < .001) and with improved survival at 1 year (92.0 vs 81.8%, P < .001) and 5 years (80.7 vs 63.3%, P < .001). Additionally, freedom from MACCE (P < .001) was greater in the CABG group and cumulative readmission, rates of MI, and rates of repeat revascularization were lower with CABG (each P < .001). Among patients undergoing complete revascularization, overall survival (1 year: 92.7 vs 83.9%, P = .010; 5 years: 81.1 vs 69.4%, P < .001) and freedom from MACCE (1 year: 92.3 vs 75.2%, P < .001; 5 years: 81.7 vs 61.4%, P < .001) remained higher for the CABG group; cumulative incidence of readmission was also decreased in those undergoing CABG (P < .001). CONCLUSIONS: In this real-world analysis of patients with MVCAD presenting with NSTEMI, revascularization with CABG resulted in improved survival with lower rates of MACCE and readmission as compared to PCI, which persisted when accounting for complete revascularization.


Assuntos
Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/mortalidade , Doença das Coronárias/cirurgia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/mortalidade , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/epidemiologia , Transtornos Cerebrovasculares/epidemiologia , Ponte de Artéria Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Taxa de Sobrevida , Resultado do Tratamento
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...